Misinformation X

I have a lot of blog posts in the works right now. That strategy works for me because my attention has always been a problem and it works better to work on many things at once rather than bogging down on one. I decided to post on this topic and the one that may be the most relevant. The content of my blog tends to go from scientific and medical topics, to social topics, to a lot of posts that address current misinformation. The Information Age has become the Misinformation Age and there is probably no better example than the platform formerly known as Twitter.

Twitter used to be an invigorating and informative place for physicians. I could count on reasonable discussions and literature references by daily participation and focusing on specific colleagues. In psychiatry – there is a chronic misinformation problem dating back to Szasz, Foucault, and others in the 1970s.  They created tropes and memes that are still repeatedly used by antipsychiatrists today to deny the reality of mental illness and the real function and value of psychiatry. In many ways this sort of criticism has generalized to the rest of medicine and that became very clear during and after the pandemic.  The takeover of Twitter by Elon Musk and his so-called “free speech” policies made that site a fountain of misinformation.  The amount of misinformation would be embarrassing to anyone concerned with the truth or reality but these days those constraints clearly do not apply.  The truth is of little value in much of what can be read on X.  I would go as far as saying the truth is actively devalued on X and you can read falsehoods about settled areas of science, medicine, and public policy.

There is a clear positive correlation between the transition in management and an increase in misinformation, hate speech, hate speech and antisemitism.  Problems also existed before that transition and some were highlighted during the pandemic. Misinformation about vaccinations, masks, and public health personnel were clear problems. Despite what happened during the pandemic that misinformation has clearly increased.  The day before I started writing this post there was a great deal of misinformation about how “jabs” (misinfospeak for COVID immunizations) cause blood clots and that there would be a tsunami of deaths from thromboembolic diseases.  Several physicians posted clearcut evidence to refute this misinformation.  Most physicians are also aware of the fact that immunization are the single most effective intervention to prevent death in large populations. That evidence, including the evidence for COVID-19 immunization effectiveness is indisputable.  Medical research on Long-COVID or chronic symptoms following infection with the virus is also clearer now. Trying to avoid that chronic state and the associated disability is another good reason to get immunized.    Practicing physicians have a healthy respect for respiratory viruses.  We have all seen healthy young people die from infections with what are considered common cold viruses.  

A great solution for physicians and scientist would be a medical or scientific Twitter.  It seems like a simple matter but I suppose maintenance and day-to-day fees would need to be covered in addition to the original programming. To prevent the vulgarians shouting in the city square behavior of X – a simple model of behavior consistent with what would be expected in a medical or scientific staff meeting should suffice. No personal attacks, gaslighting, ridiculing, etc. and active moderation.  People would certainly be able to debate the merits of climate change and other controversial topics – but the arguments would need to be based on facts and scientific merit rather than political rhetoric. People would not be allowed to post baseless claims about another person, a theory, or a piece of research. 

The defenders of name calling, gaslighting, and misinformation all tend to hide behind the First Amendment. There is plenty of evidence in the current news that there is no absolute right to say whatever you want to say about a person or a business.  Hundreds of millions of dollars have been assessed as legal penalties for those statements in several high-profile civil suits. Litigation is a crude and expensive instrument for keeping discourse focused and civil.  A specific environment is a much better approach. Instead of proclaiming a web site as having absolute free speech – it is far better to have the exchanges moderated according to specific rules. Hence the staff meeting approach.  I have certainly been in staff meetings where tempers flared, but there was no name calling or threatening behavior. There was disagreement about information but at no point was there any question about deliberately misrepresenting the information or repeatedly lying about it.  The largest professional staff I worked with was about 35 psychiatrists.  The entire time I worked there I had no doubt about the integrity or sincerity of my colleagues – even though some of the disagreements were intense. 

Who might run such a Twitter-like operation?   The American Psychiatric Association (APA) ran an email listserv that I participated in for decades.  They decided to stop this in the past year.  It had probably run its course.  The number of new participants and total participants was low.  Discussion by email tends to become too diffuse and they are difficult to reference later. There were also limitations on discussions based on the charitable status of the organization – no political discussions.  Twitter seemed like an ideal format for discussions, educational threads, and daily reviews. I doubt that the APA or AMA have the resources for a Twitter like platform but they might and it could be seen as a benefit to potential members. Doximity comes to mind.  Currently Doximity has threads that are posted as news updates presumably by their editors. They tend to be much less interesting than good Twitter threads and discussions.  A Twitter like platform would be a greater asset in attracting physicians to the site.  LinkedIn tends to have the same constraints as Doximity but it does allow member to start new threads. All of the commercial threads suffer from commercialization and overly intrusive members.  I don’t want to see an endless sequence of friend or connection requests when it is obvious that I have nothing in common with those requestors.  On Twitter – the commonalities were obvious and I knew who to follow.   

