Carl Sagan’s Baloney Detection Kit and the Birth of “Addiction Medicine” as a New Discipline: The Need for an in Utero Diagnostic Assessment Prior to Delivery

3b67f56268909f1dfa2a168a352ad09a“One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.”

― Carl Sagan, The Demon-Haunted World: Science as a Candle in the Dark


Carl Sagan devised a toolkit for nonsense-busting and critical thinking, which includes these nine rules:

  1. Wherever possible there must be independent confirmation of the “facts.”
  2. Encourage substantive debate on the evidence by knowledgeable proponents of all points of view.
  3. Arguments from authority carry little weight — “authorities” have made mistakes in the past. They will do so again in the future. Perhaps a better way to say it is that in science there are no authorities; at most, there are experts.2Q==
  4. Spin more than one hypothesis. If there’s something to be explained, think of all the different ways in which it could be explained. Then think of tests by which you might systematically disprove each of the alternatives. What survives, the hypothesis that resists disproof in this Darwinian selection among “multiple working hypotheses,” has a much better chance of being the right answer than if you had simply run with the first idea that caught your fancy.
  5. Try not to get overly attached to a hypothesis just because it’s yours. It’s only a way station in the pursuit of knowledge. Ask yourself why you like the idea. Compare it fairly with the alternatives. See if you can find reasons for rejecting it. If you don’t, others will.

  6. Quantify. If whatever it is you’re explaining has some measure, some numerical quantity attached to it, you’ll be much better able to discriminate among competing hypotheses. What is vague and qualitative is open to many explanations. Of course there are truths to be sought in the many qualitative issues we are obliged to confront, but finding them is more challenging.
  7. If there’s a chain of argument, every link in the chain must work (including the premise) — not just most of them.carli
  8. Occam’s Razor. This convenient rule-of-thumb urges us when faced with two hypotheses that explain the data equally well to choose the simpler.
  9. Always ask whether the hypothesis can be, at least in principle, falsified. Propositions that are untestable, unfalsifiable are not worth much. Consider the grand idea that our Universe and everything in it is just an elementary particle — an electron, say — in a much bigger Cosmos. But if we can never acquire information from outside our Universe, is not the idea incapable of disproof? You must be able to check assertions out. Inveterate skeptics must be given the chance to follow your reasoning, to duplicate your experiments and see if they get the same result.

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A November 2014 Viewpoint article in the Journal of the American Medical Association entitled Addiction Medicine: Birth of a new Discipline describes the need for “integration of addiction specialty physicians throughout the health care system” and how they plan to accomplish this. Citing the 2012 “National Survey on Drug Use and Health” findings that only 11% of Americans in need of treatment recevied it, the authors conclude that the number of addiction psychiatry diplomates (1139) is not meeting the country’s “overwhelming need for addiction specialists. To close this “addiction treatment gap” they propose “greatly expanding addiction physician specialists to include physicians from internal medicine and other specialties.”

Lax Standards

The American Society of Addiction Medicine (ASAM) only requires that you complete a residency — any residency, even dermatology or surgery — plus one year of work in the field and then 50 hours of “education.”  I took the test in 2010 and passed by a large margin without any preparation.

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Remarkably, I received my “diploma” in the mail without every meeting or speaking with anyone.   I simply paid the fee and took the test at one of the local testing centers.   This is concerning as my prior board certifications required accredited residency and training programs and were dependent on not only successfully completing those programs academically but on the reports of my superiors documentation of my character and integrity.  Screen Shot 2014-03-03 at 1.22.02 PM

With these lax standards, the ASAM have been able to create a legion of board certified addictions specialists – outnumbering psychiatrists in the field by 3 to 1.

Takeover of state Physician Health Programs (PHPs)

These ASAM “addiction experts” have become so numerous they have been able to take over almost all the state Physician Health Programs (PHPs). Their national association—the Federation of State Physician Health Programs (FSPHP)–has a stated goal of universal acceptance of the 12-step doctrine: lifelong abstinence, and spiritual recovery as the one and only treatment, as spelled out in the “PHP Blueprint.”

Very much like Straight, Inc in the 70s and 80s, they have cast a wide net with doctors to ensnare them in an endless loop of drug testing and rehab—whether the tests are fabricated or not. The doctors will enjoy no sympathy from the public, and complaining about it is deemed a sign of your “disease.”   Furthermore, ASAM recommends that physicians only be referred to “PHP approved” facilities.  

The medical directors of these facilities can all be found on this list of ”Like-Minded Docs.”  Surprisingly, many Like-Minded Docs were former addicts and alcoholics, some even with criminal backgrounds.  There are felons and even double-felons on the list.

It’s a rehab shell game. Heads I win tails you lose.

