Disrupted Physician 101.5: The American Society of Addiction Medicine (ASAM) uses (or misuses) Alcoholics Anonymous (AA)

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 The goal of the ASAM has always been to get the medical establishment to accept 12-step spiritual recovery.

AMSA evolved into the ASAM

AMSA evolved into the ASAM

According to the American Society of Addiction Medicine The ASAM Principles of Addiction Medicine is the “go-to textbook in the specialty of addiction medicine” and:

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The 4th Edition of The ASAM Principles of Addiction Medicine contains an entire section entitled “Mutual Help, Twelve Step, and Other Recovery Programs” containing three chapters entitled “Twelve Step Programs in Recovery,”1 “Recent Research into Twelve Step Programs”2 and “Spirituality in the Recovery Process.”3

Despite the all-encompassing title of this 31-page section (pages 911-942) no “other recovery programs” are described. In fact, no other programs bar 12-step ideology are even mentioned.

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I have read through each chapter word-for-word three times just to be sure; and although the chronic relapsing brain disease model of addiction requiring lifelong abstinence and spiritual recovery is described, trumpeted and proselytized in great detail, not one other model of addiction is even named.

As with anything I write I encourage you to fact-check this. My goal here is to present my opinions with facts and evidence that can be checked and verified. Point out any errors of fact and I will promptly remove and correct them. 

If a Cardiology textbook had a section entitled “Cholesterol, Statins and other Lipid Lowering Agents” with three chapters that only described Lipitor it would be correctly lambasted from every angle by the entire field of medicine as soon as it hit the shelves.

The lack of evidence-base and conflicts-of-interest would be recognized and dealt with immediately and when it was realized that many of the authors not only profited from, but  based their very own cardiac health on Lipitor they would rightly be held accountable. Such is not the case in Addiction Medicine.

The validity and reliability of opinions lie in their underlying methodology and evidence base. Reliance on the personal authority of any expert or group of experts is the fallacy of appeal to authority.

An appeal to Authority is a fallacy with the following form:

  1. Person A is (claimed to be) an authority on subject S.
  2. Person A makes claim C about subject S.
  3. Therefore, C is true

The fallacy is committed when the person (or group) in question is not a legitimate authority on the subject. If person A is not qualified to make reliable claims about subject S then the argument will be fallacious.   Since this sort of reasoning is fallacious only when the person is not a legitimate authority it is necessary that acceptable standards be set and the following standards are widely accepted.

  1. The person has sufficient expertise in the subject matter in question.
  1. The claim being made by the person is within her area(s) of expertise.
  1. There is an adequate degree of agreement among the other experts in the subject in question.
  1. The person in question is not significantly biased.
  1. The area of expertise is a legitimate area or discipline

With the exception of number 5 the ASAM fails on all counts, but policy makers, members of the press, politicians and others have been successfully bamboozled into believing the ASAM are indeed “experts” in Addiction Medicine.   imgresOver the years, the American Society of Addiction Medicine has continued to promote the AA position that alcoholism (and by inference any other addiction) is an illness which only a “spiritual experience will conquer.” All addictions are believed by ASAM to be caused by a lifelong chronic relapsing brain disorder that can only be treated by complete abstinence from all mood-altering substances (with the apparent exceptions of tobacco and caffeine interestingly) and the vast majority of ASAM doctors believe that the only effective treatment for addiction must include surrendering one’s “will and life over to the care of God.”

Because addiction is defined as a disease, addicts must be “treated” (often coerced) and “cured” (which is defined as remaining abstinent).

The medical profession needs to reexamine its role in Addiction Medicine.

Confusing ideological opinions with professional knowledge is unacceptable.   Presenting it as textbook science is not only dangerous but fosters negligence, abuse of power, self-interest and prejudice on the part of the medical community with respect to the treatment of all patients.

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To be clear, just as Lipitor may be the best treatment for some individuals with elevated cholesterol, AA and 12-step may be the best treatment for some individuals with addiction and substance use disorders. If it works for them, then more power to them. I have no problem with that.

What I do have a problem with is imposing and mandating any treatment on others.

Under a dictatorship everything else becomes subordinated to the guiding philosophy of the dictatorship.   Corresponding doctrine replaces professional guidelines, standards of care, and evidence based medicine.  And unfortunately in the case of Addiction Medicine the guiding philosophy often trumps autonomy and ethics.

Inherent in the current chronic brain disease model of addiction is the importance of external control over individuals.  Political correctness and the oversimplified medicalization of addiction is allowing it.   Demanding scientific literacy and discriminating good science from bad science would prohibit what is occurring and In order to save American Medicine this problem needs to be clearly recognized. Otherwise we will become a profession that is essentially defined by the false dichotomies and grand illusions defined by the impaired physicians movement.

  1. Schulz JE, Williams V. Twelve Step Programs in Recovery. In: Ries R, Fiellin D, Miller S, Saitz R, eds. Principles of Addiction Medicine. Baltimore: Lippincott Williams & Wilkens; 2009:911-922.
  2. McCrady BS, Tonigan GS. Recent Research into Twelve Step Programs. In: Ries R, Fiellin D, Miller S, Saitz R, eds. Principles of Addiction Medicine. 4 ed: Lippincott Williams & Wilkens; 2009:923-937.
  3. Galanter M. Spirituality in the Recovery Process. In: Ries R, Fiellin D, Miller S, Saitz R, eds. Principles of Addiction Medicine. 4 ed. Baltimore: Lippincott Williams & Wilkens; 2009:939-942.
Please donate to Disruptedphysician.com here to keep this blog running.  It is expiring in 21 days and any contribution would be appreciated.   We are making significant gains with articles such as  Physician Health Programs Under Fire .     These issues may seem small in the current turbulence, a small whirlpool in a maelstrom, but in reality they have enormous implications for all of us.  Please help out if you can-ML

 

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Physician Suicide, the “Impaired Physician Movement” and ASAM: The Dead Doctors at Ridgeview Institute under G. Douglas Talbott

 

FullSizeRenderThe Elephant in the room is the state Physician Health Programs organized under the FSPHP.    Nothing has changed–they have only grown more powerful and opaque and removed themselves from accountability and culpability.  Moreover,  they are expanding to other fields. Just ask the airline pilots. They eventually want to expand to students and children.   Just take a look at the ASAM White Paper on Drug Testing or Dupont’s Keynote Speech before the Drug and Alcohol Testing Industry Association.

If this does not affect you yet it eventually will and by then it will probably be too late.

Illegitimate and irrational power is very dangerous.  But no one is really paying attention.   This is just a few public policy steps away from you. Speak now before the door closes for good!

 

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mllangan1's avatarDisrupted Physician

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“It is easier to believe a lie one has heard a hundred times than a truth one has never heard before.” –American sociologist Robert S. Lynd

Ridgeview Institute was a drug and alcohol treatment program for “impaired physicians” in Georgia created by G. Douglas Talbott, a former cardiologist who lost control of his drinking and recovered through the 12-steps of Alcoholics Anonymous.

Up until his death on October 18, 2014 at the age of 90, Talbott  owned and directed a number of treatment facilities for impaired professionals, most recently the Talbott Recovery Campus in Atlanta, one of the preferred referrals for physicians ordered into evaluation and treatment by licensing boards today.

G. Douglas Talbott is a prototypical example of an “impaired physician movement” physician–in fact in many ways he may be considered the”godfather” of the current organization.  He helped organize and serve as past president of the American Society of Addiction Medicine (ASAM) and was a formative…

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Abuse Hidden Under a Veil of Benevolence: Bill Cosby, Physician Health Programs and Cognitive Dissonance

Fake ASAM ‘Doctors’ Push AA Cult For Profit.

The blue slides below are from a  presentation at the 2014 FSPHP spring meeting in Denver, Colorado and can be seen here.   The presentation was given by past FSPHP President Gary Carr, MD, Current FSPHP President Warren Prendergast, MD, West Virginia PHP Director Brad Hall, MD and Montana PHP Director Mike Ramirez, MS.

 

This needs to be seen as a "to-do" list.

