The Dispensable Man

 

A recent case involving the drug related arrest of a Baton Rouge medical
professional and his subsequent dealings with the Louisiana Physician’s Health
Partnership illustrates the ineffective, costly, and ultimately corrupt system of drug
rehabilitation currently in place in this state.

It’s important to note at the outset that all charges against Terry Braud, at that time employed as a physician’s assistant at Louisiana Spine and Sports Medicine in Baton Rouge, Louisiana, were dropped by the district attorney’s office. Several employees of that clinic were involved in falsifying Roxicodone scripts and selling the product on the street, but Braud wasn’t one of them. It was also true that he had been prescribed Reprexain, a painkiller, by his own physician. Braud’s arrest, on March 13, 2014, was an understandable mistake, but a mistake nonetheless, and it was soon corrected. The problem was that when Braud began his mandatory three day, $3,000 substance abuse evaluation at Palmetto Addiction Recovery Center in Rayville, Louisiana, he was believed to be a criminal, therefore an addict and, labeled as such, was perfunctorily and falsely diagnosed with opioid dependence. Had he waited just one week, after the charges had been officially dropped, the outcome of the evaluation would have been different. This isn’t speculation. When Braud received a subsequent substance abuse evaluation from the Talbott Recovery Campus in Atlanta, he was not diagnosed with opioid dependence. Braud gave them the exact same information that he provided at Palmetto, but the Talbot eval took place after the charges had been dropped.

Many of the details of his arrest and weekend incarceration at the Baton Rouge Parish Prison speak to the attitudes and misconceptions in this country that reflect, and drive, our wrongful and ineffective drug policies. The DEA agent who arrested Braud that Friday afternoon, handcuffed him behind his back, and charged him with the manufacture and distribution of schedule II and III substances, kept repeating, “Terry, we want you on our team, team America.” If he said it once, he said it fifty times. Irritating as it was, it was apropos: America incarcerates more people, both in sheer numbers and in proportion to the population, than any other country in the world, and half of these individuals are locked up for drug offenses.

With the exception of a very few, Braud’s fellow detainees were friendly and respectful. At 60 years of age, he was one of the oldest men in the place. He was surprised to be on the receiving end of lot of solicitous behavior: “Are you okay Pop?” “Are you comfortable, Pop?” To a man, however, the behavior of the guards was demeaning. A couple of them admonished Braud for giving out pain killer prescriptions. In a holding facility, the guards make two assumptions: first, that the detainees are guilty, and second, that they are worthy of scorn and derision. Most of the individuals in the Baton Rouge facility were held on drug charges. As will be shown, Braud’s treatment by the guards in jail was not markedly different from the drug rehab culture: if you are suspected of drug use, you are automatically assumed guilty, relegated to the criminal class, and treated with contempt.

The letter informing Braud what he knew all along, that he was innocent of wrongdoing, didn’t arrive until June 12, 2014. On June 3 he met with a representative of the state’s medical board, the Louisiana Physician’s Health Partnership. Since Braud had been arrested on drug charges, he was required by the board to undergo substance abuse evaluation, and he had to do it at one of a handful of locations approved by the board. The representative gave him a list of five treatment centers, located in five different states, to choose from. All required 3- day evaluations and expensive 90 day inpatient programs. Palmetto was the nearest.

As a result of the false arrest, Braud had been wrongfully terminated from his job, but he quickly found another one. All he needed was to complete a substance abuse evaluation to reactivate his P.A. license. Although there was no time requirement to do so, he wanted to get it over with and get back to work, so he chose the closest option. “I’m not a drug abuser,” Braud said. “I figured I’d go to Palmetto, get the eval done, and that would be that.” He made the three and a half hour drive to Rayville the same day he’d spoken to the board representative.

He arrived at six that evening and checked in. Nurses searched his suitcase and confiscated his protein bars. They took his vital signs and obtained blood, hair, and urine samples for drug screening. The nurse became irritated when he had difficulty peeing into the cup under her scrutiny. She threatened him with extracting the sample with a catheter. “That will be fine,” said Braud, who didn’t want to hold up progress, but the threat was an empty one; either they didn’t want to- or didn’t know how to- employ the catheter. It took some time but they finally got their sample.