The competitors that were started based on Twitter’s obvious demise – Blue Sky, Threads, and Mastodon just don’t seem to have active physician communities at this point.  As more physicians leave Twitter – there is a clear socialization and discussion gap. It is probably obvious that I have no clear solutions for that gap – other than a hope that somebody with enough resources and insight to the value of Twitter for physicians can get a platform established.  Alternately – more networked and focused discussions on Blue Sky and Threads is still a possibility.  Either way – I think we need a functional blue bird back in one form or another….

 

Happy New Year!

 

George Dawson, MD, DFAPA 

Why The Antipsychiatrists Have It All Wrong

Twitter is an odd place to read about antipsychiatry.  There are apparently some academics in the UK who are keeping it alive and well. I sent this Tweet about the continued mischaracterization of psychiatry by various antipsychiatry factions. Those factions certainly are varied ranging from cults to academics - but they all seem to have an agenda that they are promoting. I certainly don't hope to correct their various rants and obvious conflicts of interest - only to set the record straight from this psychiatrist's perspective.

In a previous post, I pointed out how some of the more famous antipsychiatrists characterize psychiatry as monolithic and fail to appreciate both the diversity in the field and the complexity of the field.  Examples of those errors abound and I included them in previous posts about the monolithic mischaracterization and another rhetorical attack on the DSM-5.

It comes down to power and that argument is a gross distortion of reality. Before I proceed, let me say that I am talking about the time frame that encompasses my training and clinical practice. At this time that is the last 32 years post residency. During that time I have lived and breathed psychiatry and know what really happens in the field.  I came in to this field with my eyes wide open since I had a family member with severe bipolar disorder who was treated for years by primary care physicians with benzodiazepines and antidepressants so that by the time she was able to see psychiatrists - she could be partially stabilized but continued to have significant comorbidity. That family member was my mother.  As her son, I experienced first hand the lack of concern and care by any responsible entity in the community.  When she was extremely agitated and ill to the point that the police were being called repeatedly, I know what it is like when you are a kid and an angry cop says to you: "Do you want us to lock her up like a chicken in a chicken coop?" The cop of course knew nothing about severe mental illness and just wanted to leave and not have to deal with my mother's illness and her 5 young kids (my father was deceased).  In addition to my mother's illness, I witnessed first hand the toll that psychiatric illness had on the neighborhood as I walked to school every day. My point here is that I am not the only kid who had these problems.  In fact, I am certain the general view that psychiatric illnesses and addictions are diseases begins with this experience.

As a clinical psychiatrist with a solid medical orientation, my method has always been one that tries to engage the patient in a detailed analysis and solution to their problem.  Like many physicians, as a resident there is always an emphasis on what you are doing to solve the person's problem, but it was fairly evident that medical interventions themselves were risky and that higher risk interventions should be reserved for high risk conditions. It was also obvious that medical treatment depended on informed consent.  In other words provide the information to the patient and they either consent or don't consent to treatment.  It is really no different than seeing any other physician.

Since antipsychiatrists are a diverse group, they advance diverse rhetoric to advance their agendas.  That typically includes making money or seeking to elevate their status over psychiatry.  I will focus on a single common agenda and that is power.  The last time I actually studied power it was in a physics class.  It certainly never came up in medical school.  Studying psychiatry was an identical process to studying medicine and surgery.  Recognize the problems, diagnose, and treat them.

Somewhere along the line I realized that people were using rhetoric based on Foucault and whatever Szasz adapted from that to suggest that psychiatry had a hidden agenda.  It is so well hidden that it is unknown to psychiatrists.  It is more or less of a conspiracy theory that psychiatry wants to medicalize the treatment of all human behaviors and treat those behaviors as an illness.  Of course along the way, psychiatrists will enrich themselves and inflict untold suffering on the people they misdiagnose and treat.  Take a look at this argument that the DSM-5 was supposed to be a manual about how to live as an example. Their supporting arguments range from the non-existence of all mental illness to the fact that there are no tests that prove there is such a thing as mental illness.  The underlying antipsychiatry theories are predominately from the 1960s and 1970s and they have been classified by philosophers (1).  There has been little change since then - just a long series of repetitive recycled arguments.  The rhetoric can range from the recycled arguments of Szasz to overt threats.  One uniform feature of antipsychiatrists is that they believe they are above any sort of criticism.

