EtG–The Rosie Ruiz of Bent Science and Bad Medicine

The Displacement of the idea that facts and evidence matter, by the idea that everything boils down to subjective interests and perspectives is — second only to American political campaigns — the most prominent and pernicious manifestation of anti-intellectualism in our time. — Larry Laudan, Science and Relativism (1990)Screen Shot 2015-03-19 at 11.55.08 PMOn April 21, 1980 Rosie Ruiz appeared to win the 84th Boston Marathon’s female category with a time of 2:31:56.  Her time would have been the fastest female time in Boston Marathon history and and the third-fastest female time ever recorded in any marathon.

“Miss Ruiz, an administrative assistant for Metal Trading Inc. in Manhattan, received the traditional laurel wreath, a medal and a silver bowl for her victory,” According to the New York Times

Ruiz was unknown in the running world and her victory raised suspicions.  After studying marathon photographs she didn’t appear in any of them until the very end and conducting interviews.

The problem was that, according to Runners World: “Ruiz had dropped out of the race, hopped on the subway, got off about a mile from the finish line, and ran in from there.”   It is believed Ruiz intended to jump in in the middle of the pack but miscalculated when she joined so close to the end not realizing she was ahead of the other 448 female runners.Screen-Shot-2014-12-29-at-10.16.38-AM

Marathon officials stripped Ruiz of her title on April 29, 1980, and named Jacqueline Gareau of Canada the women’s division champion with a time of 2:34:28.  It was later discovered that she had also taken the subway during part of the New York City Marathon which qualified her for the Boston Marathon.  In 1982 she was caught stealing money from her employer and was subsequently caught selling drugs to an undercover officer in Florida.


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In the early 1950’s it was discovered that a small fraction of ingested alcohol in rabbits gets metabolized by conjugation with glucuronic acid to form Ethyl Glucuronide (EtG)..1,2 The potential of EtG as a marker for alcohol consumption was recognized in the 1990s and analytical methods for its determination were developed in urine, blood and hair.3-5

It’s use as a marker of alcohol consumption in forensic settings was subsequently suggested by Dr. Friedrich Wurst based on studies showing that urine EtG could be detected after complete elimination of alcohol from the body (up to 80 hours), and he suggested the alcohol biomarker be utilized in forensic monitoring to improve public health.   6,7

Wurst et al note that a “marker of high sensitivity and specificity capable of monitoring patients in treatment for alcohol or other drug abuse” could “improve therapy outcome and quality of life in patients, increase safety at work places and in traffic, avoid harm to the unborn during pregnancy (fetal alcohol syndrome) and reduce costs by making therapy more effective and reducing productivity loss.”7

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A literature search from 1952 to 2002 yields one conclusion and once conclusion only; EtG measurements increase with alcohol ingestion. There are no studies considering what other factors might increase EtG measurements.

The false logic takes the following form:

  • Premise: Event A occurred after (or with) event B.
  • Conclusion: Therefore, event A caused event B.

But in 2003 Wurst and Gregory Skipper, M.D., FASAM, Medical Director of the Alabama Physician Health Program reported at an international meeting of the American Medical Society that EtG provided proof of alcohol consumption as much as 5 days after drinking an alcoholic beverage and that there are now a substantial number of studies in the world literature that support the clinical importance and reliability of EtG as a marker of recent alcohol consumption.8

“In the future it will be negligent not to test for EtG when monitoring recovering alcoholics,” reported Dr. Skipper.8

Also, in 2003, Skipper pitched the test to National Medical Services, Inc. (NMS labs) who then developed it as a Laboratory Developed Test (LDT).9

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Because of its high sensitivity the newly marketed test was suggested as a tool to monitor health care professionals by Skipper in 2004.10   Skipper then approached the Federation of State Medical Boards and pitched the test to them proposing it be used in the assessment and monitoring of doctors by state Physician Health Programs.   In a stunning example of policy entrepreneurship a market was created and filled simultaneously.

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“Detection of Alcohol Use in Monitored Aftercare Programs: A National Survey of State Physician Health Programs11 published in the Journal of Medical Licensure and Discipline in 2004 found that “surreptitious alcohol use was a significant concern” for state Physician Health Programs (PHPs) yet no “best methods for detecting alcohol use.” The 36-question phone interview was conducted with directors of PHPs in 46 states regarding current methods of drug testing and notes:Screen Shot 2015-03-20 at 4.06.32 AM

“Because alcohol is the most frequently abused substance adequate monitoring for alcohol is a major concern. During rehabilitation and recovery, the potential for alcohol abuse may increase due to the lack of efficient screening tests. The ingestion of alcohol while in aftercare is a violation of the contractual agreement made with the monitoring program and may lead to relapse and/or abuse of other psychoactive substances, thus rendering the practitioner unsafe to practice their profession. Therefore, alcohol detection remains an important component of contract compliance and sobriety.”

Screen Shot 2015-03-19 at 9.09.39 PMThey conclude that: “EtG can be detected in urine as long as 18 hours after blood alcohol levels reach zero and demonstrates exceptional specificity (100 percent) and sensitivity because even small amounts of alcohol (7 g, or less than one alcoholic beverage) can be detected.”

This very same issue of the Journal of Medical Licensure and Discipline contains an article written by Skipper concerning new marker to detect alcohol use in “recovering physicians” that “has recently been introduced in the United States and an assay for EtG is now commercially available.”12

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Skipper states that “EtG is not detectable unless alcohol has been consumed” and notes the “usefulness of the test was affirmed in one study involving psychiatric inpatients”Screen Shot 2015-03-19 at 9.09.15 PM

An EtG above 500 renders it “extremely unlikely” that alcohol was not ingested and adds “ In any event, if testing is positive” in monitored doctors it is advisable to refer them for further in-depth evaluation by clinicians or programs skilled and adept at evaluating physicians.”

