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posted by martyb on Monday February 18 2019, @05:23AM   Printer-friendly
from the getting-sick-is-hazardous-to-your-health dept.

https://blogs.bmj.com/bmj/2019/02/13/richard-smith-most-devastating-critique-medicine-since-medical-nemesis-ivan-illich/

Seamus O'Mahony, a gastroenterologist from Cork, has written the most devastating critique of modern medicine since Ivan Illich in Medical Nemesis in 1975. O'Mahony cites Illich and argues that many of his warnings of the medicalisation of life and death; runaway costs; ever declining value; patients reduced to consumers; growing empires of doctors, other health workers, and researchers; and the industrialisation of healthcare have come true.

[...] Unlike Illich, who believed that modern medicine counterproductively created sickness, O'Mahony does see what he calls a golden age of medicine that began after the Second World War with the appearance of antibiotics, vaccines, a swathe of effective drugs, surgical innovations, better anaesthetics, and universal health coverage for most of those in rich countries. It ended in the late 1970s, meaning that O'Mahony, who graduated in 1983 and is still practising, enjoyed little of the golden age. We are now "in the age of unmet and unrealistic expectations, the age of disappointment."

[...] O'Mahony begins his dissection with medical research, "the intellectual motor of the medico-industrial complex." Governments see life sciences as a saviour of economies, and charities urge us to give more to cure every disease. Big Science, which appeared after the golden age, has provided jobs and status but "benefits to patients have been modest and unspectacular." A study of 101 basic science discoveries published in major journals and claiming a clinical application found that 20 years later only one had produced clinical benefit. Big Science is corrupted by "perverse incentives, careerism, and commercialisation."

[...] No disease is better marketed than cancer, and after Richard Nixon's War on Cancer, Barack Obama launched his Cancer Moonshot, which is now renamed Cancer Breakthroughs under Donald Trump. As O'Mahony writes, the language around cancer "is infected with a sort of hubristic oedema." For Big Science cancer is a blessing, leading to huge investments in molecular biology and genetics, but, as cancer researcher David Pye put it: "How can we know so much about the causes and progression of disease, yet do so little to prevent death and incapacity."

[...] "The medical profession," he writes, "has become the front-of-house sales team for the [drug] industry." He argues that "doctors' professional culture obliges them to do something—anything," but he is too easy on doctors, who could push back. Society, he says, displays "childishness" in going along with these expensive treatments: "we must have higher, and better, priorities than feeble, incremental and attritional extension of survival in patients with incurable cancer."

[...] The first thing that I ever had published in a medical journal was a letter to the Lancet in 1974 asking why there had been no response to an article in the journal by Ivan Illich describing in detail how modern medicine was a threat to health. (It would cost me $35.95 today to access the letter, about 50 cents a word from memory.) As a medical student I expected that the leaders of medicine would carefully dissect Illich's argument and with evidence show him to be wrong. But such a response never came. I was naive: I know now that it's easier simply to ignore cogent criticisms. I hope that O'Mahony's book, a Medical Nemesis for 2019, will not be ignored. It deserves to be taken very seriously.


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  • (Score: 1) by fustakrakich on Monday February 18 2019, @06:13AM (16 children)

    by fustakrakich (6150) on Monday February 18 2019, @06:13AM (#802793) Journal

    Pain relief... It's what they ration more than anything else.

    --
    La politica e i criminali sono la stessa cosa..
  • (Score: 2) by krishnoid on Monday February 18 2019, @06:26AM (7 children)

    by krishnoid (1156) on Monday February 18 2019, @06:26AM (#802802)

    Then why the opioid epidemic? It seems like they can't get enough of prescribing pseudo-opioids to their trusting patients.

