I want to leave EM and open a ketamine/wellness clinic

[Porfirio]

The average American is full of excuses. There are lots of poor people in great shape. There are lots of rich people in poor shape. There are lots of people with kids in great shape. There are lots of people without kids in poor shape. The average American is in much worse shape than 50 years ago. Excuses got people into obesity and it’ll keep them there.

Let me know when you have the OnlyFans up.

---

Members don't see this ad.

 

[JacobMcCandles]

Let me know when you have the OnlyFans up.

If you’re paying big bucks, let me know. I think you’ll like what you see.

 

[RustedFox]

You guys asked for it.

ORANGE HELMET MASTER CHIEF SEES YOU.

Shirtless radical pose available upon popular demand. Warning: I get even whiter if you take off the shirt and will not be held responsible for seared retinas and related visual loss. I'm gonna be modest, at least at first.

My point is this:

Nobody fixes YOU but YOU. I don't wanna hear bogus-ass excuses made by whiners who won't put in the work. Things like: "ACKCHUALLY weight training isn't GOOD for weight LOSS.. and CARDIO isn't all THAT good EITHER." I'm not special or unique; there are millions of people who turned their lives and health around just like this. Train. Lift. Swim. Run. Bike. Whatever. Eat right. It works; and everyone knows it.

A lot of you probably remember a few years back where I was just a seething hot mass of hate. Some of you even PM'ed me or made phone calls to check in and make sure that I wasn't gonna do something regrettable. Thanks for that.

I was 38-39 then. 5'6'', close to 190 pounds. 22% body fat. Sad, fat, drunk, and pathetic. I hated everything and I made my excuses. "I worked so hard today and it sucked SO much. BEERs, hot wings, and vidya games will make me feel better." I even had myself convinced that: "Well, I was entering middle age now, so this is EXPECTED."

Sad excuses from a sad person.

People look for the shortcut... the hack... those are LIES. The shortcut doesn't work. The "hack" doesn't get you there, and certainly won't KEEP you there. You gotta change EVERYTHING. Instead of "give me THIS pill for THAT problem and THAT pill for THIS problem, and THIS shot for THAT and (so on), I got a grip and kept it - and this is what Americans need to do. Stop looking for the pill, the shot, the drug, the WHATEVER to fix the problems that are ENTIRELY within your control. The EASY way does NOT work. Kick your own ass.

Now: close to 43. 158 pounds. Still five-foot-six. Joined the 1000-pound combined lift club and have no intentions of stopping.
... and it DOESN'T take that much work. 3-4 one-hour sessions a week in the gym. Yeah, be smart about it. Conventional gymbro wisdom is conventional because it works.

Americans by and large don't need more pills and meds, they need a reality-check and an attitude adjustment.

Join me, brothers and sisters.

Move big weight.
Eat much protein.
Sleep like a king.
Feel like a God.

This is the way.

 

[PB2464]

You guys asked for it.

ORANGE HELMET MASTER CHIEF SEES YOU.

View attachment 394826


Shirtless radical pose available upon popular demand. Warning: I get even whiter if you take off the shirt and will not be held responsible for seared retinas and related visual loss. I'm gonna be modest, at least at first.

My point is this:

Nobody fixes YOU but YOU. I don't wanna hear bogus-ass excuses made by whiners who won't put in the work. Things like: "B-but weight training isn't GOOD for weight LOSS.. and CARDIO isn't all THAT good EITHER." I'm not special or unique; there are millions of people who turned their lives and health around just like this. Train. Lift. Swim. Run. Bike. Whatever. Eat right. It works; and everyone knows it.

A lot of you probably remember a few years back where I was just a seething hot mass of hate. Some of you even PM'ed me or made phone calls to check in and make sure that I wasn't gonna do something regrettable. Thanks for that.

I was 38-39 then. 5'6'', close to 190 pounds. 22% body fat. Sad, fat, drunk, and pathetic. I hated everything and I made my excuses. "I worked so hard today and it sucked SO much. BEERs, hot wings, and vidya games will make me feel better." I even had myself convinced that: "Well, I was entering middle age now, so this is EXPECTED."

Sad excuses from a sad person.

People look for the shortcut... the hack... those are LIES. The shortcut doesn't work. The "hack" doesn't get you there, and certainly won't KEEP you there. You gotta change EVERYTHING. Instead of "give me THIS pill for THAT problem and THAT pill for THIS problem, and THIS shot for THAT and (so on), I got a grip and kept it - and this is what Americans need to do. Stop looking for the pill, the shot, the drug, the WHATEVER to fix the problems that are ENTIRELY within your control. The EASY way does NOT work. Kick your own ass.