In Bending Science: How Special Interests Corrupt Public Health Research13, Thomas McGarity and Wendy Wagner describe how special interest groups scheme to advance their own economic or ideological goals by using distorted or “bent” science to influence legal, regulatory and public health policy.

The authors describe a “separatist view” of the world that assumes scientific research is sufficiently reliable for public policy deliberations and legal proceedings once it flows out of the realm of science through a pipeline in which the scientific community has ensured through rigorous peer-review and professional oversight that the final product that exits the pipeline is unbiased and produced in accordance with the norms and procedures of science.

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This view does not consider the possibility that the scientific work exiting the pipeline could be distorted and contaminated by biasing influences.

If we look at this through the lens of “bent science” several issues arise including a failure to adhere to the norms and standards of toxicology and forensic drug and alcohol testing, an absence of evidence base and glaring conflicts of interests.

Norms and Standards of Toxicology and Forensic Drug Testing

On September 15, 1986 President Ronald Reagan signed Executive Order 12,564 requiring that the urine of federal employees in “sensitive” jobs be sampled randomly for illegal drugs. In 1988 Congress followed with the Drug-Free Workplace Act and drug testing became common organizational practice by the mid 1990s. Most followed the federal norms and procedures in their testing.

The Department of Health and Human Services (DHHS) had established specific cutoff levels that define a positive result.   These values were developed to help eliminate false-positive results.14 The cutoff levels were originally established at a drug concentration that produced an analytic signal some multiplicative factor above the noise level (the signal obtained from drug free urine).

“The concept of cutoff for major urine screening programs has two basic applications: the lower limit of reliable testing based on the techniques involved in the testing and the lower limit of reliable testing based on the possibility of interference from medications, foodstuffs, environmental exposure, or endogenous processes.”15

“Urine Drug Testing in Clinical Practice: Dispelling the myths & Designing Strategies cautions about “caveats to interpretation.” “As with any unexplained test result, it is important to clarify the interpretation with someone knowledgeable in clinical toxicology.”16

Evidence Base

What was in the pipeline when the EtG was proposed as a forensic monitoring tool can be illustrated below:

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Taking Advantage of a Loophole

The EtG was developed by NMS labs as a “Laboratory—Developed Test” or LDT. The LDT pathway does not even require proof of validity, that the test is actually testing for what it claims to be testing, and with no FDA oversight a lab can claim any validity it wants in its marketing and sales, and they did.   Proponents for regulation of LDTs argue this lack of oversight is a direct threat to patient care and safety. An viewpoint piece in JAMA states that a   “patient’s life or death could hinge on whether a single, unregulated diagnostic test result is meaningful.” 17

In the case of EtG Skipper arbitrarily chose a value of 100 as a cut-off for EtG. The rationale behind this value is not cited. Interference with foods, medications and environmental exposures had not been worked out. The results were predictable.

Aftermath was Predictable and Therefore Avoidable

The case of EtG is exemplifies ‘policy entrepreneurship” and “bent science” at its worst. It shows how junk-science can be introduced into the market without any real difficulties or meaningful opposition and how self-interest is promoted in defiance of science in an effort to manipulate public policy. This is nothing more than opportunist exploitation of the regulatory framework and the FSMB eagerly complied.   Without this “regulatory sanctification” none of these tests would have ever made it to market.

EtG was subsequently found to be so sensitive that it could measure incidental exposure to alcohol in foods, over the counter cold medications, mouthwash18,19, hand sanitizer gel20, nonalcoholic beer21, and nonalcoholic wine.22

“Exposure to ethanol-containing medications, of which there are many, is another potential source of “false” positives.

Forbidding patients/subjects access to such medications may be unrealistic, and even unwise.”23

The United States Substance Abuse and Mental Health Services Administration warned against using a positive EtG as primary or sole evidence of drinking for disciplinary or legal action.24 The advisory states:

“Although positive biomarker results should be taken seriously, use of certain biomarkers, such as EtG, is now warranted as stand-alone confirmation of relapse because research has not yet established an acceptable standard to distinguish possible exposure to alcohol in various commercial products from consumption of alcoholic beverages.”

The Wall Street Journal in 2006 reported the problems with the EtG to the general public.25

The authors of a 2011 study demonstrating that hand sanitizer alone could result in EtG concentrations of 1998 concluded that:

“in patients being monitored for ethanol use by urinary EtG concentrations, currently accepted EtG cutoffs do not distinguish between ethanol consumption and incidental exposures, particularly when urine specimens are obtained shortly after sustained use of ethanol containing hand sanitizer.”26

images-5Sauerkraut and bananas have even recently been shown to cause positive EtG levels.27

A 2010 study found that consumption of baker’s yeast with sugar and water28 led to the formation of elevated EtG above the standard cutoff.images-6

EtG can originate from post-collection synthesis if bacteria is present in the urine.29 Collection and handling routines can result in false-positive samples.30

EtG varies among individuals.31 Factors that may underlie this variability include gender, age, ethnic group, and genetic polymorphisms.

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The Cochrane Collaboration does systematic reviews of the literature using conscientious, explicit, and judicious criteria to in order to produce and disseminate only high quality and evidenced based health care, exclude bias, and enhance transparency.

The Cochrane database is internationally recognized as the standard in evidence based health care.   It records just 5 controlled trials under the topic ethyl glucuronide.22,31-33

These 5 studies represent the only high-quality evidence regarding EtG to date. Information provided by the five studies suggests the following, and only the following:

  1. EtG measurements increase with alcohol ingestion.
  2. The window of detection is shorter than what is commonly proposed (80 hours).
  3. Individual values are variable both within and between subjects.
  4. Non-alcoholic wine can cause positive levels.

During this time period any rational authority would have admitted error and removed the test from the market. Skipper’s approach was to keep raising the cutoff level from 100 to 250 to 500 to 1000. With EtG paving the way for other laboratory developed tests he then added “confirmatory” LDTs such as EtS and PEth. The EtS was found to have the same problems and PEth inevitably will but this is now a billion dollar market and they plan on using these tests on almost everyone including kids.

