medicine

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Late-arriving, futile “justice” and reminders of a life that has been all but annihilated

I read the news yesterday, oh boy.  And yes, it was about a lucky man‒luckier than I am, anyway, at least in some ways.

There was a doctor in the heartland of America somewhere, I don’t recall where, who had been convicted of, apparently, inappropriately prescribing very large amounts of pain meds, the report quoting the number 500,000* (It seems unlikely that there were 500,000 prescriptions**, so it probably was that number of pills).

Anyway, his conviction was overturned on appeal, because apparently, in 2022, the SCOTUS handed down a ruling that the prosecution had to prove in such cases that there was “intentional or knowing” inappropriate prescription for it to rise to the level of a crime, and the jury hadn’t been appropriately instructed regarding that fact.

I looked up the case, and I’ve even downloaded the PDF of the case.  Although I haven’t read through it yet, the summaries make it clear that, yes indeed, this is a new and specific requirement.

Silly me, I had always thought that mens rea was a crucial requirement for nearly any criminal case, certainly one that rises to the level of a felony charge.  I brought that up with my (public) defense attorney, trying to point out that I shouldn’t be convicted of a crime since I literally had never intended to do anything but treat patients who had chronic pain‒which I did because I had chronic pain, and it had already severely harmed my life.  I knew how hard it was for even a physician, who at the time had good health insurance, to be able to get adequate treatment and even to get his prescriptions filled by often-judgmental pharmacists who looked at him as if he were a criminal just because he wanted to try to mitigate his pain with the most effective medicine that was available.

But no, apparently, according to my attorney, the prosecutor didn’t have to prove any such thing specifically; it could just be inferred.  And apparently I’m not exactly the sort of person to elicit sympathy from a jury in south Florida, because my voice tends to be monotone and my face tends to be expressionless and I don’t look like someone who is frankly worthy of sympathy.

All the charges against me were created by the PBSO, who sent in undercover people with (evidently) faked MRIs and fake complaints, who complained of chronic, severe pain and said they were in pain when I examined them***, and whose own secret recordings and records showed that there were often only one or two other patients in the whole office when they were there‒hardly what one would call a “pill mill” I should think.

Anyway, I was offered a plea bargain and I took it, because unless you’ve got a lot of money or you literally have nothing to lose, you will take a plea bargain in the right circumstances, even though you know you’re innocent.  I’ve written a blog post about how the plea bargain system is an extortionate game slanted against especially the underprivileged.

The statutes involved in my charges were designed by that <sarcasm> bastion of intelligentsia and morality, the Florida State Legislature </sarcasm>, to give judges no leeway, and to grind away maximally at anyone charged with “trafficking”.   If a jury decided that they should convict on at least one charge, since the state had created so many charges against me (each prescription being a charge, and twenty something having been conned out of me by various lying police officers over time) and the number seems impressive, I still could have faced a minimum of fifteen years in prison.

In retrospect, I think I would have been little worse off if I had, given the mockery and shambles my life has become.  But at the time, I hoped to see my kids again, perhaps sometime before they were adults.  Three years was better than fifteen (or potentially the rest of my life), and I had no one else to help me with a legal fight, and certainly no reservoir of money, so I took the deal.

The way things are now, though, I might not have been charged, or might have been offered some misdemeanor plea deal.  Or I might have gone to trial and won with relative ease, since the fact that I never knowingly or intentionally mis-prescribed medicine was a fact I knew for certain, at a Cartesian, cogito ergo sum sort of level, since it was a fact about my own mental state.

I may be naïve, and I often do not understand humans.  I am often easily misled and manipulated and used and misused and probably abused, because I am socially and emotionally very clueless and believe in giving other people the benefit of the doubt (to hold them innocent until proven guilty, in other words).  But I have never been greedy or unscrupulously opportunistic, and I took the practice of medicine and my duty and goal to relieve suffering very seriously.  I was never into making a lot of money, though it was good to be able to buy books I wanted and to take care of my kids.  I lived in a one-bedroom apartment and drove a ten-year-old Toyota Sienna.

