Naloxone for Chronic Pain

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My trusty Google search bot fleet turned up this recent article highlighting a recent piece on NPR (radio) that I had not heard or heard tell of as we say in the South since I work and cannot listen to it as much as I would wish. It concerned a trend in utilizing naloxone in treating chronic pain.

This is somewhat significant as naloxone is about as far away from using opioids to treat pain as you can get. Naloxone is used to treat addictions and simply cannot be viewed at all in the same pejorative light as opioids.

Naloxone, without boring the reader with a brainy, academic, overly pharmacologic explanation of the in’s and out’s of this area of “medication-assisted treatment” (MAT in the new parlance of addictionology), is a blocker of effects of opioids and helps to blunt the effects by which opioids and even alcohol induce and sustain addiction. It is both a generic (not a brand name, i.e., not expensive) drug and a brand name form drug, Vivitrol (super expensive and highly promoted by its parent manufacturer.

Naloxone has been around for decades. It has a well-established place in the pantheon of tools to treat addictions, along with, of course, the cognitive therapies and my sentimental favorite the 12 Step programs that I view as all-important in the journey of anyone in recovery.

As an aside, I will never forget my first patient with alcohol addiction as a naive, dumb, unschooled psychiatry resident over 45 years ago at Duke. He was not my then biased stereotype of a problem drinker, someone who had lost almost everything, came into the hospital inpatient service in alcohol withdrawal, etc. On the contrary, he was a professional, respected in his circles, accomplished, educated and showing almost none of the physical issues or stigmata of the ravages of alcoholism. He had relapsed. His treating Duke psychiatrist, my instructing attending was wise enough to ask this man to educate me about his disease. And this was in the days when moral opprobrium still reigned supreme toward alcoholism and addictions. the concept of addiction as a disease was just making headway into the lingua franca of our world then as the new enlightened way to view and approach addictions courtesy of two of then past giants in addictions, the recently late Dr. Herbert Kleber MD then of Columbia University Dept. of Psychiatry and UNC-Chapel Hill School of Medicine’s Dr. John Ewing, a giant in alcoholism research and treatment, founder of the Center for Alcohol Studies.

My patient above told me his ‘story.’ I had the sense to listen to him for as long as he wished to talk. He took me through his life account for well over an hour. I was astonished at how open he was with me about his failings, drinking, failures, and relapses. When I intimated that I would have to digest all that he had told me, he surprised me further. He asked me if I knew about A.A., Alcoholics Anonymous. I answered honestly that I knew very little. I recounted that I remembered my parents taking in geologists and mining engineers from my father’s international mining teams when I was a kid, who had been alcoholics and helping them get back on their feet. I said I only knew that my father had helped them go to AA and that it helped them but that was about the sum total of my knowledge.

My attending’s patient then proceeded to tell me of his years’ involvement with AA and gave me an introduction I would not forget. He helped me to see it as one of the most accepting, supportive organizations ever. I kept thinking to myself while he told me of AA, why weren’t most of our social organizations more like AA? Churches, fraternal orders, etc. I marveled at the trust he felt he was able to place in persons in AA.

However, what blew me away was one of the final points he left me with. He was a traveling professional, who worked in other professional centers somewhat regularly. He told me of how AA saved him from his core internal loneliness and depression that he struggled with. He spoke of his long past pattern of drinking to salve his loneliness in hotels away from home and family in the evenings after he had completed his consultations.

AA helped him to break that many year pattern by going after supper in hotels or restaurants to local AA meetings. He told me that he knew wherever he found himself, there would be an AA fellowship of persons in which he could find acceptance, support and positive booster inoculation against drinking. He described as the western world’s largest support community. I was flabbergasted as I grasped what he was conveying. And I never lost that sense of AA.

Back to naloxone. The article that set off all this in me, “In Tiny Doses, An Addiction Medication Moonlights As A Treatment For Chronic Pain,” from just days ago (Sept. 23, 2019) is well worth the reader’s attention.

One of the issues that might not strike the reader right off is that this long generic, out of patented brand name status, money-making status, has only modest research behind it to explain its now anecdotally reported effectiveness in unrelated pain syndromes. But reports are continuing to surface in some number and frequency that this medication is making perhaps a more and more solid case for more clinical investigation of it in pain control.

