Burden of Pain: A Physician's Battle with Justice, the Opioid Crisis, and Self-Discovery Through Writing

When a physician's dedication to easing pain collides with the justice system, what unfolds is not only a legal drama but a profound human struggle. Dr. J Joshi, our guest this week, opens up about his indictment by the Department of Justice and the arduous journey to clear his name, while adhering to the CDC guidelines for opioid prescriptions. The heavy hand of the DEA and the resulting personal and professional turmoil, including incarceration and the fight to reclaim his medical license, are laid bare, offering a rare glimpse into the precarious balance between healthcare and law enforcement.

Navigating the murky waters of the opioid crisis can lead to unexpected destinations, and for some, it's a path marred by life-altering choices. Our conversation with Dr. Joshi confronts this reality, as we discuss the agonizing decisions patients face when legitimate pain relief is out of reach, pitting them against the dangers of street drugs and potentially fatal additives like fentanyl. Yet within this struggle, there's a beacon of hope through self-expression; I candidly share how writing became my life raft, a therapeutic endeavor that helped me reclaim my story and my self-worth amidst adversity.

Wrapping up, we don't shy away from the hard truths about pain management and the biases that skew its perception and treatment. The final chapter of our dialogue with Dr. Joshi turns a critical eye on the stigmatization of pain and how it differs vastly from the approach to other medical conditions. We examine how the 'War on Drugs' and the politicization of issues like abortion complicate patient care, advocating for a more compassionate and informed healthcare system. Dr. Joshi's book, "Burden of Pain," stands as a call to action, beckoning readers and listeners alike to join the conversation and become a part of the solution for those suffering in silence.

Connect with Dr. Joshi:
info@burdenofpain.com
https://www.daily-remedy.com/about-us/

Though I am a physician, this is not medical advice. This is only a tool that physicians can use to get ideas on how to deal with burnout and/or know they are not alone. If you are in need of medical assistance talk to your physician.


Learn more about female physicians' journey through burnout to thriving!
https://www.theworthyphysician.com/books

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Battle of the Boxes

21 Day Self Focus Journal

Transcript

Dr. Shah-Haque: 0:01

Welcome to another episode of the Worthy Physician. I'm your host, Dr Sapna Shah-Haque, and today I have Dr Jay Joshi, who is an author and physician, and this is actually a story that we've not had on the podcast before. It's unique in, I think, the pain and the absolute nightmare J. Thank you very much for agreeing to be on here and for your bravery to tell your story.

Dr. Joshi: 0:31

I appreciate it. Thank you for the opportunity.

Dr. Shah-Haque: 0:33

Tell us about your story. Tell us about what was the inspiration behind writing the Burden of Pain.

Dr. Joshi: 0:44

Sure Burden of Pain was an inspiration born out of a lived tragedy that really began back in 2018, when I was indicted by the Department of Justice for prescribing low dose opioids on Norco 7.5-3-25 twice a day, outside the scope of medicine, to an undercover DEA agent who came presenting with cramp-like leg pain and had recently according to the story he told me, had recently moved from Florida to Indiana and was looking for insurance and was wondering if he could initiate his continuity of care with me while he was in the process of obtaining Indiana-based Medicaid. I trusted the patient, I ordered imaging studies, I reviewed his prescription database, I lowered his prescription medications, but back in 2018, during the heyday of the opioid epidemic, none of that really mattered and, to the DEA and Department of Justice's credit, they have revised their policies and the Supreme Court has revised the law under which they are implementing and enforcing the Control Substance Act, and much has changed since then, but it doesn't really do much for those who are targeted by the DEA. As I was Going back to 2018, after I was targeted, I really didn't have a choice but to plead guilty. This was before the Supreme Court case ruled on the United States, before we began to learn more about addiction as clinical care as opposed to addiction as a criminal behavior, and so I didn't have the opportunity to defend my actions as a clinician. I could not use what the court of law defines as good faith defense, effectively saying I thought this undercover DEA agent was a patient. I treated the patient in accordance to standard of care as defined by the 2016 CDC guidelines for prescribing opioids.