And the program is expanding. The organization that oversees the licensing for all medical doctors, the Federation of State Medical Boards, adopted a new policy and approved the concept of “potentially impairing illness” and the Orwellian notion of  “relapse without use.”

Signals for “impairment can be as benign as not having “complete accurate, and up-to-date patient medical records” according to Physician Health Services, the Massachusetts PHP.  Despite the overwhelming amount of paperwork physicians now have, incomplete or illegible records could be construed as a red flag, since as Associate Direct of PHS Judith Eaton notes “when something so necessary is not getting done, it is prudent to explore what else might be going on.” The question is, who is next?”

Not Just For Doctors, But for Everyone

Most of us are unaware of this quiet operation to police and punish our private choices. This is the New Inquisition: a move to expand this program to virtually all professions, all Americans. They want to replace the system currently being used in pilots, bus drivers, and Federal Employees with “comprehensive drug and alcohol testing” that consists of the Laboratory Developed Tests (LDTs) they introduced. Their goal is 24/7 sobriety with complete abstinence, and zero tolerance using tests of unverified validity and unknown reliability.

And they have an implementation plan.  The American Society of Addiction Medicine (ASAM), bolstered by billions of dollars from forced rehab and mandatory drug testing, has a long reach and powerful political friends. ASAM plans to force your physicians to collect your urine in the name of preventive care.

That’s right, that free preventive care you’re getting under Obamacare might soon come packaged with drug screening, as outlined in the ASAM White Paper on Drug Testing.  . Drug testing, they say, is  “vastly underutilized” throughout healthcare. The White Paper—which is well worth reading—describes the use of drug testing “within the practice of medicine and, beyond that, broadly within American Society.”

No matter your profession, if you come for a check up, you may be unwittingly looped into being referred for  “assessment” and “treatment” in a “PHP-approved” facility, where to get free, among other things, you will have to admit you are powerless and surrender to God.

If we don’t start pushing back now, soon there will be mandatory drug testing for every citizen..  A good case can be made for forced drug testing for virtually every profession –a few well-placed opeds in The New York Times and pretty soon we’ll begin to think it’s reasonable to test teachers, food handlers, you name it. They are even recruiting pediatricians to test children.      And in the new system they will not have to change your test from “forensic” to “clinical.”   A doctor-patient relationship renders the test “clinical” and by having doctors collect these specimens and calling the consequences “treatment” they can successfully use these unverified and unregulated tests introduced and marketed through a loophole into mainstream medical practice through a loophole.

One of the major goals of ASAM is recognition by the American Board of Medical Specialties. Should this occur it will inevitably lead to the end of Addiction Psychiatry and, by outnumbering them 3:1 it will be enveloped into the all encompassing field of “addiction medicine.” “Who needs two specialties?” they will argue, especially since most medical experts have accepted that addiction is a chronic relapsing “brain” disease.

And this legion of “authority” will infest our hospitals and mainstream medicine where they will join hospital formulary, ethics, research and other committees where they will be able to outnumber and outvote those of open mind and critical thought just as they did in the PHP system and the field of medicine will then be subverted to the guiding philosophy of the “impaired physicians movement.”

Addiction is a serious problem and those afflicted with it need proper assessment, diagnosis and treatment.  This illegitimate and irrational authority does not provide that.  Having had a disease does not confer authority status–I have asthma but that does not make me an expert in reactive airway disease.    Neither does interest in something, no matter how sincere, make one an expert.  I’ve had a sincere interest in science since I was a child but did not claim to be an expert in science when I was 7 because I was a member of Sir Isaac Newton’s Scientific Club.   Aside from the $2200 I had to pay and sitting through the exam gaining  ABAM certification was not all that different. This is not “expertise.”

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Prior to accepting “addiction medicine” as an ABMS approved specialty their research, tenets and basic principles of should be subjected to critical reasoning and academic analysis of the Cochrane caliber to see if they are actually valid.  This includes their claims of remarkable success in treatment and the non-FdA approved laboratory developed tests (LDTs) that they introduce.d.    The authorities and experts involved in promoting the ideology, testing and treatment should  be subject to and Institute of Medicine (IOM) conflict of interest analysis.   Who is profiting? And all of the statements, claims and suppositions regarding addiction and the guiding philosophy of the group should be subjected to Carl Sagan’s Baloney Detection kit.   If this were done the results would be failure on all three counts. False premises lead to false constructs.

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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 LDT drug and alcohol testing and 12-step assessment and 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.images

Diagnostic Testing 101.1: The Importance of Sensitivity, Specificity and Diagnostic Test Accuracy

To have striven, to have made an effort, to have been true to certain ideals — this alone is worth the struggle. We are here to add what we can to, not to get what we can from, life. – William Osler


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Diagnostic Medicine

Diagnostic medicine is the process of identifying the condition or disease that a patient has and  ruling out conditions or diseases the patient does not have through assessment of  the patient’s signs, symptoms, and results of various diagnostic tests.

