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Join us for a fascinating podcast episode as we explore the dangerous consequences of propaganda and misinformation within the context of the opioid epidemic. Our guest, Jay K. Joshi, a family physician and author of Burden of Pain: A Physician’s Journey through the Opioid Epidemic, shares his personal experiences and insights. Discover the chilling tale of how sensationalized news articles distorted the truth, affecting the author’s reputation and public perception. We delve into the impact on relationships with colleagues, friends, and family, as well as the consequences of self-promotion and the manipulation of narratives. Jay critically examines the way the opioid epidemic is discussed and emphasizes the dangers of simplification and assigning blame. Tune in for an eye-opening conversation that sheds light on the complexities of the epidemic and the urgent need for a more nuanced understanding and effective solutions.

Jay K. Joshi is a family physician.

He shares his story and discusses his book, Burden of Pain: A Physician’s Journey through the Opioid Epidemic.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today we welcome Jay Joshi. He’s a family physician, and he’s the author of the book Burden of Pain: A Physician’s Journey Through the Opioid Epidemic. Jay, welcome to the show.

Jay K. Joshi: Thank you for having me.

Kevin Pho: So we’ll get into your book in a little bit. First off, briefly share your story and journey to where you are today.

Jay K. Joshi: Sure. My journey really began with my first medical practice, which I had opened in 2016 in Munster, Indiana, a suburb you could consider part of the broader Chicagoland area. I was the first primary care practice to incorporate telepsychiatry into the primary care setting, meaning I was combining behavioral health and primary care back when that was quite stigmatized. Well, the care I was providing for vulnerable patients with chronic pain, substance use dependency, and mental health conditions was eventually misconstrued as enabling addictions among high-risk patients. While I was garnering awards from organizations like NPR and the NCQA, I was also attracting attention from the DEA and DOJ. Eventually I was indicted for prescribing low-dose opioids, Norco 7.5/325 milligrams twice a day, outside the scope of medicine, for an undercover agent who presented with cramping back and leg pain.

Well, I went through the entire ordeal, and I’ll save you the details because you can find them in Burden of Pain. But lo and behold, I’m back practicing medicine in the same area, just a few miles from where I was before. I regained my medical license, got reinstated into Medicare, and I’m back now to tell my story, to help inform patients and physicians that you can care for stigmatized patients, you can have stigmatized conditions, and still be considered part of the health care system.

Kevin Pho: So I read a little bit about your story online, and of course it’s found in your book. But for those who just aren’t familiar, and of course your book just came out, briefly share the story of the indictment and how you came back from that.

Jay K. Joshi: Certainly. So what had happened is, after the DEA began to look into my practice because they felt that the quality of my patients was not sufficient for the care that I was providing, they basically made the statement that the quality of a physical exam that I performed on an undercover DEA agent was not sufficient to justify the continuation of opioids, even though the patient presented himself as a non-opioid-naive patient with chronic pain. We reviewed his prescription history, we ordered a urine drug screen, and we requested imaging studies. But this was before 2022, when the Supreme Court required the criminal intent mandate to prosecute physicians. So effectively, back then in 2018, it was the interpretation of a non-clinically trained DEA agent versus my interpretation of clinical care as a physician, and I’m sure you can guess who won.

Well, flash forward to sentencing, because I eventually had to plead; there’s really no fighting this in court. At sentencing, I ended up getting 11 months, one week, and three days in federal prison, which was a shock, because part of why I felt I could plead guilty was that my attorney and everybody around me were telling me, “Oh, it’s just low-dose opioids. They’re just trying to make an example out of you. This is the opiate epidemic. Just quickly plead, and you can go back to resuming your practice.” And I bought into a lot of that chatter. When I found out I was sentenced to federal prison, it just shocked my mind, and I fell into a deep depression, as I’m sure you can imagine. It was there that I wrote the first copy of Burden of Pain, all by hand, all 100,000 words of it. In many ways it was my way to cope with everything that was happening, my way to find solace in sorrow, if you will.

Part one of Burden of Pain really details my story: how I built the first primary care practice in Northwest Indiana, incorporating behavioral health, as I mentioned, the accolades we achieved, the ill attention that we garnered from law enforcement, going through my legal proceedings, and just the massive propaganda campaign. I’m sure you saw some of it. When you just Google my name, you can still see some of those articles about how I’m apparently prescribing 6,000 opioids, how I’m imitating other physicians, how I’m doing this, how I’m doing that. It just becomes a cataclysm of misinformation. We saw it during the pandemic in acute time, but on a much longer time horizon, we’ve seen it for years with the opiate epidemic: wave after wave of misinformation, personal anecdotes turning into health policies. I hope that my book helps to destigmatize a lot of those false narratives so that we can now finally say, “Here’s the truth, and here’s how we should understand the overdose crisis.”