Dr. Joshi: 2:35

I don't understand why I am being prosecuted in this way, but unfortunately, what had happened is the risk of diversion, or at least what the DEA and DOJ perceive to be.

Dr. Joshi: 2:47

Diversion supersedes any individual care or right of patient provider and there now starting to get a balanced approach to looking at general oversight at individual patient care and physician rights.

Dr. Joshi: 3:02

But at that time it was clearly skewed against the diversion risk, and I think what we start to see now is when you focus too much on the diversion risk, you really start to put patients and physicians in very speculative positions and often, at least, do more harm than good.

Dr. Joshi: 3:23

And now flash forward to the present. I've regained my medical license, I've been reinstated into Medicare and I've resumed my clinical practice, but it's very difficult to go through what I had to go through, given I had to spend 11 months in federal prison, given that I wasn't able to practice for many years. All of these things are very stressful and, as a physician, being what would many consider society as to be a successful individual, to then reach the depths that I had to go through really affects you mentally, and I think that I try to come to terms with what had happened to me by sharing my story, by trying to help patients and physicians who've been similarly disenfranchised as I had. But my book, burden of Pain, is really an opportunity to share my story and to help others share their stories as well, because once we start to discuss what is going on, it becomes less stigmatized and more acceptable for people to discuss and effectively reform misguided government policies.

Dr. Shah-Haque: 4:27

Until then, peace. I actually just had to pause the recording because that hits me on multiple levels and the sense that we go into medicine in order to help patients, and I guess I don't understand why somebody would do that, like a DEA coming in and saying X, y and Z and again, yes, it was supposed to be X amount of morphine equivalents. As far as what was it 90? It's supposed to stand for 90 morphine equivalents.

Dr. Joshi: 5:07

To give you an example Norco 7.5-325 twice a day, the hydrochloric bone component 7.5 multiplied that by 2, 15. So in terms of my morphine milligram equivalent, I was at 15, which is within the CDC guidelines for treating a patient for the first time who is not opioid naive.

Dr. Shah-Haque: 5:27

Right, I'm aware of those standards and absolutely, and so it just baffles me as to why they would do that, because that puts, like you said, not only the physician but also the patients in harm's way. But yet they were more concerned about the diversion of the medication.

Dr. Joshi: 5:50

Yeah, knowing what I know now and being so active and helping to reform policy, I learned a lot about how the DEA thinks and how they operate. For context, as I've written Amiga's briefs, legal documents for federal cases involving opioids like Walmart VDOGA. I mentioned briefly about RULE on the United States. I learned through these writings how the DEA approaches the act of prescribing and what's very interesting is that they remove it of its clinical context. And the reason why they do that is because the way the DEA is trained is distinctly non-clinical. They develop their investigative tactics from borrowing playbooks from ATF Bureau of Alcohol, tobacco and Firearm and the FBI, both institutions not known for having any clinical expertise whatsoever. And the way the DEA does this by having these straw men quote unquote these undercover agents come in soliciting prescription medications is actually taken from the ATF's strategy to find those who are selling firearms without an appropriate license. And that's a very important correlation to understand.

Dr. Joshi: 7:16

When the DEA or ATF create these kind of undercover bust, the buy bust that they like to use, because they like to use very kind of flamboyant language when they stage these buy bust, they're essentially focusing on inherently illegal activity. So the selling of firearms without a license is inherently illegal. The selling of illicit substances like heroin or crack cocaine or whatever is inherently illegal, but the act of prescribing medications to a patient is very much legal. In fact it's germane to the act of clinical care. Patient comes in, 26-year-old male with upper jaw pain, found to have an infection. You prescribe antibiotics and you provide medications to relieve the pain in the interim until the antibiotics take place.

Dr. Joshi: 8:20

Never should it cross the mind of a physician that he or she is engaging in activity that could be construed as illegal. You're caring for a patient and in this context, when an undercover agent comes in stating he has cramp leg pain, my instinct isn't to say should I trust you? Is what I'm doing legal or illegal? It's rather to understand what is in the patient's best interest and provide care accordingly.