The center’s campus is large, set up like summer camp, with an array of cabins adjacent the bayou, the men’s residences on one side, the women’s on the other. A big common building for meetings divided the two sections. Although he was on campus strictly for evaluation, Braud was placed in the residential population, given a large notebook binder with the activity schedule in it, and shown to cabin number ten. The cabin consisted of four bedrooms with three beds in each, a kitchen, bathroom, and large porches in front and back. Residents tended to hang out on the porches, smoking. Braud didn’t smoke, but he hung out on the porch anyway, talking with the guys in treatment. He was settled in by 9:00 P.M. The nurse administered to him the Lunesta, a prescribed sleep medication that he’d brought with him, and he went to bed.

Palmetto, like 96% of all treatment centers in America , is an “abstinence based” facility. The default treatment paradigm of these places is the 12 step program that originated with Alcoholics Anonymous. The ensconced orthodoxy of abstinence programs in our society appears to rest on something other than any evidence of treatment efficacy; long term studies (Polich, Armor, & Braiker, 1980; Vaillant, 1995) place their recovery rates between 5 and 7 per cent, and 12 step programs in particular that are used in the treatment of alcoholism- the condition these programs were originally intended to address- fare no better. The success rate of AA itself is anything but remarkable, somewhere between five and 10 percent (http://www.lancedodes.com). Those numbers are even worse than they seem at first glance, as numerous studies (http://orange-papers.org/orange-effectiveness.html) have found those same rates in the spontaneous remission of alcohol and drug abuse. In other words, AA has a zero per-cent success rate. Nor does administering an ineffective treatment in an expensive hospital setting improve matters. One study (Miller and Hester, 1986) noted no differences in treatment outcomes whether the setting was residential or non, longer programs versus shorter, or more or less intensive.

If abstinence based programs, inpatient or out, don’t work, then why their pervasive use? The answer can be found in the experiences of those undergoing “treatment” in such places. Braud’s three day evaluation began at 6:30 the following morning with an AA style cabin meeting, the residents starting off with the mechanical introduction, “Hi, I’m (insert name here) and I feel (insert feeling here).” The rest of the group then obediently repeats the feeling word aloud, in unison. For fifteen minutes the residents discuss cabin issues: someone didn’t clean the kitchen, someone else forgot to sweep. Following 30 minutes of walking up and down the driveway (the exercise period), the residents returned to the cabin, did their chores, and received their meds from a staff nurse.

The community meeting, another AA style get together, commenced at 9:30 AM. This time the attendees, about 90 of them, still all male, introduced themselves with their name followed by the declaration that they were an “addict” and their addiction of choice. Again, the other attendees echoed in chorus. Not being an addict but resigned to following procedure, Braud found himself in a bit of a quandary. What should he claim as his addiction? Perhaps “anger,” considering the excessive time and expense involved in an evaluation that could doubtless be accomplished in a single interview. After introductions, the group members took turns reading out of the “big book,” followed by a discussion period.

The Big Book is the AA bible, so to speak, written in 1939 by one of the founders of AA, Bill Wilson, and containing the vaunted 12 steps. The “bible” analogy is appropriate, since the thrust of AA treatment is not scientific but religious. As it says in the Big Book,

“To some people we need not, and probably should not, emphasize the spiritual feature on our first approach. We might prejudice them. At the moment we are trying to put our lives in order. But this is not an end in itself. Our real purpose is to fit ourselves to be of maximum service to God.”

Some AA proponents point to the “as you understand him” phrase in reference to God (who is mentioned directly in six of the twelve steps) as indicating their program qualifies as secular, but the United States judiciary disagrees. As recently as 2013, Circuit Courts of Appeals have ruled that mandatory participation in 12 step programs is a violation of 1st Amendment rights.

The unscientific methodology of the Big Book is no recent revelation. A book review by the Journal of The American Medical Association, written in the same year as the book’s publication (1939), offered an astonishingly prescient assessment not only of the 12 steps but of inpatient, abstinence based treatment in general:

“For many years the public was beguiled into believing that short courses of enforced abstinence and catharsis in “institutes” and “rest homes” would do the trick, and now that the failure of such temporizing has become common knowledge, a considerable number of other forms of quack treatment have sprung up. The book under review is a curious combination of organizing propaganda and religious exhortation. It is in no sense a scientific book…which would save other addicts by a kind of religious conversion.”