But, and it is a BIG but, it has not much potential as a MONEY MAKER. No drug company appears likely to pick it up and develop it as a pain modifying medication. The company marketing Vivitrol is not going to do so as documented in this NPR article.

So this possible more desirable medicine will be left to the backbench of interventions. It is not addictive in and of itself at all, like buprenorphine can be which is also used as an “MAT” medication in the treatment of opioid addiction.

This medication has little support for its use and ‘development.’ By development, I mean good clinical, nationally coordinated research that would establish its “place” in pain control clinical practice.

I think that generic medications such as this with a clearly very valuable social medical potential should be ‘adopted’ by the national research and clinical research arms that be. Monies to support and drive the clinical research that should be devoted to a medication such as this, ought to be easily devoted to its cause. A new mechanism of initiating, driving, funding and sustaining the R&D of such a lowly generic medication ought to exist. I would even propose a policy of supporting monetarily pharmaceutical companies to jointly share somehow monetarily in the sale of a naloxone category of medicine so that the use of naloxone or medicines like it, would not be a marginal effort but part of mainstream medical practice to benefit the huge cohort of pain patients who need an effective non-addicting medication intervention.

Just because a medication would never make BILLIONS for companies as the Oxycontins of this world have done, does not mean it should not be developed in a way that paves the way for its mainstream use and establishes its scientifically based modes of action in the mysterious world of pain.

Pedophile Hunter Podcast

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To start on a light note, and at the risk of making a series of incredibly bad puns, I wish to note that in our American linguist Inc. lexicon we have had fortune hunters, Easter egg hunters, the infamous and racist “Great White Hunters,” sunken treasure hunters, and especially in America which probably still is one of the preeminent shopper cultures, the ever famous “bargain hunters.”

To this list I wish to add a new phenomenon that took me somewhat by surprise a very few days ago when one of my trusty search bots which brings me legal, psychiatric, philosophical, social policy related terms having to do with the infamous topic of pedophilia, turned up a one episode installment of The Guardian British newspaper’s podcast series which focused on a group in Scotland known as the Wolfpack, and specifically a housewife who lives east of Glasgow who heads up a loose network of citizen pedophile hunters.

I have enclosed herein the URL link to this single podcast episode which features the reporter Libby Brooks and her profile of the housewife “Cici.”

The loose-knit pedophile hunting organization, Wolfpack apparently has been in existence for at least 18 months according to the podcast. Their sting operations have resulted in prosecutions on an impressive frequency of approximately four per month. This group apparently consists of ordinary citizens who pose as underage minors on social media websites and make themselves available in disguise and “pick up” pedophiles who frequent such sites and make online overtures to the hunters. The hunters then reel them in with a series of back and forth social media texts and posts and eventually meet up with the predatory pedophiles in person. The hunters take care to identify themselves as underage and state their ages variously as below the age of consent in the United Kingdom. This is an effort to give the predators every opportunity to back out of the interaction, I suppose to avoid the taint of illegal entrapment. I make this tentative assertion out of knowing ignorance, as I have NO idea about how the concept of entrapment is handled in the UK.

The podcast is sort of fascinating because these interactions are not only recorded but are also streamed live (!) on Facebook and have gobs of interested persons who view them live. The reactions of the pedophiles when they realize they have been nabbed and apprehended ranges from dishonest excuses to actually emotionally breaking down crying etc. as the police are called and close in to arrest them.

There is commentary that is very well done to give the listener a great deal to think about and reflect upon. I, for instance, found myself still wondering from an American’s point of view with a cautious backdrop of respect for an individual’s legal rights even when being arrested, of worrying that this still constituted a degree of entrapment. But the other moralistic, ethical, and mental health side to me, still felt that this was probably a legitimate enterprise although a very novel and unique one. Part of me could not help but applaud the efforts of these citizen anti-pedophile crusaders.

I don’t know of a similar effort in my home country the United States. I have no idea how this would be accepted in legal circles and how law enforcement agencies at any level whether local regional state level or federal–national would accept and work with such an effort. I have known for years that with the rise of the Internet many law enforcement agencies have begun to go after sexual predators utilizing the Internet as a platform to draw these individuals out, and utilize similar techniques of posing as underage vulnerable individuals and to gather enough proof, evidence and confirmation of the identities of such individuals thereby making possible legal arrests and prosecutions. I have not known of citizens undertaking such efforts though, for all I know, such efforts have been ongoing for years and I just haven’t run across them.