    • (Score: 4, Insightful) by sjames on Monday February 18 2019, @09:28AM (6 children)

      by sjames (2882) on Monday February 18 2019, @09:28AM (#802861) Journal

      In some cases, the rationing creates the crisis. Patient gets necessary opoids. Patient gets cut off because the pain "should" be gone. Maybe it is and maybe it isn't, but the patient is definitely addicted. So the patient resorts to street drugs and eventually ends up in jail, in the gutter, or dead. Addiction is a medical problem and should have been treated medically. But then some federal supercop with no medical training might decide the doctor needs to go to jail.

      Some of the "crisis" is hysteria. Terminal patient has pain. A lot of pain. The doctor can either offer unlimited pain killers knowing the patient will probably OD sooner or later and die or the patient can die a month later in screaming agony. Since opoids were involved we all yell that the sky is falling and nobody notices that not dying wasn't among the available outcomes. Those deaths used to be officially attributed to the underlying disease, now they're counted as oppoid deaths.

      There have been some excess deaths due to opoids. It seems a pharmaceutical company fudged some research and advertised a particularly addictive opoid as less addictive. Nobody went to jail but the patients that got hooked and a few of their doctors.

      Another way rationing leads to addiction is when the patient gets inadequate pain relief such that they end up counting the minutes until they get their next dose (which will not effectively relieve pain until the next dose). Keep them like that for a week and they get so busy counting the minutes until their next dose that they don't notice that the pain is no longer that bad.

      A final more speculative possibility. The last time I was prescribed a significant dose of opoids, I found them obnoxious. I hated feeling like I might fall asleep any minute. I resolved to take them as little as possible. It turned out that was zero times, and that was fine by me. Perhaps we simply have more people feeling like they need to escape more than they need to stay in the moment now. We know that rats provided a stimulating and pleasant environment will voluntarily consume less opoids than rats in a barren and unpleasant environment.

      Pain is hard to guess. Some people won't complain even if the pain is severe, others will claim terrible pain when they have none just to get high. The same injury is very painful to some, barely noticeable to others. We don't have a device that can objectively read out how much pain the patient feels but for some reason we expect doctors to provide "just enough". We do know that recovery is faster and complications fewer if pain is adequately managed.

      • (Score: 4, Insightful) by Runaway1956 on Monday February 18 2019, @09:41AM (5 children)

        by Runaway1956 (2926) Subscriber Badge on Monday February 18 2019, @09:41AM (#802869) Journal

        Very good analysis, but you got one point wrong, or at least off target. The sons of bitches outright LIED TO CONGRESS, and the lie was repeated often enough that it became "truth". The lie was that "only 1% of opioid prescriptions lead to addiction". I really don't know what the real percentage was BEFORE the opioid crisis (can find it if I really want to), but it has been documented that this particular lie resulted in the relaxation of the law.

        Without that lie, without the relaxation of laws and regulations, the number of opioid addicts created by the medical profesion would have remained relatively stable over the past 20 or 30 years. Depending on the definitions of "crisis" being used, we could still be said to have a crisis. But, it wouldn't be nearly as great a crisis as we have today.

        Even with the lie, even with the relaxation of laws, if the drug pushing sales droids hadn't been out there rewarding doctors for over prescribing, the crisis would be considerably smaller than it is.

        All the salesmen, all the CEO's who pushed those salesmen, need to sit in prison for a long time. They are no better than the punk on the street corner pushing drugs to school kids.

        • (Score: 2) by sjames on Monday February 18 2019, @10:15AM (4 children)

          by sjames (2882) on Monday February 18 2019, @10:15AM (#802887) Journal

          The laws surrounding medical use of opoids need to ho away entirely. None of them are written by doctors and none of them are enforced by doctors (I'm not convinced any of the writers or enforcers have ever experienced more pain than a paper cut).

          Some of the salesmen need to go. Especially the ones that claimed Oxycontin was less addictive than other opoids. The classic Dr. Feelgood is a problem, but we need to be careful there. Some doctors prescribe a lot more opoids than others because they specialize in conditions that are more painful. The DEA doesn't seem to know that (because as I said, they're not doctors and have no business making medical decisions).