Diagnostic Test Accuracy

Diagnostic test accuracy is simply the ability of the test to discriminate among alternative states of health (Zweig and Campbell, 1993).

If a test’s results do not differ between alternative states of health, then the test has insignificant accuracy; if the results do not overlap with other states of health then the test has perfect accuracy.  Most tests accuracies fall between these two extremes.

The intrinsic accuracy of a test is measured by comparing the test results to the “true condition status.”

‘True condition status”  refers to one of  two mutually exclusive states.  Either a condition is present or it is absent.  

We determine true condition status by means of a “gold standard” which is a source of information completely different from the test under evaluation which tells us the true condition status of the patient.

Say we want to develop a new rapid test for detecting strep throat.    Strep throat is caused by the Streptococcus bacteria.   Although more common in children and adolescents it can occur in people of all ages.  Strep throat is one of many possible causes of sore throat and pharyngitis.   It is contagious and can cause complications such as rheumatic and scarlet fever.  Treatment with antibiotics can shorten the course of the disease and reduce the risk of complications.

Pos_strep

A throat culture is obtained by swabbing the patient’s throat with a cotton swab.  The sample is then sent to the lab where it is cultured.  If strep is present it will grow on the culture and look as below.     The bacteria either grows on the culture or it doesn’t.  A throat culture is the “gold standard” for diagnosing strep throat.  The problem is it may take two days to get back.

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Sensitivity and Specificity

The two most important measures of diagnostic test accuracy are sensitivity and specificity.     

The probability that a test will be positive in someone with the condition =  Sensitivity

The Probability that a test will be negative in someone without the condition = Specificity

For diagnosing strep throat we want our test to be as close as possible to the gold standard in terms of both sensitivity and specificity.

Sensitivity and specificity can be illustrated by a table with two rows and two columns.  This simple  Decision Matrix  where the rows summarize the data  according to the true condition status of the patients and the columns summarize the test results.  This table is called a “count table” because it indicates the numbers of patients in various categories.      The total number of patients with and without the condition is, respectively n\ and n0; the total number of patients with the condition who test positive and negative is respectively s\ and s0; and the total number of patients without the condition who test positive and negative is respectively r\ and ro.

The total number of patients in the study group N, is equal to N = si+so+rx+ro, or N = n\ + no·

The true condition status is symbolized by the variable D, where D = 1 if the condition is present and D= 0 if the condition is absent.

Test results indicating the condition is present are called positive; those indicating the condition is absent are called negative.

Test results are symbolized  by the variable T, where T =1 denotes positive test results and T= 0 denotes negative test results.

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The sensitivity (Se) of a test is its ability to detect the condition when it is present.

We write sensitivity as Se = P(T = 1 | D = 1), which is read:

“sensitivity (Se) is the probability (P) that the test result is positive (T = 1), given that the condition is present (D = 1).”

Among the n\ patients with the condition, s\ test positive; thus, Se = s\/n\.

The specificity (Sp) of a test is its ability to exclude the condition in patients without the condition.

We write specificity as Sp — P(T = 0 | D — 0), which is read:

“specificity (Sp) is the probability (P) that the test result is negative (T = 0), given that the condition is absent (D = 0).”

Among no patients without the condition, ro test negative; thus, Sp — TQ/UQ

False Negative and False Positive Tests

There are consequences associated with all test results.

False Negative Tests:   If a test falsely indicates the absence of a condition in someone who truly has it then treatment can be delayed or not provided.

The consequences of a false negative strep test depend on what we do with it.   Serious consequences can arise if we use our new strep test as the sole basis for subsequent decision making.     Putting complete trust in the negative test result would lead to no antibiotic treatment provided to a patient with Strep  and can lead to continued illness,  spread of the disease and complications that would not have occurred if antibiotics were provided.  The patient could potentially get rheumatic or scarlet fever.

If the new test is negative  but a culture was drawn the false results could delay treatment by a couple days or so but treatment is nevertheless provided.  The consequences are likely to be minimal.   It is highly unlikely a patient would get rheumatic or scarlet fever  as, although a little later, they are still  being treated with the proper antibiotics.

False Positive Tests:   If a test falsely indicates the presence of a condition in someone who does not truly have it then unnecessary tests and treatments can occur.  Incorrect treatment and false labeling of patients can also occur.

In the case of a false positive strep test, a patient may undergo a course of antibiotics when they do not need them.     Although the patient may suffer side-effects from the antibiotics the severity and duration of any  of these consequences are minimal.