This needs to be seen as a “to-do” list.

A.A. = ASAM = FSPHP 

The quote is from Alcoholics Anonymous and the full passage is as follows:

“We are convinced that a spiritual mode of living is a most powerful health restorative. We, who have recovered from serious drinking, are miracles of mental health. But we have seen remarkable transformations in our bodies. Hardly one of our crowd now shows any mark of dissipation.
      But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”–Alcoholics Anonymous, 4th Edition,  The Family Afterward

Federation of State Physician Health Program (FSPHP) physicians often quote A.A. because they are defined by A.A. in both mechanics and mentality.  The “impaired physician” movement began with evangelical recovered addict and alcoholic physicians whose recovery was based on 12- step spirituality.  As this group molded into the American Society of Addiction Medicine (ASAM) many of them found employment at 12-step rehabilitation facilities and others joined their state Physician Health Programs and organized under the FSPHP.   Their ability to make authoritative pronouncements on physician impairment is  based on their own claim to insiders knowledge of recovery as brandished in this A.A. passage which I find condescending toward the medical profession and oddly narcissistic.

This special knowledge, of course, was based on the chronic relapsing brain disease model with lifelong abstinence and participation in 12-step recovery.

These “miracles of mental health” joined their state PHPs and those who did not agree with their rigid inflexible views were removed.   Those with access to special secret knowledge were eventually able to outvote those with intelligence and open minds as this groupthink infested and eventually monopolized  PHPs.


 

It is important to understand that the ideology of  A.A. is the ideology of the ASAM is the ideology of the FSPHP 

Like all “front-groups” the ASAM purports to serve one agenda while in reality serving another.  The ASAM claims to be a “physician society with a focus on addiction and its treatment” According to their website their mission is to

  • increase access to and improve the quality of addiction treatment;
  • to educate physicians (including medical and osteopathic students), other health care providers and the public;
  • to support research and prevention;
  • to promote the appropriate role of the physician in the care of patients with addiction;
  • and to establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public

In order to accomplish this the  American Board of Addiction Medicine certifies doctors  to “provide assurance to the American public that Addiction Medicine physicians have the knowledge and skills to prevent, recognize and treat addiction.”

Ostensibly these are laudable goals that are almost universally endorsed.   The perceived organizational purpose and public persona are altruistic and humanitarian.  Treating addiction not only saves individual lives but improves the community.  It is for the common good.


 

Abuse Hidden Under Benevolence and Torture as Treatment

History reveals that all manner of abuse can lie underneath a patina of benevolence.   In the past few months alone we have both Bill Cosby and the  British Parliamentary pedophile ring as prototypical examples.  Both cases reveal a decades long coverup of allegations in which the abusers escaped little or no investigation into their alleged crimes. Abuse of power with a large gap between the power of the abuser and the powerlessness of the abused is a common denominator.  If the abuser endorses our own beliefs systems it creates a discord that promotes disbelief.  It does not fit.   Accusations are dismissed, deflected or otherwise suppressed.   Power effectively extinguishes the truth.  Disbelieved and delegitimized, information is suppressed, charges are not filed and law enforcement and the media turn a blinkered eye for decades. Indifference, disbelief, rationalization and cognitive dissonance prevent exposure and accountability. Hidden in plain site the truth was there and easy to find.  The problem was no one was looking. Most did not want to look.

It does not take much sleuthing to uncover what is beneath the veil of the American Society of Addiction Medicine.  The history, mentality and mechanics are well documented and reveal where they came from,  how they evolved and what they have planned.    It is a complicated web and hard to explain but once the pieces of the puzzle are fit together it is clear.  But it involves assembling a complex puzzle by finding the individual pieces scattered in disparate areas including the regulatory, clinical, administrative and professional niches of the medical profession,  Alcoholics Anonymous and 12-step related organization, public policy, all levels of the political arena and other areas. Once put together the portrait is clear.

In reality the ASAM is a political action group or special interest group that is designed to cement the chronic relapsing brain disease model with lifelong abstinence and spiritual recovery as the one and only treatment for addiction.   A.A. is used as the energy source of the operation.  By labeling addiction a “disease” requiring “treatment” in which someone is helpless they are able to dictate all aspects by coercion and control.  But in my opinion the A.A. ideology is just used as a ruse to support the multi-billion dollar drug and alcohol testing, assessment and treatment industry.  The zero-tolerance mindset of the “treaters” combined with the “helplessness” of the diseased enables them to erect a revolving door of testing, assessment and treatment that provides them with both control and a steady stream of money.

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The FSPHP mandates 12-step ideology on all doctors in a zero-tolerance system of abuse and control while at the same time putting out misinformation that the PHP programs are the “new paradigm.”  The page below is from the book Drug-Impaired Professionals by Robert Holman Coombs.

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This is they type of propaganda these groups have propagated.   What is described above is absurd and unrealistic but it is reported, reproduced and repeated to the point that it is accepted as the truth.

The majority of physicians referred to these programs are not even addicts. These programs of Zero-tolerance and 12-step indoctrination are based on coercion and control.  They are causing many doctors to die by suicide as they are feeling hopeless, helpless and defeated.    This portrayal of a group of blissful 12-stepping doctors over the moon because they found spirituality is nonsense.

But you will not find many doctors speaking out against them for fear of “contingency management.”  Disagreeing or even questioning PHP practices including the validity of 12-step can literally cost you your license.

I have spoken to multiple physicians and nurses and have encouraged them to tell their stories here but they are afraid of retribution and “unintended consequences.”  And who can blame them?

They can send you back to one of the “PHP-approved” facilities for “stinkin thinkin.”

Unfortunately the ASAM and FSPHP have successfully bamboozled others into believing they are true experts with noble intent.  They have bamboozled the Federation of State Medical Boards (FSMB) to the point where they have gained autonomy and unrestrained managerial prerogative.    They essentially use the state Boards to impose sanction on doctors who they report doctors for “noncompliance” which includes disagreeing with or questioning mandated A.A  or refusing to admit you have a chronic relapsing brain disease when you in fact do not.    They are in fact imposing A.A. on doctors and forcing them to accept their thinking under threat of loss of licensure.  This  violates the Establishment Clause and is a very serious problem that is being ignored.  It is a slippery slope we are on.

The FSMB House of Delegates adopted an updated Policy on Physician Impairment at their 2011 annual meeting distinguishing “impairment” and “illness”  stating that Regulatory Agencies should recognize the PHP as their expert in all matters relating to licensed professionals with “potentially impairing illness” that predates impairment often by many years.”  

It also defines “relapse without use” as “behavior without chemical use that is suggestive of impending relapse.”Screen shot 2013-05-13 at 1.30.29 PM

G. Douglas Talbott defines  “relapse without use”  as  “emotional behavioral abnormalities” that often precede relapse or “in A. A. language –stinking thinking.”

The ASAM has  monopolized addiction treatment in the United States.  But what the FSPHP arm has done is far more sinister.   A.A. has effectively taken over regulatory medicine and the private lives of doctors as a form of social control.  A doctor can be referred to a PHP for virtually anything and if the PHP believes he or she is in need of an assessment it will be done by a “PHP-approved” facility which means it will be done by a 12-step facility.  The PHP selects who will be monitored and dictates every aspect of what that entails and the entire process is done within the confines of A.A. ideology.  It is a, in fact, a  rigged game as the medical directors of the PHP approved facilities can all be seen on this list of like-minded docs who refer to theselves as “trusted servants” and “believe that evidence from extensive, well-designed studies demonstrates the great benefits of Twelve-Step recovery modalities including Twelve Step Facilitation in promoting long-term recovery.”

A.A. is imposed  on doctors through the FSPHP.  The FSPHP political apparatus exerts a monopoly of force.    And the bottom line is that A.A. has taken over all aspects of “physician health” and is forcing doctors to accept doctrine that is perhaps helpful to a few, useless or unneeded for many, and harmful and sometimes lethal to others.  This is unacceptable and it needs to be recognized.


 

“New Paradigm” of Zero-Tolerance and 12-step Spirituality Based on “success” of PHP to Move to Other Occupations and Kids.