There has been no academic, public policy or conflict of interest analysis of all of this. As probably the worst case of bent-science in history there needs to be.

  1. Kamil A, Smith JN, Williams RT. A New Aspect of Ethanol Metabolism: Isolation of ethylglucuronide. Biochemical Journal. 1952;51:32-33.
  2. Kamil IA, Smith JN, Williams RT. Studies in detoxication. L. The isolation of methyl and ethyl glucuronides from the urine of rabbits receiving methanol and ethanol. The Biochemical journal. Jun 1953;54(3):390-392.
  3. Schmitt G, Aderjan R, Keller T, Wu M. Ethyl glucuronide: an unusual ethanol metabolite in humans. Synthesis, analytical data, and determination in serum and urine. Journal of analytical toxicology. Mar-Apr 1995;19(2):91-94.
  4. Schmitt G, Droenner P, Skopp G, Aderjan R. Ethyl glucuronide concentration in serum of human volunteers, teetotalers, and suspected drinking drivers. Journal of forensic sciences. Nov 1997;42(6):1099-1102.
  5. Aderjan RE. Ethyl glucuronide. A non-volatile ethanol metabolite in hair. 1995.
  6. Wurst FM, Seidl S, Alt A, Metzger J. [Direct ethanol metabolite ethyl glucuronide. Its value as alcohol intake and recurrence marker, methods of detection and prospects]. Psychiatrische Praxis. Nov 2000;27(8):367-371.
  7. Wurst FM, Seidl S, Ladewig D, Muller-Spahn F, Alt A. Ethyl glucuronide: on the time course of excretion in urine during detoxification. Addiction biology. Oct 2002;7(4):427-434.
  8. Martin DM, G.E. S, Costantino A. Alcohol Use Can Now be Detected for Days Rather than Hours Using a New Test, Ethyl Glucuronide. 2003; http://www3.firstlab.com/media/16032/EtGFirstLabReport.pdf.
  9. Skipper G. “Urine Luck” Overview of New Drug Testing Technologies and Conundrums. http://gregskippermd.weebly.com/uploads/7/4/7/5/74751/skipper.urine_luck_2014_aaap_meeting.pdf. Accessed March 17, 2015.
  1. Skipper GE, Weinmann W, Thierauf A, et al. Ethyl glucuronide: a biomarker to identify alcohol use by health professionals recovering from substance use disorders. Alcohol Alcohol. Sep-Oct 2004;39(5):445-449.
  2. Jansen M, Bell LB, Sucher MA, Stoehr JD. Detection of Alcohol Use in Monitored Aftercare Programs: A National Survey of State Physician Health Programs. Journal of Medical Licensure and Discipline. 2004;90(2):8-13
  1. Skipper G, Weinmann W, Wurst F. Ethylglucuronide (EtG): A New Marker to Detect Alcohol Use in Recovering Physicians. Journal of Medical Licensure and Discipline. 2004;90(2):14-17.
  2. McGarity TO, Wagner WE. Bending Science: How Special Interests Corrupt Public Health Research. Cambridge, MA: Harvard University Press; 2008.
  3. US Department of Health and Human Services. Mandatory guidelines and proposed revisions to mandatory guidelines for federal workplace drug testing programs: notices. Federal Register. April 13, 2004;69(71):19659-19660.
  4. Clark HW. The role of physicians as medical review officers in workplace drug testing programs. In pursuit of the last nanogram. West J Med. May 1990;152(5):514-524.
  5. Resnick RB, Volavka J, Freedman AM, Thomas M. Studies of EN-1639A (naltrexone): a new narcotic antagonist. Am J Psychiatry. Jun 1974;131(6):646-650.
  6. Sharfstein J. FDA Regulation of Laboratory-Developed Diagnostic Tests: Protect the Public, Advance the Science. JAMA : the journal of the American Medical Association. Jan 5 2015.
  7. Costantino A, Digregorio EJ, Korn W, Spayd S, Rieders F. The effect of the use of mouthwash on ethylglucuronide concentrations in urine. Journal of analytical toxicology. Nov-Dec 2006;30(9):659-662.
  8. Reisfield GM, Goldberger BA, Pesce AJ, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash. Journal of analytical toxicology. Jun 2011;35(5):264-268.
  9. Rosano TG, Lin J. Ethyl glucuronide excretion in humans following oral administration of and dermal exposure to ethanol. Journal of analytical toxicology. Oct 2008;32(8):594-600.
  10. Thierauf A, Gnann H, Wohlfarth A, et al. Urine tested positive for ethyl glucuronide and ethyl sulphate after the consumption of “non-alcoholic” beer. Forensic Sci Int. Oct 10 2010;202(1-3):82-85.
  11. Hoiseth G, Yttredal B, Karinen R, Gjerde H, Christophersen A. Levels of ethyl glucuronide and ethyl sulfate in oral fluid, blood, and urine after use of mouthwash and ingestion of nonalcoholic wine. J Anal Toxicol. Mar 2010;34(2):84-88.
  12. Jatlow P, O’Malley SS. Clinical (nonforensic) application of ethyl glucuronide measurement: are we ready? Alcohol Clin Exp Res. Jun 2010;34(6):968-975.
  13. Administration SAaMHS. The role of biomarkers in the treatment of alcohol use disorders. In: Advisory SAT, ed2006:1-7.
  14. Helliker K. A test for alcohol–and its flaws. The Wall Street Journal2006.
  15. Reisfield GM, Goldberger BA, Crews BO, et al. Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer. Journal of analytical toxicology. Mar 2011;35(2):85-91.
  16. Musshoff F, Albermann E, Madea B. Ethyl glucuronide and ethyl sulfate in urine after consumption of various beverages and foods–misleading results? Int J Legal Med. Nov 2010;124(6):623-630.
  17. Thierauf A, Wohlfarth A, Auwarter V, Perdekamp MG, Wurst FM, Weinmann W. Urine tested positive for ethyl glucuronide and ethyl sulfate after the consumption of yeast and sugar. Forensic Sci Int. Oct 10 2010;202(1-3):e45-47.
  18. Helander A, Olsson I, Dahl H. Postcollection synthesis of ethyl glucuronide by bacteria in urine may cause false identification of alcohol consumption. Clinical chemistry. Oct 2007;53(10):1855-1857.
  19. Helander A, Hagelberg CA, Beck O, Petrini B. Unreliable alcohol testing in a shipping safety programme. Forensic science international. Aug 10 2009;189(1-3):e45-47.
  20. Sarkola T, Dahl H, Eriksson CJ, Helander A. Urinary ethyl glucuronide and 5-hydroxytryptophol levels during repeated ethanol ingestion in healthy human subjects. Alcohol and alcoholism. Jul-Aug 2003;38(4):347-351.
  21. Hoiseth G, Bernard JP, Stephanson N, et al. Comparison between the urinary alcohol markers EtG, EtS, and GTOL/5-HIAA in a controlled drinking experiment. Alcohol and alcoholism. Mar-Apr 2008;43(2):187-191.
  22. Wojcik MH, Hawthorne JS. Sensitivity of commercial ethyl glucuronide (ETG) testing in screening for alcohol abstinence. Alcohol and alcoholism. Jul-Aug 2007;42(4):317-320.

