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A lot of Atlanta area psychiatrists are going to hear "you aren't helping me like Dr. N did" over the next few years.
 
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Murder? Doesn't that require intent? I'm all for cracking down on reckless prescribing, but unless he forced the pills down their throat, I don't see how he can be charged with murder. What's next, charging a gun store owner with murder?

WingedOx said:
A lot of Atlanta area psychiatrists are going to hear "you aren't helping me like Dr. N did" over the next few years.
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I'll bet his patient satisfaction scores are sky-high.
 
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Trismegistus4 said:
Murder? Doesn't that require intent? I'm all for cracking down on reckless prescribing, but unless he forced the pills down their throat, I don't see how he can be charged with murder.
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Exactly. It sounds like this guy used his medical license to be a drug dealer. Murder, though, seems to be a clear overstep. I expect he *intended* to make money and was at worst indifferent about enabling overdose deaths. There seems to be no evidence that his goal was to kill people.
 
Bartelby said:
Exactly. It sounds like this guy used his medical license to be a drug dealer. Murder, though, seems to be a clear overstep. I expect he *intended* to make money and was at worst indifferent about enabling overdose deaths. There seems to be no evidence that his goal was to kill people.
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He could certainly be acquitted of the murder charges if there is insufficient evidence that he intended to kill people. The fact that he was indicted on murder charges means it's what the DA's office wanted. Maybe they are trying to make an example of him because of the opioid abuse epidemic.
 
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Bartelby said:
Exactly. It sounds like this guy used his medical license to be a drug dealer. Murder, though, seems to be a clear overstep. I expect he *intended* to make money and was at worst indifferent about enabling overdose deaths. There seems to be no evidence that his goal was to kill people.
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Felony murder, not malice murder.

Sadly, based on the drug regimens we get from the community, I think there would be a lot more of this guy if stimulants and benzos killed people as easily as opioids. I suspect lots of psychiatrists simply just leave the opioids to other providers and aren't fundamentally different, except they are shooting with a bee bee gun instead of a rifle.
 
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While it's true the charges could be dropped, there is precedent for the charges sticking. For instance, see http://www.cnn.com/2016/02/05/health/california-overdose-doctor-murder-sentencing/ in which a California doctor handing out opiates to addicts received 30 years to life after being convicted for murder. Her defense claims that she was in over her head and didn't know how to deal with manipulative drug-seeking patients. While that is quite likely BS, I still worry about a slippery slope. How egregious must the conduct be to qualify for a murder charge? For instance if we inherit a patient on inappropriately large benzo doses and continue them, could we end up with a murder charge?

It's all quite unsettling to me. I think without intent it isn't murder, full stop.
 
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According to ProPublica's treatment tracker, he had the 6th largest medicare patient population in the state and his #1 prescribed drug was alprazolam. If xanax, norco, and soma are among a psychiatrist's top 50 prescribed drugs, he or she might want to revisit their prescribing practice- before someone with a badge does.
 
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Bartelby said:
While it's true the charges could be dropped, there is precedent for the charges sticking. For instance, see http://www.cnn.com/2016/02/05/health/california-overdose-doctor-murder-sentencing/ in which a California doctor handing out opiates to addicts received 30 years to life after being convicted for murder. Her defense claims that she was in over her head and didn't know how to deal with manipulative drug-seeking patients. While that is quite likely BS, I still worry about a slippery slope. How egregious must the conduct be to qualify for a murder charge? For instance if we inherit a patient on inappropriately large benzo doses and continue them, could we end up with a murder charge?

It's all quite unsettling to me. I think without intent it isn't murder, full stop.
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While I don't buy her defense (especially when she had patients coming from all over the Southwest to see her), we really do need better training for students and upcoming physicians about this.

For all the endless SP training they throw at students, have a session to say no to a suffering but drug-seeking patient, have the patient flip out and call the student a "c-nt" when they do it. Get students used to processing those types of scenarios because they're a reality of practice.
 
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Bartelby said:
While it's true the charges could be dropped, there is precedent for the charges sticking. For instance, see http://www.cnn.com/2016/02/05/health/california-overdose-doctor-murder-sentencing/ in which a California doctor handing out opiates to addicts received 30 years to life after being convicted for murder. Her defense claims that she was in over her head and didn't know how to deal with manipulative drug-seeking patients. While that is quite likely BS, I still worry about a slippery slope. How egregious must the conduct be to qualify for a murder charge? For instance if we inherit a patient on inappropriately large benzo doses and continue them, could we end up with a murder charge?

It's all quite unsettling to me. I think without intent it isn't murder, full stop.
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I agree. I was unfamiliar with the "felony murder" concept, but no matter how much precedent it has, it makes me uncomfortable. I just don't see how we can consider a person just as culpable for a death as an indirect result of recklessness as if they had actively killed the victim. Isn't that why we have the concept of manslaughter?