Dr. Joshi: 8:48

Now I understand the DEA's perspective in that they want to ensure that all prescriptions are done, all prescribing practices are done in a responsible manner. But the way we in the clinical world identify as responsible patient behavior is to order imaging studies, check prescription records, reduce the medications in a consensually safe manner. Those concepts, believe it or not, are very foreign to DEA, because it doesn't abide by the ATF and FBI playbooks that they're borrowing from, and I think the DEA really needs to come to a recognition that it needs to develop more clinically sound, patient-appropriate techniques to determine what is quote unquote within the scope of prescribing medicine. Otherwise it's going to do as you mentioned cause a lot of harm to patients and really destroy the fabric of the patient-physician relationship.

Dr. Shah-Haque: 9:47

I couldn't agree more exactly what every point you said, except I was not aware of the playbooks that the DEA used. Under everything that happened to you Unjustly and I'm thankful that you have your license again why continue with medicine after everything you had unjustly been through?

Dr. Joshi: 10:17

That's a great question. So many people have asked why don't I move into a different field like consulting? Why don't I move to another state, effectively start over? Quote unquote. I'm making a conscious decision to resume my clinical practice basically in the same area as I was before, literally minutes away from my previous clinic. And the reason why I'm doing that is twofold One, personal, in that I want to demonstrate that what happened to me does not define me. Rather, it's my ability to overcome what happened to me that will define me. Two, I believe through my story, through my legal writings, through burden of pain, I can serve as an example of how a physician can be mistreated by the legal system.

Dr. Joshi: 11:11

Yet come back and find ways to reconcile the medical and legal worlds and having the ability, the willingness to want to find common ground is not something you see often. And what more of our people just entrenching into these one-sided arguments that we have to cut off the supply of all medications, we have to bomb Mexico, we have to attack China, we have to cut off all patients, and these narratives sound very nice and I'm sure that a lot of people are scoring a lot of political points by making these arguments. The reality is far less glamorous. The reality is to build trusting relationships between patients, physicians, law enforcement and find common ground.

Dr. Joshi: 12:03

Are there examples of patients with chronic pain that are developing dependencies? Of course there are. Are there examples of patients who have struggled with addiction that want to now find medically appropriate ways to treat their underlying conditions? Of course there are. You don't stigmatize and label these individuals. You see them as patients, and that requires a sense of coming together, finding a balanced approach to care and doesn't quite make the talking points that some of these other narratives make, but effectively, that's what good clinical care consists of Trust, compromise and finding a balance to good clinical decision making.

Dr. Shah-Haque: 12:48

Thank you for that, and yes, it's always a multifaceted approach, isn't it? It's not a one answer, a one line solution Such as life. Life is very messy.

Dr. Joshi: 13:02

Life is very messy, very complicated, but we for some reason cannot overcome this tendency to want to simplify it or want to create a broad stroke narrative and I think that tendency has really done a lot of patients this service because we have very few impositions of power that are wanting to take the time and energy to delve into the clinical nuances.

Dr. Shah-Haque: 13:26

Yeah, I just think I don't know if there's a good financial incentive to do that, because that seems to be, and it seems to draw a lot of, or navigate a lot of, what is talked about.

Dr. Joshi: 13:37

It's very interesting. You mentioned that I got a chance to talk to a lot of reporters who are tracking opiates element dollars for contacts with those who may not know. In recent years there's been just a series of bombastic class section lawsuits against pharmaceutical firms, against medical distributors so many firms that either like tangentially or directly involved in the manufacturing and prescribing and distribution of prescription opioids. The most famous example would be a Purdue Pharma with the Sackler family. Now, in that instance were there examples of probably maybe less than fully honest marketing? I think you can say that there's probably less than fully honest marketing. Could you make the direct correlation that marketing efforts led to patient X, y and Z developing addiction, developing an overdose, event that becomes very speculative. But what has happened is the Attorney General's office, the federal prosecutors. They see, hey, we can make billions upon billions of dollars in class action settlements by targeting Walmart, by targeting Medline. Is this actually going to help overdoses? No, clearly they're rising, to show you how disingenuous that process is.