Before yesterday, it had been a long time since I’d bothered thinking about what my life might have been like if things had not gone the way they did.  There didn’t seem to be any point.  I was a lost cause and that was that.  But this has made me feel acutely once again the cut of all the lost time with my kids and my lost ability to practice medicine, and all the other losses I’ve experienced as part of this debacle of a life.

What’s more, there’s been salt and vinegar rubbed into the wound by the fact that it took a Supreme Court dominated by many justices who’d been appointed by The Donald to require courts to require prosecutors to prove something that was supposed to be a necessary element of almost any serious criminal charge:  actual criminal intent.

That’s all leaving aside the un-ethics and illogic of the government of the “Land of the Free” dictating what people can put into their own bodies when it doesn’t directly harm other people in the first place.  I won’t get into that because it had no bearing on my medical practice‒I was not in the business of dealing in euphoriants, I was trying to relieve actual suffering.

One cannot really apply new jurisprudence to old cases in which a sentence has already been carried out and finished, and when the consequences thereof are already irrevocable.  I cannot regain the time I have lost with my children or the time I have lost when I could have been practicing medicine, or the time I spent at FSP West or in the Palm Beach County Main Detention Center, where even the people who worked there frequently asked why the hell I was there, or still there (I spent 8 months in the place, on the mental health floor, because I couldn’t make bail, but finally my former girlfriend’s mother helped secure it‒at least she got all her own back after I was sentenced, and I appreciate her very much, though I might as well just have stayed in jail, since at least the whole sentence would have ended earlier given “time served” and I was basically homeless when out on bail, having lost everything I owned and relying on the generosity and kindness of friends/former coworkers).

So I am stuck with a ruined life and a twisted mockery of myself.  The fruits of a considerable number of years of time and effort and thought and creativity on my part**** were all taken away by the mindless grinding of a huge stupid machine of “criminal justice” that has little to nothing to do with the latter part of the term.  I don’t claim not to be stupid or foolish or not to have ever made mistakes in the whole situation.  I make many mistakes.  But it is maddening to see how misapplied the law can be and to experience it for oneself, especially when one is now by oneself, partly thanks to that misapplication, and then to learn that now the law is changed (or correctly applied) such that I could have been in a better situation had that change come sooner.

I often consider the possibility of going to the Palm Beach courthouse, dousing myself in various flammable liquids, and turning myself into a “bonfire of the unsanities and inanities”, to bring attention to some of the costs of misapplied “justice” and to bring an end to my own mis-called life.  I even have two gallons of paraffin lamp oil and six liters of charcoal lighter fluid and a big enough backpack to carry them all, in case I decide to do it.

Death by fire is intimidating, though‒I am no Buddhist monk by any means.  And I also dislike causing inconvenience to other people, even those involved in an institution that had no qualms about recklessly “judging” me and ruining my life.  But it is tempting, and I feel right now even more than usual the utter pointlessness of continuing, even while stupidity in the office in which I work grinds away at me further (though, to give him credit, my boss tries hard to keep things as sane as he can).

I feel rotten enough and alien enough even at baseline, and all this doesn’t help.  I have lost almost all that mattered to me, and I live alone in a stupid one-room (plus bathroom) “in-law” suite that is smaller than many hotel rooms.  All my previous friends are far away, and most are doing much better with their lives than I am and don’t really have much in common with me anymore.  In any case, I don’t really talk or otherwise communicate with them, though it would be nice.

There are also plain few people where I am now who have anything in common with me.  Very few people have much in common with me:  a disgraced physician unable to practice, with a love of math and physics and biology and of Shakespeare and horror fiction and science fiction/fantasy (reading and writing it) and of science and rationality-oriented podcasts and books and videos, who wants to learn or relearn more about modern physics at a deep level and whose brain doesn’t seem to run the same operating system as most of the people around him‒a Linux in a world of iOS, or worse.

So, I don’t know what I’m going to do.  Knowing me, I’ll probably just grind along until I’m worn to a nub and then tumble into the trash can, unmarked and largely unlamented.

I know that I won’t be sorry‒not about that.