The table below contains some of the common rhetoric used by antipsychiatrists. It is not exhaustive, but it is a good example of the rhetoric I referred to in my Tweet.

Here is why their power arguments and all of the associated rhetoric are irrelevant. The reality is that psychiatrists represent only 5% of mental health providers in the US.  Primary care physicians and now nurse practitioners and physician assistants prescribe far more medications than psychiatrists do and they have for some time.  Even though psychiatrists are a little slow in picking up on it – health plans are replacing physicians with non-physician prescribers and that is also true of psychiatry.  In fact, in most cases if you are trying to see a psychiatrist about medications you will end up seeing a nurse practitioner. Does that sound like an all-powerful profession?

The second point that the detractors seem oblivious to is that physicians in general have not run the field of medicine for the past 35 years. Nobody cares what a psychiatrist or for that matter any physician has to say.  Businessmen and politicians determine who patients see, for how long, and what those physicians are paid.  The only exception is specialty groups (Radiology, Orthopedics, Neurology, Urology, Ophthalmology) that can avoid employment relationships with healthcare organizations.  Does that sound like an all powerful profession? Strange that the antipsychiatrists with guild issues don't get that since they are under the same constraints from these monopolies.  

More to the point – if you see any physician in the USA and you don’t like what you are hearing – you are free to walk away and see somebody else.  It is not a question of being a victim of medical or psychiatric treatment.  In fact, psychiatric treatment is just as straightforward as I have portrayed it.  Come in, sit down and we will talk about your problems. My job is to give you the best possible scientifically based advice.  Your job is to decide whether to take it or not.  There is no medical treatment known that does not involve some risk.  Accepting treatment involves risk. If you accept that risk and are injured that does not mean that you were intentionally victimized by that physician or the profession.  In fact, only antipsychiatrists seem to routinely use that argument. 

Consider an example very familiar to me. Let’s say you are diagnosed with a hormone secreting pituitary adenoma.  The neurosurgeon you are seeing recommends removal but also says there is a chance that the carotid artery may be cut and the result would be catastrophic and irreparable.  Your choices are an experimental procedure with an uncertain outcome that may lead to surgery or radiation therapy (gamma knife) or doing nothing and trying to manage symptoms that will lead to your eventual death by congestive heart failure.  The risks are clear and significant, but the majority of people who I have met who have had this conversation decided on surgery. Antipsychiatrists will say it is not the equivalent to a suicidal person deciding to take an antidepressant.  I would say the risk of no treatment is equivalent, but the actual risk of psychiatric treatment is much less.  I have not seen a catastrophic, irreversible event from taking antidepressants as prescribed.  As far as the power dynamic – there is no comparision.  Being unconscious under general anesthesia for hours while an ENT surgeon and a neurosurgeon drill through your sphenoid bone into your pituitary fossa doesn’t compare to consciously talking to a psychiatrist for an hour, picking up a prescription, and then deciding on a day to day basis to keep taking an antidepressant pill.  There is really no comparison at all.

The point of this example is not that patient injuries do not occur during patient care. The point is that they do occur but that is the risk people generally have to take to get well.  The notion that psychiatrists are somehow more likely to cause these injuries and that the entire profession should be blamed as a significant cause of injuries compared with other specialists is a dubious argument at best.   

Antipsychiatry rhetoric has really not changed much over the years.  There is just a question of how much distortion, overt paranoia, or conflict of interest it contains.  In the 50 years that the antipsychiatrists have been hard at work, they have had more than ample time to come up with an alternate way to help people with severe mental illness.  To my knowledge they have not come up with a single treatment for mental illness. Of course that is no problem if you don't believe mental illness exists or that there is any way to diagnose or treat it.

That would also mean that the antipsychiatrists would have to do something positive instead of just blaming psychiatrists.  I am not holding my breath for that day to come.

George Dawson, MD, DFAPA




References:


1:  Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.



Graphic Credit:

Samei Huda contributed 3 points on the graphic.

Another PSA On Pain, Opioids, and Addiction

It turns out that Twitter is an inadequate forum for discussing the issue.  Twitter is an ideal format for discovering if a poster knows anything at all about the problem.  A lot of people don't and they seem to just be there to argue.  I don't have a lot of time to waste on political approaches to medicine.  Political approaches to medicine typified by managed care companies, pharmaceutical benefit managers, and government guidelines that are supposed to improve care but don't are the reasons we have an expensive, fragmented and inefficient health care system.