But this podcast episode is fascinating since it tells all in that it records the face-to-face interactions once the pedophiles are revealed. And the technique of streaming and broadcasting the interactions with the ped for pedophiles live on Facebook was quite startling to me and perhaps altogether a new phenomenon in this arena.

I leave it to the reader to listen to this podcast episode from The Guardian newspaper and render their own judgment.

The Sad Saga of Jeffrey Epstein and His Suicide

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Sometimes I am very reluctant to weigh in on recent prominent national stories. At times I prefer to let the dust settle from the controversy of such issues, and also to permit my own reflective and responsive observations a chance to percolate through my mind and catalog of past experiences that I often like to bring to bear on very contentious, and especially emotionally upsetting national stories. This very sad saga, and recent suicide just a few days ago of the extremely controversial, to say the least, story of the convicted sexual trafficker and apparent pedophile, wealthy mysterious financier Jeffrey Epstein formerly of Florida is no exception. It has many attributes that could furnish an opening to the ever-present temptation to be very sensationalistic regarding numerous features of his life story. Most of us have had a very negative view of his sexual predatory misadventures of years ago when he was convicted, and as well, of the apparent exceptional and questionable treatment he was afforded in his prosecution and sentencing several years ago. I daresay few people registered any quiet self-contained objection to his being arrested again weeks ago for crimes committed in the New York jurisdiction.

But nonetheless, his death by suicide a few days ago is sad by any measure. But it brings up many issues. I have no desire to contribute to the already inflammatory usual stupid Internet-based extreme reactions such as conspiracy theories as to why his death came at this point in time etc. One of the stories is of course the expectable moral umbrage and outrage from a governmental and bureaucratic perspective voiced through the person of Atty. Gen. Barr. There is some understandable justification for this institutional reaction and inevitable review. For instance, it may be hard for many to comprehend how in the world this man could’ve suicided in such a secure facility with the capability for extreme observation and safeguards against such an occurrence of a person hanging themselves. There has been much discussion of why Mr. Epstein was not placed on 24 our suicide watch etc. And this is also understandable since very apparently, this gentleman made an alleged suicide attempt on July 23, 2019.

I have made it a point to listen to many of the news television outlets’ analyses and have not heard really only a very few analysts voice what I thought were well-placed thoughts. One clinical mental health person gave a very good explanation of the usual process that clinicians in such settings employ to ascertain whether a person is still potentially at risk to harm themselves, i.e. suicidal. This analyst made the telling points that individuals still if they are very sophisticated and capable of very polished dissimulation can mislead and in effect, deceive even the most competent mental health examiner. This analyst gave a very reasonable scenario that anyone could’ve employed to emerge from the close clinical precautions that intensive mental health facilities whether jails or inpatient psychiatric hospital units, employ to monitor for the possibility of and to prevent suicidal behaviors. But this analyst’s efforts were by far the exception. Many of the accounts either outrightly stated or hinted at, clinical and institutional malfeasance that they cited without information or evidence to back up their somewhat irresponsible or cavalier attributions of guilt and fault.

I do not wish to venture into the briar patch of cavalierly diagnosing Mr. Epstein either in order to flim-flam the reader into believing some faulty analysis I might employ. And I can easily resort to throwing around sophisticated-sounding and perhaps seemingly plausible diagnoses as a clinical psychiatrist.

I do wish to approach this very sad and tragic occurrence from a very different perspective. I don’t think for instance, that it is necessary to invoke a “fifty-dollar” diagnostic term to open a discussion of why I think what happened was possible. Instead, I think I can contribute a wee bit of earnest analysis and explication by simply focusing on this gentleman’s past history and behaviors.

More importantly, even to me as a psychiatrist, I find it completely irrelevant whether he is a certain clinical or personality diagnosis. It is simply not needed in order to generate a bit of understanding why this happened. Again, the basis for my approach in looking at this is sufficiently supported by looking at his characteristic behaviors.

