…and back again.

The CDC guidelines on opioid prescribing just landed like a ton of bricks. The media blitz has begun.

They’re pretty straightforward. In the context of the most godawful opioid epidemic in living memory, you could probably guess the content without seeing them. Let’s try a game, shall we? Pick the item not included in the recommendations. The answer is at the end, NO PEEKING!


 

  1. Opioids are the work of Satan on earth.
  2. People who take opioids are likely to BECOME ADDICTED AND DIE.
  3. Nobody should ever take opioids for acute pain for more than 3 days or they could BECOME ADDICTED AND DIE.
  4. OPIOIDS = DEATH
  5. Ibuprofen is nice.

 

The answer is number 3; the guidelines actually recommend no more than 7 days of opioid therapy for acute pain.

OK. I’m exaggerating some.

My feelings about this, I admit, are a little paradoxical. I spend half my days withdrawing people from heroin and trying to get them into long-term treatment, and the other half dealing with folks whose pain treatment has gone completely to hell. I do all this in one of the most drug-ravaged cities in the country. If I found out what proportion of the inpatients I have seen over the years died in this overdose epidemic I probably wouldn’t get out of bed for a week. I have been up close and personal with the failures and horrors of opioids for my entire professional life.

To be clear, my discontent is not exactly with the guidelines and certainly not with their intent. Opioids were handed out as monotherapy way too often, with way too little evidence of long term benefit, and with remarkably little appreciation of long-term risks.

Here’s my problem: I don’t think the steady drumbeat about the dangers of opioids is as much a change of course as it is part of the same cycle that produced the epidemic in the first place. If that’s true, then I suspect we’re just setting ourselves up for the next one, a generation or so down the line.

Here’s my take on the history of these epidemics. On the upswing, generational forgetting sets in and the horrors of the last epidemic fade, and maybe some new thing happens. Perhaps there’s a newest-latest-greatest drug that’s “different.” Less stigmatized, believed to be less habit forming, or what have you. Perhaps a higher potency, cheaper version comes out. It could be any of those; but some combination of destigmatization, increased availability, a more behaviorally powerful drug, and perception of low risk gets a lot of people exposed.

At the crest, the drug spreads up the social ladder – suddenly it is not just the endemic population of impoverished, stigmatized “criminals” who are using it; it’s Aunt Effie who’s hooked on her pain pills. Alarm bells start ringing.

On the downswing, the stigma reasserts itself, new legal and regulatory controls are put in, and the drug’s perceived safety goes out the window. Any benefits are judged to be trivial relative to the risk and, in hindsight, any who believed otherwise are considered naive fools. The drug settles back into the endemic, stigmatized population and bides its time.

Thus we find ourselves at the crest of the opioid epidemic, and just starting to notice that we’re in the midst of a benzodiazepine epidemic, while happily skipping along as marijuana slides from illegal to pseudo-medical to accepted recreational. As to the latter, I don’t think it’s a coincidence how many people have been showing up in ED’s rip-roaring psychotic off the various synthetic cannabinoids that you can buy in a 7-11 these days.

Here’s what doesn’t happen: We never figure out what the actual risks and benefits of these @#&#^ things are. While in one generation we decide cannabis is the destroyer of youth and weigh down research; in the next that very lack of information allows anecdotes to fuel its return as a “treatment” for everything from glaucoma to nausea to mood disorders.

So now we’ve gone from “there is no top dose of opioids” to “over 50mg of morphine is the danger zone” in the last ten years or so, with barely a shred of evidence in support of either. Pop back over to those CDC Guidelines, and you’ll notice the evidence base for these recommendations is barely better than expert opinion. That being exactly the grade of “evidence” that led to the prior approach to pain that got us into this mess.

So the pendulum swings back. Again.

Where is the sweet spot between deadly ignorance and what have we done? What is the rational approach to the use of opioids?

We still don’t know. 

As physicians we are advised to take functional outcomes into account, when opioids have but moderate effects on chronic pain intensity and even less on function. We are advised to screen for risk of addiction when that entity is poorly defined for prescribed opioids,  and the instruments that purport to screen for it are poorly validated and barely break a sensitivity of 50%. It also doesn’t address the public health consequences of putting opioids in more medicine cabinets.

So are we any closer to preventing the next epidemic, once we work our way through the shattered lives, and death, and the secondary heroin epidemic, and the tertiary spikes in HIV and hepatitis and crime and all that misery? Are we finally going to learn something?