To move this “new paradigm” to other populations they had to gain control of the doctors first.  They have not only created a monopoly but buffered themselves from physicians who may disagree with what they are doing to others.  This current system essentially stifles them.

The power, immunity and impunity this group yields over doctors was done silently and with no opposition. It was done by sequential public-policy steps.  This is why anyone interested in civil liberties and human rights should recognize the menace this presents to society.   The scaffold is in place and they are just adding more nooses.  Just ask the airline pilots.  They plan to impose similar systems on teachers, students and athletes.

And this is all spelled out in the ASAM White Paper on Drug Testing.   What people need to realized is what is described therein is just a few public policy steps away from them.  The only organization they have to convince is the organization that regulates any type of professional license, employment or benefit.

Gaining regulatory sway in the medical field and control over individual doctors was necessary to move this model to other populations.  It is merely a stepping stone for things to come.  It is only a few public policy steps from us to you.

This impacts us all.   It enables control of research, public policy and public health.   It is a system that suppresses dissent and shapes conformity.  The FSPHP  encourages the confidential referral of outliers.

The ASAM is pro-drug war and anti-medical marijuana.  This essentially silences most doctors for fear of being recognized and being brought in.  I know many doctors who will not even talk about it in public.

This is fixed doctrine and will not change.

That is why the ACLU and other groups who promote civil rights, those who are against the drug war and anyone involved in Medical Marijuana need to step in.    These  groups need to recognize the reality of who these people are, what they have planned and understand why they need to be stopped.   They are currently not even in the public eye and by outward appearances they appear to be benign.   In truth they are malignant and rapidly metastasizing without any symptoms.

In Order to Stop This the Following Must be Done

1) get a team of epidemiologists/statisticians to attack the “evidence-base” and “research” that the ASAM/FSPHP has used to support their claims (junk science, pseudoscience, success of 12-step, etc) and do a Cochrane type meta-analysis that will show there is little to no basis for it.

2) Demand accountability of the PHPs. Assign accountability to the Medical Societies and Departments of Public Health. Demand they be accountable for state-contractors with the Medical Boards (many of whom are complicit–in Massachusetts the Board of Registration in Medicine is simply an extension of the state PHP-i.e. Like-minds.

3) Demand that the criminal activity taking place within these PHPs be addressed by law enforcement.

4) Demand the Attorney General enforce the rampant Establishment Clause Violations occurring with mass 12-step coercion.

5) Identify and expose the  backgrounds of many of the individuals involved including felons and double felons who reinvented themselves as “addiction medicine” doctors. Many of these individuals are repeat offenders with a history of manipulating the system who should have never had their licenses returned.  In my opinion the ASAM/FSPHP/LMD rigged system is an example of corporate psychopathy.  While corporate level psychopathy is estimated at around 3% the numbers here appear to be much higher if one looks at the moral disengagement, unethical decision making, lack of empathy and externalization of blame evident in their personal histories.

6) Correctly identify that this system of institutional injustice is responsible for the astronomical suicide rate in physicians. This is due to the fact that doctors who need help are not getting it for fear of being ensnared by the state PHP and those already ensnared are being subject to coercion, abuse, institutional injustice, degradation, dehumanization, delegitimization and civil and human rights abuses and that this is a public health emergency that needs to be addressed.

7) reveal the scam set up between the PHPs, rogue labs, and “PHP-preferred” assessment and treatment gulags.

8) show how this is only a few public policy steps from Doctors to Pilots to Teachers to students to kids. etc. etc.

This necessitates that we get the conversation going before it is too late.

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Physician Suicide

Physician Suicide.

Physician Suicide 101:  Secrets, lies and solutions by Dr. Pamela Wible, M.D., is now featured on KevinMD.com.  Please read and comment!   We need to use this as a stepping stone to start discussing the Elephant in the room; state Physician Health Programs (PHPs) organized under the Federation of State Physician Health Programs.  These programs once served the dual purpose of helping sick doctors and protecting the public from harm.

Taken over by the “impaired physician” movement the current manifestation is one of absolute power and unrestrained managerial authority with no meaningful oversight, regulation or accountability.  It is a culture of institutional injustice that is preventing doctors from seeking help for fear of being ensnared and monitored by them.  Those being monitored by them are subject to bullying, abuse and forced 12-step indoctrination under threat of loss of licensure.  Many of these doctors do not even have an addiction or substance use disorder.   Situational factors, a “one-off” or even a false accusation can result in monitoring by these programs that encourage confidential referral for things such as being behind on medical charts.  Sham peer-review is rampant.32-640x472

Moreover, the authority bestowed on this group is both illegitimate and irrational. The mechanics and mentality of the Federation of State Physician Health Programs conforms to that of the American Society of Addiction Medicine (ASAM). Although there are some Addiction Psychiatrists involved, the vast majority are  “specialists” in “Addiction Medicine.

The ASAM is not even recognized by the American Board of Medical Specialties as a bona fide specialty. It is a Self-Designated-Medical-Specialty; an AMA term used to keep track of what any group of doctors is calling themselves.

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Dr. Gregory H. Miday (1982-2012) A Doctor who would have made this world a better place.

In fact, American Board of Addiction Medicine (ABMS) “board certification” is little more than a diploma mill.

Yet these “specialists” are now in charge of ALL things related to PHYSICIAN HEALTH.

Many of the physicians running these programs had their licenses revoked and got them back by claiming salvation through the good graces of Alcoholics Anonymous and other 12-step methodology. Many have felony convictions. Some have double felonies.

At best we have unqualified zealots. But one major problem I have heard over and over again from physicians forced into these programs is an absolute lack of justice, empathy and even civility by those in charge.

A note from Dr. Karen Miday whose son Greg died by suicide after having a Corona in Peurto Rico while on vacation:

Dr. Gregory H. Miday ( 1982-2012) My physician son died of suicide 2 years ago while being monitored by the Missouri PHP. When he called to notify them of his relapse (while vacationing in Puerto Rico) and his intent to admit himself to a local public treatment center (decision made in consultation with his psychiatrist during an office visit that morning) the PHP said they did not approve of the plan. They told him to come speak with them instead. He chose otherwise. His phone calls to the PHP were the last ones he ever made. Clearly, he did not see them as benevolent. I sincerely doubt that he is their only casualty. Yet, where are the statistics? How many others have died under their watch. Strangely, the clinical director ( an RN, and likely recovering addict) told my husband that no internal review of my son’s case was planned. Such reviews after a suicide are mandatory at every public mental health facility I have practiced at. Our best and our brightest are being subjected to substandard care without any oversight or accountability. I can’t bring my son back. I do hope, however, that others will join me in an effort to pull the curtain back on these programs and perhaps save other lives. Karen Miday, MD, Cincinnati, OH

Misconduct, fraud, and even crimes are being reported.

Perhaps the 12-step salvation is just a ruse for some of them; a convenient cloak under which to hide all manner of abuse with impunity and immunity.

These individuals have been granted unrestrained managerial prerogative and absolute power over doctors. They decide not only who to monitor but how that monitoring proceeds in every last detail. Our fates, literally, lie in the hands of this group. No more physicians should die by this system of institutional injustice, bullying and pseudoscience. The conflicts-of-interest are abhorrent and would be incomprehensible in any other venue.

Isn’t it time we take charge? And the solution is fairly simple.

Oversight, regulation, and auditing by OUTSIDE groups. That is how it’s done everywhere else. Why do these guys get a pass?  Why would anyone be against procedural fairness and transparency in any situation? These are legitimate questions.

State Medical Societies, Departments of Public Health, the American Medical Association, the American Council on Graduate Medical Education, the Institute of Medicine and other Accreditation and Professional Organizations need to start addressing this.

This is a Public Health Emergency that is not going away.  It needs to be addressed directly and with urgency; not with kid gloves and temporization.

Accountability is without exception.  It requires both the provision of information and justification for actions.   Accountability also requires consequences for actions if they breach standards-of-care, ethics and the law.