Now: close to 43. 158 pounds. Still five-foot-six. Joined the 1000-pound combined lift club and have no intentions of stopping.
... and it DOESN'T take that much work. 3-4 one-hour sessions a week in the gym. Yeah, be smart about it. Conventional gymbro wisdom is conventional because it works.

Americans by and large don't need more pills and meds, they need a reality-check and an attitude adjustment.

Join me, brothers and sisters.

Move big weight.
Eat much protein.
Sleep like a king.
Feel like a God.

But what about Ozempic bro?! Ozempic!

 

[RustedFox]

But what about Ozempic bro?! Ozempic!

GIBS US THAT OZEMPIC OR WEGOVYY AND KETAMINES AND THC AND ANYTHING BUT HAVE ME CHANGE MY LIFE FOR THE BETTER.

 

[JacobMcCandles]

Join me, brothers and sisters.

Move big weight.
Eat much protein.
Sleep like a king.
Feel like a God.

This is the way.

Proud of you. I didn’t quote your entire post but you speak the truth. There may not be a more welcoming community than gym bros. The only caveat is that if you make excuses or don’t believe in yourself. Other than that, you’ll never have a bigger fan. I encourage anyone who thinks they can’t improve to read RF’s post again.

 

[southerndoc]

You guys asked for it.

ORANGE HELMET MASTER CHIEF SEES YOU.

Proud of you for turning your life around. Not proud of you for helmet selection. LOL

 

[RustedFox]

Proud of you for turning your life around. Not proud of you for helmet selection. LOL

You don't like the orange?
Matches the MTB.

 

[dozitgetchahi]

You guys asked for it.

ORANGE HELMET MASTER CHIEF SEES YOU.

View attachment 394826

Shirtless radical pose available upon popular demand. Warning: I get even whiter if you take off the shirt and will not be held responsible for seared retinas and related visual loss. I'm gonna be modest, at least at first.

My point is this:

Nobody fixes YOU but YOU. I don't wanna hear bogus-ass excuses made by whiners who won't put in the work. Things like: "ACKCHUALLY weight training isn't GOOD for weight LOSS.. and CARDIO isn't all THAT good EITHER." I'm not special or unique; there are millions of people who turned their lives and health around just like this. Train. Lift. Swim. Run. Bike. Whatever. Eat right. It works; and everyone knows it.

A lot of you probably remember a few years back where I was just a seething hot mass of hate. Some of you even PM'ed me or made phone calls to check in and make sure that I wasn't gonna do something regrettable. Thanks for that.

I was 38-39 then. 5'6'', close to 190 pounds. 22% body fat. Sad, fat, drunk, and pathetic. I hated everything and I made my excuses. "I worked so hard today and it sucked SO much. BEERs, hot wings, and vidya games will make me feel better." I even had myself convinced that: "Well, I was entering middle age now, so this is EXPECTED."

Sad excuses from a sad person.

People look for the shortcut... the hack... those are LIES. The shortcut doesn't work. The "hack" doesn't get you there, and certainly won't KEEP you there. You gotta change EVERYTHING. Instead of "give me THIS pill for THAT problem and THAT pill for THIS problem, and THIS shot for THAT and (so on), I got a grip and kept it - and this is what Americans need to do. Stop looking for the pill, the shot, the drug, the WHATEVER to fix the problems that are ENTIRELY within your control. The EASY way does NOT work. Kick your own ass.

Now: close to 43. 158 pounds. Still five-foot-six. Joined the 1000-pound combined lift club and have no intentions of stopping.
... and it DOESN'T take that much work. 3-4 one-hour sessions a week in the gym. Yeah, be smart about it. Conventional gymbro wisdom is conventional because it works.

Americans by and large don't need more pills and meds, they need a reality-check and an attitude adjustment.

Join me, brothers and sisters.

Move big weight.
Eat much protein.
Sleep like a king.
Feel like a God.

This is the way.

Exactly.



In my senior year of college, I reached a peak weight of 282lb at 6 foot 2.

Diet + exercise + learning in medical school just how bad all that excess weight is for you = by the end of medical school I weighed 205. I reached a nadir of 198 during residency. I ate clean, keto leaning meals. Focused on reducing portion sizes. Stopped drinking soda. Did a lot of aerobic exercise then but started lifting in fellowship.