Oh, I hope so. I just don’t see it happening. In my more optimistic moments, I think there are opportunities to learn. There are testable hypotheses here. Here are mine:

  1. Long-term (years) chronic opioid monotherapy for chronic pain probably doesn’t work all that well, though it might do something.
  2. The endless pseudoaddiction vs. addiction debate will only be settled by (mostly) ignoring it and agreeing on identifiable, countable aberrant behaviors as bad outcomes.
  3. The risks of chronic opioid therapy depend intimately on how risk-averse prescribers are. When prescribers think it’s high risk, only the most carefully selected patients are exposed and adverse outcomes are minimal. That implies that in the opioids are evil era prevalence of bad outcomes will be low, which then primes the pump for the generational forgetting that can drive the next opioid epidemic, just like the success of vaccines opens space for the anti-vaccine movement.
  4. Attempting to treat chronic pain with a comorbid severe psychiatric condition without making treatment of the psychiatric condition co-primary (or, maybe even primary) is a losing game. So we have to fix the ridiculous divisions in our payment system.
  5. Standard addiction treatment systems are poor at managing people with opioid use problems and chronic pain. That has to be fixed or screening for addiction in this context becomes a circular mess. It’s a sick, sad thing when someone has to wind up switching over to street heroin to finally get into treatment for addiction, but that’s what I’m seeing aplenty these days.

In all fairness and in a moment of seriousness, I applaud what the CDC is trying to do. What I really, really want is for us to stop the cycle of stupidly lyonizing these drugs, causing untold harm, then demonizing them in a panic. The problem isn’t whether they should be demonized or lyonized.

The problem is the stupid (and the panic).

In the absence of any new, real data; I’m afraid we’ll win the battle only to set the stage for the next one. I may still be alive, and maybe even still practicing, to see it.

Here’s hoping I’m wrong. What I’m seeing right now is a bloody disaster, and it would break my heart to see it again.

Teetering.

“I’m kind of scared of it, yaknow’msayin? Like, I’m gonna lose my edge.”

He’s talking about stopping heroin. He’s a lifelong dealer, so that has to change, too. There’s a crude but clear slogan in the Fellowships around here: “A monkey can’t sell bananas.”

“Doing what I do, you know, you make enemies. For all I know, I relax, I forget to look behind me one day, and something from 15 years ago comes up. That’s it for me.”

He’s still wearing a hospital gown but it’s backward, showing his chest. He sprawls with the affected don’t-give-a-damn manner common to the street guys, but there’s a restlessness.

He should go to a residential program after he leaves but he doesn’t talk about it. It’s his first time getting help, and he doesn’t know anything about recovery. Instead, he talks the three cardinal just haftas. Just hafta be strong, just hafta remember how bad it was, just hafta get a job and keep busy. 

Me, I translate strong to mean walk blindly into temptation and expect not to give in. Memory fades too, scary fast.

The other things he talks about are his girlfriend, and moving to the county. Getting a house to themselves, after getting a warehouse job.

Half the time he talks about these things he’s not looking at me. Then he sounds like  he’s making up a story and listening if it sounds right, or maybe trying to convince himself.

He reminds me of this soldier who left Afghanistan and landed in a bottle. The two of them look nothing alike, but the soldier talked about marrying his girlfriend and getting a job in the same way; like it was some place he had only read about. I remember thinking, “So that’s what the thousand yard stare looks like.”

The man in front of me has taken some bullets, too. There are still some left in him. I reckon he’s dealt a few as well, but I don’t inquire after that. Best to wait until he’s willing to tell the truth, rather than having him lie and then have to stick to it.

One minute he talks about how the drug life kept him sharp, and strong. He’s afraid if he’s not hustling, if he drops his guard, something – seen or unseen – is going to get him. It’s a belief rooted in a kind of backward Darwinism. If you’re still alive, you must be the fittest. So what kept you alive must be working.

The next minute he talks about how the drug kept him numb, and mean. How he’s chasing a high that barely even happens any longer.

“I lie to my family. I hurt people, you know. I break laws all over, and then the law takes my freedom. I’m tired of all that.”

He’s never held a real job for longer than a month. I’d lay solid money he’s never written a check or had a bank account. Never had to swallow his temper when a boss talks down to him.