First off, he apparently was an immensely wealthy individual. Being wealthy does not necessarily make one an evil individual. But the way this man utilized his wealth and immense resources in dishonest, predatory and heinous ways are explanatory. He apparently had utilized his wealth to buy his way into whatever social arena he wished to enter. And he apparently used his entry into those private walled-off worlds because he knew he could operate in the shadows and carry out his reprehensible behaviors. These of course allegedly included recruiting vulnerable underage adolescent girls for abusive sexual purposes.

Second, he utilized his wealthy resources to pay off accusers and victims to protect himself from exposure and prosecution for many years. This is a further extension of his “evil” (and I do not think this is too strong or inappropriate a descriptor to apply to his behaviors) modus operandi. The use of the word evil gets this entire discussion out of the trap of misusing speculative pseudo-clinical diagnostic exercises that are not only empty but misleading, and into a more appropriately morally based discussion. Nowadays to be politically correct, sometimes we are not supposed to use the word “moral,” at all. But I think it is appropriate here because of the gravity and the nature of his apparent offenses.

In other words, this man was wealthy enough to not only afford but most importantly, regrettably protect himself from the consequences and discovery of his offenses. He was able to apparently very much lessen the consequences of even his prosecution and penalties several years ago in Florida. There has been much discussion of what has been called a “sweetheart deal” and I won’t add to that presently.

What I do wish to do is to discuss this again as I have been implied above, from a very different perspective. I think that anyone who permits themselves to become ensnared by the universal temptations to our baser impulses that all of us have, and who are wealthy enough, to permit ourselves to be corrupted by the kinds of power that extreme wealth confers, can evolve into the kind of person that apparently this gentleman became. This is a viewpoint that originates from my mental health background and my own view of human nature. Some quarters of intellectual and moral thinking recoil at this postulate that any of us is capable of evil if we succumb to these universal temptations; but I have long thought that this is the case and is the reason for laws, moral precepts, religious beliefs and admonitions, and all the societal safeguards that every culture has.

There is a body of literature in psychiatry and in specifically in psychoanalytic theory and practice of several decades ago that originated from a group of psychiatric and psychoanalytic writers. That group of influential practitioners talked about these kinds of people in very telling detail. I do not wish to name this “school” of psychoanalytic and psychiatric thought, nor one of its primary proponents as it would tend to lead us down the rabbit hole of viewing this kind of personality aberration in the all too restrictive pigeonhole of a certain set of diagnostic concepts. But this school of thought is quite accurate and has a few concepts that I think are worth conveying.

One of the issues is that these kinds of people who have wealth, power, great influence and deficiencies in their personal ways of behaving and codes of ethics, function very much alike and very predictably. They are used to getting their way and can use their wealth to see that this happens. This is an old story and not a new concept to be sure. It is repeated over and over again in the hallways of power whether in corporations, government circles, military endeavors, etc.

Attendant to living in this rarefied world of extreme personal power that can be exercised often with almost total impunity, enjoying the lack of checks and balances by others, is that these folks view themselves as not only all-powerful but also not subject to the moral precepts built into the fabric of the governance of our social contract.

Consequently given this kind of sense of true invulnerability, these individuals live their lives certain that they can never be brought to justice, never be subject to effective criticism or correction and live a life that is totally foreign to the rest of us.

But when they come up against a final reckoning, a set of corrective circumstances that their money and power cannot protect them from, they fall very far, very fast and surprise us all. They suddenly are revealed as being as weak and vulnerable as anyone else. Their fall from power as it is often termed surprises many observers but in my view really should not be surprising at all.

This very special kind of person can react self destructively and suicidally in very short periods of time with little or no indication that they are crumbling within. And they can and often, will self-destruct almost immediately when their powerful self-protection is breached.

And this is what I feel happened to this gentleman. He functioned well in his own misguided way as long as his defenses, coping mechanisms as we mental health types would call them, were intact and effectively deployed. But when they no longer protect such an individual, the structure implodes from within and these folks suddenly become nonfunctional. The contrast between their previously powerful status and their dissolution is truly surprising to those who have not seen this before.

