Since 2020 Dr. Roneet Lev has been doing podcasts called High Truths, most often about addiction and drugs. So, I was happy to participate in an episode about fentanyl. It turned into quite a bit more.
You probably know the old joke: What is the difference between God and doctors? God doesn't play doctor.
This is just a way of saying that doctors usually don't like having people argue with them. Yet during a rather spirited podcast on Dr. Roneet Lev's "High Truths" series, we both agreed and disagreed on a number of issues, including the utility of the MME conversion chart (Dr. Lev finds it useful, I think it is the work of Satan), and the contribution of abuse-resistant OxyContin to the surge in heroin use, which later became fentanyl use. But we both enthusiastically agreed that the term "guideline," as in the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (she finds it useful, while I think it's pure evil) makes all the difference in the world. Government should not be playing doctor. Period. Guidelines are fine, but unfortunately, guidelines quickly became laws in more than 30 states, leaving both pain patients and doctors at the mercy of the heavy-handed DEA, pretty much the last agency (maybe after Fish and Wildlife) that should have any say in what doctors can and cannot prescribe (1).
But I think you'll find our disagreements to be enlightening; Dr. Lev's point of view comes from her experience in treating an unremitting stream of drug overdoses that end up in her Emergency Department in San Diego while mine comes from being an organic chemist and now a pain-patient advocate who gets from a never-ending stream of emails from desperate pain patients who have run out of options; sometimes their only viable option being suicide. I think it's safe to say that both of us believe that government ought to stay the hell away from medicine.
Other topics covered included:
- Illicit fentanyl and its far worse analogs.
- The ease of synthesis of fentanyl and how organic chemistry can make it next to impossible for law enforcement to keep track of fentanyl chemicals.
- Despite my warning that her listeners would hurl themselves out of windows, we nonetheless ventured into stereochemistry (Dr. Lev majored in chemistry!) as it pertains to the products of methamphetamine synthesis as well as the unintended consequences of putting Sudafed behind the counter.
- How Narcan might be useful or not, depending on the time during that it was administered as well as the dose and composition of the drug causing the overdose.
- How the Organic Food industry and marijuana industries both benefit from the same "natural is better" fallacy by selling products that are widely seen as either safer or superior because they "contain no chemicals" and how both industries are prospering by making use of a scam.
There is much more, but I cannot resist including the following from Dr. Lev's email:
"My mom really liked [this podcast] - she pointed this one out. She liked you more than Patrick Kennedy."
Dr. Roneet Lev's mom, a woman of obvious discerning taste.
I encourage you to listen to me babble speak for about 50 minutes. There's some pretty interesting stuff in there. Just as Dr. Lev's mother said.
NOTE:
(1) The FDA has jurisdiction over all drug matters. And well they should. I haven't seen even a shred of evidence that the CDC has any knowledge whatsoever about this topic. Which makes things even murkier given that CDC and PROP (another bunch of drug illiterates) ended up making drug policies that changed the face of today's medicine.