 Hopefully this article will succeed in framing certain questions for the medical profession; questions that we all need to think about now before the door closes for good.

Physician Suicide 101: Secrets, Lies & Solutions by Pamela Wible, M.D.

Physician Suicide, the “Impaired Physician Movement” and ASAM:  The Dead Doctors at Ridgeview Institute under G. Douglas Talbott, by Michael Langan, M.D.

Wanted!–a Few Statisticians, Biostatisticians and Epidemiologists who want to make a difference in Medicine, Society and our Future

 “That everyone shall exert himself in that state of life in which he is placed, to practice true humanity towards his fellow men, on that depends the future of mankind.” – Albert Schweitzer 
“By and by never comes” –St Augustine

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“A day’s impact is better than a month of dead pull”-Justice Oliver Wendell Holmes, Jr.

 I am looking for a few honest and credible statisticians, biostatisticians or epidemiologists who want to make a difference in the spirit  of service and helping others.  I can’t pay you but you would be combating injustice, corruption and dishonesty.   You would be doing your part in helping the Medical Profession, honest and decent doctors, our country and  perhaps our future.  

It is only a few public policy steps and minor changes in state regulatory statutes before what is described in the ASAM White Paper on Drug Testing comes to fruition.  Before we know it the Drug and Alcohol Testing Industries “New Paradigm” as described here by Robert Dupont will be ushered in as it did with doctors; not with a bang but a whimper.  From the ASAM white Paper:

“THIS WHITE PAPER ENCOURAGES WIDER AND “SMARTER” USE OF DRUG TESTING WITHIN THE PRACTICE OF MEDICINE AND, BEYOND THAT,BROADLY WITHIN AMERICAN SOCIETY. SMARTER DRUG TESTING MEANS INCREASED USE OF RANDOM TESTING* RATHER THAN THE MORE COMMON SCHEDULED TESTING,* AND IT MEANS TESTING NOT ONLY URINE BUT ALSO OTHER MATRICES SUCH AS BLOOD, ORAL FLUID (SALIVA), HAIR, NAILS, SWEAT AND BREATH WHEN THOSE MATRICES MATCH THE INTENDED ASSESSMENT PROCESS. IN ADDITION, SMARTER TESTING MEANS TESTING BASED UPON CLINICAL INDICATION FOR A BROAD AND ROTATING PANEL OF DRUGS RATHER THAN ONLY TESTING FOR THE TRADITIONAL FIVE-DRUG PANEL.”

To prevent this future drug testing dystopia, that includes testing schoolchildren, we need to take a step back and analyze the reliability and credibility of the “evidence-base” behind these multiple non-FDA approved forensic drug and alcohol tests and testing devices the ASAM proposes be used on the population at large utilizing the Medical Profession as a urine collection agency and bypassing forensic drug testing protocol by calling this “evaluation” and treatment rather than “monitoring” and punishment. New definitions, loopholes, secrecy and subterfuge are the bread and butter of these prohibitionist profiteers.

Amazingly, there has been no Academic review of these tests, let alone a Cochrane type critical analysis.  It is essentially untapped territory.  In addition there has been no Institute of Medicine type Conflict of Interest Analysis.  And that is why I am asking for help from statisticians, biostatisticians and epidemiologists.  The task would entail a review of the literature prior to the introduction of these tests for evidence base of forensic applicability (there essentially is none) and a review of the literature peri-and post marketing of these devices to assess the reliability and credibility of the underlying methodology and ascertain the evidence-base.  The goal would be publication in both academic journals and presentation to the general public through media publication with the assistance of investigative journalists and other writers. The goal is to get the truth out about these tests and allow both the medial profession and public at large to awaken to the menace this presents to medicine, our society and our future.

 Lack of Evidence-Base, Bias and Conflicts of Interest:  Making the Data Fit the Hypothesis

I am no epidemiologist or statistician but as with pornography I know junk-science when I see it.  Almost all of these tests were introduced with little or no evidence-base and, as with most of their endeavors, they did it below board via loopholes and cutting corners.

The overwhelming majority of papers are small, methodologically flawed, non-randomized, non-blinded  retrospective studies in that appear to make the data fit the hypothesis.   The authors can invariably be linked to those profiting from the tests of the testing process ( the patent holder, doctors associated with the drug testing labs, ASAM or FSPHP, Robert Dupont, Greg Skipper, etc.)

 

Ethyl Glucuronide (EtG) was introduced in 1999 as a biomarker for alcohol consumption,1 and was subsequently suggested as a tool to monitor health professionals by Dr. Gregory Skipper because of its high sensitivity to ethanol ingestion.2   

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Described as the  “innovator of EtG as an alcohol biomarker,” Skipper and  Friedrich Wurst,  “convinced” NMS labs in Pennsylvania “to start performing EtG testing in 2002.

The study most often cited as 100% proof that there is 100% accuracy in EtG testing proving alcohol consumption involved a mere 35 forensic psychiatric inpatients in Germany that was published in 2003.3  

Shortly thereafter the Physician Health Programs began using it in monitoring doctors and other professional monitoring programs soon followed.

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Screen Shot 2014-11-29 at 5.16.18 PMLaboratory Developed Tests -A Loophole to Avoid FDA Approval and Accountability

Up until the birth of the EtG tests used for forensic drug and alcohol monitoring had to go through the arduous, expensive and necessary FDA approval process.   The LDT pathway was designed to develop simple tests with little risk that have  low market potential (i;e. the cost of the normal FDA approval process would prohibit them from coming to market).  The LDT pathway was designed to improve patient care and help improve diagnosis and treatment. It was not designed for forensic tests.  LDT approval does not require in vivo testing.  It is essentially an honor system and to develop an LDT it is not even necessary to prove that the test is actually testing what it is purportedly testing for (validity).

So with little to no evidence base they introduced the EtG, had it developed and marketed as a LDT in collusion with unscrupulous labs, and then began using it on physicians being monitored by State PHPs. This then spread to other monitoring organizations in which there was a large power-differential between those ordering the tests and those being tested (criminal-justice, other professional monitoring programs).  These biomarkers have never been used in Federal Drug Testing, SAMHSA approved, DOT, and other organizations where unions or other organizations are present and looking out for the best interests of those being tested.

Another example of how this group removes accountability.  There has been essentially no oversight or regulation of LDTs.  Although there was a recent push for regulation of these tests the Drug and Alcohol Testing Industry Association lobby made sure that forensic tests would be exempt.

They then began publishing “research” on the EtG using the physicians being monitored as subjects. Many of the studies promoting the EtG and other biomarkers can be found  in  Journals that are linked to organizations that are linked to AA and were organized to educate the medical community.

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These small, methodologically flawed studies amount to little more than opinion pieces but   This “evidence-base” is predominantly in biased journals published by biased medical “societies.  
The EtG was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash4,5, hand sanitizer gel6, nonalcoholic beer7, and nonalcoholic wine.8  Sauerkraut and bananas have even been shown to cause positive EtG levels.9
The United States Substance Abuse and Mental Health Services Administration warned against using a positive EtG as primary or sole evidence of drinking for disciplinary or legal action.10  The Wall Street Journal in 2006 reported the problems with the EtG to the general public.11   
Screen Shot 2014-03-23 at 10.45.36 PMAs any rational authority would do, the majority of monitoring agencies abandoned the EtG after these flaws were revealed. The PHPs did not.  They continued to use the EtG on doctors uninterruptedly by telling them to avoid any products that could potentially contain alcohol; a ubiquitous substance in the environment. Since that time they have justified and rationalized (EtG)2,12 13  use by sequentially raising cutoff levels from 100 to 250 to 500 to 1000 to 2000 to now unknown and adding other LDTs as “confirmation tests such as Ethyl Sulfate (EtS)14,15 Phosphatidyl-Ethanol ( Peth)16 17 and other devices such as the Subcutaneous Remote Alcohol Monitoring Bracelet (SCRAM) and, their newest device the Cellular Photo Digital Breathalyzer (CPDB) that has recently been launched, just like the EtG Screen Shot 2014-02-23 at 10.00.22 PMwith little to no evidence base other than a pilot study done by Greg Skipper and Robert Dupont.18 
A  2013 article published in an ASAM incubated journal Alcoholism: Clinical and Experimental Research promotes the Phosphatidyl-ethanol (PEth ) test to confirm drinking.16  The study was done on physicians being monitored by the Alabama Physician Health Program who tested positive for EtG/EtS alcohol biomarkers. It is co-authored by Robert Dupont, Greg Skipper, and Friedrich Wurst and involved 18 subjects who tested positive for EtG/EtS of whom 7 claimed they did not drink.  After finding that 5 of the 7 tested negative for PEth they concluded that “positive PEth testing following positive EtG/EtS results confirms recent drinking.  Hard to wrap your head around the science in that one.Screen Shot 2014-04-30 at 1.06.53 PMSkipper is also using both Scram ankle bracelets and the CPDB monitoring in pilots in the Human Interventional Motivational Study (HIMS) Program that was developed in 2009 to “identify, treat and, eventually, re-certify airline pilots with substance abuse problems. 
 