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The importance of a Diagnostic Accuracy in testing is directly proportional to the tests potential to cause patient consequences and harm.

Diagnostic Medicine uses a patient’s signs, symptoms and the results of various diagnostic tests to arrive at a diagnosis.

In diagnosing strep throat a good clinician will take into account  a number of variables in consideration of a differential diagnosis and base testing and treatment on the preponderance of information supporting or opposing the diagnosis.

For strep throat using the new test in addition to a throat culture, history and careful physical exam and basing the decision to prescribe antibiotics on clinical acumen based on the overall picture is the best approach.     The test can  be considered a piece of the puzzle but does not define it.  Therefore the risk of a false positive or false negative is minimal as it is just one data point.

Diagnostic accuracy is necessary if a test is being used as the  basis for further tests and treatment.  If  a test  is  being used as the sole basis for further tests and treatment it needs to be accurate.   If the results of a test can cause significant patient harm or death then it needs to  be either 100% accurate or combined with other highly accurate tests to confirm the diagnosis.

The specificity of a test is particularly important as a false positive can result in unneeded interventions and treatment.     Stand-alone tests used in diagnosis and treatment need to be both sensitive and specific.    Diagnostic accuracy is a product of consequences of  false-negative and false positive tests.

 Diagnostic Research Methodology

Research to discover the accuracy of a diagnostic test should be straightforward; administer the test to a group of people and see if it works.

The test being tested is the “index test”. Results of the index test are compared with the results of a “gold standard” reference test.

The research question is, “How accurately do index test results predict the (true, gold standard) reference test results?”

Diagnostic test accuracy studies require a sample of subjects  who have been given the test under evaluation,  some form of scoring of the tests findings and a reference or “gold standard” to which the test findings are compared.   Examples include autopsy reports, surgery findings and pathology results from biopsy findings.

The gold standard for a patient’s true disease status may not always be available.    A  brain biopsy could be considered a gold standard for diagnosing Alzheimer’s disease but is neither practical nor humane.

The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool is a set of fourteen questions that investigate the methodologic quality of scientific studies that quantify diagnostic test performance.

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The questions identify research methodologies known to bias the accuracies research discovers.

Multiple factors need to be considered in  evaluating the diagnostic accuracy of a test including diagnostic validation and  verification.   Is the test testing what it is supposed to be testing for and are we doing it correctly?

Diagnostic accuracy of a test necessitates a reference standard,  The reference standard can be the best available method for establishing the presence or absence of a condition (such as the throat culture for strep throat) or a combination of methods (imaging, neuropsychological testing, clinical exam, etc. in Alzheimer’s disease.

Any test that is going to be used as a basis for decisions that impact other human beings needs to  be validated before it is introduced on the market.  The literature needs to  be reviewed critically and trials must be designed using objective evidence that validates the test is testing for what it purports to be and verifies the correct methodology of the test.  Verification that the test is being collected, handled, stored, transported and processed  correctly is requisite.

Cutoff levels, , cross-reactivity and myriad other issues need to be worked out prior to bringing a diagnostic test to market.

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The reliability, validity and accuracy of drug test results needs to  be known prior to using a test.  Specificity and sensitivity must be known prior to using a test on any population.

This should go without saying as to do anything else would be irresponsible and careless.

References

Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: part 7: systematic reviews and meta-analyses of diagnostic accuracy studies Pain Physician 2009, 12(6):929-963. PubMed Abstract | Publisher Full Text

Jaeschke R, Guyatt G, Lijmer J: Diagnostic tests. In Users’ guides to the medical literature: a manual for evidence-based clinical practice. Edited by Guyatt G, Rennie D. AMA Press; 2002:121-140.

Lundh A, Gøtzsche PC: Recommendations by Cochrane review groups for assessment of the risk of bias in studies.BMC Med Res Methodol 2008, 8:22.doi:10.1186/1471-2288-8-22 PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

Streiner DL: Diagnosing tests: using and misusing diagnostic and screening tests.J Pers Assess 2003, 81(3):209-219. PubMed Abstract | Publisher Full Text OpenURL

Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J: The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003., 3(25)  http://www.biomedcentral.com/1471-2288/3/25 webcite

OpenURL

GCP, good clinical practice; GCLP, good clinical laboratory practice; GLP, good laboratory practice; STARD, standards for reporting of diagnostic accuracy. See Section III, 2.13  From Nature Reviews Microbiology 4,S20–S32(1 December 2006) | doi:10.1038/nrmicro1570

GCP, good clinical practice; GCLP, good clinical laboratory practice; GLP, good laboratory practice; STARD, standards for reporting of diagnostic accuracy. See Section III, 2.13 From Nature Reviews Microbiology 4, S20–S32 (1 December 2006) | doi:10.1038/nrmicro1570