medicine

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The Emperor of Silence reaps no relief from pain…or something like that

Welcome to August, everyone.  For today is August 1st, 2026 (AD/CE).  How exciting.  Huzzah.  Yippee ki yay motherf…

…or goodness sake, we certainly have a rather Roman day today, don’t we?  The month is named after a Roman emperor (the first “official” one, though I wish he’d just kept the name Octavian, since Augustus has too much of a try-hard vibe), and the day is named after the Roman god, Saturn.  Sailor Saturn is also my favorite sailor soldier*.  Though, that last thing doesn’t have anything to do with Rome.

I’m working today, just to confirm what would probably be your conclusion if you were even thinking about the question.

It’s not an absolute correlation, by any means; it’s possible, and not even unreasonably unlikely, that I might write a blog post but not go to work, or that I might go to work but not write a blog post.  The latter has happened more times than not (by far) throughout my life, but we need not worry about that likelihood, since it is ruled out by the fact that I am indeed writing a blog post.  You can tell, because you’re reading it (albeit not while I’m writing, as far as I know).

I am still quite sore all over, especially in my thumbs, back, hips, knees, ankles, shoulders, middle back and right side and flank***.  So, yeah, I don’t feel very great.  I also still have some residua of my apparent middle respiratory inflammation, but I think that’s improving.

Maybe it will be good for me to go through a bit of time with basically no NSAIDs in my system‒they’ve been there a lot, for a long time, and cannot fail to have had unintended effects.  We’ll see how the lack thereof even for a few days impacts my health.

On the other hand, NSAIDs can reduce some kinds of depression, and I think they did at least some of that for me.   Still, I am using Tylenol, and that seems possibly to help not merely with physical pain, but also with psychical pain (a little bit).

Weird, right?  And it doesn’t do that by decreasing inflammation in the brain, as NSAIDs appear to do.  It definitely works differently than NSAIDs, though it is not entirely unrelated.

It’s interesting how modules in the nervous system became repurposed (or added-purposed) for later mental functions in larger brains and especially in social animals.  The mental processes associated with physical revulsion and disgust/avoidance toward potential toxins and infectious materials became tied to our moral emotions of judgement, condemnation, and contempt.

Physical processes of fear became connected with anxiety about social opprobrium‒though, in a species like humans, social ostracism really was a serious danger to one’s life in the ancestral environment, to say nothing of being a rather obvious impediment to reproduction.

Anyway, the point is, it shouldn’t be too very surprising that a substance that attenuates physical pain can also ease psychological torment, at least a bit.  We know that opioids do this as well, and to a much greater degree than acetaminophen.

That’s one issue they have.  If a person has a lot of psychic pain‒and many of us do, which is predictable given that we are creatures adapted to hunting and gathering in the savannahs of Africa but are now living in the nightmare/fever dream/bad acid trip that is the modern world‒and has no better, more available, way to assuage it, they’re going to be tempted to reach for the tools they have, however blunt.

If we can figure out better ways of easing those pains, ones that are available and usable by everyone who needs them and which have acceptably few side-effects, that would be nice.

Okay, well, I don’t know if I’ve written anything coherent here, but I’m going to keep this relatively short, because I am still feeling poorly.  I hope you all have a good day and a good remainder of the weekend.

*Not counting Sailor Moon, who has the same unfair advantage over the others that the Beatles have over other bands.  Sailor Saturn is my Radiohead**/Pink Floyd sailor soldier.

**Heck, on one of my favorite songs by Radiohead, No Surprises, the chorus is followed by the invocation, “Silent.  Silent.”  And Sailor Saturn is the sailor soldier of silence, wielding the Glaive of Silence, with the power to end the world and bring about…well…silence.

***This makes me nervous considering my urinalysis strangeness, but I haven’t yet checked that today.  It feels like it is improving.

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“A distant ship smoke on the horizon”

Well, it’s here at last:  the final day of June in 2026 AD/CE.  You might say it’s the hospice day for the first half of this year.  Let us try to make its passing as peaceful and comfortable as we can.  I recommend high doses of opioids.

I’m kidding.  I don’t actually recommend such a thing unless one is in severe pain that’s simply not responding to anything else, or unless all the other stuff is simply too toxic.