I gained back like 40 lb during the CoVID debacle, but since then have been able to start losing weight again.

It’s not magic. I think the “obesity medicine” doctors have really done everyone a disservice by disseminating this message that it is nearly impossible to lose weight and keep it off without drugs. You just need to get off your ass and eat properly.

 

[gruemd]

Exactly.



In my senior year of college, I reached a peak weight of 282lb at 6 foot 2.

Diet + exercise + learning in medical school just how bad all that excess weight is for you = by the end of medical school I weighed 205. I reached a nadir of 198 during residency. I ate clean, keto leaning meals. Focused on reducing portion sizes. Did a lot of aerobic exercise then but started lifting in fellowship.

I gained back like 40 lb during the CoVID debacle, but since then have been able to start losing weight again.

It’s not magic. I think the “obesity medicine” doctors have really done everyone a disservice by disseminating this message that it is nearly impossible to lose weight and keep it off without drugs. You just need to get off your ass and eat properly.

Agreed. I'm 6'2" as well and peaked about 18 months ago at 240. Heaviest I had ever been after I let my hobbies/exercise die in residency and then COVID. Still trying to get back into exercise more as I've had a couple medical issues that make it harder, but went back to intermittent fasting like I did through most of college and med school and wouldn't you know it, not eating as much makes you lose weight! I'm down to 205, aiming to get below 200 but have plateaued recently. Still, I feel and look way better.

 

[Powdermonkey]

...
People look for the shortcut... the hack... those are LIES. The shortcut doesn't work. The "hack" doesn't get you there, and certainly won't KEEP you there. You gotta change EVERYTHING. ....

Americans by and large don't need more pills and meds, they need a reality-check and an attitude adjustment.


...

This is the way.

... There may not be a more welcoming community than gym bros. The only caveat is that if you make excuses or don’t believe in yourself. Other than that, you’ll never have a bigger fan. ...

So. Much. Truth. Similar story. Towards the end of med school, I was by myself on rotations, no lady friends, running, biking, working out and doing an elimination diet trial. I got down to 185 as a 5'10" dude, felt amazing, and I was strong. Ran a few marathons. Then I met my wife and while we still went hiking and adventuring, I was spending time with her, and she was way cooler than me, so I spent less time biking and running. Residency and a bum thyroid kicked my butt and I left residency around 200. Some other family drama and just the stress of the job, and I was stable at 210. Felt like dog doodoo. I tore my ACL because my legs got a little weak. Then I got the ACL fixed, got my butt back in the gym, got my hormones and thyroid figured out, but not much was changing. I was able to find a sports nutritionist that works at my gym and understands and supports the crazy crap I like to do. I turned a freaking corner. Weight is down to a solid 190-195, all my pants and clothes are loose and fit better (except in the quads and glutes because, well, it's always leg day ). But I got myself into the 1100# club last year, hit a number of life time lifting goals, and then trained and just finished my first 100 mile race. I'm broken, I know, but hard stuff is fun. Any my wife being the crazy supportive nut that she is ran the last 20 miles with me.

The point is, just like the guys above said, it's not easy. It's not fun. I want to eat cookies every day. But I know that's not the right answer. So we don't buy them anymore. I aim for 0.6-0.8g/lb of protein a day, and I've found that my slowly sneaking my daily calories up to somewhere around 22-2300, I feel better, I'm more energized, and I'm keeping the weight and fat off. I love it. I don't want to go back.

Part of my journey that has led me to become more healthy has also made me look long and hard at the EM field, and I've started to think that I need a change. I'm looking at applying for a fellowship next year that will take some of the stress off of my day to day. But that's a story for another thread. I think it's what I need to stay healthy, sane, and to be able to continue practicing medicine for the next 20-30 years. I'm doubtful that retirement will ever truly come for our generation, but one can always hope. In the meantime I'm going to prep for a longer career that I can stay healthy and wind down in much easier than The Pit^TM.

 

[PB2464]

I can't believe people have to come in here giving examples of how working out/weight lifting has helped them with weight loss to combat the pill pushers. What a clown world.

 

[VA Hopeful Dr]

I can't believe people have to come in here giving examples of how working out/weight lifting has helped them with weight loss to combat the pill pushers. What a clown world.

The term us hippies in FM use is "meeting patients where they are".