After the Big Book discussion, new attendees were required to talk about why they were there. Braud got yet another demonstration of a program whose clinical methodology, as he was already beginning to suspect, was of dubious value. When it was his turn, he began by saying that he worked as a physician’s assistant at a clinic, now under investigation for drug charges, where he had a hydrocodone prescription. At that instant, eight or nine of the group members exploded into action, doing somersaults, giving high fives, and exclaiming with enthusiasm how much they “loved that stuff.” This outburst lasted fifteen or twenty seconds. It was no impromptu performance; it was obviously part of the “treatment” regimen.

Back at the cabin one of the residents, an attorney Braud had met the previous night, pulled him aside. “Your story sounds legitimate,” he said. “I know you’re following directions, but don’t say you’re an addict at the start of group meetings. Just say your name and that you’re here for an evaluation.” The fellow was as serious as he was sincere, and his meaning had almost sinister undertones: don’t give these people anything they can use against you. Braud thanked him for his advice, and followed it.

On several occasions during the three day evaluation, Braud met separately with various professionals for individual interviews. Numerous times he told the story of his arrest and the charges against him- the charges, it will be remembered, that would soon be dropped. His side of the story, that is, that he was innocent, was rejected out of hand by all of the Palmetto staff. In rehabilitation settings, a popular and time-worn joke reflects the proper stance rehab counselors are trained to take with their clients: “How do you know when an addict is lying? His lips are moving.” This attitude, and the manner in which the Palmetto staff interacted with him on this subject, Braud found to be identical to that of the guards at the parish prison: he was arrested and charged, therefore guilty, and a criminal, and an addict.

Part of the time he filled out personality questionnaires- 12 in all- under the rubric of “psychological testing.” One was an IQ test, one a physical exam, and the bulk of them were personality “inventories.” These inventories are actuarial, that is, they compare one’s responses to the responses of individuals with previously identified problems or diagnoses. They cannot, in and of themselves, be used to make a diagnosis. The use of these assessments, including the IQ test, in a drug treatment setting is odd. The regimen certainly isn’t tailored to the “intelligence” of the participants, as determined by an IQ test, but the use of personality inventories is even more problematic. Not one of them can predict with any accuracy whether or not an individual will engage in a specific behavior- such as drug use- but more importantly, they cannot confirm whether or not an individual has engaged in a specific behavior in the past. In an inpatient, 12 step, abstinence based program, everyone gets the same treatment. Why administer costly, time consuming tests when they don’t affect what treatment the residents receive?

When Braud was interviewed face to face, the content was generally the same: personal and family mental health history followed by specific questions about his opioid use. Braud was relieved; finally, some relevant activity. The questions were aimed at diagnosing whether or not he was opioid dependent, as determined by the Diagnostic and Statistical Manual of Mental Disorders: did he need more amounts of the drug to achieve the same effect, and did the same amount give him less of a high? Did he experience withdrawal symptoms or take the drug to avoid them? Did he use more of the drug, or for longer periods, than he intended? Has he tried, and failed, to curtail his use? Did he spend a lot of time obtaining the drug (visiting multiple doctors or driving great distances) or using it, or recovering from its use? Has he given up, or reduced, important social, occupational, or recreational activities in order to use? Did he keep using the drug despite physical or psychological problems caused by its use? These questions were asked in three separate individual sessions by three different staff members, including the psychiatrist. Every time, Braud’s answers were the same, an unequivocal “no.”

As Braud’s three day stay wore on, the more questionable the facility’s methods became. “Group therapy” was usually a straight up AA meeting. Sometimes the large number of attendees didn’t allow time for every person to stand and make his ‘fess up’ introductions; in these cases, the group session consisted of a lecture out of the Big Book. At no point was any treatment method utilized that required the information supposedly gleaned from the personality inventories or the IQ test. But it wasn’t until Braud was made the focus of the group sessions that he began to truly understand the warning he’d received earlier from his fellow resident.