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Still looking for Statisticians, Biostatisticians and Epidemiologists to debunk Junk-Science

photo 1Wanted!–a Few Statisticians, Biostatisticians and Epidemiologists who want to make a difference in Medicine, Society and our Future.

Up until the birth of the EtG,  tests used for forensic drug and alcohol monitoring had to go through the arduous, expensive and necessary FDA approval process.   The LDT pathway was designed to develop simple tests with little risk that have  low market potential (i;e. the cost of the normal FDA approval process would prohibit them from coming to market).  The LDT pathway was designed to improve patient care in the diagnosis and treatment of patients.  It was not designed for forensic tests.  LDT approval does not require in vivo testing.  It is essentially an honor system and to develop an LDT it is not even necessary to prove that the test is actually testing what it is purportedly testing for (validity).

So with little to no evidence base an ASAM/FSPHP physician introduced the EtG, had it developed and marketed as a LDT in collusion with unscrupulous labs, and then began using it on physicians being monitored by State PHPs.  This then spread to other monitoring organizations in which there was a large power-differential between those ordering the tests and those being tested (criminal-justice, other professional monitoring programs).  These biomarkers have never been used in Federal Drug Testing, SAMHSA approved, DOT, and other organizations where unions or other organizations are present and looking out for the best interests of those being tested.

 

The Plan to introduce non-FDA approved drug and alcohol tests into the Healthcare system and require doctors drug-test ALL PATIENTs including students and kids!

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The Plan to introduce non-FDA approved Laboratory Developed Tests (LDTs) into the Healthcare system and require doctors drug-test ALL PATIENTs including students and kids!

The ASAM plans to introduce non-FDA approved “forensic”  Laboratory Developed Tests (LDTs) into mainstream healthcare via a loophole.    This same group introduced most of these tests through a loophole and now they want to drug-and alcohol TEST EVERYBODY including STUDENTS AND KIDS through another loophole!   These tests are of unknown reliability and accuracy.  The LDT pathway does not even require proof that the test is even valid  (i.e. that the test is actually testing for the substance it claims to be testing) but with no FDA oversight or regulation the labs can claim anything they want in marketing it and they do.

If a doctor collects a test on a “patient”  the test is rendered “clinical” rather than “forensic” and by deeming this drug-testing  “clinical” rather than “forensic”  they can then call the consequences of a positive test “treatment” rather than “punishment.  ” It is via this loophole they plan to introduce and unleash the panoply of junk-science tests currently being used on other groups who have no say in the matter (probationers, parolees, private professional monitoring groups, etc. ) onto the general population at large.    A boon for the Drug and Alcohol Testing Industry Association and the assessment and treatment industry but a bane to the rest of society.    And to prevent this from happening more people need to be talking about this.

The Medical Profession, Moral Entrepreneurship, Moral Panics, and Social Control

The Medical Profession, Moral Entrepreneurship, Moral Panics, and Social Control.

As a society governed by organizations, associations,  institutions and regulatory bodies, the medical profession is not immune to “moral panics” and “moral crusades.”

A threat to patient care or the values of the profession can be identified and amplified.   A buildup of public concern fueled by media attention ensues creating a need for governing bodies to act. Medical Professionalism and the Public Health has been assailed.

Unbeknownst to the general population and most members of the medical profession at large, certain groups have gained tremendous sway within organizational and regulatory medicine. Through  moral entrepreneurship they have gained authority and become  the primary definers of the governance of the medical profession and the social control of  doctors.  To benefit their own interests they have fostered and fueled “moral panics.” Exhorting authorities to fight these  threats by any means necessary  they have successfully made and enforced rules and  regulations and introduced new self-serving definitions and tools that neither help doctors nor protect the public.

Anatomy of a Forensic Fraud: The Reality of Drug and Alcohol Testing

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The juxtaposed documents in and of themselves reveal a number of red flags.  How does one “revise” a chain-of-custody”?    If you do a google search you will not find “chain-of-custody” as an object of the verb revise. It is an oxymoron.  A document or opinion can be revised.  A chain-of-custody, by its very definition, cannot.  This collusion to fabricate a positive test has coined a new oxymoron—“revised chain-of-custody.”     Go ahead and look it up. It is a novel one.     As it should be.

