When cause of death is opioid overdose is it murder or malpractice?

https://drjengunter.wordpress.com/2015/09/02/when-cause-of-death-is-opioid-overdose-is-it-murder-or-malpractice-the-case-of-dr-tseng/

Is a doctor guilty of malpractice or murder or is the patient responsible for his or her actions when there is a death by overdose? This is the question that a jury in Los Angeles will have to decide as they are presented the facts in the case of Dr. Lisa Tseng.

The prosecution’s version is that Dr. Tseng handed out opioids like candy without any regard for standard of care. Over the years at least 12 of her patients died from overdoses. She is now standing trial for three deaths…

So opioids are a big deal. I was once a far more liberal opioid scribe than I am now. Fifteen years ago we were all “under treating” pain and so we prescribed more and more opioids. That is what our professional societies told us. I saw almost no one get better or lead a more productive life. I also heard of more lost prescriptions than I can count. Pain scores rarely budged, but doses gradually escalated.

I don’t understand why doctors expect miracles from opioids and discount the stabilization of pain levels (scores).  All treatments tried by a patient up to this point have not been able to provide enough relief, so opioid therapy is chosen. And when pain levels are stabilized, that’s not considered a success? Keeping a person off disability is not considered a success? Allowing patients to keep caring for themselves and remain independent is not a success? Keeping a chronic pain patient from committing suicide is not a success?

I would never keep someone on a beta blocker if it wasn’t controlling their hypertension, so why would I keep someone in an opioid if it wasn’t lowering their pain score? If 240 Norco and 60 OxyContin a month isn’t helping your pain dramatically then you have opioid resistant pain…

Asking for opioids to “control” pain is, like I said, asking for miracles. Some patients will be helped “dramatically” with opioids, but some not. Some patients can’t tolerate opioids and some have a metabolism that decreases the effectiveness of opioids. Saying that a patient’s pain must be helped dramatically at a certain dosage sounds like this doctor treats patients like robots on a conveyor belt.

About ten years ago I decided that chronic opioids were not for my practice. The percentage of people in my 15+ year career in chronic pain who have truly benefited from them, meaning a significant reduction in pain scores with a corresponding improvement in functionality, is very small…

Expecting patients disabled by pain to increase their functionality just because they take opioids is a fairly narrow view of pain syndromes. I wonder, do you treat any cancer patients, Dr. Gunter? Anyone with trigeminal neuralgia? Tell me, doctor, do your chronic pain patients achieve “a significant reduction in pain scores with a corresponding improvement in functionality” with any other treatment you prescribe?

Oh wait, it looks like Dr. Gunter prescribes yoga:

The Feldenkrais Method® is a form of somatic education that uses gentle movement and directed attention to improve movement and enhance human functioning. Through this Method, you can increase your ease and range of motion, improve your flexibility and coordination, and rediscover your innate capacity for graceful, efficient movement. These improvements will often generalize to enhance functioning in other aspects of your life. The Feldenkrais Method is based on principles of physics, biomechanics and an empirical understanding of learning and human development. By expanding the self-image through movement sequences that bring attention to the parts of the self that are out of awareness, the Method enables you to include more of yourself in your functioning movements. Students become more aware of their habitual neuromuscular patterns and rigidities and expand options for new ways of moving. By increasing sensitivity the Feldenkrais Method assists you to live your life more fully, efficiently and comfortably.

Is this description from their website supposed to be easily understandable?  Dude, it’s yoga, no need to make it sound so fancy. And I don’t need to pay a doctor to tell me to try yoga. While yoga and stretching exercises can be part of a home treatment program, rarely do they help enough to be the only treatment being used. In fact, without something to decrease the pain, either before or after (and sometimes both), I can’t perform all of my daily stretching exercises. If Dr. Gunter was my doctor, I guess I’d be SOL.  (Free the weed.)

Speaking of freeing the weed, there’s no mention of cannabis in this doctor’s post. For anyone who alleges to treat pain, without offering access to cannabis (or opioids, in this case), you’re really worth nothing to me.

There is no scenario where I can see giving a 21 year man from out of state an opioid prescription of any kind unless he was in the emergency room with a traumatic injury. It doesn’t sound as if Dr. Tseng was anyone’s family doctor or internist trying to keep people afloat. Whether she started out with good intentions and was the most gullible person on the planet or this was truly a pill mill will be pretty easy to tell from a record review…

I love how doctors stand up for each other, don’t you?  Even if Dr. Tseng is guilty of being gullible — or if she’s simply guilty of trying to help treat the pain reported by her patients — she’s not a criminal. She’s not a murderer. And even if she was running a pill mill, do you think 100% of her patients were drug addicts and none of them were chronic pain patients? I wonder what happened to all her abandoned patients…

Are alcohol, car, or gun salespeople (dealers) responsible for those who abuse their products? If someone gets drunk, robs a bank with a gun, uses a getaway car, and then drives over a cliff like Thelma and Louise, who’s responsible? The person who sold him the alcohol, gun, or car? Or now that he’s dead, since he’s an alcoholic and a bank robber, who cares?

Under comments:

The DEA keeps a list of criminal prosecutions of doctors who lost their DEA registration as a result: http://www.deadiversion.usdoj.gov/crim_admin_actions/doctors_criminal_cases.pdf

There are at least two prior instances of physicians getting convicted of murder for improper subscribing. Dr. Harrison Bass of Las Vegas was convicted of second degree murder in 2008 for a death related to running what sounds like a mobile pill mill. Dr. Noel Chua of Georgia was convicted of felony murder in 2007 for illegitimately prescribing “multiple controlled substances” to the victim.

Additionally, Dr. James Bischoff of Montana pled guilty to charges including negligent homicide in 2006 and Dr. Jesse Henry of New Mexico pled guilty in 2004 to charges including seven counts of involuntary manslaughter related to at least three deaths linked to over-prescribing of multiple opioids.

POSTED BY DAN | SEPTEMBER 3, 2015

http://www.latimes.com/local/lanow/la-me-ln-murder-trial-tseng-doctor-20150829-story.html

During opening statements in her case Monday, Tseng hunched forward in her chair, settling in for a landmark second-degree murder trial that’s expected to last for months. The general practitioner, who scribbled notes on a yellow notepad and tapped her foot over and over, is the first California doctor ever charged with murdering patients who overdosed merely for prescribing them medication, Niedermann said…

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