The apparent political factions on Twitter consist of pain specialists who take the position that pain care and access to opioids is now being rationed and their pain patients are being unjustly treated.  They claim there is a faction of addiction specialists making various claims that they take offense to.  But my experience there is the past few days is that these are all basically red herring arguments.  A few of those claims include the idea that addiction specialists would consider pain patients "drug seekers", would recommend treating pain with only acetaminophen, are calling pain specialists "quacks", and of course that addiction specialists have some interest in distorting and overplaying the dangers of opioids.  In some cases the arguments have gotten to the absurd claim that the pain advocates (or more appropriately anti-addiction contingent) claims that most heroin users start using heroin directly rather than using legitimately prescribed or diverted pain medications first.

Where is the reality in all of this distortion?  The reality centers like most things in medicine in primary care settings.  The hundreds of thousands of internists and family physicians who provide the bulk of care for almost all problems in the US.  As I have posted on this blog many times, the evidence from both the CDC and CMS is that the majority of these physicians do a good job with opioids.  Only a fraction of their number prescribes a disproportionate amount of opioids.  Many of these physicians have a bias to underprescribing if anything.  That means the bulk of physician punitive legislation about mandatory course for opioid prescribing for these physicians will be just that - punitive toward most physicians who already know about prescribing these medications.  That legislation is also untested in terms of whether it will have any impact on the physicians who are overprescribers.

The other facet of the problem is overprescribing in general.  Part of the quality problem in medicine today is that the business and governmental management systems are focused on a brief physician-patient encounter where some medication gets prescribed.  That is the focus of the encounter. Patients expect that and come in the door with a medication request.  That results in predictable overprescriptions of medications from many classes.  The classes that reinforce their own use - opioids, stimulants, and benzodiazepines are more problematic than the rest.

At the extremes of this landscape are the pain specialists on one end and addiction specialists on the other.  Both have a broad spectrum of quality settings from state of the art to nonexistent.  These specialists know this and they know there is very little that can be done about it except to mind your own business and do the best job possible.  There are pain clinics that are "pill mills" where there is an understanding that a cash exchange with a prescriber will get you a script that can be filled on site for opioids.  That prescription is then sold in the parking lot for diversion.  There are other pain clinics where no attention is paid to addiction, psychiatric comorbidity, polypharmacy or the functional capacity of the patient being treated.  There are similarly low quality addiction treatment facilities where people are warehoused with no active treatment.  Where there is no therapeutic environment because nobody in the program is willing to consider that they may have an addiction.  There are programs where there is no medical supervised detoxification.  There are programs where there is no medication assisted treatment for opioids or alcohol use.  There are programs that do not address psychiatric comorbidity.  There are programs based on some sketchy ideas that have no proven relevance in treating addictions.  The houses of both pain and addiction specialists are not perfect because of these serious flaws.  And let's face it - the regulators of every state in the union are to blame for having so many low quality pain and addiction treatment facilities open for business and accepting reimbursement for shoddy services.   

For a moment - let's return to the idealistic world of the Twitter protagonist where the position seems to be "I am all knowing and do a perfect job."  The realities will  differ based on whether you are on the addiction or pain specialist end of the spectrum.  To illustrate, I am on the addiction end and 100% of the people are see have addictions or substance use problems.  On any given day the problematic substances average out to about 30% alcohol, 30% opioids, 20% mixed, 15% stimulants, and 5% cannabis.  Of the opioid users 30-50% have chronic pain problems.  In every case, I have a detailed discussion with the patient about how their substance use problem evolved and what keeps it going.  Over the years I see thousands of people with these problems and in that process come to know a lot about the associated issues.  My opinion is not based on my personal experience or politics.  My opinion is based on understanding the problems of thousands of people that I am supposed to help.  For example, when somebody tells me that the "average" heroin user in this country starts using heroin rather than prescription painkillers - I can say that is unequivocally wrong.  I have heard all of the details about how heroin use begins and it is almost always with a prescribed or diverted pain medication.  When somebody tells me that taking a person who is addicted to opioids and who has chronic pain off of opioids is cruel - I can also say that they are wrong.  I have had those same people tell me that they have never felt better and in less pain in years.   I can also say the following based  both on research, theory and clinical experience:

 1.  A significant portion of the population is predisposed to addiction - 

My estimate would be about 40%.  When a genetically predisposed person uses an intoxicant their reaction to it is markedly different from a person who lacks that predisposition. Opioid users report an energetic hypomanic felling where they have mental clarity like they have never experience before.  In some cases they will say that they felt like they had become the person they always thought that they could be.  This is a highly reinforcing state that leads to more opioid use.