 

[RustedFox]

So. Much. Truth. Similar story. Towards the end of med school, I was by myself on rotations, no lady friends, running, biking, working out and doing an elimination diet trial. I got down to 185 as a 5'10" dude, felt amazing, and I was strong. Ran a few marathons. Then I met my wife and while we still went hiking and adventuring, I was spending time with her, and she was way cooler than me, so I spent less time biking and running. Residency and a bum thyroid kicked my butt and I left residency around 200. Some other family drama and just the stress of the job, and I was stable at 210. Felt like dog doodoo. I tore my ACL because my legs got a little weak. Then I got the ACL fixed, got my butt back in the gym, got my hormones and thyroid figured out, but not much was changing. I was able to find a sports nutritionist that works at my gym and understands and supports the crazy crap I like to do. I turned a freaking corner. Weight is down to a solid 190-195, all my pants and clothes are loose and fit better (except in the quads and glutes because, well, it's always leg day ). But I got myself into the 1100# club last year, hit a number of life time lifting goals, and then trained and just finished my first 100 mile race. I'm broken, I know, but hard stuff is fun. Any my wife being the crazy supportive nut that she is ran the last 20 miles with me.

The point is, just like the guys above said, it's not easy. It's not fun. I want to eat cookies every day. But I know that's not the right answer. So we don't buy them anymore. I aim for 0.6-0.8g/lb of protein a day, and I've found that my slowly sneaking my daily calories up to somewhere around 22-2300, I feel better, I'm more energized, and I'm keeping the weight and fat off. I love it. I don't want to go back.

Part of my journey that has led me to become more healthy has also made me look long and hard at the EM field, and I've started to think that I need a change. I'm looking at applying for a fellowship next year that will take some of the stress off of my day to day. But that's a story for another thread. I think it's what I need to stay healthy, sane, and to be able to continue practicing medicine for the next 20-30 years. I'm doubtful that retirement will ever truly come for our generation, but one can always hope. In the meantime I'm going to prep for a longer career that I can stay healthy and wind down in much easier than The Pit^TM.

1. Bravo, Bro. Bravo.
2. Remind me tomorrow sometime (I have a big day of an insane variety of things to do) to post a mini RustedFox Rants on a tangential topic.
3. 1100 pound club? - Post your breakdown, please. I'm 300 bench, 400 deadlift, 300 squat. My squat is pathetic, and you should shame me. It will only make me better.

 

[RustedFox]

The term us hippies in FM use is "meeting patients where they are".

No shade thrown, amigo. I love you and your contributions - especially as one of the designated FM-Bros.
There's "meeting patients where they are" (a rather nice way of saying harm reduction), and then there's enablement.
I think we as medical professionals need to rethink that line.
In the SUD treatment world, they love to say: "Harm reduction saves lives", while true, I feel like they're leaving out what should be the second half of that statement, which in total would read: "Harm reduction saves lives, and propagates the problem more often than we'd like to admit."

 

[Powdermonkey]

1. Bravo, Bro. Bravo.
2. Remind me tomorrow sometime (I have a big day of an insane variety of things to do) to post a mini RustedFox Rants on a tangential topic.
3. 1100 pound club? - Post your breakdown, please. I'm 300 bench, 400 deadlift, 300 squat. My squat is pathetic, and you should shame me. It will only make me better.

Thanks, Rusty. 315 bench (three plates goal), 375 squat, 410 deadlift. Fitness by shame is one of my favorite varieties. Peer pressure makes you stronger.

 

[VA Hopeful Dr]

No shade thrown, amigo. I love you and your contributions - especially as one of the designated FM-Bros.
There's "meeting patients where they are" (a rather nice way of saying harm reduction), and then there's enablement.
I think we as medical professionals need to rethink that line.
In the SUD treatment world, they love to say: "Harm reduction saves lives", while true, I feel like they're leaving out what should be the second half of that statement, which in total would read: "Harm reduction saves lives, and propagates the problem more often than we'd like to admit."

So before I tackle this, can you clarify what you mean by "propagates the problem"? I want to make sure we're on the same page here first.

 

[RustedFox]

So before I tackle this, can you clarify what you mean by "propagates the problem"? I want to make sure we're on the same page here first.

Excellent question.

There's many examples, often involving the mental gymnastics that people will go to in order to justify their behavior. I should know, as I was a terrific drinker when I burned TFO in 2020.