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The Cochrane Collaboration does systematic reviews of the literature using conscientious, explicit, and judicious criteria to in order to produce and disseminate only high quality and evidenced based health care, exclude bias, and enhance transparency. The Cochrane database is a current and evolving database that includes the accuracy of diagnostic tests and is internationally recognized as the standard in evidence based health care.  This benchmark for evidence based health care and systematic reviews, records just 5 controlled trials under the topic ethyl glucuronide.8,19-21 These 5 studies represent the only high-quality evidence regarding EtG applying to EtG. Information provided by the five studies suggests the following, and only the following:

  1. EtG and EtS measurements increase with alcohol ingestion.
  2. The window of detection is shorter than what is commonly proposed (80 hours).
  3. Individual values are variable both within and between subjects.
  4. Non alcoholic wine can cause positive levels.

Notably, there are no studies that fit Cochrane Criteria, other than non-alcoholic wine, that look at the pharmacokinetics of EtG or EtS in terms of dose-response curves, cut-off levels, specificity drug and food interactions, or modes of ingestion.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Phosphatidylethanol (PEth), SCRAM, and the  yields no data as a test in the Cochrane library.

SAMHSA notes that there is little research on PEth and that EtG, EtS, and PEth “do not have a strong research base,” and that “it is not known at this time how the test results might be affected by the presence of physical diseases, ethnicity, gender, time, or the use of other drugs. Until considerable more research has occurred, use of these markers should be considered experimental.”

Evidence based medicine (EBM) can be defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.22

Medical progress and scientific advancement is occurring so fast that the volume of medical literature is expanding at a rate of greater than 7% per year.23

Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.22  

Expert opinion is the lowest level of evidence available in the EBM paradigm.24,25

Fortunately, the scientific method is a tool to help people progress toward the truth despite their susceptibilities to confirmation bias and other errors.26

Unfortunately, due to a confluence of factors (including political) this has not been done.  But, unless we want a  future as envisioned by Robert Dupont and explained in the the ASAM White Paper on Drug Testing we need to act now.  This is not a “New Paradigm” but a “New Inquisition.”

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  1. Wurst FM, Kempter C, Seidl S, Alt A. Ethyl glucuronide–a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcohol. Jan-Feb 1999;34(1):71-77.
  2. Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol Alcohol. Sep-Oct 2004;39(5):445-449.
  3. Wurst FM, Vogel R, Jachau K, et al. Ethyl glucuronide discloses recent covert alcohol use not detected by standard testing in forensic psychiatric inpatients. Alcohol Clin Exp Res. Mar 2003;27(3):471-476.
  4. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. J Anal Toxicol. Nov-Dec 2006;30(9):659-662.
  5. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. J Anal Toxicol. Jun 2011;35(5):264-268.
  6. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. J Anal Toxicol. Oct 2008;32(8):594-600.
  7. Thierauf A, Gnann H, Wohlfarth A, et al. Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of “non-alcoholic” beer. Forensic Sci Int. Oct 10 2010;202(1-3):82-85.
  8. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  9. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  10. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  11. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  12. Wurst FM, Skipper GE, Weinmann W. Ethyl glucuronide–the direct ethanol metabolite on the threshold from science to routine use. Addiction. Dec 2003;98 Suppl 2:51-61.
  13. Wurst FM, Alling C, Aradottir S, et al. Emerging biomarkers: new directions and clinical applications. Alcoholism, clinical and experimental research. Mar 2005;29(3):465-473.
  14. Anton RF. Commentary on: ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials. Alcoholism, clinical and experimental research. Jul 2014;38(7):1826-1828.
  15. Hernandez Redondo A, Schroeck A, Kneubuehl B, Weinmann W. Determination of ethyl glucuronide and ethyl sulfate from dried blood spots. International journal of legal medicine. Jul 2013;127(4):769-775.
  16. Skipper GE, Thon N, Dupont RL, Baxter L, Wurst FM. Phosphatidylethanol: the potential role in further evaluating low positive urinary ethyl glucuronide and ethyl sulfate results. Alcoholism, clinical and experimental research. Sep 2013;37(9):1582-1586.
  17. Hahn JA, Dobkin LM, Mayanja B, et al. Phosphatidylethanol (PEth) as a biomarker of alcohol consumption in HIV-positive patients in sub-Saharan Africa. Alcoholism, clinical and experimental research. May 2012;36(5):854-862.
  18. Skipper GE, Thon N, DuPont RL, Campbell MD, Weinmann W, Wurst FM. Cellular photo digital breathalyzer for monitoring alcohol use: a pilot study. European addiction research. 2014;20(3):137-142.
  19. Hoiseth G, Bernard JP, Stephanson N, et al. Comparison between the urinary alcohol markers EtG, EtS, and GTOL/5-HIAA in a controlled drinking experiment. Alcohol Alcohol. Mar-Apr 2008;43(2):187-191.
  20. Wojcik MH, Hawthorne JS. Sensitivity of commercial ethyl glucuronide (ETG) testing in screening for alcohol abstinence. Alcohol Alcohol. Jul-Aug 2007;42(4):317-320.
  21. Sarkola T, Dahl H, Eriksson CJ, Helander A. Urinary ethyl glucuronide and 5-hydroxytryptophol levels during repeated ethanol ingestion in healthy human subjects. Alcohol Alcohol. Jul-Aug 2003;38(4):347-351.
  22. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. Jan 13 1996;312(7023):71-72.
  23. Norwitz ER, Greenberg JA. Promoting evidence-based medicine. Rev Obstet Gynecol. Summer 2008;1(3):93-94.
  24. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. Feb 25 2009;301(8):868-869.
  25. Straus SE, Green ML, Bell DS, et al. Evaluating the teaching of evidence based medicine: conceptual framework. BMJ. Oct 30 2004;329(7473):1029-1032.
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Disrupted Physician 101.4–The “Impaired Physician Movement” takeover of State Physician Health Programs

Forget what you see
Some things they just change invisibly–Elliott Smith

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Physician Impairment

The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence, published by the American Medical Association’s (AMA) Council on Mental Health in The Journal of the American Medical Association in 1973,1 recommended that physicians do a better job of helping colleagues impaired by mental illness, alcoholism or drug dependence. The AMA defined an “impaired physician” as “a physician who is unable to practice medicine with reasonable skill and safety to patients because of mental illness or excessive use or abuse of drugs, including alcohol.”

Recognition of physician impairment in the 1970s by both the medical community and the general public led to the development of “impaired physician” programs with the purpose of both helping impaired doctors and protecting the public from them.

IMG_1010The 1975 media coverage of the deaths of Drs. Stewart and Cyril Marcus brought the problem of impaired physicians into the public eye. IMG_0940Leading experts in the field of Infertility Medicine, the twin gynecologists were found dead in their Upper East Side apartment from drug withdrawal that New York Hospital was aware of but did nothing about. Performing surgery with trembling hands and barely able to stand, an investigation revealed that nothing had been done to help the Marcus brothers with their addiction or protect patients. They were 45 –years old.