What these documents show is, in fact, indefensible ethically, procedurally and legally.  The first document signed by Dr. Luis Sanchez, past President of the FSPHP and past Medical Director of Physician Health Services, Inc.  (PHS) was sent to the Board of Registration in Medicine on December 11, 2012 and is notable for two statements.   The letter from Dr. Sanchez asserts that “Yesterday, December 10, 2012, Physician Health Services, PHS received a revision of a laboratory test result,” but it did not matter because PHS was {unaware} ” of any action taken by the Massachusetts Board of Registration in Medicine as a result of the July 28th, 2011 report.   However, based on the amended report, PHS will continue to disregard the July 21st PEth test result.”

The second document, addressed to Dr. Luis Sanchez, is dated October 4, 2012 (67 days earlier) and shows the first document to be a bald-faced lie.

On July 28h 2011 Dr. Luis Sanchez reported to the Medical Board that I had a positive alcohol test.

Although I knew that Dr. Sanchez had fabricated the test I  had no way of proving it. I requested the “litigation packet,” which records “chain-of-custody” from collection to analysis in August of 2011.  At first they  refused.  PHS then tried to dissuade me (“it will be costly, involve attorneys, etc). Finally they agreed but threatened me with “unintended consequences.”

I was finally able to get a copy of the “litigation packet”  in December of 2011.  Remarkably, it  showed that Sanchez had requested my ID # and a “chain-of-custody” be added to an already positive specimen. I reported this to the Board but they ignored it. I also filed a complaint with the College of American Pathologists.Screen Shot 2014-11-06 at 11.17.32 PM

On October 23, 2012 Sanchez reported to the Medical Board that I was “noncompliant” with requirements with A.A.  meetings that I was supposed to go to as a direct result of the positive test and my license to practice medicine was suspended as a result in December 2012.

On December 10, 2012 I contacted the College of American Pathologists who told me the test was “amended” from “positive” to “invalid” on October 4, 2012. I confronted Sanchez and PHS and they said they did not know anything about it.

The following day, December 11, 2012, they sent out a letter saying that the test was invalid but that they were “unaware of any action taken against my license as a result of the test.”  

The documents show that on  July 19th, 2011 Sanchez requested my ID # 1310 and a “chain-of-custody” be added to an already positive specimen and on October 4th 2012 the test was “appended” to “external chain of custody not followed per standard protocol.”

Please note again that  Dr. Sanchez stated on December 11, 2012 that he “just learned” about this on December 10, 2012. He reported me to the Board as “noncompliant” on October 23, 2012 and my license was suspended in December 2012.   These documents show he had full knowledge that the test was invalid and as an agent of the Board this is under “color of law.”   Both he, and PHS, need to be held accountable for this.

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Lies, Lies, and More Lies

10:19:12-Verbal Compliant Noncompliance f:u written 10:19:12–BORM Complaint Committee

The contradictory documents from Sanchez alone constitute a crime (withholding information in concealment and providing false information to a state agency).  But what he did is far far worse.

I just obtained the October 4th document. Although I knew it existed, PHS suppressed it and refused to acknowledge it.   But in response to a complaint I filed against PHS and the labs it was revealed by USDTL that the test in question (phosphatidyl-ethanol) was not sent as a “forensic” specimen but collected as a “forensic” specimen, then changed to a “clinical” specimen at the request of PHS Program Director, Linda Bresnahan.   The specimen was kept at the collecting lab (Quest) for 7 days as a  “clinical” specimen, then sent to the analyzing lab (USDTL) with specific instructions from Quest to process it and report it as a “clinical” specimen.  PHS then used it as a “forensic” specimen by reporting me to the Board of Registration in Medicine and  requesting I undergo an evaluation for alcohol abuse.

As a “clinical” specimen it is rendered “Protected Health Information” (PHI) and thus under the HIPAA Privacy-Rule.   So with the help of the College of American Pathologists I requested my PHI from both Quest and USDTL. Quest refused (for obvious reasons) but USDTL complied.   And that is how I was able to obtain the October 4th document revealing that Dr. Sanchez lied to the Medical Board.     I would love to hear him, or PHS MRO Wayne Gavryck, defend the indefensible (and unconscionable).

Dr. Sanchez is correct when he pleads ignorance of any action taken by the Board as a result of the July 21st PEth result.   It was his report to the Medical Board  that I was “noncompliant” with attending AA meetings (that I was supposed to go to as the direct and sole result of the positive test)   that he reported to the Board just two weeks after the October 4th appended test.

The test was sent as a “clinical” specimen intentionally. PHS is not a clinical provider but a monitoring agency. They cannot send clinical samples.   But since clinical samples are “protected health information” and under HIPAA the lab had to give me the records and here you have them.

The distinction between “forensic” and “clinical” drug and alcohol testing is black and white.  PHS is a monitoring program not a treatment provider.  The fact that a monitoring agency with an MRO asked the lab to process and report it as a clinical sample and then used it forensically is an extreme outlier in terms of forensic fraud.  The fact that they collected it forensically, held it for 7 days and changed it from “forensic” to “clinical” to bypass strict “chain-of-custody” requirements  deepens the malice.  The fact that they then reported it to the Board as a forensic sample and maintained it was forensic up until now makes it egregious.   But the fact that the test was changed from “positive” to “invalid” on October 4th, 2012 and Sanchez then reported me to the Board on October 23rd 2012 for “noncompliance,” suppressed it and tried to send me to Kansas for damage control makes it wantonly egregious.   (they didn’t think I’d ever find out).

Add on that the fact that I’ve been questioning the validity of the test since day 1 and they violated the HIPAA Privacy Rule over and over and this is reckless and major health care fraud.

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Fax from PHS to USDTL on July 19th, 2011 asking that my ID #1310 be added to an already positive test and a “chain-of-custody” be “updated”

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USDTL complies with PHS request to and adds my ID #1310 and a date of collection (July 1, 2011) to an already positive specimen

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No date of collection, no unique identifier linking specimen to me. Multiple “fatal flaws.”