Dr. Joshi: 15:03

Coming circling back to the point I was getting at originally, when you track the opioid settlements, only 80% have to go to patients struggling with addictions, 20% can go to other initiatives, state-based initiatives, and of that, 80% that's used for substance-dependent patients. Every state has varied degrees of accountability. In some states you could just build fancy rehabilitation facilities that only the upper echelon of society can really afford, or in other instances you can create more hospitals that are effectively recycling the same manufacturing-based model of primary care. It's very difficult to understand how those legal entities at the state and federal level that so voraciously targeted all these healthcare entities are now somehow struggling to really understand what to do that they chased after, and I think it goes to show that very few honest actors in this space no, I agree, Because it never made a lot of sense for the reasons that you described.

Dr. Shah-Haque: 16:17

There's a lot of the overdoses that we're seeing is unnecessarily from manufacturers. It's a lot of what's peddled on the streets, if I'm not mistaken. Yeah.

Dr. Joshi: 16:27

So a lot of synthetic fentanyl and fentanyl-based derivatives.

Dr. Joshi: 16:30

What you'll see commonly nowadays are patients who were, let's say, many years taking low-dose opioids and anxiety medications as well. The physician basically put in a position where asking the patient to choose either take your pain medications or anxiety medications, and then the patient will choose one or the other. And then what the patient doesn't choose, the patient goes onto the street and finds some synthetic derivatives that typically are laced with fentanyl or some other substance to provide more profit for the drug dealers. And it's one of those situations where everybody knows it happens. There are websites out there streetrxcom that display the street value of certain medications and that gives us a sense of just how prolific this underground market has grown into. And for those who have positions of power the policy makers I find it difficult for them to understand how they can reconcile targeting healthcare entities within the legitimate opioid manufacturing business but somehow not target all these entities that are contributing to the solicit market. And again, I think it's a combination of lack of understanding and lack of full transparency.

Dr. Shah-Haque: 17:54

So you've come to understand where the DEA their line of thought or their understanding, so you can see both sides of the aisle. And you chose to continue in medicine, in the same area, where this minute's away from previous, and I have a lot of respect for that because you're absolutely right, you are going to define who you are, not previous, not an experience. Throughout all this, how did you stay positive, how did you keep your head above the water, because this could have resulted in so many different possibilities, and I'm glad it didn't.

Dr. Joshi: 18:39

Yeah, it wasn't easy. I definitely engaged in a lot of self-destructive behaviors. I would lash out emotionally. I just want to be fully transparent about this. One of the things I would do is I would get a six-pack of beer and I would just basically drink it until I would pass out, and it was very difficult to reconcile everything that had happened and maintain an emotional cool about it. I don't want to make any pretense that this is somehow easy for me in any capacity.

Dr. Joshi: 19:08

I think what really gave me the outlet that I needed was my writing, because when you write and you put something out there, you empower yourself. When you write something and it gets accepted into federal court, you feel that much more empowered. When you write a book and people read it again, on and on, it grows exponentially. What I did and I glossed over this at the beginning, but I want to maybe highlight this a little bit further when I was in federal prison, I had a choice to make I could succumb to the depression or I can find an outlet, and I almost had to read and write in order to not just succumb to self-destructive tendencies that were all around me. So I would read a book every two days write, and I wrote Bird of Pain by hand, the first draft, while I was away. I basically spent the first six months while I was there just reading, learning how to write, drafting short stories, just learning the art of an introductory paragraph, how to develop narration, how to create prose, and from there I spent the remaining time, the remaining five months, writing Bird of Pain, and I think that drove me to stay positive.

Dr. Joshi: 20:32

Then, when I got out, I started writing on my blog, daily Remedy, or on other sites about my experiences about health policy, and as that began to derive recognition, I felt more confident Again. The self-destructive thoughts still appear. They still come. You never get rid of them, quote unquote. You only learn how to address them and not respond or react to them. And I think anybody who's listening to this. I just want to be very clear that their days when you feel defeated, you face a setback and you just go back to the same thought patterns, same defeatist mentality, even an outlet to give you self-esteem. That's what I had to do and that's what my writing does for me.

Dr. Shah-Haque: 21:19

You mentioned self-esteem. How did you maintain your self-worth, that internal compass of self-worth, throughout all this?