Example:

Patient has opioid use disorder.
They don't want to think they have a problem.
They get enrolled in MAT clinic with "harm reduction philosophy".
Use recurrence is not met with accountability or consequences, because "harm reduction."
They see that they can go on intermittently using because "no consequences".
"I don't REALLY have a problem after all (insert common justification about how their addiction "wasn't that bad").
They think: "I can handle it, I just need to be better. I don't need THERAPY or to change the underlying problem."
They use again.
They get hot dose.
They die.
OR:
They get involved in associated narcotic related behavior.
They get busted.
"But wait! Where were my CONSEQUENCES to let me know that it was a PROBLEM!?"


They never learn the principle of accountability.


I'm being deliberately blunt to illustrate the point (and typing on mobile) but the outline here is:

Behavior + removal of consequences = reduction of PERCEIVED degree of severity of problem thru abdication of accountability = greater downstream consequences.

The AA folk will tell you that the worst thing that can happen during a relapse is: "nothing". Why? Because if nothing happens, it leads to the two most dangerous words that the person can say:

"I'm cured."

 

[emergentmd]

I firmly believe that the vast majority of people who are overwt and unhealthy has some form of mental illness/depression. They have an unhappy/unhealthy home life and bring their unhappiness to work. For these people it is very difficult, if not impossible to get healthy until they fix their mental illness. When your depressed, you do not want to get up and do anything eventhough you know you should.

I am lucky that I do not have a depression bone in my body. Nothing bothers me outside of my health/family/religion. I nap all the time and never have a problem sleeping because my mind doesn't think about unimportant stuff all the time. I have been 5'7 and 150-160lb for the past 40 years and never go on diets/crazy work out regimens that I know I could not keep long term. I eat what I want, never restrict myself, but will eat when I am hungry and not because I need it to fill some void. I just run 3 times a week, lift weights maybe 1 time a week. Probably 2-3 hrs total a week of exercise. Truthfully, I just don't like to work out/run but I know I need alittle of this for health reasons. I started to pick up golf and play prob 10 hrs a week because I enjoy it.

If you want to stay healthy/fit long term, you need to fix whatever mentally is holding you back. Its really this simple but also very hard for many people.

The principle of accountability/get up and just exercise/eat right is simple for people in a good mental state. It is very hard for those with depression.

I am confident if God put 100 pounds on me tomorrow, I would get back to my 150-160lb within 6 months just essentially doing what I do now. Eat when I am hungry, work out 2-3hrs/wk, and sleep well because I have a clear mind.

There are no shortcuts. Ozempic will create some big issues in the future. Crash diets never works. Fix your mental state and everything will follow. Happy people mentally are happy people physically.

 

[sloh]

If you want to stay healthy/fit long term, you need to fix whatever mentally is holding you back. Its really this simple but also very hard for many people

It’s hard for a lot of these people bc they are simply wired that way lol. It’s kind of like you can’t “fix” someone’s intelligence. Neuroticism (big 5) doesn’t really change through someone’s life. Having encountered many of these people throughout my life, keeping them in your life just leads to more liability and burden.

 

[RustedFox]

It's worth mentioning that "unhappy home life and they bring their unhappiness to work" works in both directions.

 

[emergentmd]

This is why people who do crash diets/intense work our routines almost always go back to their old self. They put a 6 month patch on but never fixed the underlying reason.

This is why you see those before and after weight loss pics on TV. Those people are paid actors who were fit to begin with and just put on some weight for the advertisement. It is easy for them to lose weight.

Those that lose and keep it off, fixed the underlying problem

 

[emergentmd]

It's worth mentioning that "unhappy home life and they bring their unhappiness to work" works in both directions.

I think the home to work is exponentially more common. Happy home people can handle almost anything at work other than truly toxic environments because they know they are coming home to a happy place. Unhappy home people go to work to vent and bring coworkers into their dark lives.

 

[sloh]

This is why people who do crash diets/intense work our routines almost always go back to their old self. They put a 6 month patch on but never fixed the underlying reason.

This is why you see those before and after weight loss pics on TV. Those people are paid actors who were fit to begin with and just put on some weight for the advertisement. It is easy for them to lose weight.