Braud’s medical history with Hydrocodone was unremarkable, but it became a big focus of his so called “group work” at Palmetto. Back in February, he’d met with his prescribing physician, a doctor at the clinic where Braud worked. Braud was an avid runner and swimmer but, at age 60, his bones and joints weren’t what they once were. The physician had previously prescribed hydrocodone. Braud wanted the appointment for a checkup because he’d been getting refills for a while and he wanted the doc to see him. At the appointment, he asked the assistant if he could have a drug screen. “The doctor won’t make you get a drug screen,” the assistant told him. When the physician came in, he didn’t have Braud’s chart with him. He asked Braud what problems he was having and what meds was he taking. Pain in both shoulders and both knees, Braud replied, reminding him about his script for Hydrocodone. The doc inquired about the dose, and how often he took it. Braud asked for a drug screen, then insisted on it because he didn’t have one on the chart. The physician refilled the prescription and ordered the screen. Braud obtained the lab results, which were negative. He went back in March about continuing joint problems, saw the P.A., and got an order for physical therapy. Three days later, he was arrested as part of the DEA investigation.

Early in Braud’s assessment, one of the social workers pulled him aside for a quick meeting . On the way to her office, she told him that Palmetto was where he needed to be.

“You’ve been arrested, you’re going to jail, and you’re going to lose your license,” she said. “We can take care of all that for you.”

Braud was a little taken aback. “No, I really don’t think I’m going to jail,” he said.

“How many agents came to arrest you?”

“Three.”

“If they send more than one, you’re going to jail,” she said. Before Braud became a physician’s assistant, he was a social worker. Her statement, and the blandly assured way she made it, was puzzling at the time. Besides the element of absurdity – the number of arresting agents as a predictor of incarceration – it was flatly inappropriate. It was as if he’d already been convicted.

In her office, she asked him if she could call the clinic where he’d worked in order to verify his employment history. Braud had no problem with that. When the social worker later met with Braud, she told him that she’d spoken with Braud’s prescribing physician, who denied writing him the prescriptions for hydrocodone and claimed Braud had obtained them surreptitiously from the medical assistant. Braud was flabbergasted and not a little confused. Why on earth would he say that? Braud explained to the social worker that there were three ways to get a refill: call the refill line; have the pharmacy call for the refill; or call the medical assistant or nurse. In the 9 years he’d worked at the clinic, Braud had seen his doctor utilize all of those methods at one time or another. The doctor told the social worker he didn’t okay Braud’s scripts, but even if he didn’t, that’s not the patient’s lookout. That’s how you do a refill, and if the assistant refills it, that’s between the doc and his assistant.

It should be noted here that the Braud’s prescribing physician is currently under FBI investigation for multiple counts of Medicare fraud, which might account for his lying to the social worker over the phone.

At Palmetto, Braud offered to obtain his medical chart to prove what he’d been saying. His story would have been simple enough to verify, but Palmetto staff chose instead to accept the physician’s word at face value. It isn’t hard to understand why: first, Braud’s lips were moving, which meant that he was lying, but more to the point, what the doctor had told them fit their agenda of labeling Braud an addict. After all charges had been dropped, and before going for his second unwarranted $3,000 evaluation, Braud went back to his office and obtained his chart- the one his doctor didn’t bother bringing with him to the appointment- which documented all visits, the negative drugs screen, the written prescriptions for him for the hydrocodone, and so on. At Palmetto, however, Braud’s status as criminal/addict was solidified.

Some of the meetings at Palmetto were intended for professional people, doctors, nurses, pharmacists, veterinarians, and so on. Ordinarily, males and females are segregated on campus and forbidden even to interact, but at this meeting, both men and women attended. Other meetings were larger or smaller, but the regimen never varied. One component was invariably readings out of the Big Book. The other was placing the attendee on a kind of hot seat where he or she was “confronted,” which translates to “harangued and belittled.” There was nothing clinical, or therapeutic, about it.

As per the routine for whoever was on the hot seat that meeting, Braud first ran through his personal drug history, beginning with the first sip from his father’s glass of beer at the dinner table at age nine or ten. Once that was done, the session started. Again, Braud couldn’t discern anything that could be construed as “treatment;” rather, the process consisted entirely of the staff and other attendees taking angry pot shots at him. This interrogation (not an unreasonable word for it) lacked any purpose other than to hassle the identified individual. Usually they focused on the crime Braud did not commit, had not been tried for, and had not been found guilty of. At other times they wandered from subject to subject in the manner of righteous townspeople throwing rocks at a sinner.

“So, Terry, how many Roxicodone scripts did you write?”

“None.”

“Were you getting kickbacks?”

“No.”

“Your doctor said he didn’t write you any prescriptions for Hydrocodone.”