Early on, the dealers have a similar problem to the prostitutes – access to large amounts of cash fast. They have records, records that include things like “with intent to” or “with a firearm,” so bad jobs are hard to get and good ones might as well be on the moon. Unlike the prostitutes they make victims and nobody thinks they are victims. They get locked up for long times for doing very, very bad things.  Drugs make the money, then drugs take the money. The meat grinder keeps turning and young men’s corpses pile up.

He’s right about old times coming back. You can quit the life but it may not quit you. Somebody he burned might be waiting outside his mother’s or sister’s or girlfriend’s house one day.

With all that: Here he is, though. I’ve met a lot of men in his line of work. Some take pride in what they’ve become, slyly bragging about what they think they’ve gotten away with; or just doing their best to impress me with their brutality and callousness before talking about how they’re tired of it.

This fellow, he’s not in that spot. There’s real remorse there, mixed in with a fear. Fear, I think, of peace. Having it but not belonging in it, or finding out it’s just a story he’s been sold. Having heard his history, I can’t say I would trust it, either.

A question everybody faces, but magnified twenty fold for him: What do you pick, what you know or what you want? Hope or fear?

I like the ambivalent ones. The ones who want to stop but are afraid of everything that could go wrong, who still remember the good things about the drug life.

They are the ones for whom a thumb on the scale could tip it. They’re the ones you can help.

I say, “Sounds like there was a lot you liked about that life.”

He looks at me, just a little surprised. I’m supposed to be lecturing him. I won’t.

Yeah,” he says. “I know it’s crazy, but there was.”

“So when it comes down to it, how are you going to keep yourself from doing what you want?”

“I’m not even thinking about that now.”

“You will, and you are.”

He doesn’t say anything. That’s good.

“You’re going to have to deal with a lot of things you have never dealt with. That’s going to be rough.”

“Yeah.”

“You think you’re going to do that by yourself?”

He looks at me, the tiredness and sadness looking out of place in that sprawl.

“No.”

It’s on.

 

Redemption through irritation management

Dr. K’s Law: Use your irritation to help the patient.

When last we left our heroine and her interlocutor, Arpie had just provided a story that strained the principles of probability, thermodynamics, biochemistry, and behavioral science. She risked tearing a hole in the space time continuum to convince Dr. C. she was not using marijuana.

A question was raised toward the end, there; a question about the character of this Dr. C. person and his backing Arpie into a corner about her (admittedly, glaringly obvious) lie. Is he, perhaps, enjoying this a little too much? This cat-and-mouse, I’ve-got-you-my-pretty game he’s playing?

What if you knew that every minute poor Ms. Arpie is squirming, Dr. C is chewing nails, too?

Dr. K’s Law is named after one of my many mentors, a brilliant and all around loveable curmudgeon. The good Dr. K was known for:

  1. A scent reminiscent of burning cured leaves wafting from his non-smoking office. Strange, that.
  2. A picture from a certain era involving long hair and a Harley.
  3. A vocabulary that would make a $10 impolite-word-for-sex-worker blush.
  4. Being approximately 95th percentile in eff you.

I love that SOB, for the record.

In addition to the above, Dr. K was known for taking on some patients that most other docs would not touch with a very long and highly insulated pole. The severely personality disordered, the manipulative, the deceptive, the intolerably histrionic. He took absolutely no crap off them. He liked them. He thought they were fun. He got them better.

Now, how could one of the most no-s@#t people you could ever meet manage that feat? Because he is an absolute master of managing countertransference, you see.

A little technique here: “countertransference” is a historical word that harks back to psychoanalysis. Without getting too bogged down in (completely crazy and unsubstantiated) theory, “transference” is the patient’s reaction to the therapist, which is expected to echo relationships with important prior figures. In psychoanalysis, a lot of the technique involves the therapist “interpreting” the transference, pointing out how the therapy mirrors life, thereby helping the patient achieve insight so the patient can stop repeating these patterns.

Countertransference is the therapist’s complementary reaction to the patient. 

General therapeutic principle: Countertransference sucks.

Here is an example of the development and operation of countertransference:

Patient: Hello, Doctor. Thank you so much for your help last week.

Doctor: So you took my advice and had that conversation with Jenny?

Patient: After I thought about it, I decided I was making a mountain out of a molehill.

Doctor: So you didn’t discuss your sense that she’s been undercutting you?

Patient: No.

Doctor: I see. Well, how have you been doing?

Patient: OK. It’s just whenever I talk about my work, Jenny tells me to stop complaining. I feel like every aspect of my life is just miserable.