          All in all, I suspect we would have less addicts if we had less laws and more low cost /no cost treatment for addiction. How likely would you be to seek treatment if even admitting you have the disease is tantamount to admitting to committing a felony? Especially when it's the kind of felony where the cops kick in your door, throw grenades around and steal everything you own?

          • (Score: 2) by Runaway1956 on Monday February 18 2019, @10:55AM (3 children)

            by Runaway1956 (2926) Subscriber Badge on Monday February 18 2019, @10:55AM (#802899) Journal

            I can agree that law enforcement are often a bunch of heavy-handed thugs. But, no laws? Not even laws or regulations administered by the medical profession? With no laws and regulations, it would be a free for all, with rogue doctors intentionally over prescribing stuff that the patient doesn't even need. The same doctor can create an addict, intentionally, then "cure" that addict, all the while making money.

            I'm all for making dangerous drugs difficult to get, unless some need is demonstrated. Once that need is demonstrated, then they should be readily available. A lot of that has to be the doctor's judgement - he might be wrong sometimes. But, that seems more a matter for professional organizations to deal with, than for general law enforcement.

            But, IMO, Patient Sixpack should not be able to wander into a doctor's office, and demand a script for whatever drug is fashionable this week/month/year. There have to be some kind of guidelines, don't there?

            • (Score: 2) by sjames on Monday February 18 2019, @06:19PM (2 children)

              by sjames (2882) on Monday February 18 2019, @06:19PM (#803082) Journal

              We would still have the usual professional standards, ethics, and liability. Also the same body of laws that in general would punish a doctor for deliberately making the patient sick(er) in order to cure them or otherwise through a procedure or prescription. There's no need to single out "fun" drugs there.

              Patients go into doctor's offices or online demanding a prescription for Viagra all the time. The doctor is obligated to meet at least minimal professional standards and make sure the patient doesn't have any likely conditions that would make viagra a bad idea and to do followups to make sure the patient isn't being harmed by side effects. Failure to meet those minimum standards could cause a doctor to lose his license to practice medicine as well as significant civil liabilities. If the patient dies or is seriously injured from a reasonably forseeable exacerbation of an existing medical condition the doctor could face criminal penalties as well.

              The same would apply for opoids. Doctors would have to weigh risk vs. benefit like any other drug.

              • (Score: 2) by urza9814 on Tuesday February 19 2019, @07:58PM (1 child)

                by urza9814 (3954) on Tuesday February 19 2019, @07:58PM (#803637) Journal

                In order to even have the doctors be involved, you still need laws regulating what drugs can be prescribed for what conditions and under what circumstances. You still need the Controlled Substances Act, which is written by non-doctors and is not written from the perspective of patient care but instead focuses almost exclusively on criminal justice and maintenance of existing power dynamics. But without that, everything is just over-the-counter and some people will take what their doctor recommends while others will start popping every pill that gets mentioned on Oprah. Which wouldn't necessarily be worse than the current system, but it's not likely to fix this particular problem.

                You can't just revoke a couple laws and assume that standard negligence/malpractice will cover it. You've gotta build a whole new system, built on a foundation that is actually based on medical science rather than politics and profit. That's an interesting challenge....

                • (Score: 2) by sjames on Wednesday February 20 2019, @03:15AM

                  by sjames (2882) on Wednesday February 20 2019, @03:15AM (#803840) Journal

                  There are no laws saying what condition a doctor can prescribe what drug for or under what conditions other than the general professional standards. Drugs cannot legally be advertised off-label but they can be prescribed off-label.

                  But my point was that we don't need special laws and handling of opoids.

  • (Score: 2) by HiThere on Monday February 18 2019, @07:03PM (7 children)

    by HiThere (866) Subscriber Badge on Monday February 18 2019, @07:03PM (#803094) Journal

    I wish you were right. Unfortunately, all the things that produce pain relief have significant drawbacks. Every single one of them. Among drugs, you can say that different drugs have different drawbacks, but there are none without any, and chronic use makes them worse, sometimes much worse.

