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Join L. Joseph Parker, a research physician, as we delve into the evolving definitions of addiction, particularly in the context of chronic pain management. Explore the historical shifts in diagnostic criteria, the challenges faced by chronic pain patients, and the potential impact on their treatment. Discover how Joseph envisions a more patient-centered approach in future diagnostic frameworks.

L. Joseph Parker is a distinguished professional with a diverse and accomplished career spanning the fields of science, military service, and medical practice. He currently serves as the chief science officer and operations officer, Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity into the realms of space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions for the complex challenges of space travel, including space transportation, energy storage, radiation shielding, artificial gravity, and space-related medical issues.

He can be reached on LinkedIn and YouTube.

He discusses his KevinMD article, “Vague criteria can lead to misdiagnosis and prison.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back L. Joseph Parker. He’s a research physician. Today’s KevinMD article is titled “Vague criteria can lead to misdiagnosis and prison.” Joseph, welcome back to the show.

L. Joseph Parker: Thank you, sir. I appreciate it.

Kevin Pho: So Joseph has been on recently. Go to KevinMD.com/podcast; in the upper right-hand corner there’s a search icon, and you can search his previous episodes to hear his story. Today, let’s jump right into this article, “Vague criteria can lead to misdiagnosis and prison.” What led you to write this article?

L. Joseph Parker: There is a specific problem with the 2013 version of the Diagnostic and Statistical Manual, which is DSM-5. It was recently updated and “TR” was added, but the problem is still there. Right now, I really want to talk about the confusion that can arise when you’re trying to diagnose addiction in patients who suffer from chronic pain, the potential legal consequences of misdiagnosis, and the differing opinions people have about what addiction even is.

Kevin Pho: So tell us about the challenges you mentioned in diagnosing addiction in those who are being treated for chronic pain.

L. Joseph Parker: Sure. Well, there’s kind of a war being fought today between doctors who believe that it’s all right to treat pain with medications that have been approved for that purpose, specifically opiate medications, and doctors who treat addiction and law enforcement personnel who seem to think that treating pain with opiates enables diversion, and that treating addiction enables addiction, especially when you treat it with medications, which many of them object to. And while they may not have the right to dictate the practice of medicine, according to the Supreme Court, they absolutely have the power to do so, and they’re doing it. I wanted to go over some of the criteria for addiction in the DSM and explain why those criteria are so vague that they apply to every pain patient you have.

Kevin Pho: So let’s go ahead and do that. How does the DSM-5 define addiction?

L. Joseph Parker: First, we’ll say that the federal government and many states have laws forbidding a physician from prescribing an opiate for the purpose of treating what is sometimes called chemical dependency and other times called addiction. Now, the DSM-5, the fifth revision, in 2013, got rid of the diagnosis of addiction. You can no longer diagnose someone with addiction. Everything became substance use disorder, which is a spectrum. Before that, substance use disorder started here, and once it got really severe, it became addiction. But now addiction is gone from the diagnostic manual, and everything is substance use disorder.

That means that if anyone shows the slightest symptoms consistent with a possible diagnosis of substance use disorder, both state and federal governments can now come in and say your patient had addiction, or was at risk of addiction, which is one of the things they like to say, and that you continued treating them, and therefore you had no legitimate reason to treat. That’s sort of the code word that allows them to prosecute a doctor. They will say there was no legitimate reason. If they don’t agree with why you treated, you may think that you’ll be able to make a coherent argument about it, but who are you going to make it to? These aren’t doctors arguing with you. And they will find a physician somewhere in this country who will review your chart and assassinate your character and absolutely everything you did.

In some extremes, I have seen it said that any other medication prescribed with an opiate is polypharmacy and puts the patient at risk, even an antibiotic. So doctors are prosecuted, and an expert will get up there and say, “Well, he prescribed an opiate and an antibiotic, and that’s polypharmacy, and that antibiotic could have affected the opiate, and this could kill someone.” And the jury, being medically naive, is nodding its head. If you were in front of a medical board, you would at least have other physicians, but don’t think that’s going to make you safe, because most physicians do not understand the diagnosis of addiction, mainly because it’s not something we focus on in our medical education. It’s a complicated subject, and neuroscientists are just now really discovering what it is.

