A doctor in Virginia named Joel Smithers was serving a 40-year sentence in an Atlanta prison when he won his appeal to the 4th Circuit. No, he didn’t shoot someone. That’s probably 25 years. He treated patients in pain. Now, he will get a new trial where he will be bludgeoned again with false metrics and innuendo. To ensure that the benefit of the doubt prevails, a Reuters article starts with, “A Virginia doctor who prescribed more than 500,000 opioid doses in less than two years …” OK. Opioids are the only effective medication for moderate to severe chronic pain, so … Yes. They aren’t perfect, but they’re all we have.
It is extremely discouraging to see the media still following this narrative. I could say, “What happened to journalistic integrity!” but we all know. The past bulwark against government oppression has become a megaphone of misinformation used to bury any potential juror under tons of anti-physician propaganda long before the doctor gets a chance to say a word. One reason I write is to at least give a shout of counternarrative as we are shoved en masse off the cliff. So, let’s look at this one and see where the facts lead us. It’s not nearly as lucrative as following feelings and rage, but hey, that’s science.
The article immediately quotes that “overprescription of painkillers is one of the main causes of the nation’s opioid crisis. Nearly 645,000 people died in the United States from overdoses involving opioids from 1999 to 2021, including 80,411 in 2021 alone, according to the U.S. Centers for Disease Control and Prevention.” Well, that’s one way to scare a potential juror, I guess. But there is a big problem with their narrative. The fact is that overprescribing opiates had nothing to do with the surge of deaths we saw AFTER the CDC guidelines were issued.
Opiate prescriptions went up in the early 2000s as we recognized the dangers of untreated pain. They leveled off around 2020 and, by 2012, were on their way down. Without anyone spending decades in prison. But what else happened in 2012? Around this time, cartels realized they could buy legal precursors purchased cheaply in China and make their own fentanyl. But they had a problem. People were used to heroin. So, they solved this issue by making fake heroin. The problem, besides the obvious, was quality control and dosage. Nothing will kill you in a small enough dose. One molecule of botulinum toxin or VX would go unnoticed by anyone. But even water can kill you if you drink enough at one time.
The fake heroin was inconsistent in strength and started killing a lot of people. This is unlikely to be the cartels’ goal, as dead drug users don’t buy anymore. It’s much more likely to be the result of wannabe chemists with inferior equipment putting in too much fentanyl accidentally. This would be easier than you might think. Even careful measuring might lead to overdose and death. The pharmaceutical industry usually makes fentanyl citrate as it is more stable and soluble. But most illicit fentanyl is pure fentanyl base. The difference is that fentanyl citrate is 528.6 g/mol while fentanyl base is only 336.5 g/mol. A difference of 57 percent. I don’t know if this is contributing to illicit pharmacist errors, but it could be.
This difference could also be used to help differentiate deaths due to prescription fentanyl from those due to illicit fentanyl. But this was not done. The CDC attributed all fentanyl-related deaths to doctors and not the cartels and our own lack of sufficient border security at commercial checkpoints. This is where illicit drugs come into the US. On our highways. So now doctors are not just being called drug dealers but prosecuted for the government’s own failings to deal with the real drug dealers. You know what happened next. Prosecutions of doctors went up, doctors stopped treating pain, pain patients were thrown on the streets, and the cartels started making fake pills.
This is terrible for doctors but horrendous for patients and even for the average young person, whose adventurism can now get them killed. A 19-year-old college freshman named Paige Gibbons was planning to become a doctor. She was studying at Hobart and William Smith Colleges when she was invited to a party. At the party, she was given a pill that looked like a Percocet and that she was told WAS a Percocet. Percocet is, of course, 10 mg of oxycodone with 325 mg of acetaminophen (Tylenol). This is a very common medication for the treatment of moderate chronic pain and acute severe pain. It is never a smart decision to take any medication not prescribed specifically for you.
From all accounts, Paige was a very smart young woman, but she was also a human being. Human beings want to fit in and have new experiences, and there with her friends, she took the pill. Had it been what it looked like, it is almost impossible that she would have died. The LD50 of oxycodone in mice is about 426 mg/kg. In rats, it is 1,288 mg/kg. In humans, it is harder to determine as we can’t run the same tests. Human toxicity has been estimated at about 0.14 mg/kg (makes you sick), with a normal lethal dose being 10 mg/kg (LD50, so the dose where 50 percent of opioid-naive people will die). Opioid-tolerant people can take much higher doses and be just fine.
This pill turned out to be “100 percent fentanyl,” according to the newspaper, and by that, I think they mean it had no active drug besides fentanyl. Paige died, and her parents were told she died of an overdose. I disagree. If I gave you a glass of whiskey (where the active ingredient is ethanol), you might get drunk. If I hand you a glass of methanol, you might die. If I did this to you, it’s not an alcohol overdose. It is poisoning. As are almost all those other deaths. By destroying pain and addiction treatment in America, at the same time, they are restricting the production of real medication; the DEA is creating an opioid crisis of its own making. If they were to go to those border checkpoints and do their actual jobs we could end this.
The average doctor used to have about 20 percent of their practice be pain management. Once all the GPs became too scared, the burden on pain specialists increased. At first, they were happy because that meant more money, and, like most specialists, they often think they are the only ones who can treat this problem “properly.” This is why they are prone to going into court or a medical board meeting and excoriating any doctor who dared treat pain who was NOT an interventional pain specialist from anesthesiology. Especially ER doctors. For some reason, they refuse to accept that ER sees more pain in a day than they do in a week. I digress so let’s get back on track.
No one wants to treat pain right now because they know they will be a target. Hardly anyone has ever wanted to treat addiction because there is a strong tendency in the medical community to see those treating the rich at fancy hospitals as respectable and those treating the minorities and the poor as questionable. It has always been this way, and without tremendous social pressure, always will be. So what happens to the few of us willing to treat addiction? We get targeted by the DEA. Less than 4 percent of physicians bothered to get certified to treat addiction. What do you want to bet that a much higher percentage of those get targeted? It is time that we take the DEA out of the doctor’s office and start to heal again.
All that being said, where does that leave the doctor in Virginia? Without a fair trial, that’s where. The media won’t even entertain the possibility that he might be innocent, thanks to the success of the government’s new Reefer Madness efforts, and he will be facing a jury that just watched “Dope Sick” (a little sensationalized but not bad overall) and then “PainKiller,” (over the top but hey, it’s the Sacklers) and then “Pain Hustlers,” which is so unfactual as to have kicked “Reefer Madness” from its throne. After the last one, the only question from the jury is, “Where’s the noose?” None of this is helpful to people like Paige or the millions of legitimate pain and addiction patients who can no longer get care.
L. Joseph Parker is a research physician.