Those of us who treat individuals like this know this is a constant risk. And unfortunately it takes a wealth of experience and supremely skeptical clinical objectivism to remain ever mindful that their surface presentation with all their charm and urbane manipulative confidence is straining to the utmost to deceive a mental health examiner and to maintain the long term facade of power. And even the most skilled mental health clinician still can be deceived by them since we never can know fully and exactly what the person across from us in a clinical evaluation interview is truly thinking and intending.

Mr. Epstein saga I think is an example of this kind of clinical situation that is exceptional, but nonetheless still frighteningly instructive. No one should bring to bear too much self-righteous and indignant, ill-informed, criticism of how this played out recently unless there truly was careless clinical practice. We need to keep level and clear heads and at best, strive to learn from this very public and sad example of how a tragedy can sneak through the best of safeguards in the most secure of settings despite the committed earnest efforts of many kinds of professionals who are tasked with the thankless job of navigating these shoals of complexity on a day-to-day basis.

A Manic Politician of History

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The ?Manic Political Long Family of Louisiana

From the pen of the human interest, humorous columnist Jim Bradshaw of the St. MaryNow.com website of Lousiana came the following hilarious piece regarding the Governor Earl Long, scion of the even later and more famous Huey Long, of “A Chicken in Every Pot” Depression Era fame: JIM BRADSHAW: WHEN EARL LONG’S MENTAL STATE MADE NEWS. I am always on the lookout for pieces that document the foibles of the famous cultural figures of our time, both for purposes of humor and for instructional examples to use with trainees in medicine and psychiatry in my work. This piece is worth the read. I would commend it to the reader for a pleasant interlude.

I have another purpose as usual. I had in decades past some older ancestors of my father’s family located in Louisian. Early on in my life in childhood and teen years I was exposed to one great aunt in that state on periodic visits to her home there. She was in 80’s by the time I came to hear family stories about the Civil War and other fascinating tales involving my father’s family’s long gone relatives. A few of those stories involved that branch of my father’s ancestors with the infamous Huey Long who ran for President and was one of the reactive voices of common people’s Populism during the Great Depression which my father and his own family lived through.

The tales I heard about “The Kingfish” as Huey Long came to be known, were incredible. I heard of demoagogic speeches that could spell bind huge outdoor audiences, hard drinking, a talent for non stop off the cuff jokes and so much energy that almost no one could keep up with him.

Gov. Huey Long at the Microphone

Then in later years as accounts of Earl Long’s own clearly “manic” spells came out, I began to wonder about the fast paced, non stop life that was Huey Long’s. In my residency and later practice years, I came be exposed to persons who were not fully manic but who clearly were non stop persons as I called them. I came to view as a distinct type, a diagnostic category in my own mind that was not recognized, and may never be, in the bible of psychiatry, the DSM, the Diagnostic Statistic Manual. These were persons who were always “on,” always hypomanic or just below that level of revved-up-ness. I once knew a salesman who could sell out his luxury foreign car dealership in three months and then spent the rest of his work year languishing at his NC beach house until the new model year of luxury cars came in. He would then return and then proceed to sell the stock out, drive out all the other salespersons and make the dealership owner most happy. He finally had a manic episode and confirmed my psychiatric musings about him. I met and knew over the years such figures who all worked inhumanly impossibly long hours, had non stop energy, could drink everyone under the table, were the dominating person in any room they graced, had insatiable sexual appetites, and were enormously successful. They were company heads, surgeons, attorneys and politicians of course. Most of them never evolved into full blown officially symptomatic manics, but many of their progeny did and that is how I came to know them and suspect the truth about them. Their genetic diathesis, posing as this constellation of lifelong energy and such, sometimes emerged in the full evolution of their hidden “bipolar” subclinical makeup.

And that is my take on the Longs, Huey was a closet hypomanic and Earl was a full blown hypomanic-manic person in times when all this was poorly understood and denied.