Kevin Pho: So you spent time in federal prison. Tell me the story since then, how you came back from that, and what’s the practice like now?

Jay K. Joshi: Yeah, so I came back. I went in front of the medical licensing board and told them I would like to resume my medical practice, and after a probationary period, they gave me my unrestricted medical license. I have since petitioned to vacate my conviction on the grounds that there was DEA misconduct. The first part of that investigation led to me being reinstated into Medicare. The second part of that investigation is for them to formally validate or verify that, yes, there was misconduct. So the first part was easy to get; the second part’s a little harder to get, as I’m sure you can imagine.

But once I got reinstated to Medicare and got my unrestricted medical license, I basically went back to all the physicians that I had as part of my referral network, and I told them, “This is my story. This is what happened to me.” I was open, honest, and candid. I told them, “You can possibly question my clinical decision-making as to whether I was right in trusting that undercover DEA agent, but you can’t say I was acting like a criminal.” I think that’s the key factor here, right? When we criminalize clinical decision-making that we may not agree with, we transform the conversation into something that it really isn’t, because clinical decision-making requires a certain degree of uncertainty. You could argue that all of clinical decision-making is in the face of some degree of uncertainty, and it’s hard to dispute that. But when you take that uncertainty and you criminalize it, what you end up doing is changing the conversation, changing the decision-making to where it’s less about what’s right for the patient and more about protecting yourself as a provider legally. That makes for bad medicine.

When I started to extrapolate these thoughts into words, into conversations, into the book, eventually people started to say, “Hey, let’s give this guy a chance. Let’s help him get back up.” There were hospital systems in the area, and there were physicians in the area, who were willing to help me, willing to help me get back up and allow me to sublease space. Now I’m practicing in the same area, just a few miles away. I don’t prescribe any opioids. I don’t prescribe any controlled substances outside of Schedule II. So my goal is to really focus on traditional primary care with behavioral health, just excluding the element of Schedule II.

Kevin Pho: Now, as you replay this story, is there anything that you would have done differently?

Jay K. Joshi: I think the one thing I would have done differently in hindsight, and again, I’m being completely honest here, is that I probably would have required verification of insurance from the undercover agent before beginning to treat that person as a patient. I know that sounds quite jaded, particularly in this world where Medicaid plans are changing and a lot of patients have to go one or two months without insurance before they get into a new Medicaid plan. But what happens is that Medicaid verification is a form of validation in the eyes of law enforcement. So if you have a cash-paying patient, let’s say, who moved from one state to another and is waiting to get onto that state’s Medicaid plan, that patient is automatically triggered as a high-risk patient, rightfully or wrongfully, in the eyes of law enforcement. If you were to provide the same quality of care as a physician, it would be perceived differently.

So going forward, and again, it’s unfortunate to say, because it is in many ways compromising quality of care, I would first make sure that patients have valid insurance before I initiate care. If they don’t, I would honestly tell them, “This is what happened to me. I now have to take this precaution.”

Kevin Pho: All right, let’s talk about your book, Burden of Pain: A Physician’s Journey Through the Opioid Epidemic. So we know why you wrote it, but I just wanted to start by asking you, why is it so important for you to tell your story?

Jay K. Joshi: It’s important to tell my story because it’s important to destigmatize shame and humiliation in the physician. I remember reading a statistic that one out of every three physicians experiences some degree of malpractice lawsuit throughout their career. That’s an extraordinarily high number, but very few physicians openly talk about it. It’s this kind of hidden shame that you just tuck away, and you move on with your career. Well, I don’t want to do that. My case was extraordinarily extreme compared to what most physicians face, so I feel like because it was so severe, I have a different vantage point, a different perspective. I want to tell my story because I want people to know what I went through, what I endured, and how I came back. And I’m telling my story because it’s part of my legacy, and I believe it makes me a stronger physician.

Similarly, I want physicians to look at their own journeys, to look at down points in their career, and not tuck them away but talk about them. That one time where you made a clinical decision, and the patient took it the wrong way, and it ended up becoming a lawsuit, was that fair? Why don’t you talk about it? Why don’t you discuss the clinical decisions you made and why you made them? Perhaps in the future, that will no longer be a potential lawsuit but a source of conversation. I feel that by talking about the down moments in medicine, we destigmatize the shame and humiliation that physicians endure, and we make it more open to talk about clinical decisions, more open to acknowledge points where things would have been different, where things should have been different, and just improve the quality of care overall.

Kevin Pho: Now, as you were writing this book and getting it ready for publication, was there anyone who told you, “Hey, maybe this isn’t a good idea”? Did your attorneys ever say maybe you shouldn’t share your story? Anyone who told you otherwise?