Doctor: Quietly contemplates risks and benefits of executing WWE style backhand slap upside patient’s head.

The doctor did not, in fact, execute a WWE style backhand slap upside the patient’s head. He did not consider it. Even for a moment. This is entirely fiction.

If he had done such a thing, that would be countertransference in a nutshell. One of the things that makes psychiatrists (and all other psychotherapists) different is that when we’re doing psychiatrism, we have to be looking three different directions.

The first is the everyday talking-to-someone level. Then there’s the inward eye, watching constantly what you’re feeling and thinking, looking for something fishy. Am I angry? Sad? Pitying? Is it more than it should be? That’s the countertransference. Last is the version of yourself that stands six feet to the left and watches. What is it about this interaction that is triggering that feeling? That’s the process, the secret dirty trick of all psychotherapists. After that last part, it is time to employ the Second Law.

In the best case scenario, the next few minutes go like this:

Doctor: When you first came to see me I asked what the trouble was, and you didn’t know, except that you had some sense that you were “stuck.” Since you couldn’t see any particular problem to address, I started offering you specific advice. Each week, I offer more advice, and you say you will try it, but so far not much has changed. To be frank, I’m  getting pretty frustrated. Yet still, despite the fact it clearly doesn’t work, I find myself telling you what to do.

I remember you said that Jenny constantly nagged you to do things, and she didn’t understand how hard it was for you. You said you kept trying to do what she wanted, but eventually just gave up and ‘shut down.’

When I look at what’s happening in therapy and what happened with her, I wonder if there may be some common pattern?

Patient, as heavenly shaft of light shines down upon him: O sage and clear-eyed doctor, now I see! I seldom directly deal with the obstacles in my life. When someone offers advice after I complain about my lack of progress, I resent her for making me feel guilty. Eventually she takes me for a passive-aggressive kvetch and explodes, thereafter executing a WWE style backhand slap upside my head. Eureka! My eyes are open! No doubt I will have difficulty overcoming my passive coping style, but at least I can communicate to people that I only need them to listen when I have a difficult time; and perhaps I can commit to using that listening time to come up with plans rather than simply complaining and resenting my partner for making suggestions I find frightening. Thank you, O healer of my soul!

That never happens, but oh it felt good to pretend for the few minutes it took me to write that. Actually, I’m going to pause and savor that for a couple more seconds. Pardon me while I glow.

To be completely fair, that does happen. What I just presented is the  “inspired by true events,” Lifetime network,  “Courageous story of a woman who escaped her baby-eating Satanist husband” version of the process. The way the real thing works is a lot more slowly.

Back to Arpie and Dr. C.

A thing you might not know, on account of your not paying attention when I didn’t tell you, is that this little encounter is the middle of a longer story. The beginning was some weeks ago, when Arpie brought someone into her house who was actively using drugs against the advice of everyone she knew, including her counselor and the good Dr. C. Not only is Arpie lying, she is lying to the people who care about her who are exactly the ones who told her not to get into this situation in the first place.

After heaven knows how many cycles of this, Arpie’s friends and family are long fed up with her. Let’s be frank here, Dr. C. is pretty fed up, too. So is her counselor, an otherwise superhumanly patient soul who’s been on the front lines watching this slow rolling train wreck for weeks and powerless to do anything about it. 

Dr. C. could just call her on this crap, and tell her straight out that she’s lying and he’s not going to reward such behavior by cutting her any slack. Satisfying, in its way. The psychotherapeutic equivalent of the WWE upside-the-head slap option. Except, you see, confrontation doesn’t work so well. Particularly for somebody who’s angry.

Why? Could be for a thousand reasons. The lie, like other strategies for dealing with a problem, has a function. Just ripping that crutch right out from under someone probably just leaves him flat on his tuchus , equally scared and frustrated but with no idea what to do about it. Which tends to mean he gets really mad at whoever dumped him on his tuchus and maybe just bails right out of treatment. At which point the Fundamental Law of Prognosis takes full effect.

(Attentive readers will note I just avoided unprofessional language such as a@@. I’m getting better!)

Alternately, Dr. C could just nod, smile sympathetically, and let nature take its course. Let her keep lying until she slams head first into reality. That will teach her.

Except it won’t. The goal is to stop the relapse in progress; not to let it take its course until she’s a bloody wreck and out of treatment to boot.

So calling her out doesn’t work, and doing nothing doesn’t work. Now what?