I have to not tease the reader with all this. I have reprinted Jim Bradshaw’s article on the late Earl Long below for your immediate gratification and your own judgment:

The Equally Spellbinding Gov. Earl Long

“Sixty years ago Louisiana and the nation watched with a combination of awe, incredulity, and amusement, a political episode that was bizarre even by the standards of Long-era Louisiana.
During the summer of 1959 newspaper front pages were filled daily with the tirades, tantrums, and shenanigans of Gov. Earl Long that caused him to twice be confined in mental institutions, and to briefly act as governor while he was an inmate in one of them.
The manic episodes, family members said, were the result of Long’s return to heavy drinking and taking an assortment of pills either to help him sleep or keep him awake. Long said that was humbug (in much saltier words).
He was always volatile and hot-headed, but reporters began to publicly hint at the governor’s overuse of alcohol as early as April, when the Associated Press reported the governor’s hijacking of a legislative budget hearing “with his bottle of Tichenor’s antiseptic on the table before him.”
But things really began to unravel in late May, when Long railed for more than an hour and a half and, the AP said, “poured out scathing criticism” on legislators and political enemies … “as he screamed into the House microphone in a stinging, stump-speaking style.” They noted that he drank from a glass filled with “what appeared to be grape juice” during the tirade.
Two days later, the governor’s wife, Blanche, announced that Long had been ordered to bed “for several days” and that he was suffering from exhaustion. One of the people helping to make that decision was Jesse Bankston, Louisiana’s director of hospitals, who thought Earl needed more than bed rest at the governor’s mansion.
He thought Long needed to be confined for psychiatric evaluation and that the confinement needed to be outside Louisiana, so that he could not use his powers as governor.
On Saturday, May 30, Earl was strapped to a gurney, put aboard an Air National Guard airplane, and flown to the John Sealy Hospital in Galveston. The doctors were told that Earl had agreed to be admitted. They soon found out differently. The AP reported that Long “refused to cooperate with hospital authorities.” The Galveston Daily News said his refusal included “a couple of violent episodes.”
He threatened his wife with federal kidnaping charges, and court-appointed lawyers in Texas filed papers claiming he was taken to Texas against his will. Long himself signed the legal papers, “Earl K. Long, gov. in exile by force and kidnaping.”
The hearing June 16 on his petition for release, according to United Press International, was punctuated by Long’s outbursts against, among others, “the horse doctors” who were overseeing his treatment. When the judge tried to quiet him, Long said he was just trying to help his lawyers prove he was sane.
Before the ruling came down in Texas, however, Long made a deal with Blanche and with his nephew Sen. Russell Long that he would consent to being moved to the Ochsner Foundation Hospital in New Orleans.
He was there one day before he reneged on his promise. He told Blanche he’d said he would go to Ochsner, but that he didn’t say how long he would stay. There was also a rumor, reported in the Alexandria Town Talk, that once the airplane was over Louisiana, Long planned to order the Louisiana National Guard pilot to take him to his farm in Winnfield, rather than New Orleans. It didn’t happen, but it sounds plausible.
When Earl reneged, Blanche had a friendly judge sign orders committing the governor to the Southeast State Mental Hospital in Mandeville. Once again, “a screaming, cursing Gov. Earl K. Long was hauled to a mental hospital.”
But this one was a state institution in Louisiana. While an inmate at Mandeville, Long called a meeting of the State Hospital Board and had its hand-picked members fire Bankston as state hospital director and appoint a new one, who, in turn, fired Dr. Charles Belcher, the superintendent of the hospital.
Belcher’s replacement saw no reason to continue to hold Long, nor did a friendly judge when the family tried to keep him confined.
The AP reported on June 26, “Gov. Earl K. Long swept out of a jammed courtroom a free man today — a complete victor over his family and state officials who committed him to a state mental hospital.
“Gov. Long immediately set up a temporary statehouse at the Great Southern Hotel … near Lake Pontchartrain. From room 221 in the hostelry, the governor is expected to drop the axe on political enemies.”
Which he did.
A collection of Jim Bradshaw’s columns, “Cajuns and Other Characters,” is now available from Pelican Publishing. You can contact him at jimbradshaw4321@gmail.com or P.O. Box 1121, Washington LA 70589.”

SC State Hospital To Undergo JCAHO Review After Patient Demise

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South Carolina State Hospital Historical Marker

The South Carolina state psychiatric hospital, historically called “Bull Street” for decades in the past, Brian (state) Hospital in Columbia SC, recently had a sad and tragic occurrence, a suffocation death of a patient apparently undergoing a hands on restraint for out of control behavior by multiple staff.