Jay K. Joshi: Yeah, I got that a lot when I was going through the medical licensing process, getting that back up. Everybody said there was going to be some degree of retaliation. I heard a lot about how the DEA would retaliate against me in some capacity. I think the DEA has done a great deal of harm to the medical community, but I don’t think that they are the boogeyman that we make them out to be. I think that they are trying to do good in their own way. The more I interact with the DEA to work to get this conviction vacated, the more I’m starting to understand that they are complex organizations. All these legal entities, whether a state AG’s office or the medical licensing board, are a complex entity of individuals, and we often simplify them into these behemoth organizations where we think, “Don’t rattle them. Don’t do this.” I actually feel like by leaning into them and talking to them as individuals, they better understand you, and you better understand them.

But yeah, from the very beginning, I got a lot of pushback saying, “Don’t rattle things any further. Just lay low, get all your licensing back, and then talk.” I felt like that was a bit hypocritical. I felt that I should talk from the jump, because what’s the point of talking when I’m fully safe, when I’m back up and running? Why not talk when I’m vulnerable? Because that’s when I’m at my most honest.

Kevin Pho: And as you tell your story, give us the spectrum of reactions that you’ve seen.

Jay K. Joshi: Two tiers. One, from the chronic pain and substance use dependency community, there was just over-adulation that there is a physician telling a story from a point of vulnerability. Talking about the pain and suffering that I went through in a very vulnerable way is unique for physicians. Most patients see physicians talking from the perspective of a subject matter expert; very few physicians talk about their vulnerabilities. So I think that honesty really struck the chronic pain and substance use dependency community.

With policy leaders, one of the things that I’m doing that’s quite unique is I’m taking this book and introducing it to judges, to legislators, to politicians, because I don’t want this to come across as antagonistic in any way. I want this to be a bridge connecting law enforcement and the clinical community. So among that tier, tier two, I would say that there’s a quiet acceptance, a wait-and-see approach. For example, when I met the lieutenant governor of Indiana and introduced the book to her, she was very interested in it. She wanted to learn more about it, she wanted to read it, and she connected with one of her staffers and was starting to have conversations about implementing some of the ideas from the book.

But that over-adulation, like, “Oh, I love this book, thank you so much,” I think that’s really coming from that first group, the patient population themselves. And that’s natural, right? You have that target demographic, the patients, and then the patients sway the policymakers. So I think that’s a very natural trend.

Kevin Pho: As you were going through this ordeal, and there was just so much propaganda and misinformation that was written about you, tell me some of the emotions and thoughts in your head that you were going through at that time.

Jay K. Joshi: Yeah, I mean, I lost my self-esteem. I lost my sense of identity. I just couldn’t even think straight. There was always this cognitive dissonance where it was like, “Man, that’s a rough article. But that article wasn’t so rough. Well, this one really got me.” I’m not going to lie, it still kind of affects me. I’ve built a certain wall where I can compartmentalize some of those emotions, and I’ve learned to be indifferent. But I would say there was this Pavlovian learned helplessness when article after article was just coming, and I was just like, “Oh my God, another one.” It’s like I’m a tenant on this news cycle.

It was really tough, you know? I mean, I was 33 at the time. My first clinic was opening. I was so proud of the clinic that had opened just a year earlier, and then all this happened. It was a very powerful set of emotions, and I don’t think that I’d be able to talk as openly and candidly as I am now about everything that happened to me if I hadn’t been through something so brutal, truly brutal. I don’t want to call it torture; I don’t want to misuse that word. But I was really exposed in ways that most people are not. It hurt, no doubt, but it built something unique.

Kevin Pho: What did you turn to for support during your lowest moments? Because obviously this isn’t something that is taught in medical school or residency, how to deal with all this misinformation that’s out there. What did you turn to for support and advice?

Jay K. Joshi: You know, the usual. Family helped. But I want to nuance it a little bit more, because it’s important to talk about all the times I reached out for help but was turned down. I think that’s an important part of the conversation. There were quite a few physician leaders in the community, and I don’t want to name names; I harbor no ill will whatsoever. There were a lot of physician leaders in the community that I had reached out to that did not respond or stated that they were unable to help, when just a month earlier, I know that they would have been in positions to connect. Remember, there were certain family members that looked at me a certain way. Propaganda exists because propaganda works. There is something about the human condition that if you’re told something repeatedly, even if you know it’s false, you have to at least assume some part is true in some capacity. It’s just human nature.

So for anybody who’s going through a rough time, or any tough period in their life, there will be times when you reach out to people, and there will be times when you are turned down. Please do not stop reaching out, and please do not vent on the person who turns you down. Everybody has their own journeys, and if people are not in a position to help you, please do not take that out on that person.