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    • (Score: 1) by fustakrakich on Tuesday February 19 2019, @12:05AM

      by fustakrakich (6150) on Tuesday February 19 2019, @12:05AM (#803250) Journal

      all the things that produce pain relief have significant drawbacks

      Not for the people that sell them. And we can thank the Controlled Substances Act for protecting their business model.

      --
      La politica e i criminali sono la stessa cosa..
    • (Score: 2) by dry on Tuesday February 19 2019, @03:53AM (5 children)

      by dry (223) on Tuesday February 19 2019, @03:53AM (#803334) Journal

      What are the significant drawbacks of heroin? Not counting the artificial ones caused by the law and society being down on certain behaviours such as addictions.

      • (Score: 2) by takyon on Tuesday February 19 2019, @04:11AM (3 children)

        by takyon (881) <reversethis-{gro ... s} {ta} {noykat}> on Tuesday February 19 2019, @04:11AM (#803336) Journal
        • (Score: 2) by dry on Tuesday February 19 2019, @04:24AM (2 children)

          by dry (223) on Tuesday February 19 2019, @04:24AM (#803340) Journal

          OK, I should have included when used as directed and purity is known, needles are clean, which I hinted at, as most OD's are due to unknown strength of street drugs or impurities. Interesting about the brain damage though, wonder how it compares to other common drugs such as alcohol

          • (Score: 2) by takyon on Tuesday February 19 2019, @04:46AM (1 child)

            by takyon (881) <reversethis-{gro ... s} {ta} {noykat}> on Tuesday February 19 2019, @04:46AM (#803342) Journal

            I refer to this: http://www.ias.org.uk/uploads/pdf/news%20stories/dnutt-lancet-011110.pdf [ias.org.uk] when comparing drug safety. I don't think it gets into "this drug causes more brain damage than this other drug" but you can probably find info to that effect if you look around.

            At the end of the day, you want to avoid opioids unless you have some severe pain issues. I'm sure some people could benefit from a clean, 100% pure source, but you aren't likely to find that on the illicit market unless you know wtf you are doing.

            It would be interesting to see people with pain issues (not addicts... yet) getting cheap/free supply from supervised injection sites.

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            • (Score: 2) by dry on Tuesday February 19 2019, @06:30AM

              by dry (223) on Tuesday February 19 2019, @06:30AM (#803381) Journal

              Personally I don't like opioids but some people sure do, and some seem to be in mostly mental pain.
              They've been doing a small test of giving addicts clean heroin here, stop at clinic, get fix twice a day and it seems fairly successful. Junkies actually working rather then struggling for their next fix, maintaining a home kind of success. Listening to one, it was just so much of a relieve not to be living life wondering how to get the next fix.
              Be nice if the supervised injection sites could supply drugs to go with the needles, but they've been pretty successful about preventing OD deaths. Helps too that the cops will just herd the junkies the the supervised injection site instead of busting them.
              Unluckily there is a good chunk of the population who thinks it is just enabling giving out clean needles or worse, clean drugs.

      • (Score: 2) by HiThere on Tuesday February 19 2019, @05:15AM

        by HiThere (866) Subscriber Badge on Tuesday February 19 2019, @05:15AM (#803359) Journal

        All opioids have problems with habituation requiring continually stronger doses until you reach the LD-50 or higher. Some are faster than others.

        Additionally, the use of opiods for chronic pain becomes useless. Reportedly less effective than aspirin. It is supposedly excellent for acute pain if used as directed, but NOT for chronic pain. Only partially because of habituation. Partially because it just becomes less effective as the body adapts. (I'm not speaking from personal experience, so I don't know what the difference between the decreased effectiveness and the habituation is, but they are reportedly separate considerations.)

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