In a recent article written by Avery G. Wilkes of The State newspaper of Columbia SC, entitled: “Suffocation Death of SC Mental Health patient under review by group that accredits hospitals,” published July 17, 2019, the sad story of this tragedy is detailed. In this article, there is described the possibility that some of the staff involved in this patient’s restraint event, were not adequately trained in these highly complicated and at times, hazardous to all involved, events. I will try to comment on my own experience with these events below. In any case,

The results of such investigations are made public. This is not a closed process with no transparency. Sometimes the public can be overly suspicious that transparency is not being followed by officials at the state or hospital levels when the media note that officials could not and would not discuss details of these reviews at first until the results are determined and made public. An article published September 8 ,2017 by the Wall Street Journal authored by Stephanie Armour entitled: Hospital Watchdog Gives Seal of Approval, Even After Problems Emerge: The Joint Commission, which the government relies on to accredit most hospitals, rarely withdraws its approval in the face of serious safety violations,” gave a cursory overview of this issue which was taken up by the U. S. House of Representatives in 2018 with a request for documentation (House committee probes CMS, Joint Commission over accreditation process,” published in Modern HealthCare magazine). Unfortunately I have not been able through my searches to find left over record by that Commerce Committee of the House as to what eventually came of the initial inquiry.

But it is my opinion and experience, that one of the reasons the Wall Street Journal found that only 1% of hospitals nationwide are ever de-accredited is that wealthy private hospitals are de-accredited less than the state psychiatric hospitals. Medical hospitals are now usually huge conglomerates and rarely are penalized at such a level. Small poorer community hospitals seem to be more vulnerable to such review based censures. And they are closing across the nation now anyway for reasons of declining revenues but that is another story for another day. Suffice it to say that state psychiatric hospitals, as maligned as they still are, operate in a far more regulated and highly scrutinized environment than private psychiatric hospitals or units/services within large wealthy, private, or university medical center based entities.

States’ governmental laws regulating their health care facilities, as well as private hospitals, require investigations and review by various bodies locally and nationally, deaths of patients by unnatural causes. Local review bodies include legislative oversight committees, the states’ own departments that oversee state psychiatric and private medical/psychiatric hospitals, national bodies such as the Joint Commission for the Accreditation of Hospital Care Organizations (the famous “JCAHO”), CMS (the federal agency for Medicare and Medicaid)C etc. Investigations such as these are very important since failure and loss of accreditation by these bodies can result in loss of ability to receive reimbursements from various insurers, especially the federal ones, Medicare and Medicaid. And for state psychiatric hospitals, this is extremely important. State psychiatric hospitals serve mostly poorer patients on Medicaid and Medicare or the uninsured, and loss of these operating funds means that the state legislatures’ budgets then have to make all the lost funds until the hospital which has lost such accreditation and funding can regain such. This always involves submitting to the mandates the hospital must put into place. This process is always lengthy, detailed and usually requires “corrections,” “actions plans” etc. It is not a trivial event then when a state psychiatric hospital has such a tragedy, and when a “deficiency” is found. The investigative review process is arduous. It requires no questions asked cooperation by the hospital staff and leaders. Staff are subject to detailed interviews and scrutiny. Hospital policies are reviewed and the review personnel check to make sure that the policies are indeed followed and fully implemented. If there are deficiencies found, then the corrective actions are imposed and possible penalties such as loss of accreditation are imposed.

Now there are wealthy(ier) private psychiatric inpatient systems that have been de-accredited in the past few years and I would be remiss in my own ethical standards if I did not mention a couple of them. One was the Timberlawn Hospital of Dallas TX that in its heyday was truly a very good inpatient treatment facility. I had a former mentor from my long ago training days who migrated to work there and did exemplary work with adolescents. But the leadership and ‘mission’ of the facility changed a decade or so ago and it went rapidly downhill, quality of care suffered and tales/rumors of its bumblings, then deaths and such, began to emerge. It underwent investigation, lost accreditation which was a genuine shock to many who knew it in its heyday, and closed only a very few years ago. Another chain of psychiatric inpatient centers in the Boston area garnered such scrutiny, was loudly hectored in the media for a variety of missteps, some of them quite major and involved a lot of financial misdoings and lost its accredited standing also. So this does happen with some monied, strongly capitalized psychiatric inpatient entities, but I feel it does not happen enough and helps the explain the findings in 2017 of the WSJ article/expose.’