Dr. C. spent some time building this cognitive dissonance up. Is it because he’s an antagonistic #$@# and he’s miffed with her? Let’s be honest: YES. Countertransference is certainly a factor here. 

In his defense: It is, however, consciously managed countertransference.

Perhaps someone who has certain . . . difficult .  .  . personality traits and some hard earned (through the equivalent of a number of WWE-style-yadda-yadda from reality and the occasional friend, mentor, or wife) self-awareness may apply those characteristics to the present situation in some way that is beneficial to his patient.

For one thing, he is one stubborn @#%#@, and he doesn’t like letting one of his flock go without a fight. For another, he likes the underdogs. Perhaps he has some sympathy for those with certain ahem personality characteristics.

So maybe, just maybe, he used that rough streak and his own irritation to set up an endgame. Cognitive dissonance is the motivational equivalent of stored energy. It wants to discharge itself. While Arpie’s doing her level best to dodge the consequences of her behavior; this Dr. C. keeps just forcing her over and over to become more and more uncomfortable with how inconsistent what she’s doing is with the better self she’s been building. Even more diabolical, he hasn’t given her the least excuse to blame him for it.

Now, what can that endgame be?

Maybe saying something like:

Arpie, I have no crystal ball and I can’t read anybody’s mind. There are two possibilities, though. One is that you’ve been positive for marijuana for weeks on several pretty specific laboratory tests, and you’re not using. If that’s the case, then I am terribly sorry for what is about to happen to you. You’re going to lose this program.

The other is that you’re doing something that’s causing this. It wouldn’t be unusual if somebody was reluctant to talk about that. But that’s actually the better option. Because if that’s true, then you can do something different.

If this program matters to you, and there is anything at all you can do that will lead your tests to be negative, you should do that. We all care about you, and you’ve done really well here, and we would hate to lose you.

Every word is absolutely true, absolutely authentic, and passive-aggressive as all get-out. The lie is called without being called. There is nothing to manufacture anger from and blame the injustice of it all for what she’s doing. She’s stuck, faced only with a bunch of people who care for her and her own behavior, and that wrong feeling in her gut.

Arpie looked a little trapped and sputtered half-heartedly for a while. Then she looked lost, like all the fight was out of her. She walked out looking resigned.

What happened after that?

She pulled it out of the fire. Well, the one Arpie mostly is pulled it out.

It took a while for the testing to show up negative – weed takes a long time to wash out. Could be that she got an extra week or two once some doctor or other heard that she threw that guy out of the house. Could be.

The day came, though, when she tested negative and got back into that better life.

Hopefully, she never has to deal with that Dr. C guy again.

He can be . . . difficult.

He does mean well, though. Every once in a while, he probably even helps somebody out. Not every time. Let’s hope, for his sake and his flock’s, that it is enough.

Maybe there is enough redemption to go around.

Let’s hope.

 

…with both hands and a flashlight.

Dear my friends in the news media, repeat after me:

An infant cannot be born #$%#$% addicted to drugs.

I do not know what’s been going on lately, but I have seldom heard so much flat-out stupid, uninformed, backward reporting on the opioid epidemic as I have been hearing in the last couple of weeks. It’s been so widely distributed among different outlets that I’m not sure it’s even fair to single out any one particular corporation.

The first such noises I heard were about “fetal assault” laws. It boils down to threatening imprisonment for women who are pregnant while using illegal drugs if they don’t get treatment. The getting-into-treatment part I dig; however, interestingly enough, one often finds such States have a lot more room in jails than they do in treatment programs. Funny, that. Wouldn’t it be nice if the States had enough treatment slots to provide treatment on request and massively ramp up the drug court system, instead of all this retroactive stuff? I think so.

The media pointing out the ethical problems of this is fine with me. However, we got into a whole other realm when pregnancy outcomes started getting discussed. One was the neonatal abstinence syndrome – basically, opioid withdrawal in an infant. In some of these reports, reporters were constantly and unself-consciously referring to “infants born addicted to drugs,” including when talking about kids born to mothers who take methadone or buprenorphine.

There are several huge problems with this and I’m only going into a couple because I’ve already had too much coffee and I’m trying to maintain normotension. The first is this: Why are you not talking about cigarettes and alcohol?