Dr. Joshi: 21:30

You used the word. How did I maintain my self-worth? I honestly I can't say I really maintained my self-worth for the longest time. I felt worth less.

Dr. Joshi: 21:41

Like I was telling you earlier, you see some family friend or some relative in social settings. They look at you differently. You see the differences on their looks. You see the contours. You see their eyes looking a little different. What's on the back of their mind? They know what's on the back of their mind and they're not saying it. And in that silence comes shame, comes humiliation. The difference in the way people treated me before and after this incident really led to a loss of self-esteem, a loss of self-worth.

Dr. Joshi: 22:17

Again, I have to continually tell myself don't look to other people to define yourself. Don't look to other people to define yourself. And it's very easy to say that to other people, it's very easy to give that advice. It's very difficult to tell yourself that and actually believe it. Again, what I do is I talk about it, I put myself in situations where it comes up and I bring it up. And by doing that I take away that silence, that awkward facial expression, and I bring everything to the forefront and then it becomes something that we can discuss together. So it's not a narrative in somebody's mind, it's a conversation we're having together and by doing that I can show people where I was, what I'm doing and how I'm overcoming. And I think by putting yourself in a situation where you bring it up, you empower yourself to change the thoughts in people's minds. And I'm saying it works all the time, but it's better than most.

Dr. Joshi: 23:22

There are people that just want to think badly about me. There are people that are in some ways feel a sense of gratification. That just happened to me. That, oh, I always knew he was like this. Or I remember one time, a few years ago, he said something and I didn't like good for him. He deserved this. And people are gonna think like that and you have to understand that. Everybody has their own mental compass. Everybody makes their own internal calculations about how they want to think of other people. What other people think of you is not your business and that is so hard to believe. It is so hard to actually believe that. But when I put myself through enough of these situations, endured enough awkward conversations, endured enough kind of disrespect from people, it eventually calluses you. So you just get better at it. If it doesn't become easy, you just get better at it.

Dr. Shah-Haque: 24:17

I think that's an important distinguishing remark that you don't get. You get better at it. It doesn't get easier and there's a difference. There's a difference to that right, because when you get better at something, you just sail through, but it's still hard every time. It's still hard every time. Another thing that you said is what people think of us or what somebody thinks of you is not of your business. I always tell my kids what matters is what you think of yourself.

Dr. Joshi: 24:53

Yeah.

Dr. Shah-Haque: 24:54

That's your business, that's where you can concentrate your energy, and so thank you for pointing that out, because in medicine it's very much a culture of people pleasing, based on our training. So burden of pain there's after looking at that title and after hearing your story and I know that we've talked before this recording, but the more and more I hear what you've been through and I look at that it's a burden of pain, not just treating a patient's pain, but also your pain and also the things that happen under policies that are written but not fully understood.

Dr. Joshi: 25:39

It's very interesting to see how much we as people are defined by our circumstances, our general societal understandings. It influences us far more than we realize. We have this belief that we're all individuals capable of free thought, capable of being independent and thinking independently. What we fail to understand is that the systems around us largely define us, and it happens at such a subconscious level that we don't even understand that it's happening. America is quote unquote war on drugs. It's been an abysmal failure, but people continue to believe it because the powers that be continue to implement it. And so when I talk about pain and treating patients with pain and being a patient in pain, I allude a lot to just the stigma of pain. When a patient talks about his or her diabetic condition, nobody ever judges that patient for being non-compliant.

Dr. Joshi: 26:44

When you talk about pain, people always judge pain, and I think there's something very fundamental to pain, that being a shared universal experience.

Dr. Joshi: 26:56

We all come to terms with it differently and that's probably why it's so stigmatized as it is, because there's just so many people getting involved in just the treatment and management of pain.

Dr. Joshi: 27:11

And I'll give you a perfect example Contrast someone like myself, a physician who basically went through the DEA-based third deal and a physician who did not, our decision-making would be very similar for patients.