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I file complaint with CAP January 12, 2102. CAP forces USDTL to amend test from “positive” to “invalid” which they do on October 4, 2012. PHS conceals this fact until December 11, 2012

Letter from Chief of Toxicology at MGH–Ignored by PHS, USDTL, and the BORM         11:5:12-Dr. Flood Letter–Ignored by PHS:USDTL:BORM

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A Golden Age

BY TIMOTHY STEELE

Even in fortunate times,
The nectar is spiked with woe.
Gods are incorrigibly
Capricious, and the needy
Beg in Nineveh or sleep
In paper-gusting plazas
Of the New World’s shopping malls.
Meantime, the tyrant battens
On conquest, while advisers,
Angling for preferment, seek
Expedient paths. Heartbroken,
The faithful advocate looks
Back on cities of the plain
And trudges into exile.
And if any era thrives,
It’s only because, somewhere,
In a plane tree’s shade, friends sketch
The dust with theorems and proofs,
Or because, instinctively,
A man puts his arm around
The shoulder of grief and walks
It (for an hour or an age)
Through all its tears and telling.

Timothy Steele, “Golden Age” from Sapphics and Uncertainties: Poems 1970-1986. Copyright � 1986, 1995 by Timothy Steele. Reprinted with the permission of the University of Arkansas Press, www.uapress.com.

Source: Sapphics Against Anger and Other Poems (1986)

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Disappointed that his grandiose proposal to test the urine of half the U.S. population for illicit drugs was declined in the 1980’s, Bob realizes such a large swath was too tall an order. Acknowledging that his dream of lifelong urine drops for each and every one of the riffraff at least once a fortnight will take time, he decides to focus his attention on specific subsets of the great unwashed such as school-children, welfare mothers, the unemployed and whatever they are calling Hippies these days.

Medical Urban Legend–The Legacy of the 4 MDs and why B.S. Needs to be Identified from the Get-Go!

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“Because I can Biotches! That’s right..because I can!” 

According to G. Douglas Talbott, rehabilitation programs that evaluate and treat the rest of the population for substance abuse issues are incapable of doing so in doctors as they are unlike any other inhabitants of our society.   Physicians are unique. Unique because of their incredibly high denial”, and this genetically inherent denial is part of what he calls the “four MDs.” Used to justify the thrice lengthier length of stay in physicians the “four-MDs” are as follows: “M-Deity”, “Massive Denial” “Militant Defensiveness” and “More Drugs.”

He states that “Impaired doctors must first acknowledge their addiction and overcome their ‘terminal uniqueness’ before they can deal with a drug or alcohol problem.”
Now some  doctors are arrogant undisciplined egotists but narcissistic personalities exist in any profession and expanding traits that may apply to a small percentage of doctors to include all doctors as a universal truth contradicts reality. Applying a stereotypical paternalistic length of treatment in doctors three times as long as non-doctors to force a “one-size” fits all treatment on them has no evidence base.

tumblr_kuwuugSEmN1qz6z0no1_500This dicto simpliciter argument can, in fact, be refuted simply by pointing it out! Sadly, no one ever did so the ASAM front-group hasbeen able to establish this caricature of the arrogant paternalistic know it all needing 3 months or more of treatment as standard of care for our profession. They did this by getting medical boards and the FSMB to accept fantasy as fact by relying on board members tendency to accept expert evidence at face value–which they always do and that is a personality characteristic that I would argue is not dicto simpliciter.

Physicians are unique only insofar as the unique elements required of the profession to become and be a physician such as going to medical school and completing the required board examinations.

Any and all doctors referred to a PHP for assessment will spend at least 3 months in treatment if the facility feels it is indicated. It is inevitable. No one has challenged a patently absurd generalization that has absolutely no evidence base or plausible scientific or medical explanation. Of course those sentenced to the 3 or more months have complained but by that time they are de-legitimized and stigmatized. No one to complain to.  After all, these are just redeemed altruistic non-profit  good guys protecting the public and helping colleagues forge a path to salvation!
All the ASAM/FSPHP quacks have to do at that point to deflect legitimate concerns is point out the one doing the complaining is an “addict” who is “in denial” and it is part of his “disease.”  The mere accusation of substance abuse is used to disregard the claims of the accused.
Authoritative opinion entrenched. Someone should have called B.S. long ago.  But no one did and if they had we would not be in the current situation which is only going to go from bad to worse as the ASAM plan for universal contingency-management and urine usury unfolds-–A “golden age.” And the 4MDs Talbott attributes to doctors are all wrong. There is only one MD and it is “medical license.” On second thought that may not be entirely true.  “More money” may be another. And I am not talking about a doctor’s income. I am referring to insurance and the specter of depleting home and hearth.   Fiscal annihilation. Your license or your life.   And the only true  and plausible answer that Talbott could give to justify the lengthy stay is “Because I can biotches!” And “contingency-management” sounds better than extortion doesn’t it?  And  using your medical license as “leverage” sounds a helluva lot better than holding it for ransom.
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The ‘A’ Word: Are Doctors Arrogant?
Leslie Kane
June 17, 2014
Good Doctors Have Some Bad MomentsDoctors’ personalities have become a hot topic, not only because warmth and pleasantness count toward patient satisfaction, but also because positive patient interactions have a role in better outcomes.Physicians’ personalities are under the microscope as patients post reviews of doctors on numerous Websites. In some reviews, the word “arrogant” has shown up. But calling doctors arrogant is nothing new.Are there really so many arrogant doctors? No doubt, some physicians deserve the label, but it seems to be a stereotype that has blossomed and taken on its own life.”Arrogance among doctors is not the norm”, says Marion Stuart, PhD, co-author of The 15 Minute Hour: Therapeutic Talk in Primary Care, and Professor Emeritus in the Department of Family Medicine at UMDNJ-Robert Wood Johnson Medical School. “Someone who has done the hard work and has gone into medicine because they care about people, and are interested in helping peoples’ lives and making the world a better place, is not going to be arrogant.”So how did the arrogant doctor epithet arise?In the past, doctors were considered authorities who told compliant patients what to do and treated them with a paternalistic attitude. Some doctors may retain those behaviors today.Another possibility is overgeneralizing. A patient sees a doctor who has a difficult personality and assumes that the trait is more widespread within the profession than it really is.