Top: Twin Gynecologists Stewart and Cyril Marcus Bottom: The Movie

Top: Twin Gynecologists Stewart and Cyril Marcus
Bottom: The Movie “Dead Ringers” starring Jeremy Irons based on the Marcus twins

Although the New York State Medical Society had set up its own voluntary program for impaired physicians three years earlier, the Marcus case prompted the state legislature to pass a law that doctors had to report any colleague suspected of misconduct to the state medical board and those who didn’t would face misconduct charges themselves.


Physician Health Programs

Physician health programs (PHPs)  existed in almost every state by 1980. Often staffed by volunteer physicians and funded by State Medical Societies, these programs served the dual purpose of helping sick colleagues and protecting the public. Preferring rehabilitation to probation or license revocation so long as the public was protected from imminent danger, most medical boards accepted the concept with support and referral.

As an alternative to discipline the introduction of PHPs created a perception of medical boards as “enforcers” whose job was to sanction and discipline whereas PHPs were perceived as “rehabilitators” whose job was to help sick physicians recover. One of many false dichotomies this group uses and it is perhaps this perceived benevolence that created an absence of the need to guard.


Employee Assistance Programs for Doctors

Physician Health Programs (PHPs) are the equivalent of Employee Assistance Programs (EAPs) for other occupations. PHPs meet with, assess, and monitor doctors who have been referred to them for substance use or other mental or behavioral health problems.

Most EAPs, however, were developed with the collaboration of workers unions or some other group supporting the rights and best interests of the employees. PHPs were created and evolved without any oversight or regulation.

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The American Society of Addiction Medicine can trace its roots to the 1954 founding of theNew York City Medical Society on Alcoholism (NYCMSA) by Ruth Fox, M.D whose husband died from alcoholism.

The society, numbering about 100 members, established itself as a national organization in1967, the American Medical Society on Alcoholism (AMSA).

By 1970 membership was nearly 500.

In 1973 AMSA became a component of the National Council on Alcoholism (NCA) in a medical advisory capacity until 1983.

But by the mid 1980’s ASAM’s membership became so large that they no longer needed to remain under the NCADD umbrella.

In 1985 ASAM’s first certification exam was announced. According to Dr. Bean-Bayog, chair of the Credentialing Committee, “a lot of people in the alcoholism field have long wanted physicians in the field to have a high level of skills and scientific credibility and for this body of knowledge to be accredited.”2 And in 1986 662 physicians took the first ASAM Certification Exam.

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By 1988 membership was over 2,800 with 1,275 of these physicians “certified” as “having demonstrated knowledge and expertise in alcoholism and other drug dependencies commensurate with the standards set forth by the society.”3 “The formation of State Chapters began with California, Florida, Georgia, and Maryland submitting requests.4

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In 1988 the AMA House of Delegates voted to admit ASAM to the House. According to ASAM News this “legitimizes the society within the halls of organized medicine.”2

By 1993 ASAM had a membership of 3,500 with a total of 2,619IMG_8919certifications in Addiction Medicine. The Membership Campaign Task Force sets a goal to double its membership of 3,500 to 7,000 by the year 2000 to assure “the future of treatment for patients with chemicals. It represents a blueprint for establishing addiction medicine as a viable entity.”5

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Many of these physicians joined state PHPs and over time have taken over under the umbrella of the FSPHP.

Others became medical directors of treatment centers such as Hazelden, Marworth and Talbott.


  1. The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA : the journal of the American Medical Association. Feb 5 1973;223(6):684-687.
  2. Four Decades of ASAM. ASAM News. March-April 1994, 1994.
  3. . American Medical Society on Alcoholism & Other Drug Dependencies Newsletter. Vol III. New York, NY: AMSAODD; 1988:12.
  4. . AMSAODD News. Vol III. New York, NY: American Medical Society on Alcoholism & Other Drug Dependencies; 1988.
  5. Membership Campaign Update. ASAM News. Vol VIII: American Society of Addiction Medicine; 1993:11.

Inquisition_10_Pushing_Off_Bridge

johnnyLawrence

The Medical Profession, Moral Entrepreneurship, Moral Panics, and Social Control

The Medical Profession, Moral Entrepreneurship, Moral Panics, and Social Control.

 “Few, no matter how desperate, seek help of their own accord.”  says Dr. Marv Seppala, M.D., Chief Medical Officer at Hazelden, one of the “PHP-approved” drug and alcohol assessment and treatment centers located in Center City, Minnesota.  “Physicians are intelligent and skilled at hiding their addictions.”

“They’re often described as the best workers in the hospital,” he says. “They’ll overwork to compensate for other ways in which they may be falling short, and to protect their supply. They’ll sign up for extra call and show up for rounds they don’t have to do.”

In reality this is ludicrous–knee slapping absurd.   If the results of this authoritative opinion were not so dire these statements would, in fact, be comical.   Such is not the case, however, and opinions like Seppala’s have been taken at face value and, as a result, the aftermath has been and continues to be tragedy.IMG_0706

Addiction, alcoholism and substance abuse to any significant degree produce both physiological and behavioral manifestations in the user. It is cause and effect.  Pathophysiology conforms to law of nature and not the whims of the impaired physician movement.

What anomalous  aspect of intelligence or special skill set would enable a doctor to hide an addiction?

The ASAM definition of addiction is characterized by cognitive, behavioral and emotional changes which include “impaired control” so how would intelligence rein it in?  Furthermore, what unique logical, rational, analytical, factual, abstract, intuitive or objective aspect of intelligence is responsible for this preternatural fortitude?

How is the intelligence of a doctor any different from the intelligence of any other human being?  And what prodigious abilities do doctors have that enable them them to cloak the  behavioral manifestations and stave off the physical consequences chemical addiction to such a degree that they are able to maintain the facade of being  “described as the best workers in the hospital?”  Is it an innate inborn endowment or an esoteric knack acquired during medical training?

IMG_0728What ability and artistry would allow a profession to weave such a web of fortitude that they can convincingly shroud the myriad signs and symptoms of drug and alcohol abuse unlike the regular folk?    Perhaps access to ophthalmic vasoconstrictors and beta blockers to temper the pupillary dilation and tremulousness associated with stimulants or botox and a testosterone patch to mask the skin changes and maintain lean muscle mass in the throes of alcoholism?

How does overworking “protect their supply” and why would they keep it at the hospital?  These people have prescription pads and last I checked there were no cocktails shakers or bottles of Jameson in the doctors lounge.

And for the life of me I cannot comprehend why an alcoholic or addict doctor would sign up for extra call and show up for rounds on his day off.  What would be the point?

In reality a doctor with a drug or alcohol problem would be erratic with call and show up late for rounds.

This is just another example of authoritative opinion with no substantive value. It is moral entrepreneurship at its finest; the fallacy of appeal to authority and secret knowledge.

If Seppala were asked to provide the evidence-base and rationality of these statements he would be hard pressed to do so.  The question would be met with deflection, logical fallacy, references to the opinions of like minds and thought-stopping memes.  “You need a check-up from the neck up,”  your best thinking got you here,”  there is no “I” in “team,” “denial isn’t just a river in Egypt.”  Oh, yeah?   well “Rogue” isn’t just a river in Oregon and, while we are at it, “Boring” isn’t just a town!

It is this type of misinformation and propaganda that allows the “impaired physician movement” to  drag away the “best worker in the hospital” and deem him “in denial.”

“We were so surprised. We didn’t even know he had a problem”  say the nurses, patients and colleagues left behind.

Well the truth is he probably didn’t!

ByQiW11IYAI2Cit

Blind-faith and unquestioning allegiance to expert authority deflects scrutiny and analysis.  Few red flags are raised as this type of moral preening promotes misguided plausibility and complacency in the belief that these are indeed experts with good intentions. This needs to be addressed.

But if you look at any of the current “moral panics” that are being used to suggest random suspicion-less drug testing of doctors or promoting the Physician Health Programs as successful and replicable models, you will inevitably find a doctor on this list behind it. It is a given.