To be fair, this is a problem with the media and with the legislatures. Illicit drugs are tremendously stigmatized and they do godawful amounts of damage, but let’s face it – the legal drugs probably cause the most public health harms. If your goal was seriously to impose consequences to prevent pre-natal injury to infants, you would hang a breathalyzer around every pregnant woman’s neck and lock up anyone who tested positive for nicotine while pregnant. In terms of long-term outcomes, “neonatal abstinence syndrome” is probably nothing much compared to fetal alcohol syndrome and all the stuff that smoking can do.

So that’s one. Here’s the second: the constant lumping of therapeutic drugs in with active addiction.

It happens several ways; one of them with the use of the word “clean.” As in:

She couldn’t tolerate the withdrawal, and her doctor told her that quitting cold turkey could be dangerous. So she went to a methadone program, hoping that it could serve as a bridge to getting clean.

Because, you know, nobody on methadone is really “clean.” Even if, for the last 5 years, she happens to be showing up to work at 8:00 every morning, leaving at 6:00, looking after her kids, abiding by the law, paying taxes, and generally being a productive human being. She is still “dirty.” Unlike that guy who just walked out of detox two days ago and refused to get into the treatment that would keep him from relapsing in the next two weeks. He’s “clean.” Right? Right.

I wonder how many reporters writing these stories spent the morning talking about who’s “clean” and who’s “dirty,” and then hoisted a couple at happy hour after work.

I get my knickers particularly twisted about this because this stigma kept coming up for the people in a program I worked in. They had to be careful in the Fellowships because even though some newbie might be nodding out in the back row with pupils the size of the period at the end of this sentence; if they talked about being on methadone, they were instantly “unclean.” It’s even more ridiculous out in the community, where being on either methadone or buprenorphine cuts you off from all kinds of resources. You can have treatment for your cravings and withdrawal, or you can have a roof over your head, but not both. Crazy.

The common thread to this craziness is a fundamental confusion.

Addiction is a behavioral disorder.

You cannot know how people are behaving based on what chemicals are in their blood. Go to a cancer ward and check out how much morphine and fentanyl are floating about. Now ask which of them should be locked up, or which are “dirty.”

This also is why you can’t be born addicted. No three-day-old is going to raid Daddy’s medicine cabinet or slip out to the corner to meet his boy to cop some pills.

It’s about how you act. There are situations in which taking opioid medications, like methadone and buprenorphine, helps people act better. It helps them stop using, stop getting infected with really nasty viruses, helps them turn into functional parents and citizens. As long as there is some implicit assumption that success only counts if you do it without medicines, and the highest goal for addiction treatment is to be medication free; we will be encouraging people to stop doing stuff that works. That is not the way we’re going to dig our way out of this hole.

I don’t know why these various media outlets feel they can file such reports with an obvious lack of expert guidance. Any good they do questioning the ethics and effectiveness of criminal justice based responses gets washed away when their next sentence stigmatizes some of the most effective treatments we’ve got, and further teaches potential patients that such treatments render them “unclean.” They are operating with exactly the same stigmatizing assumptions that lead these legislators to pass these laws.

Dear my friends in the media:

Find some actual addiction docs, talk to them. Take this seriously.

The truth is out there, but on your own, you’re not going to find it …

Lyin’ Lies

Carroll’s 5th Law of Psychiatry: Anybody who says “I’ll be honest with you,” isn’t. Anybody who asks, “Why would I do that?” did that.

One thing I found hard to digest when I was starting out is that people lie to you. Well, not just people. Patients. People I’m trying to help.

I suspect I get lied to with the approximate frequency of a judge, but less than a cop. I have statistical evidence to back that up in the form of many anecdotes. I will share one with you now.

(At some point I will write a post about how anecdotes are stories of things that never happen. Ignore that, it only applies to other people’s anecdotes. Mine are entirely true, widely generalizable, and say something very important about the human condition. Promise.)

Once upon a time in Baltimore or its near environs there was a psychiatrist. He (or she – could have been anybody, really) was in a meeting where an absolutely real patient who is not at all abstracted from dozens of identical encounters was talking to him.

ARPWINAAAFDIE (Arpie for short): I am being treated horribly unfairly!

Dr. C. (not his real name, I’m sure): In what way?

Arpie: I keep getting put into all these groups. It’s just too much, I can’t get to all of them.

Dr. C. : Is there some reason for this?

Arpie: I keep coming up positive for weed! (“Coming up positive” means testing positive for a drug. Oddly enough, almost nobody ever says “I used.” One “comes up positive” as though there is a lottery for such things.)

Dr. C. : That can happen sometimes. There are false positives. So you have to go to some extra groups for a week?