Those that lose and keep it off, fixed the underlying problem

As expected haha

“I described in Chapter 2 how the effects of heredity and environment can be disentangled by means of behavioral genetic methods. The same methods used to study personality characteristics have also been used to study obesity, and with much the same results. Identical twins, whether they were reared together or apart, are usually very similar in weight in adulthood—much more similar than fraternal twins. And adoptees do not resemble in fatness or thinness either their adoptive parents or their adoptive siblings.4

Think of it: two adopted children are reared in the same home with the same parents. Their parents may be couch potatoes who nosh on caramel corn, or they may be dedicated broccoli eaters who work out daily in the gym. Both children are exposed to the same parental behaviors; both children are served the same meals and have access to the same pantry. And yet one child turns out lean and fit, the other is obese.

The heritability of fatness and thinness is somewhat higher than that of personality characteristics: about .70. But the important point is that the variation in weight that’s not due to the genes—the part that’s due to the environment—environment—cannot be blamed on the home environment. There is no evidence that the parents’ behavior has any long-term effects on their children’s weight and very good evidence that it does not. And yet newspaper columnists and pediatricians go on telling parents, in tones that admit no uncertainty, that if they “set a good example” their children will be thin for life."

 

[emergentmd]

Two adopted in the same environment having two different health profiles. One obviously eat more/work out less and the other eat less/work out more. Why is this?

One has the clear mind and the other does not. Happy people mentally have better health.

Parents setting a good example helps to show that it is possible. To do it is a different story and comes back to a clear mind.

 

[lobstar]

Jeez.
Not a thought given to "is this the right thing to do", huh?

Ketamine for all!

Mom doesn't want to mom because it's not all Instagram moments and live-laugh-love? Ketamine.

Mad at your coworkers? Ketamine.

Bummed because your sportsball team lost? Ketamine.

That's the business model. No, I'm not going to buy it that you're out there providing a critically overlooked psychiatric need.

Hey OP, I'm psych and have worked with IV ketamine clinics and have done my own esketamine clinics. RustedFox is actually on the mark here. People who have life stress sadness will absolutely be coming to ask you to help them escape. You've probably heard about the amphetamine problem in psych and FM clinics. It's looking like this will turn out the same. If you plan to look at actual indications like treatment-resistant depression or suicidal ideation (esketamine only, ketamine doesn't have FDA approval) you're going to be making a lot of patients mad by declining them and it's a particularly unenjoyable experience.

If you, like others have said, are looking to mostly hang out, make some money, do something easy, I can understand that and you'll probably be successful with the right advertising. Just make sure you think it over before starting or you could end up in the same burn out land. EM patients can be rough, and you can't really avoid that by doing psych unless you barely interact and just write the amphetamine or ketamine without much thought or effort.

 

[Franzd'Epinay]

Excellent question.

There's many examples, often involving the mental gymnastics that people will go to in order to justify their behavior. I should know, as I was a terrific drinker when I burned TFO in 2020.

Example:

Patient has opioid use disorder.
They don't want to think they have a problem.
They get enrolled in MAT clinic with "harm reduction philosophy".
Use recurrence is not met with accountability or consequences, because "harm reduction."
They see that they can go on intermittently using because "no consequences".
"I don't REALLY have a problem after all (insert common justification about how their addiction "wasn't that bad").
They think: "I can handle it, I just need to be better. I don't need THERAPY or to change the underlying problem."
They use again.
They get hot dose.
They die.
OR:
They get involved in associated narcotic related behavior.
They get busted.
"But wait! Where were my CONSEQUENCES to let me know that it was a PROBLEM!?"


They never learn the principle of accountability.


I'm being deliberately blunt to illustrate the point (and typing on mobile) but the outline here is:

Behavior + removal of consequences = reduction of PERCEIVED degree of severity of problem thru abdication of accountability = greater downstream consequences.

The AA folk will tell you that the worst thing that can happen during a relapse is: "nothing". Why? Because if nothing happens, it leads to the two most dangerous words that the person can say:

"I'm cured."

This is what's called the moral hazard and the actual data around downstream consequences differs based on the specific intervention discussed (e.g. PrEP, needle-exchange programs, naloxone, etc.). While some of the data is way more "controversial" than others (narcan, for example), generally speaking, it does end up being a lot more complex than "alleged moral hazard -> definite worse outcomes".

Personally, I adapt Ben Franklin's version of Blackstone's ratio ("it is better 100 guilty Persons should escape than that one innocent Person should suffer"): I'm ok with a bunch of drug users living another day if it means a few people are able to turn their lives around.

As an additional point, the actual specifics of the intervention do matter a lot. A recent example is Oregon giving up on their version of drug decriminalization when Portugal's version was quite successful.