Also, I think our society (not only our profession) has gone too far with the "addiction is a disease" mentality in completely absolving the addict of any responsibility for their actions. The doctor didn't force the pills down their throats (or cook them and inject the solution IV, or whatever they did.)

Guyton said:
According to ProPublica's treatment tracker, he had the 6th largest medicare patient population in the state and his #1 prescribed drug was alprazolam.
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Wow, the 6th largest Medicare population in the state. And the article about the Chinese doctor in California said her practice "raked in millions of dollars." The fact that these stories make the news every so often makes you wonder how many other docs out there spent their careers "practicing" this way, never getting caught, and are now enjoying opulent retirements while we make $220k a year cranking out 99214's.
 
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If the doctor in California didn't know how to deal with manipulative patients she shouldn't have been prescribing those meds
 
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WingedOx said:
While I don't buy her defense (especially when she had patients coming from all over the Southwest to see her), we really do need better training for students and upcoming physicians about this.

For all the endless SP training they throw at students, have a session to say no to a suffering but drug-seeking patient, have the patient flip out and call the student a "c-nt" when they do it. Get students used to processing those types of scenarios because they're a reality of practice.
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I think you're on to something here. This is something we ALL deal with, so why don't medical schools talk about it and give some guidance? I think a lot of doctors cave in and give inappropriate prescriptions because they're uncomfortable dealing with the confrontation/argument and just want to get the patient out of the office, so training medical students on how to say no to these types of patients might actually reduce the number of inappropriate prescriptions.
 
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northernpsy said:
I think you're on to something here. This is something we ALL deal with, so why don't medical schools talk about it and give some guidance? I think a lot of doctors cave in and give inappropriate prescriptions because they're uncomfortable dealing with the confrontation/argument and just want to get the patient out of the office, so training medical students on how to say no to these types of patients might actually reduce the number of inappropriate prescriptions.
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Because patient satisfaction and the current culture of teaching is to be centered around conflict avoidance. All throughout training we're taught, be sure you never say no and that no one complains about you because you'll be dismissed in some form or fashion. This type of training ensures future compliance with corporations and the government.
 
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Shikima said:
Because patient satisfaction and the current culture of teaching is to be centered around conflict avoidance. All throughout training we're taught, be sure you never say no and that no one complains about you because you'll be dismissed in some form or fashion. This type of training ensures future compliance with corporations and the government.
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Our SP department does have difficult patient encounters as part of the preclinical curriculum. None of the difficult patient encounters involve drug-seeking behavior. The fundamental defect with that training, though, is that the feedback they provide is such that if you didn't make the patient happy, it was somehow your fault. While that may sometimes be true, on rotations I've learned that often times (especially with prescribing potentially addictive drugs), it is doing the right thing that makes a patient upset.

We are constantly pushed to believe that we need to make everyone happy with us or else we did something wrong, so I'm not surprised that sometimes poor medical decisions can result from the desire not to make someone upset. That should be changed.
 
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GUH said:
Our SP department does have difficult patient encounters as part of the preclinical curriculum. None of the difficult patient encounters involve drug-seeking behavior. The fundamental defect with that training, though, is that the feedback they provide is such that if you didn't make the patient happy, it was somehow your fault. While that may sometimes be true, on rotations I've learned that often times (especially with prescribing potentially addictive drugs), it is doing the right thing that makes a patient upset.

We are constantly pushed to believe that we need to make everyone happy with us or else we did something wrong, so I'm not surprised that sometimes poor medical decisions can result from the desire not to make someone upset. That should be changed.
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I'll never forget that one of the first things we were told in our "soft skills" course 1st year in medical school was never to interrupt a patient. As though that would be possible with a chronic pain patient, or a manic patient. What's going on is a phenomenon of "doctor guilt," just like white guilt. The philosophy in modern liberal society is that in any interaction, the more powerful person, the wealthier person, the person with more authority, the "higher," is the bad guy, and the "lower" is the good guy. For a doctor to be firm with a patient, to tell him what to do, or tell him "no," is seen as a marker of paternalism, of the bad old days of authoritarian white men with their boot on the neck of everyone else.
 