At this point I would like to comment on my own experience with at least the aftermath of a state hospital-based investigation regarding the patient death undergoing a take down manual restraint.

After serving as stint for approximately 4 1/2 years is the first psychiatrist at a newly established Native American tribal mental health clinic and substance abuse services, and in the approaching twilight of my psychiatric practice career, I was looking for a more balanced and salaried position for essentially the rest of my career. As I had started out my post residency and fellowship practice career in a the North Carolina state hospital helping to start a new 44 bed acute relatively short-term adolescents psychiatry unit, I made the decision to apply for a position that my current state hospital site of employment. I initially applied through a locum tenons psychiatry job placement firm. I had a few long-term friends, fellow psychiatrists I had known through professional contacts over the years who worked there as well. I had some knowledge that this state hospital provided excellent high quality care and I was eager to apply and see if things would work out for all parties.

I’m was not prepared by the two-way exchange that I was given during the several week application and review process. I was prepared for essentially one way process in which I would furnish information and references about myself and to be judged regarding meeting the qualifications for employment at this facility and providing evidence, references and the best representation of my qualifications that I could. Instead, toward the end of the application and interview process which lasted more than one interview session and multiple visits to the hospital, I found myself being informed by the CEO psychiatrist of the hospital, of the relatively recent traumatic experience that the hospital itself had gone through. He did so for the purpose of complete transparency and honesty so that I would know fully what the hospital had gone through and be exposed to any possible negative information about the hospital organization, its own level of confidence etc. As he began to relate the history of the death of the patient within the previous two year period, I was floored by his openness. Gradually I came to understand that this incident had been traumatic for everyone involved and was witness to the extraordinary links to which the clinical leadership and staff involved at all levels, went to in order to be cooperative with the ensuing mandatory investigations, the patient’s family and the media to the extent that they were permitted by the confidentiality laws. There was no hiding of the incident, no minimizing, no bureaucratic obstruction etc. It did turn out that part of the basis for mandating corrections and deficiencies based on the circumstances of the death by virtue of the physical nature of the episode of manual restraint of a truly aggressive and supremely uncooperative patient were erroneous. I was permitted to find out and review the incident myself and learned with confirmation from the CEO that for instance, the initial pathology exam was erroneous and efficient and that a repeat exam later on in the process essentially demonstrated that the cause of death was a previously unknown cardiac condition of the patient and not the air of the hospital staff in affecting the physical restraint and control measures. But this was not accepted or validated by the investigators and sanctions were imposed including the loss of accreditation for the hospital that lasted approximately a year and a half.

I was simply ethically amazed that the hospital clinical leadership worked actively with the investigators and without any protest whatsoever submitted to the corrective actions in a dutiful accepting way seeing them as an opportunity for positive change. By the time I arrived on the hospital’s staff, the changes had been actively implemented and I was exposed to the most detailed and helpful training course in physical restraints procedures that I had ever witnessed at any hospital at which I had practiced in the past. The hospital had contracted with an outside training and consulting agency in another state and at great expense to itself, instituted a mandatory training policy for every single staff member who has any sort of clinical contact with the patient population, from behavioral nursing assistants on up through psychologists and psychiatrists without exception. This training is mandatory and is repeated annually for all clinical staff and stands witness to the openness, cooperation and commitment to high quality of patient care.

So when I read of other hospital organizations undergoing such thorough reviews and investigations by outside bodies have more appreciation for the difficulty of the task that is endured by both the reviewer in investigators and by the hospitals themselves mutually. I also am somewhat dismayed when I read accounts of hospital organizations who seem to resist these investigations and outside reviews in an almost reflexive defensive manner. I can understand usual human reactions in which we all get defensive about having our professional actions critiqued and criticized and if need be, having to submit to a professional disciplinary action especially if it involves public censure and procedures that create a negative image in the eyes of the public who cannot ever fully appreciate how difficult these processes are.

I hope that this small effort at sharing and observer’s long-term perspective and experience can help any reader more fully understand these very difficult and periodically inevitable said events and their aftermath.