Dr. Joshi: 27:27

And what would have happened for that other physician who didn't go through? What I went through was saying, oh, he's a trusting physician or she's a trusting physician, but in my situation, when I describe it, there's all the you may not have done these things and clearly you didn't act in any criminal capacity, but you must have been reckless or you must have been this or that. And the reason why I create that contrast is because the same actions and the same behaviors, when you apply the stigma of pain to is looked in a very different context, whereas in one situation a physician would be seen as trusting and another situation a physician would be seen as reckless or careless. And these are the subjective perceptions that we impose onto pain and its treatment. And when I wrote burden of pain and I was going through the experiences that I went through, I began to realize quite astutely just how fundamentally subjective all of this really is and how the systems and the powers that be influence the perceptions that are formed around pain and its treatment.

Dr. Shah-Haque: 28:36

I think you brought up very good points there. There are multiple hats that are not necessarily present within the exam room, that do weigh in on how to treat pain, and it's such it's not a one size fits all. I had never thought about that before, really, and I do think that does add to the stigmatization, doesn't it?

Dr. Joshi: 29:00

It's such a broad term it is. The more external influence that seeps into medicine, the more polarizing the specific health issue becomes. A great correlate would be abortion. Regardless of what your perspectives are on abortion, I think it's pretty naive to create laws based on the rubric of weeks five weeks, six weeks, 15 weeks as opposed to taking into account the socioeconomic situations that patients find themselves in when having to make the difficult decision of receiving an abortion or not receiving an abortion.

Dr. Joshi: 29:36

I think what has happened is abortion has become moralized into a religious issue, an ethical issue, and it's lost the medical context through which it should be seen first and foremost. And when that happens, all of a sudden you have people who perceive themselves and this is the key word perceive themselves as experts on an issue, because they choose to look at that issue non-medically. People choose to look at pain non-clinically. People choose to look at abortion outside of its appropriate clinical context. And when they do that, they impose their own biases. And when they're in a position of power, those biases become policies, and that's where a lot of these issues really come up.

Dr. Shah-Haque: 30:24

The perfect example In your right. It's whatever way you want to slice it, it's still a medical procedure and that decision-making is being taken away from the physician and patient. If the listener wanted to purchase a copy of your book because there's a lot of thought through it and the unforeseen, unfortunate and unusual circumstances that you went through, where could they find that book?

Dr. Joshi: 30:58

It's available through Amazon and IngramSparks. Pretty much every online bookseller Amazon first and foremost would have this available. So you can go to Goodreads, you can go to IngramSparks, you can go to BarnesandNovelscom, you can go to Amazoncom and you should be able to find the books very easily. Just type in Burden of Pain and it's usually the first or second that comes up.

Dr. Shah-Haque: 31:23

And how could they reach out to you to further understand or connect with you?

Dr. Joshi: 31:29

Honestly, the best way is to just email me. I'm pretty open and very transparent. I make it a point to want to reach out to people, to cold call, cold reach out, so I enjoy it when people reach out to me as well. Help me an email. But you can send me an email at info, at burdenofpaincom, i-n-s-o, at B-U-R-D-E-N-O-F-P-A-I-Ncom, and I'll let her receive a notification through my phone and I respond within 24 hours.

Dr. Shah-Haque: 31:59

I can attest to that, because any conversations we have had, you have been very. I've enjoyed the quick turnaround time and also our conversations prior to this recording. And what last pearl of wisdom would you like to leave the listeners?

Dr. Joshi: 32:20

I think, out of everything that I've gone through and everything that has happened to me, I would say my ability to want to keep moving forward, to keep fighting, is what I'm most proud of. In any story, in any ordeal, we as individuals should always consider ourselves the authors of that story, first and foremost. So I would encourage everybody who may be enduring a difficult time or going through something very crying take ownership of it, become the author of that journey and make sure that you are the one in the position to write the story when it's all been said and done.

Dr. Shah-Haque: 32:59

Those are really powerful words Because I think it goes back to your statement of writing and reading gave you an outlet, almost empowerment, putting those words on paper. So, jay, thank you so much for your time and just I'm sorry which you've had to go through an endure, but thank you for sharing your trials and tribulations and being transparent and open. It takes a lot of guts.

Dr. Joshi: 33:32

Thank you, I appreciate your time and I appreciate the opportunity coming on your podcast.

Dr. Shah-Haque: 33:36

If you have found this helpful, share it with a friend, because we could all use camaraderie.