 

[RustedFox]

Good points; all of them.
We're gonna split hairs here, because these hairs are worth splitting.

This is what's called the moral hazard and the actual data around downstream consequences differs based on the specific intervention discussed (e.g. PrEP, needle-exchange programs, naloxone, etc.). While some of the data is way more "controversial" than others (narcan, for example), generally speaking, it does end up being a lot more complex than "alleged moral hazard -> definite worse outcomes".

Yes. Yes. Yes. The actual details matter; but what derails things is "an intervention without any teeth for noncompliance."

I am involved in several organizations in the SUD world. What kills efforts at true recovery is the complete lack of consequences of ANY degree. When a patient continually fails an intervention, or there's malignant noncompliance.. something has to change. If it doesn't, the collateral damage to the organization can be a fatal error for the organization itself.

Personally, I adapt Ben Franklin's version of Blackstone's ratio ("it is better 100 guilty Persons should escape than that one innocent Person should suffer"): I'm ok with a bunch of drug users living another day if it means a few people are able to turn their lives around.

That works on paper, but all-too-often not in practice.

"Here's your Suboxone, pwease down't use opioids anymowuh mister niceman" sometimes gets a reply of "Eff off, I do what I want, including sell the Suboxone and buy meth with the money because nobody cares what my UDS is positive for and you guys said that OPIOIDS are my problem to begin with because that's what I need the MEDS for. I don't need meds or therapy for meth so whatever."

Now you've got a noncompliant patient, a diversion problem, and cross addiction.

This should have consequences, but the mealy-mouthed out there are too busy reciting "but HARM REDUCTION" like it's some kind of magical girl Sailor Moon chant.

As an additional point, the actual specifics of the intervention do matter a lot. A recent example is Oregon giving up on their version of drug decriminalization when Portugal's version was quite successful.

I wonder if there's something different about those two populations, legal systems, societies, etc. Hmm.

 

[VA Hopeful Dr]

Excellent question.

There's many examples, often involving the mental gymnastics that people will go to in order to justify their behavior. I should know, as I was a terrific drinker when I burned TFO in 2020.

Example:

Patient has opioid use disorder.
They don't want to think they have a problem.
They get enrolled in MAT clinic with "harm reduction philosophy".
Use recurrence is not met with accountability or consequences, because "harm reduction."
They see that they can go on intermittently using because "no consequences".
"I don't REALLY have a problem after all (insert common justification about how their addiction "wasn't that bad").
They think: "I can handle it, I just need to be better. I don't need THERAPY or to change the underlying problem."
They use again.
They get hot dose.
They die.
OR:
They get involved in associated narcotic related behavior.
They get busted.
"But wait! Where were my CONSEQUENCES to let me know that it was a PROBLEM!?"


They never learn the principle of accountability.


I'm being deliberately blunt to illustrate the point (and typing on mobile) but the outline here is:

Behavior + removal of consequences = reduction of PERCEIVED degree of severity of problem thru abdication of accountability = greater downstream consequences.

The AA folk will tell you that the worst thing that can happen during a relapse is: "nothing". Why? Because if nothing happens, it leads to the two most dangerous words that the person can say:

"I'm cured."

Appreciate the thoughtful response.

Let me preface by saying that I don't do MAT or really any addiction medicine, but as a PCP I'm adjacent to it and have lots of patients receiving treatment for it.

Basically we are now treating addiction as a chronic disease. You're not going to take away a diabetic's metformin because they fell off the diet wagon and are 4 pies over the weekend and ended up with a blood sugar of eleventy billion. If being on suboxone gets a heroin addict from using heroin every 1-2 days to using every 3-4 months, from a harm reduction standpoint that's a huge win. Less chance of infection (leading to expensive HIV treatment or a new heart valve). Same with alcoholics, less liver disease and less chance to drunk behavior that leads to harm (driving especially). So if it helps, and it does me when I'm feeling particularly jaded, you can look at this as a society cost saving measure.

Here's the thing though, most addicts I have met who are in treatment sought out treatment because their addiction has already lead to bad consequences. As I often say, you can't force an addict to get clean or into treatment, they have to want to and they rarely want to unless they have hit their rock bottom.

I had an uncle, huge alcoholic. Kids staged an intervention and he went to rehab. Went into DT's on his 2nd day, spent a week in the ICU. Was drinking within 24 hours of getting out of rehab. It wasn't his choice and he felt no need to stop.