If you ask a neuroscientist what addiction is, he will say, “Well, it’s clearly overexpression of the gene Delta FosB in the nucleus accumbens of the brain, creating an uncontrollable urge to use a substance or engage in an activity for the purpose of creating the sensation of euphoria.” Try giving that definition to a jury, and none of them are going to understand a word you said, and most doctors won’t either. They’ll kind of follow what you’re saying, but how many doctors actually remember where the nucleus accumbens is, what it’s connected to and how it’s used?

So this is the reward center of the brain. The nucleus accumbens is where we feel euphoria, where we feel good about doing something that has been evolutionarily good for us. We see something we find attractive, we have a steak, we win a competition, and we get a little burst of endorphins in the nucleus accumbens, and that tells us we’ve done something good: Do it again. Of course, opiates also bind these receptors and create that sensation. Addiction had been defined as the pursuit of that sensation of euphoria. Now it is defined by 11 criteria in DSM-5, and those criteria are impaired control, social impairment, risky use, pharmacological indicators like tolerance and withdrawal, time spent acquiring the drug or medication, giving up activities, physical and psychological problems, attempts to cut down, desire and effort to control use, time spent recovering from use, and reduced social, occupational and recreational activities.

The problem you’re going to find involves a doctor treating pain. Let’s say a man has an industrial job. He’s working at a tire factory, and his hand gets crushed, and he loses two fingers. He’s been to the ER, and they had to amputate a couple of fingers. Now he comes to you, and he’s saying, “I’m in terrible pain.” A crush injury will often cause phantom limb problems, so he’s feeling pain in those fingers that aren’t there anymore. The severed nerves are just generating a constant pain signal. He’s been treated acutely at the ER, and now he’s coming to you for subacute treatment.

You start treating. Maybe you’ll use gabapentin, or maybe even a benzodiazepine, to try to suppress the pain, and that doesn’t work. You can use NSAIDs, but you have to be a little careful with those; in some people they increase the incidence of stroke and heart attack, gastric ulcers and all that. All these things have to be weighed. So eventually you end up with this patient on opiates so they can tolerate the pain and try to go back to work. They feel like their fingers are on fire, the fingers that aren’t even there anymore. You continue treating that person, and after six months you still have them on opiates, because they cannot tolerate the pain without them. They’re saying, “It’s hurting so bad. I need you to increase them.” You’re afraid of being criticized, so you’re not increasing them, so he’s still in pain, but it’s better with the opiates.

Now let’s look at what’s going to happen when someone comes to evaluate your practice. Impaired control: If you ask him, “Can you go without your medicine?” he’ll say, “Absolutely not. Absolutely not. I couldn’t tolerate it.” And none of us could. If I put you in a bed, in an experiment I would never do, set your leg on fire, then beat the fire out with a baseball bat, put a bottle of oxycodone next to you and said, “Don’t reach for that; I’m going out of the room,” most likely you’re going to reach for that oxycodone. It hurts badly. None of us without severe chronic pain can understand the neuralgic pain that these patients get from nerve injuries. It is as painful for some of them as being on fire, and yet we don’t want them to take that medicine, right? Even asking for medicine can be seen as drug-seeking behavior, but it’s not. It’s relief-seeking behavior, and that used to be differentiated, but now it’s not.

Social impairment: What’s that person going to do? They’re no longer going to run around with their family and go do fun things. They’re going to be cranky and grouchy, and their family can be called in to testify, and they’ll say, “As soon as he started those medications, his whole personality changed.” Well, the truth is that as soon as his hand was crushed and he started suffering severe chronic pain, his whole personality changed. But you can’t prove that’s what it was. You can’t prove that it wasn’t the medicines. And remember, you’re not arguing to doctors; you’re arguing to laypeople.

Now, risky use: Do they ever take their medicine and drive? If they drive a car, of course they do. They’re taking their medicine regularly, and they’re driving. You’ve told them, “Don’t do it if it makes you drowsy,” and quite often it doesn’t make them drowsy at all, because if your leg’s on fire, it’s hard to sleep. That’s another problem: They take their medicine, they get drowsy and go to sleep, and their family says, “They’re on too much medicine. When they take it, they go to sleep.” But that’s because they can’t sleep in that much agony. You relieve some of that agony, and they’re finally able to get a few hours of sleep, and that’s taken as a sign of overuse and addiction, when all it is is the brain trying to catch up on the sleep the pain has kept from it.