2.  If the population predisposed to addiction is significant - the only limiting factor is access or availability -

This is the basic reality of the current opioid epidemic and of course very drug epidemic (methamphetamine, cocaine) that the US has seen over the past 200 years.  It is quite easy to look down from the high perch of a low availability area with low addiction rates to a high availability area with high addiction rates and conclude that "there is something wrong with those people".  The usual conclusion has been that they are morally defective.  This is how addiction services have been rationed, poorly researched, and fragmented over the years.  Even if you subscribe to a top health plan in the country - it is likely that you will have poor access to quality addiction care because of these attitudes.

3.  The burden of prescribing medications that reinforce their own use falls squarely on the prescriber - 

It is above all else an informed consent issue.  The patient needs to know that the medication they are taking is not a panacea and that there are significant risks up to and including addiction and death.  They also need to know that these medications can have cognitive side effects and affect their day-to-day functioning.  They should not be prescribed solely out of the notion that the physician feels like they need to do something for the patient.  There needs to be a pain diagnosis and treatment plan.  In the case of chronic pain the patient needs to know that there is no known medication that completely alleviates chronic pain and therefore continued dose escalation of opioids is not a solution.  The treatment plan needs to contain more elements than taking the opioid prescription.

An associated prescriber issue is polypharmacy.  Chronic pain is frequently associated with anxiety, depression, and insomnia.  That can lead to a contraindicated polypharmacy environment that includes a benzodiazepine, a z-drug, or a sedating antidepressant used with the opioid.  It can also lead to the patient taking alcohol or diverted sedatives on their own initiative with the opioid.

4.  Chronic pain patients taking opioids need thorough evaluations if possible -  

Some people in the Twitter debate seemed shocked by the idea that opioids are taken for reasons other than pain relief.  I suppose they would be even more shocked if they heard that there are people that take them who get no pain relief at all from them.  They taken them strictly because of the positive euphorigenic effects.  There are also people who take them despite the side effects for the same reason.  The first thing a physician needs to do is step back from the indication - prescription mode that most American physicians have been trained in to take a look at the entire prescribing landscape.

That means that is a person has come to idealize a medication or abusable substance they will start to use it for anything - insomnia, anxiety, depression, or "just to feel right to get through the day."  As many people tell me: "Look doc - if you can't get rid of this depression I know what I can take to feel OK for a couple of hours."  On Twitter and some other blogs readers are incensed that these behaviors exist and yet they are documented in the literature (see paragraph 6).

When I say if possible I am more aware of the fact that patients lie to physicians than non-addiction specialists.  I have had an endless number of patients tell me that they can get whatever addictive medication they want out of one physician or another.  The Mayo clinic had an addiction medicine conference three years ago and one of the presenters was a patient in recovery who basically talked about how he systematically lied to physicians to get opioids for years.  He talked about how he could identify a physician who would give him the script that he wanted and who would not.  In the case of the latter he would just move on to another clinic.

Many non-addiction specialists consider it to be poor form to suggest that patients lie.  That denies the basic reality that everybody lies.  It also denies the reality of addiction, that you are transformed into a person who is dishonest and a person that you never thought that you would become.  In the addiction field it is critical to acknowledge this to help people deal with guilt and shame so that they can recover.  The worst thing that can happen is to collude with dishonesty when the final result is the prescription of an addictive drug.  I do not consider it to be an issue that I can get this history when the physicians being approached for the medication cannot. It is all part of the illness of addiction.  On the other hand, if you are the opioid prescribing physician - the amount of information that you can get asking the direct questions about problematic use is not known until you try it.   

All things considered it is possible to treat people with chronic non-cancer pain with opioids.  I have been involved in that treatment before I switched to seeing only patients with addictions.  I consulted with some of the top pain experts in the state.  All the limits in this post need to be acknowledged and cautiously addressed.  The treatment of chronic pain is not perfect, I know that because I see a lot of the failures.  Addiction treatment is not perfect either.  The treatment needs to be highly individualized.

I wish that I could provide more clear guidance to the patients involved.  As an individual I cannot just start pointing fingers at the places (pain clinics and addiction treatment) that I think should be shut down.  I think that you need to depend a lot on your primary care physician referring you to places that he or she knows will do good work.  On either the addiction or pain end of the spectrum - there has to be more going on than the prescription of medications.

Even the most basic psychological models suggest that other cognitive, emotional, affiliative, spiritual and reconditioning changes need to occur.


George Dawson, MD, DFAPA