The biggest rock for me was my dad. He was always there for me, through and through, a big source of support. Some family members who I was very close with, I was no longer as close to, and that really, really hurt. And I say that with a certain gratitude, as odd as that may sound, because I’m just fortunate. All the things you go through when interacting with people, good or bad, are all positive experiences. They may not feel like that, but they’re positive experiences. Just find the ones that you can reach out to, and disregard the ones that you cannot.

Kevin Pho: So a good part of your book, of course, is your story. What are some of the other main messages you want readers to come away with after reading your book?

Jay K. Joshi: Yeah, the main aspect I want people to understand is the concept of medical uncertainty and what that means when applied in a legal framework and in a clinical framework. Uncertainty in medicine is inherent, and we have to understand that when we create laws around clinical behavior, we have to acknowledge that medical uncertainty is germane to how we understand clinical behavior and health policy as a whole. We keep going through these clinical guidelines, whether it’s about abortion, opioids, or vaping, and it’s almost a whack-a-mole process, where we think we’re solving one thing and then something else pops up. I think we need to really understand uncertainty and its true form, and how it informs clinical decision-making and, at a larger level, health policy. I want people to understand through my story the role uncertainty plays in their own clinical decision-making.

Kevin Pho: So you’ve been through a pretty extreme ordeal. It’s quite a story. How are you doing now?

Jay K. Joshi: Much better. Obviously, I’m at the tail end of things. I’m resuming my clinical practice. Things are much better for me now than they were even just a few months ago, and I’m just maintaining a positive outlook of being grateful and returning to my own self: that ambitious, goal-oriented individual with a pie-in-the-sky mindset of big dreams. All of that is coming back, and it’s just such a blessing to be able to see part of what I felt was lost forever, part of my identity that I felt was lost in this whole ordeal, come back to me. I’m starting to feel whole again, starting to feel like my confident self.

So it’s a blessing to be able to go through what I went through yet emerge from it, because I feel like a lot of physicians are going through tough times in their lives. As we know, and as you’ve covered so many times, physician suicide is at an all-time high, along with physician stress and burnout. We have to support each other, and part of supporting one another is to acknowledge that there will be down periods and recognize that those journeys downward are just as important as those journeys upward.

Kevin Pho: How’s the relationship with the local physician community who know you?

Jay K. Joshi: Surprisingly good, surprisingly good. I think I did two things off the jump that really helped. One, I just told my honest story. Obviously, I provided legal documents to whoever wanted to look at them, but I was very transparent and very humble. What I’ve noticed is when people go through situations similar to what I went through, maybe not to the extreme, there’s a tendency to be jaded, or, I don’t want to use the word arrogant, but I want to say in many ways reactionary to a negative emotion. When people saw I didn’t really have much of that, and I was willing to start at the bottom and work in whatever capacity I was able to work in to get my practice back off the ground, people appreciated that.

I mean, you know what’s very funny? I could go off on a tangent a little bit, but I think this is important. I met the prosecutor in my criminal case, who has since become a federal judge, and I told him that I’m working to vacate this conviction and that I didn’t appreciate the misconduct that took place in my case. He and I had like a five-minute conversation, a legitimate five-minute conversation, about this. He obviously has to recuse himself from future proceedings, but he said that he would go through everything and verify the misconduct that took place. I thought that was really fascinating, because for the DEA to acknowledge misconduct, they have to do it in an official capacity; they have to do that. But for a former federal prosecutor, now a judge, to come back and say, “Yeah, you know what, let me take a look back and just verify if I really got things right or if things were wrong,” that tells us a lot about who he was as an individual.

You can say so much about good guys and bad guys and simplify the narrative, but really, I think my story is a complex tale of many individuals who are trying to do what they think is right in a very difficult problem, and that’s the opiate epidemic. I feel like the way I present myself, how vulnerable I make myself and how exposed I am, allows for multiple perspectives to come in, and I think that allows people to then find bridges where there would otherwise have been battle.

Kevin Pho: And my final question, Jay: Tell us some of the take-home messages that you want to leave with the KevinMD audience.

Jay K. Joshi: The take-home message is to really understand that medicine is a complex entity, and that our tendency to reduce it to simplified narratives for a myriad of issues, the opioid epidemic, the pandemic, abortion, is really causing more harm than good. I think we need to look at medicine as the complex, uncertain concept that it is and really find solutions that take into account the complexity of medicine, because that’s inherent in all policies. Once we find out how complex medicine is, we’ll quickly find out what the right solution can be.

Kevin Pho: Jay, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Jay K. Joshi: Yeah, thank you. I appreciate it.