“Well, he did, and if you like I can show you-”

“You snuck behind his back to get scripts from the medical assistant.”

Braud repeated the three ways, all legal, to get prescriptions refilled.

“Whenever a story is this complicated, it can’t be true,” another staff member stated.

It didn’t seem complicated to Braud, but he kept this opinion to himself. He did his best to answer all questions, but many had no answers. When they brought up his arrest as part of the DEA investigation, for example, his only response would have been pointless: You can make up all the crime stories you want, but none of them have anything to do with opioid dependence. This was true only on the surface of it; the underlying fact, however, was that since Braud had been arrested, it followed that he was, by the reasoning at Palmetto, an addict. A criminal was a criminal, after all.

The group did their part to address the DSM criteria for a diagnosis of drug dependence. Did he ever take more than was prescribed, did he ever experience withdrawal, did he keep using despite etc? No, no, no, Braud replied again and again. In several group settings, then, as well as in at least three individual clinical interviews, he was able to provide a truthful response regarding his complete lack of symptoms that would indicate opioid dependence.

At times, the badgering became nonsensical, bizarre, as when Palmetto’s well dressed COO asked him about his sleep medications.

“What is the Lunesta for, Terry?”

“For sleep.”

The COO became angry and loud. “I’m a pharmacist, I know what it’s for!” (The COO is a “recovering” pharmacist.)

Then why did he ask, Braud wondered, but in keeping to the high road found there was nothing to do but state the obvious. “It’s to help me fall asleep faster and sleep longer.”

“Why do you get 90 of them?”

“The insurance company recommends a 90 day supply.”

Another staff member, a substance abuse counselor, jumped in. “What would happen if you took four of them at once?”

“I guess you would fall asleep even faster and stay asleep even longer.”

“What if you took four along with something to keep you awake?”

Braud was stumped. Not being an abuser of drugs, he would never think of doing such a thing. As it was, the question was too stupid to merit a response, so he said nothing. In fact, their interest in his prescription sleep medication was baffling. Supposedly, he was spending three days and $3,000 for evaluation of opioid dependence. The Lunesta line of questioning came to an abrupt end when the COO made another stab at his use of the sleep med.

“Terry, when was the last time you took Lunesta?”

“Last night, when your nurse administered it to me.”

That switched the subject back to Braud’s use of pain medications. “Didn’t you tell me you swam a total of three miles last month?” asked the staffer. His implication was clear, that if he could swim three miles, he didn’t need pain medication, at least not for pain. Braud could well understand the logic of the question: the substance abuse counselor was an overweight chain smoker; for him, swimming three miles under any circumstances other than being high was inconceivable.

“What happens when you take the drug?” asked another group member.

“The pain goes away.”

“And when you stop taking it?”

“The pain comes back.”

“If you took your first sip of beer at age nine or ten,” said the counselor, “then you must have an alcohol problem, too.”

It was all Braud could do not to laugh: so now he was addicted to alcohol, opioids, exercise, and Lunesta.

“Terry,” interrupted a third staff member. “I’ve just been sitting quietly listening to all this. If these folks here can pick your story apart, think what a lawyer will do to you in front of a jury.”

Braud hadn’t noticed anything being picked apart, but the fellow’s comment was telling: to the Palmetto staff, he was a guilty man on trial.

In truth, it was even worse than that. Braud’s three-day stay was no evaluation. Repeatedly, the Palmetto staff automatically assumed that an arrest equaled “addiction,” and he’d already been sentenced to inpatient drug treatment. As they left the session, the COO caught up with Braud. “Terry, I hope there’s no hard feelings,” he said. “We want what’s best for you.” He then repeated, almost verbatim, what he’d been told by the social worker. “You’ve been arrested, you’re going to jail, and you’ll lose your license. We can fix all that.”

For Braud, the group pestering wasn’t a big deal. If these were the hoops he was required to jump through in order to get his license back, so be it. But when he sat down with the social worker to go over the results of the evaluation and their recommendations, he began to realize the trouble he was in.

Palmetto came up with two “diagnoses.” The first was opioid dependence. In the document they sent to the Physician’s Health Program (PHP), they gave their justification for doing so.