They will develop tolerance. The medications will not work as well over time. The enzymes upregulate, and the receptors downregulate. You’ll need to increase the dose, and you’ll need to increase the frequency. And once they’ve developed tolerance and been on it long enough, they will develop physical dependence. This is not the chemical dependence described in the law, but the juries won’t know this. Physical dependence just means the body got used to a medicine. It happens with everything, including beta blockers. You take a beta blocker, it works great for your blood pressure for a few months, then it doesn’t work that well, and you’ve got to increase the dose. We all understand that if you abruptly stop that beta blocker, you can put that person into a stroke or heart attack by spiking their blood pressure. Physicians understand that, too, but by the government’s definition, that person is now addicted to their beta blocker, because they’ve developed tolerance and dependence. The DSM-5 does say that tolerance and dependence should not be applied to persons on chronic opiate therapy, but what it should say is that none of these criteria can be applied to someone on chronic opiate therapy, because all of them are suffered by these people, not because they’re chasing euphoria but because they’re trying to get relief from their agony.

Time spent acquiring the medication or drug: Their whole lives are focused on getting relief from their pain, so they spend an amazing amount of time trying to find a doctor who will prescribe it, trying to find a pharmacy that will fill it and trying to find a way to get to their appointments. They have to give up activities; that’s criterion number six. Of course they do. They can’t work, and then there’s unemployment. I have seen medical experts say, “Well, this person’s now unemployed; therefore the opiate impaired their occupational functioning; therefore they have addiction.” No, he can’t work because his hand is smashed and it hurts too badly, and he usually got fired while he was out hurt. This is America, after all; we don’t have a lot of support for injured workers. That’s not from the opiates; that’s from the pain. They’re suffering from chronic stress. Their stress hormones go up, their neurogenesis drops, and they get depression, and quite often they develop anxiety and PTSD, because something suddenly happened that caused them horrible pain and suffering, and they don’t want it to happen again. Their brain is looking for it, and it cranks up their anxiety and vigilance levels.

Attempts to cut down: When you tell your patient to use the minimum necessary to make the pain tolerable, and they’re able to go a day without medicine, they just discipline themselves and fight it, and they’re able to go a day, and then they test negative on a drug screen, that will be seen as an absolute sign of diversion, or as a sign that your patient doesn’t need the medicine, instead of applauding their ability to go on a drug holiday. I recommended that to my patients: “Try to go a day. Pick a weekend where you don’t have to do anything. I know you’re going to be miserable, but try to go a day without it.” And if they could, that is proof that they are in control. But I have seen experts testify that the fact that you asked them to do that is proof that they had addiction and had lost control, because they couldn’t stay off of it. Well, technically they could, but who would want to? No one wants to be in agony. So with attempts to cut down, you’re always trying to get them to cut down.

Desire and effort to control use: If they say, “Hey, I would like to cut back, but I can’t,” of course they do. We would all like for them to be able to cut back, but we also want them to have some quality of life. And controlling the use, again, goes back to human beings just not being very good at tolerating agony. I’ve said this before: Suffering is always good for somebody else’s soul. No one on fire ever said suffering is good for the soul.

Time spent recovering doesn’t really apply to someone on opiates, but they will nap. They will take a nap once they get some pain relief. And reduced social, occupational and recreational activities: Whatever caused the chronic pain is going to reduce all of those.

So all 11 of the criteria will apply to every chronic pain patient, and that leaves every doctor willing to treat patients with chronic pain vulnerable to prosecution. If you have not been prosecuted yet, it’s not because you’re a good doctor. It’s because no one’s been willing to lie about you, or to report you if you’re doing something wrong, like trading prescriptions for sex or cash. And I don’t mean patients paying cash for their visits, which some of them have to do, since you can’t take all insurances, and quite frankly a lot of doctors don’t like to take insurance at all because it’s too much hassle. I’m talking about getting paid for prescriptions for patients you’ve never seen. If you’ve never seen a patient and you issued a prescription for a Schedule II narcotic, you’re in deep trouble, and you should be.

But I’m talking about physicians who are being prosecuted under these criteria, because the government will take the DSM-5 into court, show the jury those criteria and then get family members to testify. And again, the three things I’ve mentioned, a disgruntled employee, an angry patient and a jealous competitor, are the things that will get you in trouble. When you fire a patient, they’re the ones who are going to be in court saying, “He didn’t do physical exams. He didn’t take vital signs.” And even if you have the records to prove you did, you have to go in front of a jury and prove it. These 11 criteria are going to be used to crucify you, because the pain patient has all of these.