*This sounds like an awful lot of pills, but it’s deliberately chosen to sound that way in a manipulative, rhetorical tactic as used by reporters and prosecutors alike.  Let’s run the numbers, as I am wont to do, to see how impressive they really are.

Now, if there were one patient, taking one pill per day‒perhaps the person only takes one prescription, say an antidepressant or a cholesterol med or a long-acting antihypertensive‒it would take nearly 1400 years to use that many pills.  Plain few patients live that long (see my recent blog post), and most pills would long since have expired and become inactive before the end of that time.

Still, the average physician is responsible for the care of 2,000 to 3,000 patients (see here and here), meaning that if, on average, their patients each only took one prescribed pill a day, they would go through 500,000 pills in 6 to 9 months.  But many prescriptions call for more than one pill per day, and uninsured patients cannot tend to afford the long-acting pain meds that claim to allow for steadier doses and thus slightly less risk of rebounds and escalations and all the horrors involved in that.

Now, presently, I take three to nine aspirin a day, sometimes more, and I also take two naproxen and some supplemental Tylenol as well, all of which are more directly toxic to the body than opioids, but are nonetheless over the counter (as they should be).  If I averaged ten total pills a day, then it would take me only 137 years or so to take 500,000 total pills.  That’s longer than I’m likely to be taking pills, but I’m only one person (that, as Dave Barry said, is the law).  An average practice of patients who took only six pills a day would go through 500,000 pills in one to one and a half months.  Many ordinary, non-pain-specific patients, especially those middle-aged and older, take that many and even more prescription meds a day.

In any case, an ordinary general practitioner with a light patient load of two thousand patients, each taking only an average of two pills a day, would prescribe 500,000 pills in 3 to 5 months.  So don’t be too impressed by the carefully curated numbers that prosecutors and media choose to elicit your alarm and disgust.

**Even 500,000 prescriptions, in a modest 2000 patient practice, would require only 250 prescriptions total per patient.  That would certainly take quite a bit longer than 500,000 pills would take, but given an average of only one prescription per patient per month (counting refills) it would only take a bit over 20 years, a decently short length of practice.  Many doctors see more than 2000 total patients and many patients get more than one prescription per month.  And, of course, one cannot even apply refills on “controlled substances”, they have to be literally re-written every month, and patients have to come to the doctor’s office to get them, assuming they can even get them filled.  Monthly doctor’s visits can be hard for someone trying to work a regular job while dealing with chronic pain.  Thus, the whole “mill” part of the “pill mill” trope is created by the law itself, leading to greater costs in time and fees for the patients who are trying to survive after job-related and other injuries or conditions that have caused them chronic pain and make it difficult for them to find consistent, gainful employment or to sustain health insurance.

***Pain is a symptom, not a sign, in medical terms.  We have no reliable ways of testing it, beyond patient report.  We try to find physical correlations when we can, often to see if we can find some treatable cause, but even Harrison’s Principles of Internal Medicine (I think it was on page 80 or 81 of the 14th or 15th edition, whichever one I had at the time) has clearly stated that, for instance, back pain does not correlate well even with specific injuries noted on MRIs and the like.  As large a number of people without pain will have nerve root impingements and bulging discs and the like seen on spinal MRIs as do have pain.  NO ONE KNOWS all the wherefores of this situation, but there is no serious doubt that such pain is quite real.

****It did not all happen during medical school or residency‒one does not coast along from K-12 and undergraduate college and only then start to work hard in med school, especially if one grew up in a blue-collar, factory town outside Detroit.

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The Treatment Trap

In America today, we rely far too much on pills and on procedures–on would-be “cures” for our problems–than we really should.

It may seem strange for a medical doctor like me to be saying this, but I have insight into the issue from multiple perspectives.  I’ve been one of the doctors who falls into the trap of trying to “treat” every issue rather than prevent or solve it, and I’ve been a patient who approaches things the same way.