And the invitation goes out to Seppala to debate this in a public forum on a level playing field.    Not gonna happen because it would be impossible for him to address and answer the questions rationally,  directly and with any tiny scrap of evidence based data.

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Disrupted Physician 101.3 –“For What it’s Worth”— The ASAM/ABAM Diploma Mill

ABAM Diploma Mill

Proof of Expertise or License to kill!

Disrupted Physician 101.3 –“For What it’s Worth”— The ASAM/ABAM Diploma Mill.

I can think of no other specialty or subspecialty in the profession of medicine where non-existent expertise can be incontestably announced and implemented.  If I claimed to be an ace neurosurgeon or an expert otolaryngologist and started practicing my claimed skills in the hospital I would be called on it pretty quick by both colleagues and patients–deemed a delusional fraud and run out on a rail within a week.

Yet doctors who have not met the usual and customary standards of  professional and educational quality and core competencies collectively and summarily identified  for medical specialties and subspecialties by the American Board of Medical Specialties, American Council on Graduate Medical Education and Institute of Medicine are able to claim “expertise”  in “addiction medicine” and everybody just lets them.

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As an experiment to prove this hypothesis I sat for the 2010 American Board of Addiction Medicine (ABAM) Certification Exam.

I have absolutely no training or education in the field of addiction medicine.  I didn’t pick up a book or study anything. I did not prepare at all.   I went to the testing facility and finished the test within an hour and a half and below is my score.  I passed it by a large margin with a score of 459 (passing score is > 394).  

 

Aced it!

Aced it!

I am no expert in Addiction Medicine; Point being neither is 4000 of me.

The validity and reliability of opinions lie in their underlying methodology and evidence base. Reliance on the personal authority of any expert or group of experts is the fallacy of appeal to authority.

I have asthma but that does not make me a Pulmonologist.  That addiction “specialist” diagnosing and treating you may have 5 years prior been a proctologist; and maybe not even a very good one at that.

Somewhere there may be doctor with no post-graduate training in surgery wielding a scalpel and calling himself an expert surgeon, but it is difficult to imagine that he is a very good one.

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Dr. Allwissend 01

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Disrupted Physician 101.2: “Addiction Medicine” is a Self-Designated Practice Specialty Unrecognized by the American Board of Medical Specialties–(An AMA Census Term Indicating Neither Training nor Competence)

“Spirituality can go hand-in-hand with ruthless single-mindedness when the individual is convinced his cause is just”

Michela Wrong, In the Footsteps of Mr. Kurtz: Living on the Brink of Disaster in Mobutu’s Congo

Addiction Medicine: The Birth of a New Discipline

Addiction Medicine is currently not recognized by the American Board of Medical Specialties (ABMS).  It is still a a Self-Designated Practice Specialty and the American Board of Addiction Medicine is a Self-Designated Board.  So too is the American Academy of Ringside Medicine and Surgery, the American Academy of Bloodless Medicine and Surgery and the Council of Non-Board Certified Physicians.  But these Self-Designated Boards do not have the multi-billion dollar drug and alcohol testing and treatment industry supporting them. Addiction Medicine has deep pockets, and if the November 2014 issue of the Journal of the American Medical Association (JAMA) is a harbinger of what’s to come, this self-designated practice specialty currently being certified by a self-designated Board and bereft of anything resembling the educational and professional standards for quality practice in a particular medical specialty or subspecialty as defined by the ABMS, the American Council on Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) may soon robber baron its way into acceptance by the Medical Profession.

One thing is for certain.  When society gives power of diagnosis and treatment to individuals within a group schooled in just one uncompromising model of addiction with the majority attributing their very own sobriety to that model, they will exercise that power to diagnose and treat anyone and everyone according to that model.  The birth of Addiction Medicine as an ABMS accepted discipline is sure to be a success for the drug and alcohol testing and 12-step treatment industry, but its spawn is sure to be an inauspicious mark on the Profession and Guild of Medicine and a bane of society for years to come.

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via Disrupted Physician 101.2: “Addiction Medicine” is a Self-Designated Practice Specialty Unrecognized by the American Board of Medical Specialties–(An AMA Census Term Indicating Neither Training nor Competence).

 

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Reliability of hair drug tests up for debate

“The hardest thing to explain is the glaringly evident which everybody has decided not to see”

― Ayn Rand, The Fountainhead

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The Birth of Junk-Science in Drug and Alcohol Testing

The attached article concerns the reliability of hair-strand tests routinely accepted in child welfare cases in Ontario   as evidence of parental drug or alcohol abuse.  A positive test can lead to loss of parental custody of children.

The risk for false-positive results appears to be higher in women because of the higher use of alcohol-based hair products and the limitations of these tests are addressed in the article.

Almost 98% of ingested alcohol is eliminated through the liver in an oxidation process that involves its conversion to acetaldehyde and acetic acid, but the remaining 2% is eliminated through the urine, sweat, or breath.1

Ethyl Glucuronide (EtG) was introduced in 1999 as a biomarker for alcohol consumption,2 and was subsequently suggested as a tool to monitor health professionals by Dr. Gregory Skipper, M.D.,  because of its high sensitivity to ethanol ingestion.3

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This minor metabolite of alcohol was reported by  Skipper, M.D. and Friedrich Wurst, M.D., in November 2002 at an international meeting of the American Medical Society, to provide proof of alcohol consumption as much as 5 days after drinking an alcoholic beverage, well after the alcohol itself had been eliminated from the body.

In his study Dr. Skipper arbitrarily chose a value of 100 as a cut-off for EtG. The rationale behind this value is not cited.

In 2003, because of these and other reportedly remarkable results (e.g., positive findings, confirmed by admissions by the tested individuals, after traditional urine tests had registered negative), Skipper pitched the test to National Medical Services, Inc. (NMS labs) and it was developed as a Laboratory Developed Test (LDT).

So began EtG testing began in the United States, and this paved the way for the hair tests described. The urine EtG test introduced by Skipper is the index case and prototype for an array of unproven forensic tests introduced to the market as LDTs.

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The LDT Pathway was not designed for Forensic Drug and Alcohol Testing.  It is an Unregulated Industry.

The LDT pathway was developed for laboratory tests that would not otherwise come to market due to the prohibitive costs of FDA approval (for example a test for a rare disease).

Bringing an LDT to market does not require testing in humans (in vivo). Nor does it require that it be shown the test is testing for what it is purportedly testing for (validity). It is essentially an honor system. It was not designed for “forensic” testing but for simple testing with low risk.

None of this testing is approved by the FDA. It is essentially an unregulated industry.

NMS became a leading proponent of EtG testing and, starting in 2003, began publishing claims promoting the absolute validity and reliability of the EtG in detecting alcohol. Akin to the vitamin and supplement industry those promoting and selling the tests could say anything they want—and they did.

NMS initially established a reporting limit or cutoff of 250ng/ml at or over which EtG test results would be reported as “positive” for drinking alcohol. This was later upped to 500ng/ml, then 1000 ng/ml.

NMS reported it as the “Gold Standard” claiming any value above 250 ng/ml indicated “ethanol consumption.”

It was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash4,5, hand sanitizer gel6, nonalcoholic beer7, and nonalcoholic wine.8

As the cutoff value got higher they added another minor metabolite of alcohol, EtS, as a “confirmatory” LDT.

The authors of a 2011 study demonstrating that hand sanitizer alone could result in EtG and EtS concentrations of 1998 and 94 mug/g creatinine concluded that:

“in patients being monitored for ethanol use by urinary EtG concentrations, currently accepted EtG cutoffs do not distinguish between ethanol consumption and incidental exposures, particularly when uine specimens are obtained shortly after sustained use of ethanol containing hand sanitizer.”9

Sauerkraut and bananas have even recently been shown to cause positive EtG levels.10

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A 2010 study found that consumption of baker’s yeast with sugar and water11 led to the formation of elevated EtG and EtS above the standard cutoff. EtG can originate from post-collection synthesis if bacteria is present in the urine.12 Collection and handling routines can result in false-positive samples.13

EtG varies among individuals.14 Factors that may underlie this variability include gender, age, ethnic group, and genetic polymorphisms.