 

[RustedFox]

Right on.

Appreciate the thoughtful response.

Let me preface by saying that I don't do MAT or really any addiction medicine, but as a PCP I'm adjacent to it and have lots of patients receiving treatment for it.

Basically we are now treating addiction as a chronic disease. You're not going to take away a diabetic's metformin because they fell off the diet wagon and are 4 pies over the weekend and ended up with a blood sugar of eleventy billion. If being on suboxone gets a heroin addict from using heroin every 1-2 days to using every 3-4 months, from a harm reduction standpoint that's a huge win. Less chance of infection (leading to expensive HIV treatment or a new heart valve). Same with alcoholics, less liver disease and less chance to drunk behavior that leads to harm (driving especially). So if it helps, and it does me when I'm feeling particularly jaded, you can look at this as a society cost saving measure.

Right on. I won't argue your points here because.... you're categorically correct.
What drives me nuts is that I'm seeing this approach lead to SO much cognitive dissonance by the patient, and uncomfortably often. I used to feel the other way. Not so much anymore.

Here's the thing though, most addicts I have met who are in treatment sought out treatment because their addiction has already lead to bad consequences. As I often say, you can't force an addict to get clean or into treatment, they have to want to and they rarely want to unless they have hit their rock bottom.

I'm inclined to agree with you, and yet I'm told all the time in the SUD circles that I'm involved in that the "rock bottom" concept is a common misconception in the SUD world. When I disagree; I'm told that I'm "the maverick".

I had an uncle, huge alcoholic. Kids staged an intervention and he went to rehab. Went into DT's on his 2nd day, spent a week in the ICU. Was drinking within 24 hours of getting out of rehab. It wasn't his choice and he felt no need to stop.

Yep. Seen this hundreds of times myself in the SUD world. So often, that it makes me question our current "harm reduction" approach.

 

[VA Hopeful Dr]

Right on.



Right on. I won't argue your points here because.... you're categorically correct.
What drives me nuts is that I'm seeing this approach lead to SO much cognitive dissonance by the patient, and uncomfortably often. I used to feel the other way. Not so much anymore.



I'm inclined to agree with you, and yet I'm told all the time in the SUD circles that I'm involved in that the "rock bottom" concept is a common misconception in the SUD world. When I disagree; I'm told that I'm "the maverick".



Yep. Seen this hundreds of times myself in the SUD world. So often, that it makes me question our current "harm reduction" approach.

Yeah I get the same thing. I'm sure the rock bottom thing isn't universally true but something has to make an addict to a good look inward and get them to say "Man, I really need to stop this/get help".

 

[Kryptocoin]

Ketamine is the new post-pandemic testosterone—the cure-all for modern-day problems. Except now, it can be marketed to both men and women.

It's a decent hustle as long as you know what you're getting into. Any cash-paying specialty will always have blurry ethics. When someone shows up in your clinic with $50k cash asking for ketamine, you might say no; someone else will say yes (see Matthew Perry's ketamine doctors).

 

[Powdermonkey]

Yeah I get the same thing. I'm sure the rock bottom thing isn't universally true but something has to make an addict to a good look inward and get them to say "Man, I really need to stop this/get help".

Agreed. Every person has a different 'thing' that will cause that awakening and to have them look inward. It used to really drive me nuts when I started, but over time I've come to realize that forcing someone into a time line that I feel is appropriate doesn't work. So supporting them until they are ready is the best thing. Some people don't reach that point though and might end up with poor outcomes. It's the whole 'You can lead a horse to water, but you can't make them drink' deal.

But, making sure folks have some sort of consequence for their actions is a bigger problem in our society as a whole, not just in EM or addiction medicine.

 

[TooMuchResearch]

Ketamine is the new post-pandemic testosterone—the cure-all for modern-day problems. Except now, it can be marketed to both men and women.

It's a decent hustle as long as you know what you're getting into. Any cash-paying specialty will always have blurry ethics. When someone shows up in your clinic with $50k cash asking for ketamine, you might say no; someone else will say yes (see Matthew Perry's ketamine doctors).

Even one of our well respected local urology practices now has a cash pay testosterone clinic.

 

[Apollyon]

Even one of our well respected local urology practices now has a cash pay testosterone clinic.

Back 6 years ago, the only urologist in a 50 mile radius started writing weed cards. His uro practice diminished steadily, and his income increased at the same rate.