The irony is that a great many of the health problems we face in the modern world–especially the most rampant and devastating ones, such as diabetes, high blood pressure, heart disease and their related problems and consequences–are governable simply by modifying our lifestyles.  Indeed, for many of us, these health concerns’ very existence AS problems is only CAUSED by our modern lifestyles.  I’ve already discussed in some earlier entries the mechanisms and effects of type 2 diabetes, a disorder which is becoming more and more endemic in our nation, and at younger and younger ages.  It’s absolutely clear why this is happening:  We are more sedentary and more overweight and we eat more rapidly absorbed carbohydrates than humans have ever done before in our existence.  What’s more, thanks to public health interventions and control of infectious diseases, we live long enough for these habits to matter more than they could have in the past.  We also know, quite well, many of the things that we can do to counter diabetes and its close relatives, hypertension and heart disease. Yet, instead, we allow our health to deteriorate and then rush to modern medicine to seek “cures” or at least treatments for the outcomes of our bad habits.

I suspect that this trap of habits was set for us, to some degree, by the brilliant innovation and success of antibiotics.  These are the quintessential medical cures:  When used against an infection caused by a sensitive bacteria, antibiotics actually CURE the problem (with the help of our own immune system).  To some degree anti-virals do the same, though they are more recent, and anti-parasitic agents are also analogous.

Unfortunately, most other kinds of medicines–unless you count the occasional Tylenol or Motrin to treat a tension headache or muscle soreness–don’t actually cure anything.  They simply “treat” it, governing the symptoms and consequences to some degree or other, but not addressing whatever underlying processes might be contributing to the issues.  In addition, they give the patient the illusion that the problem is now under real control.

There are, of course, times, when health problems are not soluble or easily controllable, and managing the symptoms and consequences is the very best we can do, at least for now.  So PLEASE do not think that I am advocating the elimination of Western medicine or that those being treated for chronic health conditions should just give up their pills and let nature take its course.  Yet with so many health problems, even if we have to resort to medication, we can also make lifestyle and behavioral changes that will mitigate our problems and decrease, though not always eliminate, the need for medications (and surgery, when applicable).

We all know, or should know, that taking medicine can be a double-edged sword.  Medications sometimes create new issues of their own.  The human body is an incredibly complex system–arguably the most complicated thing in the known universe, especially when you count the human brain–and when you manipulate such a  system in one way or location, unexpected consequences almost never fail to arise.  This leads to the horrible spectacle of patients receiving medication for one problem, but developing side-effects, which then need to be treated by other medications, and which cause toxicities and interactions that later have to be addressed.  The whole affair can become a vicious cycle of increasing biological chaos, like a metabolic Rube Goldberg machine.  In the elderly especially, it can sometimes be all but impossible to be certain whether new health problems are intrinsic or are caused by earlier treatments.

We try, of course, to mitigate and avoid this conundrum by studying medications as carefully as possible and learning what their possible side-effects are…but every human body is different, and that’s going to continue to be the case, since the number of possible genetically unique humans is vastly greater than the number of human beings who have ever lived.  So we can be guaranteed that the one expectation we can reliably entertain is the UNEXPECTED.

It is better by far to avoid developing problems whenever possible rather than trying to treat them.  This is true because it is simpler and more predictable, and also because it makes life better.  Rather than being a person who identifies themselves by their litany of ailments, for which they build their house-of-cards treatment regimens, we can work to maintain lifestyles that are GOOD for our health, that work with our natures, and that help us to think of ourselves as–and to feel like–healthy, vital and thriving human beings.

Medicines are indeed wonderful products of modern science and technology, and I strongly suspect that they have saved and improved many more lives than they have harmed, even despite what I’ve said above.  If I didn’t think that, I wouldn’t have gone into medicine.  Yet, it would be even better if we could avoid having the need for medications as often as possible in the first place.

I’m going to discussing more of this in future entries.  I’ll go into some fairly obvious lifestyle issues such as exercise and diet, but I’m also going to explore philosophical and psychological aspects of health that can make a great difference in not only how long you live, but also in how much you enjoy the time you have.

A life of a hundred years can be a tragedy and a life of a single day can be a triumph.  It all depends on what kind of life it is.