“Terry endorses a history of withdrawal symptoms, tolerance with increasing use over time, use of larger amounts than intended over a longer period of time than intended, increased time spent using and recovering from opiates, concurrent use of opiates with (other medications), and occupational and legal dysfunction as a direct result of opiate use. He has been working in his capacity as a physician’s assistant while under the influence of opiates. He was recently arrested for distribution of schedule II controlled medications. He demonstrated significant denial of a problem at the beginning of his evaluation but was able to see that he does have opiate dependence by the time he finished evaluation.”
It will be remembered that on at least six different occasions during the evaluation, Braud informed the Palmetto staff that none of the DSM criteria for opioid dependence applied to him. They simply disregarded everything he had said and falsified results, that is, lied, in order to produce a diagnoses that would require treatment.

The second of Braud’s diagnoses- narcissistic traits- did nothing to alter the recommendations, but its inclusion in the evaluation is one more insight into the outdated mythology about addiction and treatment that drives the thinking of places like Palmetto. The diagnoses of narcissism was supposedly gleaned from the many personality inventories that had been administered to him, but as with the main diagnosis, there was nothing to support it. The characteristics of Narcissistic Personality Disorder, familiar to everyone, are all related to an extremely overinflated sense of self importance and include fantasies of unlimited success, power, brilliance, beauty, a complete lack of empathy, a sense of entitlement, the exploitation of others, and so on. Anyone who knew Braud would find the allegation of narcissism laughable, but outside testimony is unnecessary; plenty of refuting evidence can be found in Palmetto’s own personality tests.

The Brief Assessment of Traits, the Inventory of Interpersonal Problems, the Horney-Coolidge Tridemensional Inventory, and the Personal Style Inventory are all assessments Braud took at Palmetto, and not one of these showed any indication of personality problems. The Personality Level Measurement results state unequivocally “his score of 1.2 does not suggest that significant personality problems are present.” Braud’s results on the Personality Assessment Inventory (PAI) are more descriptive. They state he “may be troubled by self doubt” (what human being isn’t?”) and “may have a tendency to minimize his successes as a result, tending to view such accomplishments as either good fortune or the result of the efforts of others.” This sounds more like the definition of humility than narcissism. At the very least these are, it hardly needs to be said, decidedly un-narcissistic traits. In the next paragraph, the PAI states “his interpersonal style seems best characterized as one of autonomy and balance,” and “his assertiveness, friendliness, and concern for others is typical for that of normal adults.” The results of the Zuckerman –Khulman-Aluja Personality Questionnaire states that Braud is “less prone than most people to aggressive and antagonistic actions and behaviors,” and “does not appear prone to feel anger or hostility when his agenda or his desires are challenged.” According to their own tests, Braud is about as far from narcissistic as one can get.

Where, then, does the finding of ‘narcissistic traits” in their diagnosis come from? It is found in the pseudo-scientific, religion based history of Alcoholics Anonymous. The narcissistic component comes from the writings of Harry Tiebout, one of the early proponents of AA.

“…the so-called typical alcoholic is a narcissistic egocentric core, dominated by feelings of omnipotence, intent on maintaining at all costs its inner integrity…Inwardly the alcoholic brooks no control from man or God. He, the alcoholic, is and must be master of his destiny.”

When Braud asked the social worker about the narcissism in the assessment, her response made little sense and had nothing to do with diagnostic criteria. “You tested high on IQ,” she said, “and you’re a health care provider, so you think nothing bad can ever happen to you.”

That Palmetto chose to ignore the results of their own personality tests, preferring instead to toss in a second false diagnosis because it fit with their agenda of finding Braud opioid dependent, is hardy surprising, since they also ignored the results of their own tests when it came to the main diagnosis. On the PAI, one of the scales concerns the test taker’s truthfulness. It found that Braud “answered in a reasonably forthright manner and did not attempt to present an unrealistic or inaccurate impression that was either more negative or more positive than the clinical picture would warrant.” Further down on the same page: “He reports NO significant problems with alcohol or drug abuse or dependence.”

Interestingly, even Palmetto’s assessment of Braud’s spiritual life flew in the face of their own conclusions. They administered a psychological test, the Assessment of Spirituality and Religious Sentiments (ASPIRES) that purports to glean an individual’s leanings in that area. It found that Braud “has created space in his life for meditation and prayer and will tend to find a personal sense of emotional satisfaction and support from his efforts to connect to some larger reality.” This is rather a different image than that of a man who “brooks no control from man or God.”