Arpie: No!

Dr. C. : No?

Arpie: I’ve been in groups for six weeks!

Dr. C : For a single positive urine test?

Arpie: No. I’ve been positive for six weeks!

Dr. C. : And why do you think that is?

Arpie: I was around some people who were smoking. My cousin does it in the house all the time with his friends.

Dr. C. : I see. You ever have a problem with marijuana?

Arpie: Used to.

Dr. C. : I see. So you previously had a problem with marijuana, and you have been in a house with several people who are smoking constantly, and you have been positive on urine testing for weeks, but you have not been smoking?

Arpie: Right. I mean, I have been doing great in this program. It saved my life. Why would I do anything to jeopardize that?

And there it was. The “Why would I do that?” Notice she did not say “I did not do that.” In fact she never flat out denied it.

The practiced eye will also note that Dr. C. never said whether or not he believed her.

From this exchange, we can conclude one very, very important thing. Arpie is probably not a raging psychopath. We’ll get back to that.

Most people really, really suck at lying. The main reason people really, really suck at lying (and I have evidence to back this up in the form of expert opinion, because I am an expert) is that we are wired for consistency. Saying one thing and believing another produces an internal tension that psychologists give a catchy name, “cognitive dissonance.” People act to minimize this. One way people minimize this is they re-align their beliefs to fit what they say. As one student of mine once said, “You remember when you were a kid and you were acting sick to get out of school, and after a while, you started kinda feeling sick?” That sort of thing.

When lying, people often minimize dissonance by half-a%%ing it. They try to get away with saying something that is as little untrue as possible. They fudge details but leave the main story intact, they talk around the lie without ever flat-out lying. This, in terms of prevarication, is a terrible mistake. Because this almost always produces an internally inconsistent narrative.

You can get away with that if your listener doesn’t care much about the answer.

Compare and contrast:

Friend: “How are you?”

Depressed person who hasn’t smiled in a month: “Fine.”

Friend: “Did you hear about what happened at that picnic?”

and:

Doctor: “How are you?”

Depressed person: “Fine.”

Doctor: “OK, now that we’ve got that out of the way, how are you?”

Depressed person: Dissolves into tears.

In the first, the question is a social nicety and nobody particularly pays attention to the answer. In the second, when somebody notices the disconnect between what is seen and what is said, and asks for real; the truth comes out.

So, if your listener is paying attention and knows what she’s doing, you’re probably screwed. If she’s good at this, she’ll be calm and nonjudgmental, so you don’t have any excuse to act angry and throw up a smokescreen. She’ll watch how uncomfortable you are. She will never commit to either disbelief or belief. Either way would let you off the hook. She will never accuse you, nor give you an excuse to attack her and discharge all that pent up tension.

She’ll also be watching to see how hard you are working not to say something. That something will be the lie. She could toss out some not-quite-neutral comment about how she’s open to believing you, like how “false positives do happen. ” She might alternate that with pushing you right into a corner repeatedly, giving you a choice between telling the lie and making up some new detail, to increase the dissonance. I was taught by one of the great masters of this, who advocated the Columbo Technique – adopting a non-threatening, bemused manner from which you can endlessly ask about “just one more thing.”

Eventually, dear liar, you’re going to be feeling quite squirmy, and she’s going to be calmly sitting across from you with one more bland, open-ended question ready to ask. A good interviewer on the scent of a lie is a lovely and terrible thing to watch.

Really, the way to lie is to go bawlz-out and tell a whopper. (Apologies for the gendered reference, but the opposite is equally vulgar and a bit too serial killer.) You can make up the details as you go, and there are no conflicts, as long as you don’t go on too long. The Nazis, vile bastards that they were, were right on that one.

Which brings us back to a point above. Arpie is not a psychopath. Psychopathy is, roughly speaking, lack of a conscience – a sort of wired-in incapacity to treat anyone else as more than a means to your own ends. People who are highly psychopathic will look at such an interaction as a game to be played for a win, and the win is getting what they want; or getting away with it once they have it. They will have no qualms about telling great big lies, even to someone who cares about them. That internal dissonance wouldn’t be there, because to such a person, lying is a matter of strategy and tactics, not morality.

So, to sum up, in order to lie effectively:

  1. Lie to someone who isn’t paying attention (Usually easy).
  2. Tell a whopper (Hard if you’re not a psychopath, so . . . ).
  3. Be a psychopath.