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you guys are always mixing up/blurring lines between the providers(whether psych or not but lets keep it to psych) who are simply ordinary candymen who write a ton of controlleds vs the people who actually do stuff to get their license pulled and arrested.

group A: psychiatrists who have a bunch of patients on 4-6 mg xanax a day, even a good number of patients on stimulants(30mg BID adderall seems to be the go to combination) with moderate to higher dose bzds, and then of course the usual crap for sleep(ambien usually). These people, whatever you say about the way they practice psychiatry, do it in a way that the state boards aren't going to be after them. Nobody is taking their licenses or arresting them. Some even have decent reps. They are generally interested in playing by the rules and mostly do what they do because of some combination of it being easy, more lucrative, and to please patients. This group will generally document appropriately and more importantly won't prescribe opiates. They will do Klonopin 2mg BID with Adderall 30mg BID(with a 15mg prn...gotta have that) and ambien 10 to sleep and of course some ssri the patient has never filled....but when asked for a prescription for oxycodone will politely answer "well I'm not a pain dr so can't do that. It's not my field. ask your primary dr about that". A lot of these psychs also take insurance. They tend to make their money with volume.

group B: just outright drug pushers. Like the guy in atlanta. Are often brought to light after a few deaths(again atlanta). They will write for lots of opiates. They are often writing 25+ opiate scripts per day....even though they are psychs. Very high doses as well. Their drug regimens often resemble the regimens you would see from a pain pill mill clinic(oxy 30 q4, soma, xanax) with maybe a little more attention on the psych drugs because...well...they are psychs. But the psych thing really isn't important. They are just dealing drugs. See bunches of patients as well but are even more likely to take cash only as compared to group A. Also care far less about documenting or even maintaining the appearance of being a psych on the straight and narrow(which is important to group A)

Almost every psychiatrist ever arrested or ever losing their license(related to rx'ing and not things like sleeping with patients or other unethical behavior) are in group B. Group A is a large group, and that group is never in any danger.
 
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Trismegistus4 said:
I'll never forget that one of the first things we were told in our "soft skills" course 1st year in medical school was never to interrupt a patient. As though that would be possible with a chronic pain patient, or a manic patient. What's going on is a phenomenon of "doctor guilt," just like white guilt. The philosophy in modern liberal society is that in any interaction, the more powerful person, the wealthier person, the person with more authority, the "higher," is the bad guy, and the "lower" is the good guy. For a doctor to be firm with a patient, to tell him what to do, or tell him "no," is seen as a marker of paternalism, of the bad old days of authoritarian white men with their boot on the neck of everyone else.
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And the US medical system seems to resist the idea that the government could know what's best for it. Same transaction, different actors.
 
birchswing said:
the government could know what's best
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The government's not some magical being. It's made up of people who probably know just about as much about any given (non-top-secret) thing as people who aren't in the government. There's no clear knowledge asymmetry. So I'll have to disagree with that analogy.
 
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FlowRate said:
The government's not some magical being. It's made up of people who probably know just about as much about any given (non-top-secret) thing as people who aren't in the government. There's no clear knowledge asymmetry. So I'll have to disagree with that analogy.
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I was making a very general point about the medical system, not specifically doctors. In fact I was thinking more about the insurance component of the medical system. The government can look at how much it is spending on healthcare, what the outcomes are at a population level, and whether anything should change as a result of looking at those two things. There is generally a resistance on the part of the insurance industry for changes that cut it out that becomes expressed through politicians in a patron-client relationship. It's fairly analogous to it just being easier for doctors to do what patients want and refusing to say no.
 
birchswing said:
I was making a very general point about the medical system, not specifically doctors. In fact I was thinking more about the insurance component of the medical system. The government can look at how much it is spending on healthcare, what the outcomes are at a population level, and whether anything should change as a result of looking at those two things. There is generally a resistance on the part of the insurance industry for changes that cut it out that becomes expressed through politicians in a patron-client relationship. It's fairly analogous to it just being easier for doctors to do what patients want and refusing to say no.
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The point I was making was not that it's easier for doctors to do what patients want and refuse to say no, it was that there's an overarching philosophy among the elites of our society, the movers and shakers, which includes the leaders of the medical profession--people like med school deans--that the powerful are bad and the weak are good. The same people who think the bad old days of paternalism, of stodgy old white male doctors giving "orders" to their patients, were so bad, think the government is good and the medical system is bad. So the analogy doesn't hold.
 
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Trismegistus4 said:
Murder? Doesn't that require intent? I'm all for cracking down on reckless prescribing, but unless he forced the pills down their throat, I don't see how he can be charged with murder. What's next, charging a gun store owner with murder? .
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Isn't that what Hillary is trying to argue? :p She supports Sandy Hooke parents to sue Remington Arms, the company that manufactures the Bushmaster rifle. Sorry couldn't resist.
 