Despite all their own evidence, then, Palmetto found Braud to be an opiate addict with narcissistic traits. By now it’s obvious that they had decided on that diagnosis the moment he walked in the door. Their recommendations followed.

Our multidisciplinary treatment team recommendations upon completion of his evaluation are:

1-Sign a minimum 5 year monitoring contract with the Louisiana PHP. Any violations of contract or positive drug screens should result in further inpatient evaluation.
2-Complete a Louisiana PHP approved long term residential treatment program experienced in treating chemically dependent professionals.
3-Terry is not ready to work as a physician’s assistant with skill and safety until he has successfully completed treatment, has a monitoring contract in place, has a continuing care plan in place and has met with his addictionist after treatment to assess his fitness to return to duty.
4-Terry should contact you as soon as possible after this evaluation to receive your instructions.

Braud’s last meeting was the most important, for the essence of Palmetto’s true mission was distilled to its purest form by this individual: the business manager. She was quite straightforward. She told him that the ninety-day program was recommended, and if he signed up today, they would knock the $3,000 from his assessment off the $29,900 cost of the program. And, if he paid in cash, they’d slash the price another $2,000! Braud had quit taking all pain medications (hardly the behavior of an addict) a couple of months before, and as a result, all of the drug screens in Palmetto’s assessment came back negative. This was a problem, not because it was yet another assessment that militated against a diagnoses of dependence, but because insurance companies looked for ways to deny payment. It would have been better if Palmetto could detox him off the drugs. When he came back, the business manager told him, they would detox him off the Lunesta. Braud said he could stop taking that at any time, but she told him no, keep taking it so that Palmetto could wean him off it as part of treatment. That would look good for the insurance company; it would increase the chances of them covering his stay, she said. (So he was told to continue taking a drug that, according to the Palmetto staff during the group sessions, was a harmful indicator that he was an addict.) The business manager acknowledged that the $29,900 price tag might be difficult, but she was ready with suggestions. Did Braud have a 401K he could borrow from, or relatives who could help out? Let us know ASAP, she encouraged, and they would hold a spot for him in the nice cabin with the other professional drug addicts.

As it turned out, Braud was one of the lucky ones, probably one of the few lucky ones. The DEA quickly found he had nothing to do with the Roxicodone scam and the district attorney promptly dropped the charges. Even so, he was wrongfully terminated from his job, and to get his license back, he had to prove he was not an addict, despite the fact that there had never been any evidence suggesting that he was. To do this, he was required to undergo a second evaluation, costing him another three grand. As mentioned, he did so at the Talbot Recovery Campus in Atlanta, one of the other five facilities sanctioned by the Louisiana Physician’s Health Partnership. He took the same personality tests and gave them the same information he’d provided at Palmetto. This time, since Braud was not deemed a criminal and therefore not an addict, Talbot found no opioid addiction, no narcissistic traits.

Braud’s experience is one more illustration of the way we deal with drug use in this country, which is wrong on so many levels. Palmetto lied about his responses during his evaluation, falsified his medical records, and knowingly saddled him with not one but two false, harmful diagnoses that could ruin his livelihood and dog him for the rest of his life. Having done so, they required him to take part in a treatment program that doesn’t work, and is probably unconstitutional, at a cost of almost thirty thousand dollars. Their actions were unethical, criminal, and corrupt, yet they are still very much in business and sanctioned by the state of Louisiana’s medical board. It would be naïve to think of Braud’s case as an isolated incident. Palmetto- and its connection to the Louisiana Physician’s Health Partnership- should be investigated.

Braud’s case is uniquely able to point up the abuses of the system currently in place, but it is by no means relevant only because he had been falsely arrested. Some people do, indeed, abuse drugs, many of them medical professionals. As it stands, however, their treatment is ineffective, cost prohibitive, and carried out in an atmosphere of contempt and the stigma of criminality. Isn’t it time we change this system?

References

MILLER, W. R. & R. K. HESTER. 1986. Inpatient alcoholism treatment: Who benefits? Am. Psychol. 41: 794-805.

Polich, J.M, Armor, D.J., & Braiker, H.B. (1980). The course of alcoholism: Four years after treatment. Santa Monica, CA: Rand Corporation.

Vaillant, G.E. (1995). The natural history of alcoholism revisited. Cambridge, MA: Harvard University Press.