They need to revise the DSM, and they need to add back the definition of addiction and the diagnosis of addiction, because no matter how pejorative it is, everybody knows what it means. It’s like when they tried to rephrase strokes as brain attacks. I remember when they did that: “Let’s not call it a stroke. We have heart attacks; let’s call it a brain attack.” Everyone pictured the old 1950s movies where the brain is jumping. It just wasn’t good, right? Stroke is good enough. Addiction is a good enough descriptor for this condition, but it only fits when the person is engaging in these 11 criteria for the purpose of seeking euphoria, not for the purpose of getting relief from their pain.

Kevin Pho: So in this framework, what are some ways doctors can navigate treating chronic pain, short of not prescribing opioids at all?

L. Joseph Parker: They have to document that these criteria exist as a result of the patient’s pain. They have to communicate with the patient and document that the patient says they cannot go without their medication, not for the purpose of feeling good but for the purpose of not suffering horribly. It’s very powerful to have things in the patient’s own words. I’m trying to work with some AI companies to get AIs to call patients and quiz them, so that you have a daily marker of how they’re doing. There are also apps being created for patients. Nothing is better than a letter from the patient themselves saying, “Here’s what my medications allow me to do. If I take my medications, I can go pick my kids up from school. If I don’t take them, I’m stuck in bed.” That is an improvement in function.

If they say, “Without these medications, I might kill myself,” that can be used against the doctor. But at the same time, many people don’t want to live a life of agony, and they can’t. Thousands of people are being thrown off their medicines unnecessarily right now, and many of them are choosing to take themselves out of the equation. I can’t say what I would do in that situation, but the fact that we might be lucky enough not to be suffering so horribly is no excuse not to empathize, put ourselves in that patient’s shoes and try to imagine what we might do. Because when these patients get pushed off their medications, they are extremely prone to suicide and overdose, because they will try to buy those same pills on the street, and on the street they are almost always fentanyl-laced fake pills. That’s what’s killing people. Prescription medicines are not killing people.

Ninety percent of overdoses are not due to prescription medicines. Those studies were done assuming that all fentanyl was prescribed because it could be prescribed, like the DAWN study, and they also assumed that even heroin was prescribed, because you can prescribe something that has heroin in it. It’s called tincture of opium, and it’s for gastrointestinal problems. It’s an old medicine that’s been around a long time; as far as I know, it’s still out there. So tincture of opium can be prescribed. It does have heroin in it; you will test positive for heroin. So they said that since it can be prescribed, all heroin overdoses are due to prescription medications. That’s ludicrous. All they had to do was check the prescription monitoring program, and no one has done that yet. No one has looked at overdoses, checked the prescription monitoring program and asked, “Did this person have a prescription?”

Ninety-five percent of people who develop addiction after being prescribed opiates had used opiates before being prescribed them and had gone to a doctor to try to get some. It’s not like we prescribe opiates and a huge number of people suddenly become addicted. Four to 6 percent of the population will have a genetic predisposition. We have to be aware of that, and it’s a fact that we needed to be more cautious in our prescribing and in our monitoring of patients. At the same time, the government’s heavy-handed response to this is absolutely exacerbating the crisis. You’ve got tens of thousands of people in agony on the street looking for something to relieve their pain, and they’re dying.

Kevin Pho: We’re talking to L. Joseph Parker. He’s a research physician. Today’s KevinMD article is titled “Vague criteria can lead to misdiagnosis and prison.” Joseph, let’s end with some take-home messages that you want to leave with the KevinMD audience.

L. Joseph Parker: For the patients: Absolutely do not take yourself out of the equation. New medications are being discovered all the time, some based on medications like ketamine that work completely differently, can help increase synaptic plasticity and neuroplasticity and might be able to relieve this nerve pain problem. This crisis will pass. At some point things will get better again, and if you’re not here to see it, it’ll be too late.

For the physicians: Understand the threat you are under. If you prescribe any controlled medication to anyone right now, you can be arrested and prosecuted for it, and you need to really study how to prescribe them and how to defend yourselves from these charges.

Kevin Pho: Joseph, thank you again for coming back on the show and sharing your time and insight.

L. Joseph Parker: Thank you very much, sir. You have a good day.