by Dr. Micaela Wexler
On February 5, 2016, Dr. Lisa Tseng, a Los Angeles area physician, was sentenced to 30 years to life for killing three patients who overdosed on pain pills she prescribed.
Prosecutors charged Tseng with murder for the deaths of Vu Nguyen, 28, of Lake Forest; Steven Ogle, 25, of Palm Desert; and Joey Rovero, 21, an Arizona State University student who prosecutors say traveled more than 300 miles with friends from Tempe, Arizona, to obtain prescriptions from Tseng at her California clinic. The prosecution made the case that she recklessly prescribed large amounts of narcotic pain killers to people who did not need them, and the jury agreed.
Her defense team has made the claim that this was a case of malpractice, not murder, that Dr. Tseng was deceived by her patients, and that physicians should not be held responsible if their patients abuse their medications, and that her patients should have known not to take large amounts of narcotics, and not to mix them with alcohol or benzodiazepines.
It’s difficult to make a case for malpractice given these facts. Malpractice is generally reserved when great harm is caused by a physician’s mistake. But, Dr. Tseng’s actions do not fall under the definition of an error. She did not accidentally prescribe the wrong medications; she intentionally prescribed opioids, Soma, and Xanax. Habitually. Approximately 25 times a day.
On her very first meeting with this out of state patient, she allegedly quickly prescribed Rovero more than 200 pills, including nearly a hundred 30-milligram doses of Roxycodone, a potent and addictive painkiller. Nine days later, he was dead, joining the approximately 100 Americans per day who die from a drug overdose. The investigation showed that in addition to the three deaths for which she was convicted, eight other patients died from overdosing on her prescriptions. Numerous others overdosed, including one in the clinic bathroom shortly after his appointment. Her staff and patients testified she spent just minutes with each patient, did not perform physical exams, and did not verify they had a true need for these medications.
I believe responsible prescribing is the duty of every physician. Having said that, what exactly does this mean?
How is one physician guilty of malpractice while yet another is guilty of manslaughter, while Dr. Tseng is the first physician to be convicted of murder for the death of patients to whom she prescribed medications?
Losing patients is the reality of being a physician. Patients routinely die even when physicians do everything possible; death can result even when a patient has been prescribed a medication that is not controlled and considered low risk, such as a patient with asthma inadvertently prescribed a beta blocker. Then we have the issue of suicide by overdose: we do not hold physicians responsible when a patient decides to ingest the entire bottle.
As a psychiatrist, I have found it extremely challenging to treat patients who request narcotic pain medications. It is difficult to determine which ones have a pain issue and which ones have an addiction. I have learned the hard way that a patient with a true pain disorder can be just as violent as one with a narcotic pain pill addiction.
I have decided that for ME responsible prescribing of narcotic pain medication means VERY limited prescribing. I do not prescribe narcotic pain medications for any patient longer than a few days, for the simple reason that I am not trained in pain management. I prescribe controlled substances such as benzodiazepines and stimulants only to patients who will be under my care long term. I educate patients about this as early as possible.
If a patient enters my care on an acute psychiatric unit while prescribed a narcotic pain medication, I advise the patient the pain medication will be continued overnight and will be discontinued if I am not able to verify that they have a legitimate prescription. To ease their discomfort I will taper rather than abruptly discontinue opioid medications. If a patient presents to an outpatient setting requesting pain medication, I advise that I am not skilled in narcotic pain prescribing, and as such, I am not able to keep them safe, so I will not be writing a prescription for narcotics.
I’ll be the first to admit: this is much more complicated than what I have just described. Most patients requesting opioid pain medications are not content with my limits. The most mild reactions are those in which they try to persuade me to give them a prescription “for a few days worth to get me by until I find a doctor.” They launch into a detailed description of their medical issues, and explain how their pain is contributing to their depression and suicidal behavior. Some will go so far as to say, “if I don’t get my pain meds (or Valium, or Xanax), I’ll go kill myself.” I have hospitalized such patients involuntarily.
These are the “easy” patients. What happens far too often is that patients become aggressive. Their behavior ranges from verbal threats, “I know where you live” is the most common, to physical aggression. I have been spit on, kicked, shoved, had books thrown on me, had my hair pulled and, in one case I was beaten up by a patient who then attempted to strangle me. I have learned I am far from alone in these experiences, so much so that I now teach a class on coping with these types of patient situations.
I have encountered numerous physicians in the rural Midwest who, as Dr. Tseng was known to do, prescribe large amounts of opioids to patients they know little about. The Drug Enforcement Administration says Dr. Tseng wrote more than 27,000 prescriptions in just three years, at an average of 25 a day. By the time Joey Rovero, a college student in Arizona, visited her California office in December 2009, Dr. Tseng had developed a reputation as a “candy doctor,” a name given to doctors who “give you whatever you ask for.”
As a medical student and intern, I delivered approximately 70 newborns. I loved delivering babies. I loved the excitement; I loved holding their slimy bodies, stimulating their faces until they cried, watching their color change from blue to pink. I loved being present as a new family was formed. So great is my love of this, that I have remained active in providing breast feeding support, because of the proximity it affords me to this process.
If I happened to be the only person around, I would certainly deliver a baby if needed. However, I would never consider putting myself in a position where I would routinely be expected to participate in deliveries. It would be horribly irresponsible, and if a baby died under such circumstances, I’m not sure it would be considered malpractice.
This is the analogy from my life which most closely matches Dr. Tseng’s situation. There is no evidence to suggest Dr. Tseng had the proper training or technique to prescribe such large numbers of opioids. Her prescription of opioids in such large amounts would be similar to me running to women’s homes to get there before the midwife, knowing that in her vulnerable state, a woman in labor might actually prefer a physician over a midwife.
While it is true that Joey Rovero was an intelligent young adult, a college student just months away from completing college, unlike Dr. Tseng, he did not have a medical degree. Like Dr. Tseng, I also attended an osteopathic medical school. I was trained that the physical exam is of utmost importance when treating physiologically based medical conditions. In addition, all osteopathic medical students learn osteopathic manipulation technique (OMT). We are encouraged to turn to OMT as much as possible, especially in treating pain.
I don’t know what motivates physicians to run what are known as “pill mills.” Prescribing opioids in such large amounts turned out to be very lucrative, as reports indicate Dr. Tseng made $5 million in three years. A couple of years ago, I discussed this issue with a friend who happens to be a malpractice attorney. He advised me these cases never make it to court because the patients are unsympathetic due to their addictions. “We always find something in their background that will make them look bad in court.”
Joey Rovero was not someone with “something bad” in his background. He grew up as a good student and athlete in a close knit family. Rather than being shamed by the circumstances of their son’s death, his parents filed a complaint against Dr. Tseng. The following year, April Rovero started the National Coalition Against Prescription Drug Abuse. She has worked tirelessly to educate students, parents and lawmakers on the dangers of narcotic prescription drugs.
Dr. Lisa Tseng’s conviction and prison sentence is a wake up call that the manner in which we treat pain, as well as how we address the problem of prescription medication addiction needs to be addressed.
Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.
Please visit Wexler Family Psychiatry to schedule an appointment.
Appointment information for Dr. Wexler: wexlerpsych.com
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