Messerschmitts said:
Isn't that what Hillary is trying to argue? :p She supports Sandy Hooke parents to sue Remington Arms, the company that manufactures the Bushmaster rifle. Sorry couldn't resist.
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Not the same thing at all because physicians can and are successfully sued all the time for negligent prescribing - what's murky is criminal prosecution for this. In contrast the firearm industry enjoys some protection from liability from the Protection of Lawful Commerce in Arms Act that other industries do not. Personally I do find it somewhat questionable suing manufacturers for this sort of thing etc, but the question is a broader one which is - do people have the right to sue? Whether the case is ultimately successful or not is another question altogether, but often these cases aren't even given a hearing.
 
Manslaughter is a more fitting charge- requires a callous disregard for life that results in the death of others. I'd say 36 dead patients pretty well demonstrates that.
 
Trismegistus4 said:
The point I was making was not that it's easier for doctors to do what patients want and refuse to say no, it was that there's an overarching philosophy among the elites of our society, the movers and shakers, which includes the leaders of the medical profession--people like med school deans--that the powerful are bad and the weak are good. The same people who think the bad old days of paternalism, of stodgy old white male doctors giving "orders" to their patients, were so bad, think the government is good and the medical system is bad. So the analogy doesn't hold.
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I'd venture to guess that most professionals don't actually think about this issue in black-and-white terms and consider the risks inherent in both extremes.
 
Did he have training in a pain management fellowship or was he just an idiot?
 
Shikima said:
Guess.
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Hard to put sarcasm on the internet.


Anyway, here is the DEAs Hall of Shame for doctors: http://www.deadiversion.usdoj.gov/crim_admin_actions/doctors_criminal_cases.pdf

I am more livid about physicians who genuinely want to treat addicts and get nailed like this guy: http://www.post-gazette.com/news/st...e-doctor-drew-DEA-search/stories/201605230016 . Look at all the people complaining about addicts in this forum. When a real physician goes to treat the junkies in slums of Philly the DEA makes it harder. WTF?!
 
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swifteagle43 said:
I am more livid about physicians who genuinely want to treat addicts and get nailed like this guy: http://www.post-gazette.com/news/st...e-doctor-drew-DEA-search/stories/201605230016 . Look at all the people complaining about addicts in this forum. When a real physician goes to treat the junkies in slums of Philly the DEA makes it harder. WTF?!
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Yep that's par for the course with the DEA--and it basically discourages primary care docs, general psychiatrists, etc from getting a Suboxone waiver...so the divide between addicts and treatment is further widened...

It still kills me that any yahoo with a DEA # can write for #90 percocet at the drop of a hat, but we have to jump through hoops to help those trying to get off the stuff.
 
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Guyton said:
Some preparations of cocaine have legitimate medical use... but the DEA specifically lists "crack" as schedule II. I can't think of an occasion for prescribing crack.
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For those times you're withdrawing from crack and need to help to feel better within the locked ER?
 
Shikima said:
For those times you're withdrawing from crack and need to help to feel better within the locked ER?
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I am pretty sure I would get the pharmacist's attention on a non-formulary request for 200 mg of cocaine base to be administered via crack pipe. It might even have more shock value then the fecal transplant order I put in recently. :yuck:
 
Guyton said:
Well, these are the same geniuses who classify marijuana as a schedule I drug with "no currently accepted medical use" but categorize crack in schedule II. So, uhm , I can prescribe crack but not pot?

http://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf
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I think you're intentionally misrepresenting that list. "Crack" is only listed as an "other name" for cocaine. The "other names" column is simply a way of saying "heads up: here's another way you might hear this substance referred to." It also lists "crank" and "speed" as other names for methamphetamine, which apparently (I didn't even know this) is a schedule II substance FDA approved for ADHD. So do you criticize them for saying you can prescribe "crank" or "speed" but not pot?
 
Trismegistus4 said:
So do you criticize them for saying you can prescribe "crank" or "speed" but not pot?
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I do. "Ice" "Crank" and "Speed" are colloquial terms to be avoided in formal writing- which I would hope the DEA aspires to in their public documents one day. The inclusion of these terms associated with schedule II medications is confusing and nonsensical. I would hazard to say no one has ever used the term "Crank" when referring to Desoxyn. Furthermore, if the DEA is going to interject the sub-cultural parlance of substance users into their prescriptive guidance, they may want to include terms of ubiquitous use like "Pot," which is idiosyncratically missing. To compound the buffoonery, "crack" refers to a specific preparation of cocaine that precludes it from acceptable medical use, yet it is listed next to Methyl benzoylecgonine which is NOT cocaine- being a product of cocaine's carboxylesterazation in the liver among other metabolites. I could go on with other substances listed in the document, but anyone with a learned eye should be able to see the multiple inconsistencies therein. Either the DEA is unaware of these or they are simply too lazy to distinguish. In either case, their inept scheduling of controlled substances requires no misrepresentation on my part to come across as ludicrous.
 
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