Arrogance or Self-confidence?

“Arrogance is totally different from self-confidence,” says Dr. Stuart. “When you’re confident, that’s your assessment of your own competence. You have the experience and the wisdom, you know what you can do, and your confidence says that. It’s your relationship to yourself and your own expertise,” she says.

Arrogance is a different ballgame. “This has to do with your judging that other people are inferior,” she says. “It has more to do with not seeing other people as being up to your standards.”

Could the confidence that comes with being accomplished and successful make someone arrogant? Typically no, says Dr. Stuart. The trait of arrogance develops or resides within a person at a much earlier stage, arising from one of two paths:

“I am indeed better.” Someone who has always lived a privileged life, feels entitled to all of the finer things, or has always been looked up to may take it as a given that he or she is better than others. “People who had a sheltered, protected existence with no perception of what the real world is like for other people may consider themselves an elite group, entitled to feel superior,” says Dr. Stuart.

“I made it, so why can’t you?” By contrast, a person who was deprived as a child and worked very hard to pull himself up by the bootstraps may then look down on others who don’t have the same perseverance or initiative to take charge of their life and create similar success.

Doctors Are Harried and Pressured; Patients Are More Demanding

Some doctors have admitted that at times it’s hard to maintain their patience, and frustration triggers a snappish response. Throw into the mix the fact that doctors may have less time to see each patient and answer questions, and you have the ingredients for a negative interaction.

“I’ve had eight years of medical education and I’ve been trying to get my patient to make healthy lifestyle changes, and he comes in with a page ripped out of a tabloid, convinced that the information is right…there’s a limit to how much time I can spend ‘educating’ or convincing them that their ‘cure’ has no scientific basis,” one physician told me.

People have come to expect the stance of “the customer is always right” and get annoyed if doctors don’t accede to all of their requests. But because of new medical practice guidelines, a doctor may not readily give the patient the test or medication they ask for. “Now, with healthcare insurers and companies setting limits on doctors, many times the patient feels that the doctor is not so much on their side, and this could be perceived as arrogant,” says Dr. Stuart.

Is There an Outbreak of Rudeness?

Barry Silverman, MD, a cardiologist and coauthor with pediatrician Saul Adler, MD, of Your Doctors’ Manners Matter: Better Health Through Civility in the Doctor’s Office and in the Hospital, says, “While most doctors are appreciated and respected by their patients, there’s a general perception that professionalism has declined.

“Patients are often more informed, ask detailed questions, and demand a high level of service, while demands on the doctor’s time increase and reimbursements fall,” says Dr. Silverman. “What patients interpret as arrogance is many times a rushed and harried doctor, not an uncaring one. Medicine can be mentally and physically exhausting, but the bottom line is that the doctor must listen and communicate with the patient to deliver quality medical care.”

Still, remaining pleasant and calm is easier for some doctors than for others. There’s no uniform physician personality; many doctors have a natural “people person” inclination, while others are more stoic.

Are doctors expected to smile and be nice in every circumstance, no matter what?

“Professionalism is not about putting on a happy face or being someone you are not; it is about providing quality care for the patient,” says Dr. Adler. “Patients are more informed and have access to more information than ever before. Much of that information is incorrect and sometimes harmful. That means that part of the professional duty is to teach as well as treat.

“Patients understand that doctors have significant restraints on their time, and it is not unreasonable for doctors to use preprinted written materials, educational resources outside the doctor’s personal office, and honest and informative Websites,” says Dr. Adler. “However, under no circumstances should the doctor be rude or abrupt; a smile and kind, considerate behavior is always appropriate.”

It would be naive to say that there aren’t arrogant doctors. But there are far more doctors trying to do their best for patients and relate to them.

Medscape Business of Medicine © 2014 WebMD, LLC

Three shells and a pea–ASAM, FSPHP, and LMD

Unknown-3She likes a rigged game, you know what I mean?”

— R.P. Murphy in Ken Kesey’s One Flew Over the Cuckoo’s Nest

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Published  in the March 17, 2014 newsletter Alcoholism and Drug Abuse Weekly, an article  entitled “Physician group urges focus on spiritual and psychosocial” describes a group of doctors who “emphasize that for all addictions, the psychosocial and spiritual interventions, including 12-step interventions must be included in the treatment process and,” according to founding board member Dr. Ken Thompson, M.D., “to not do so falls short of practicing good addiction medicine.”

With a “significant percentage” in 12-step recovery themselves, “they have formed a  group called “Like-Minded Docs,which has more than 150 physicians, many of whom are medical directors of top treatment programs and also members of the American Society of Addiction Medicine (ASAM).” Dr. Thompson is in fact the Medical Director of Caron treatment center in Pennsylvania. The group also includes the medical directors of Hazelden, Talbott, Marworth, Promises, and other assessment and treatment centers used by state regulatory agencies to evaluate and treat referred physicians.    The President of the American Society of Addiction Medicine is a Like-Minded Doc as is former White House Drug Czar (1973-1977) Robert Dupont. In addition, the physician who introduced the long-term alcohol biomarkers Ethyl-glucuronide (EtG),  Ethyl-sulfate (EtS), and Phosphatidylethanol (PEth) is a like-Minded Doc as is  Wayne Gavryck, The Medical Review Officer for the Massachusetts Physician Health Program PHS, Inc.  How does he reconcile his 12-step belief system with fraud and misconduct?   It is either doublethink or the A.A. spirituality persona is just a front.