Under ordinary circumstances, only number 1 applies, which is the only reason most people get away with the lie.

Now this is short term. This is all about whether the lie is internally consistent – meaning somebody can pick it apart right there. The main reason I’m not nearly so bugged by lies nowadays is that I’ve learned that what works in the short term, is pretty much dead opposite to what works in the long term. 

To give a concrete example, once upon a time there was a patient who had a habit of coming into the ED in distress because various family members died in terrible ways. Everybody took him at face value, until he had gone through more grandmothers than a cat has lives.

Big ol’ whopper? Yup. Inattentive listener? Well, maybe that’s unfair, but the pace of most EDs is not conducive to deep curiosity. Yet, eventually, the big lie gets too big to fit in with the rest of reality.

The psychopath thing? The very thing psychopaths have going for them in the short run fails them in the long run. No matter how superficially disarming they are, they show their colors. Then nobody believes them. Even when they tell the truth.

So to make a lie work in the long run:

  1. Keep it simple, with the deception trivial, so that most details will fit reality and not lead anybody to be too curious.
  2. Don’t be a psychopath.

Lies mostly amuse me, now. This is not to say I haven’t swallowed some in my time, and I will no doubt swallow many more before I’m done. I don’t take it personally. The best goalie on earth is still going to let some through. I do take a certain delight in the game of detecting them. If I don’t catch it at first, though, usually all I have to do is wait and watch. The truth finds a way. 

Back to poor Arpie, squirming internally while trying to hold onto this program that really has made a world of difference in her life, staring right down the barrel of losing it because she’s in too deep. What is her way out, though? To admit she’s doing exactly what may cost her that program? 

And what about this Dr. C. character? There he sits, knowing the truth, but still going through this ritual. Isn’t it a little uncomfortably cat-and-mouse? Wouldn’t it be kinder to just come out and call bull#$@t, or even just drop the hammer and throw her out?

You’re right to wonder about him. He certainly does, from time to time. Maybe we should pick up this story later. Could be, there’s redemption to be had for all. That always makes for a better story. 

Shower thoughts over coffee.

As I sit through my fourth cup of coffee eating a mooshy veggie burger at the hospital coffee joint, something keeps rattling around in my head.

I have training and experience in both pain and addictions, and I go back before our current prescription opioid epidemic. This really followed a typical pattern of a drug epidemic; the greater availability and high potency of the “new” version of the drug class, the perception of greater safety, the dissocation from the stigmatized population, etc. We’re working our way through it, and right now as everyone’s trying to get their thumbs into the dam controlling prescription opioids, the second wave is starting. Some will enter recovery, some will convert to the endemic heroin and we will see all the ugliness that comes with that; new HIV and hepatitis cases, and all the social disruption.

As that settles out marijuana is now legal in many places, talked about as if it is “medicine” though we’re not really sure how well it works – that partly because doing any real research on it is very, very hard due to government policy. Despite all this talk about it being “medicine” it is remarkably divorced from the medical system. Scheduling, regulation, even the necessity for an actual no-kidding prescription. It’s also funny how quickly after it’s medicalized-but-really-not we find greater acceptance of its use recreationally.

I have all kinds of thoughts on this, but one thing keeps clanging in my head. I gather there is a strong economic argument that legalization (which is a vague term if you think of it, ranging from laissez-faire to repenalization) is a good way to manage the problems of addictive drugs. I rather like some versions of a repenalization system myself. It might take the steam out of the illicit drug trade and reduce some of the crime associated with that underground economy. However, what happens to the prescription regulatory system?

It strikes me as an odd thing to decide that once we understand that a drug is addictive, it should then become less controlled and regulated than, say, an antihypertensive or an NSAID. Do we simultaneously allow people to buy oxycodone in a 7-11 while requiring patients with pain to go to a doctor? Right now, there are places where you can buy cannabis in all its weird chemical complexity but you have to have a prescription for purified, tested, pharmaceutical grade cannabinoids.

I do not pretend to get all the policy implications of this, but I do like people who advocate a position to be able to tell me how it would actually work, and I don’t think I’ve heard that from folk who support decriminalization, including for cannabis. I also wonder a bit about where responsibility lies. If a clinician prescribes a drug there is a clear chain of responsibility, but if someone “recommends” a drug with no clear indications which a patient could buy anywhere for any reason, where does responsibility lie? Do we just live with the “pill mill” down the way?

Moar coffee.