That’s a big part of the conundrum of opioids.  All the other types of pain medications‒aspirin, other NSAIDs, acetaminophen, lidocaine injections, steroid injections and so on‒have significant systemic toxicities, even at relatively moderate doses.  They affect the stomach, the kidneys, the liver, the local tissues, the endocrine system, etc.  Quite often, one cannot adequately control significant pain for long using them without causing actual, serious, perilous damage to some of the most essential parts of the body.

On the other hand, opioids work.  They directly hit the pain centers/processors, and they actually can relieve pain, even very severe pain.  But they don’t just relieve physical pain.

Somewhat ironically, that’s one of the big drawbacks.  Though they do not cause systemic or organ toxicity, and they will not trigger diabetes, and they will not cause you ulcers (though they may well constipate you), they can affect your behavior and even your character.  Their relief of psychical pain‒sometimes the only such relief some people have felt in a long, long time‒is like their relief of more visceral pain:  it doesn’t actually correct any underlying disorders.

Well, I suppose if the disorder is simply a neurological misfiring such as that which leads to chronic pain, you could say they do at least act on the area that is dysfunctional.  But they don’t cure it.  They almost never correct even neuropathic pain; they simply squelch the alarm for a bit.  And the successful squelching of the alarms tends to require increasing doses, and can lead to dependence and various other issues.

So, there are no very good, relatively simple corrections for significant pain.  This is probably not a surprise, if you think about it.  In some form, at least, pain is among the oldest things in nature and among the most crucial (ha ha)* functions of nervous systems‒and even things that aren’t quite nervous systems, like the internal communication systems in hydra and jellyfish or the analogous systems of plants.

Living bodies don’t readily give up on pain, and they have good reasons.  Pleasure is nice, and is useful, of course, but it’s like having a pretty picture on your wall or having nice, scented candles in your living room or what have you.  No matter how pretty your decorations, you want to have your fire alarms in good working order.  You want them sensitive enough to go off even in situations without real fires‒the classic case of burnt toast, say‒rather than take the chance that they will not to go off in the case of a real fire.  The first error causes annoyance, perhaps requiring you to wave towels at the sensors and open a lot of windows and so on.  The second error can lead to your house burning down, perhaps with you in it.

Of course, these weighted preferences are not absolute.  If one’s smoke alarms were always going off‒or even going off a significant fraction of the time‒one might very well want to wipe out the whole system, to pull all the plugs, to remove all the batteries,  to flip all the breakers to “off”.  Or, indeed, one might simply want to abandon the house entirely, if there were no way to get the alarms to shut the f*ck up.  One might even be tempted to burn the stupid place down, just as a form of petty revenge against it.

There’s a metaphor in all this, I would imagine.  I’ll leave it as an exercise for you to discern it.  I won’t say it’s particularly clever, but it’s not terrible, and it works pretty well.  Anyway, I’ve dealt with this subject before, many times, I’m sure.  It’s fairly tedious, but it does seem to stick in my mind for some inexplicable reason.  I don’t, however, know how to solve the associated problems.

Ah, well.  There are some things humans aren’t meant to know.

Ha ha ha ha!  Sorry, I couldn’t keep a straight “face” while writing something so very stupid.  Humans aren’t “meant” to know (or not to know) anything, anymore than any particular foodstuff “belongs” on a pizza.  People can try to learn and understand anything, even everything, and ultimately, in the long run, as far as I can tell, the more one knows and understands, the better.

If you want to do your best in a game, you would do well to learn the rules as well as you can.  Because, to quote an old car commercial, in real life there is no reset button.  You are the avatar and you are the player, and when you get blasted into nothingness by the depredations of the game’s limitless antagonists, then for the character and for the player, the game is done.  There is no respawning, there are no experience points, there is no starting again at the last save point.

Game over.

*I say “ha ha” because the word “crucial”, related to the Latin for cross (apparently evolving into its modern usage from a metaphor for arriving at a crossroads), is also related to the word “excruciating” which derives from the Latin use of torturing as if crucifying someone.  And that, of course, relates pretty clearly to the topic of pain.

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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.