“Exposure to ethanol-containing medications, of which there are many, is another potential source of “false” positives.15

Problems Exposed by Wall Street Journal and SAMHSA

On August 12, 2006, The Wall Street Journal published a front-page article, titled “A Test for Alcohol – And Its Flaws.”.16

Quoting Dr. Skipper, among others, the article includes:

“Little advertised, though, is that EtG can detect alcohol even in people who didn’t drink. Any trace of alcohol may register, even that ingested or inhaled through food, medicine, personal-care products or hand sanitizer.”

“The test ‘can’t distinguish between beer and Purell’ hand sanitizer, says H. Westley Clark, director of the Federal Substance Abuse and Mental Health Services Administration. . . ‘When you’re looking at loss of job, loss of child, loss of privileges, you want to make sure the test is right”, he says…”

“Use of this screen has gotten ahead of the science,’ says Gregory Skipper…”

Methinks Dr. Skipper might have realized this when he initially proposed it as an accurate test after a pilot study done on only a handful of subjects. Or perhaps when he used the LDT pathway to bypass FDA approval and oversight.

On September 28, 2006, SAMHSA, a federal agency that is part of the U.S. Department of Health and Human Resources, issued an Advisory, which on the first page contained a “grey box” warning, as follows:

Unknown-20“Currently, the use of an EtG test in determining abstinence lacks sufficient proven specificity for use as primary or sole evidence that an individual prohibited from drinking, in a criminal justice or a regulatory compliance context, has truly been drinking. Legal or disciplinary action based solely on a positive EtG, or other test discussed in this Advisory is inappropriate and scientifically unsupportable at this time. These tests should currently be considered as potential valuable clinical tools, but their use in forensic settings is premature.”17

Bias has been identified as a large problem with drug trials.18   Industry-sponsored research is nearly four times as likely to be favorable to the company’s product as NIH-sponsored research.19 As an example, one survey of seventy articles about the safety of Norvasc (amlodipine) found that 96% of the authors who were supportive of the drugs had financial ties to the companies that made them.20

But what about the multi billion dollar drug-testing industry and the financial ties here?Screen Shot 2014-02-23 at 7.52.29 PM

Imagine if this was a drug and not a drug-test.

Essentially Greg Skipper and the FSPHP arm of ASAM launched a very lucrative joint business venture with a commercial drug-testing lab. They introduced the test via a loophole as a laboratory developed test.  An LDT has no FDA regulation so the lab was able to promote, market and sell these tests with no meaningful oversight or accountability.  Quest Diagnostics and USDTL are now working with the FSPHP and engaging in the same scheme.

The lab then contracted with state licensing boards and their state PHPs (who designed, implemented and managed drug and alcohol testing programs for nurses and doctors).   A mutually beneficial scheme for the labs (who collect the samples) and the PHPs (who utilize, interpret and report the results.

The PHPs develop the arbitrary cutoff levels based on alleged “scientific” research and the labs promote whatever they say. “Gold-Standard,” “accurate” and “reliable.”  Screen Shot 2014-02-23 at 3.12.12 PM

EtG, EtS, Scram, PEth, Soberlink–all unsupported junk science introduced by prohibitionist profiteers without conscience.

How many lives were ruined by this test?   How many careers were lost, families shattered and futures erased. I would venture to say a lot. Just look through all of the legal cases as I have. It is unconscionable. Sociopathic profiteering.

How many committed suicide feeling helpless, hopeless and entrapped?

At the end of a talk entitled  Addicted Professionals: intervention, Evaluation and Treatment, Skipper presents a slide reading “Reporting or Assisting a Troubled Peer?  These doctor’s can’t help themselves….” followed by graphic images of physician suicide.   (see torrance_meeting_2 (4) ).    It is for shock value and morbid humor and it is grotesque.   He could not care less that these were human beings with wives, husbands, children and hopes and dreams.

How many scenes like this were repeated across the country because this guy gamed the system to get an ultra-sensitive test with abysmal specificity for a ubiquitous organic compound approved and marketed as a “forensic” test?

Forensic testing needs to be as close to 100% specific as possible because the results of a positive test can be grave and far reaching.   Getting this test (and all the others) approved and marketed through a loophole and then getting the state Boards and Federation of State Medical Boards to approve them by moral entrepreneurship is unconscionable.    Using the LDT pathway is just another example of how the “impaired physician movement” removes accountability and culpability by bending, ignoring or otherwise making their own rules.

And the labs have taken a “stand your ground” approach. Never admit wrongdoing. Never settle.Screen Shot 2014-02-23 at 10.00.22 PM

In a February 2007 article in the magazine “New Scientist,” Dr. Skipper is quoted

that:

“…there is not yet an agreed threshold concentration that can be used to separate people who have been drinking from those exposed to alcohol from other sources. Below 1000 nanograms of EtG per millilitre of urine is probably ‘innocent’, and above 5000 booze is almost certainly to blame. In between there is a “question zone…”Unknown-12

No Dr. Skipper—it is you who is most certainly to blame. And what of all the people whose lives you ruined by introducing junk science with no evidence base via a regulatory loophole?? “probably innocent?”   Shame on you Dr. Skipper…. Shame..shame..shame.Screen Shot 2014-02-23 at 10.00.10 PM

 

  1. Bean P. State of the art contemporary biomarkers of alcohol consumption. MLO Med Lab Obs. Nov 2005;37(11):10-12, 14, 16-17; quiz 18-19.
  2. Wurst FM, Kempter C, Seidl S, Alt A. Ethyl glucuronide–a marker of alcohol consumption and a relapse marker with clinical and forensic implications. Alcohol Alcohol. Jan-Feb 1999;34(1):71-77.
  3. Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol Alcohol. Sep-Oct 2004;39(5):445-449.
  4. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. J Anal Toxicol. Nov-Dec 2006;30(9):659-662.
  5. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. J Anal Toxicol. Jun 2011;35(5):264-268.
  6. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. J Anal Toxicol. Oct 2008;32(8):594-600.
  7. Thierauf A, Gnann H, Wohlfarth A, et al. Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of “non-alcoholic” beer. Forensic Sci Int. Oct 10 2010;202(1-3):82-85.
  8. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  9. Reisfield GM, Goldberger BA, Crews BO, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer. J Anal Toxicol. Mar 2011;35(2):85-91.
  10. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  11. Thierauf A, Wohlfarth A, Auwarter V, Perdekamp MG, Wurst FM, Weinmann W. Urine tested positive for ethyl glucuronide and ethyl sulfate after the consumption of yeast and sugar. Forensic Sci Int. Oct 10 2010;202(1-3):e45-47.
  12. Helander A, Olsson I, Dahl H. Postcollection synthesis of ethyl glucuronide by bacteria in urine may cause false identification of alcohol consumption. Clin Chem. Oct 2007;53(10):1855-1857.
  13. Helander A, Hagelberg CA, Beck O, Petrini B. Unreliable alcohol testing in a shipping safety programme. Forensic Sci Int. Aug 10 2009;189(1-3):e45-47.
  14. Sarkola T, Dahl H, Eriksson CJ, Helander A. Urinary ethyl glucuronide and 5-hydroxytryptophol levels during repeated ethanol ingestion in healthy human subjects. Alcohol Alcohol. Jul-Aug 2003;38(4):347-351.
  15. Jatlow P, O’Malley SS. Clinical (nonforensic) application of ethyl glucuronide measurement: are we ready? Alcohol Clin Exp Res. Jun 2010;34(6):968-975.
  16. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  17. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  18. Bodenheimer T. Uneasy alliance–clinical investigators and the pharmaceutical industry. N Engl J Med. May 18 2000;342(20):1539-1544.
  19. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research: a systematic review. JAMA. Jan 22-29 2003;289(4):454-465.
  20. Stelfox HT, Chua G, O’Rourke K, Detsky AS. Conflict of interest in the debate over calcium-channel antagonists. N Engl J Med. Jan 8 1998;338(2):101-106.

 

 

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