Although I  applaud the ideal of addressing the psychosocial and spiritual aspects of addiction and acknowledge that 12-step recovery is a treatment tool that can provide great benefit to some people, I do believe there is an inherent conflict-of-interest here. Having no strong feelings for or against A.A, I  view it through the same pluralistic and open-minded lens as I do religion or philosophy;  there are many paths to salvation and none superior. I have referred patients to A.A. myself  and see it as an option and a personal choice, one tool in the toolbox  that can provide great benefit to some people, do absolutely nothing for others and, in fact, harm some.   If it works for you good for you. Knock yourself out.  If not then let’s try something different.Screen Shot 2014-03-15 at 7.33.14 PM

So although the ideals of Like-Minded Docs are ostensibly laudable, the framework is not necessarily so.  What is  most concerning is a confluence of currents that preclude option and choice. It is a scaffold that can be used for coercion, control, and imposition. And this is exactly what is being done in many of the State Physician Health Programs (PHPs).

Originally funded by state medical societies and staffed by volunteer physicians, PHP’s were designed to help sick doctors and protect the public. But over the past decade these programs have undergone a sweeping transformation due to the influence of the American Society of Addiction Medicine (ASAM). Unlike Addiction Psychiatry, ASAM is not recognized by the American Board of Medical Specialties (ABMS). They created their own “board certification” (ABAM)  in 1986 and most physicians do not know that the only requirement is an M.D. in ANY specialty and some sort of experience in substance abuse.

Trumpeting the false dichotomy that addiction is a “brain disease” and not a “moral failing” while portraying themselves as altruistic advocates of the afflicted, the ASAM has cultivated an organization that exudes authority, knowledge, respectability, and advocacy. They have set forth definitions of addiction, shaped diagnostic criteria, dictated assessment protocols, and shaped public policy all under the guise of scholarship and compassion.

They introduced junk science such as the EtG and PEth alcohol biomarkers through Greg Skipper, FSPHP, ASAM, and another Like-Minded Doc.

They created the “moral panic” of a hidden cadre of drug addled and besotted doctors protected by a “culture of silence” disguised as some of the best workers in the hospital and in fact look “just like us.”  They introduced and promulgated the nebulous “disruptive physician” and successfully fostered a moral crusade to attack this huge hidden threat. And if you do a little searching you will find that their  next target is the “aging physician,”  demented doctors causing unseen mayhem and assailing the public good.  They are now  fomenting a call to arms to root out senility in medicine. It is the same tactic they used in the substance abusing and disruptive physician.  Social entrepreneurs.  Moral panic. Moral crusade.   With no evidence base and the use of  propaganda and disinformation they have convinced regulatory and administrative medicine that witches are real, witches are evil,  and they are the authority when it comes to witches and know how to identify and root them out with our witchpricking instruments.  And you know what?. It worked.

And by infiltrating state PHPs they have become the might and main of addiction medicine in the United States. By removing dissenters who disagreed with the groupthink they have taken over most of the state PHPs and organized under the Federation of State Physician Health Programs (FSPHP).

And the State PHPs under the FSPHP are very strict when it comes to choice in rehabilitation facilities for for physicians in need of assessments for substance abuse. In fact there is usually no choice in the matter.  The physician may be given a choice of facilities but that is a ruse as it is a false choice– smoke and mirrors sleight of hand. Deception.

As home to some of the countries top ranked hospitals and most prestigious medical schools Massachusetts is an international healthcare hub with world-class teaching, research, and clinical care. Two of the top three psychiatric hospitals in the United States as rated by U.S. News and World Report are found here in Massachusetts with McLean Hospital earning the top prize and Massachusetts General Hospital ranked number three. However, this medical mecca of learning and research is apparently unable to attract anyone with the competence and skill to assess a physician for addiction or substance abuse.

In Massachusetts if the State PHP, PHS,inc. feels a physician is in need of an assessment the evaluation must be done at “a facility experienced in the assessment and treatment of health care professionals.”  No exceptions. And apparently these esoteric skills are only found in Georgia, Arkansas, Alabama, Kansas, and a half dozen other far-away places.

With over 20 years experience with the Massachusetts PHP, Physicians Health Services, inc., Harvard Medical Schools Dr.’s John Knight and J. Wesley Boyd published an article in the Journal of Addiction Medicine last year concerning Ethical and Managerial Considerations Regarding State Physician Health Programs.

One of the issues they discussed was the conflicts of interest between the state PHPs and the evaluation centers. One comment I was surprised got past editorial review was that the treatment centers may “consciously or otherwise” tailor diagnosis and recommendations to the PHP’s impression of that physician. “consciously” tailoring a diagnosis is fraud. It is political abuse of psychiatry. It is unethical. It is, in fact, a crime.

If you cross-reference the  medical directors of the “PHP-preferred facilities”  with the list of LMD’s it is a perfect match.

Therefore when the PHP refers a physician for an evaluation and gives them a choice of an assessment facility there is no choice. It is three card monte. A shell game. Heads I win tails you lose.

The ASAM has imposed the prohibitionist chronic brain disease spiritual recovery model of addiction on the field of medicine. It is a system of coercion, control, and indoctrination. And another ASAM Like-Minded Doc, Robert Dupont, is calling this the “new paradigm” of addiction medicine and wants to spread it out to other venues including schools.

Like-Minded Docs solves the final piece of the puzzle. It explains why so many doctors across the country are claiming fabrication and manipulation of personality and cognitive tests to support nonexistent diagnoses. In evaluating a physician this group is not gathering data to form a hypothesis but making data fit a hypothesis that arrived well before the physician did.  And this may be part of the explanation for the recent marked increase in physician suicide. With guilt assumed from the start, no due process, no appeal, and no way out physicians are being bullied, demoralized, and dehumanized  to the point of hopelessness. This needs to end now.

Medicine is predicated on competence, good-faith, and integrity. Medical ethics necessitates beneficence, respect, and autonomy. The scaffold erected here is designed for coercion and control. Exposure, transparency, and accountability are urgent. An evidence based Cochrane type assessment of their “research” and an Institute of Medicine Conflict of Interest review are long overdue. The emperor has no clothes and sunshine is the best disinfectant.

She likes a rigged game, you know what I mean?

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