Murder charges against Calif. doc seen as warning

[101N]

http://www.google.com/hostednews/ap...z0wFeA?docId=03c18fff40bd452d8df8a09f971405cc

Murder charges against Calif. doc seen as warning
By GREG RISLING, Associated Press – 1 hour ago
LOS ANGELES (AP) — The prosecutor who took the rare step of charging a doctor with murder in the prescription drug overdose deaths of three patients said Friday that the case should serve as a warning to unethical physicians who become pill pushers.
Los Angeles County District Attorney Steve Cooley said his office will continue to prosecute greedy and unethical doctors after charging Dr. Hsiu-Ying "Lisa" Tseng, 42, with second-degree murder and 21 other felony counts. If convicted of all the charges, she faces a maximum sentence of 45 years to life in prison.
"This case was beyond anything else we have ever seen," said Cooley, who stressed that these types of cases must be carefully researched before the extreme charge of murder is filed.
Tseng made her first court appearance Friday, wearing a pink sweatshirt and looking glum. Her arraignment was postponed until March 9, when her bail, currently $3 million, also will be reviewed.
Her lawyers declined to comment after the hearing.
Tseng is one of just a few doctors nationwide to be charged with murder related to prescription drugs. Authorities have been cracking down on drug deaths, which fueled by prescription drug overdoses now surpass traffic fatalities. But the murder charges could be hard to prove because the victims played a role by seeking out and taking the drugs.
Tseng, a licensed osteopath, and her husband, also a physician, set up a storefront office in the Los Angeles suburb of Rowland Heights in 2005. Three years later, she was under investigation by the Drug Enforcement Administration and the California Medical Board for prescription irregularities reported by a pharmacy. Patient deaths were linked to her in 2009, according to authorities, but not all led to murder charges.
Tseng wrote more than 27,000 prescriptions over a three-year period starting in January 2007 — an average of 25 a day, according to a DEA affidavit. DEA agents swept into her office in 2010 and suspended her license to write prescriptions.
She was arrested this week after voluntarily surrendering her license to the Osteopathic Medical Board of California. Her husband continues to run their clinic.
The case highlights a murky region of medicine as patients hooked on prescription drugs seek out a source for their addiction. Prosecutors have charged many doctors with dispensing prescription drugs illegally, arguing they wrote prescriptions outside the normal course of practice and for no legitimate medical purpose.
There are about 880,000 doctors nationwide who are registered to write prescriptions, and federal agents investigate somewhere between 200 and 300 suspected dirty physicians every year, said DEA spokesman Rusty Payne.
But filing a murder charge against a doctor in a case where a patient dies from an overdose is extremely rare.
In 2008, Harriston Bass was convicted of second-degree murder in Nevada for the death of Gina Micali, 38, who died after taking the pain reliever hydrocodone. Bass was sentenced to 25 years to life.
A Georgia doctor was sentenced to life in prison in October 2007 for the drug overdose death of his patient and housemate. Noel Chua was found guilty of felony murder and violating the state's controlled substances act in the death of Jamie Carter III, who died of multi-drug intoxication. Among the prescriptions Carter received from Chua were oxycodone and methadone.
In Florida, Dr. Sergio Rodriguez faces three counts of first-degree murder in the overdose deaths of three patients. His case is still pending.
The second-degree murder charges that Tseng is facing rely on the theory of "implied malice." Authorities said Tseng knew that her prescriptions could have a deadly result because others in her care had died before the three alleged murder victims named in the criminal complaint.
The three victims were otherwise healthy men in their 20s who came to her with complaints of pain and anxiety. Records of the Osteopathic Medical Board showed that she gave them cursory exams that didn't meet the level of adequate medical care before issuing prescriptions for opiates and benzodiazepines.
Among the victims was Joey Rovero, a 21-year-old Arizona State University student who drove with two friends to Southern California to get prescriptions from Tseng in December 2009.
Rovero's mother, April, said her son had prescriptions filled for 90 tablets of oxycodone, 90 tablets of the muscle relaxant Soma and 30 tablets of the anti-anxiety medication Xanax. An autopsy found the younger Rovero died from a mixture of alcohol and moderate to trace levels of the three drugs Tseng gave him.
April Rovero, who founded the National Coalition Against Prescription Drug Abuse, said murder charges against Tseng are appropriate in her son's case because Tseng was told by the coroner that some of her patients were dying from overdosing on pills she prescribed.
"From all indications, she (Tseng) was warned," prior to the death, Rovero said. "It was like she wasn't listening. There were all these red flags and she did nothing."
Records showed that Rovero complained of wrist pain, but the doctor did not establish which wrist was hurting, nor did she explore the source of his complaint of anxiety.
Tseng was also charged Thursday in the 2009 deaths of Vu Nguyen, 29, of Lake Forest, and Steven Ogle, 25, of Palm Desert.
Tseng's attorneys have declined opportunities to comment, but she has previously said she is not guilty of any wrongdoing.
"I was really strict with my patients, and I followed the guidelines," she said in a 2010 interview with the Los Angeles Times. "If my patient decides to take a month's supply in a day, then there's nothing I can do about that."
Roger Rosen, a defense attorney who represented a doctor convicted with running a pill mill and sentenced to four years in prison, said doctors sometimes begin prescribing for legitimate pain management and become victimized themselves by those seeking medication for other reasons. He said many patients lie to their doctors to get medication.
"I don't know what doctor in their right mind would want to go into pain management these days. It's as if you have a bull's-eye painted on you," Rosen said. "Delivering babies is a lot easier."
Ron Clyburn knows what Rovero's mother is experiencing. In April 2008, his 23-year-old son Alex died after overdosing on pills prescribed by Masoud Bamdad, a Southern California doctor who was convicted of selling prescriptions and sentenced to 25 years in prison. However, jurors couldn't reach a verdict on four counts, including one that accused Bamdad of causing Alex Clyburn's death.
"If it's a case where the doctor is clearly abusing that privilege and people are dying, then they should be prosecuted," Clyburn said. "Looking at it from a legal standpoint, to prove murder there has to be a lot of data to back that up. It would be a shame if prosecutors filed these charges just for effect, because this is such a hot issue."
In January, federal prosecutors in Los Angeles charged a Santa Barbara doctor with illegally prescribing large amounts of painkillers to patients who didn't need the drugs, and for accepting sexual favors as payment from some women. Despite having a dozen of his patients die of overdoses since 2006, Diaz was not charged in their deaths.
A spokesman for the U.S. attorney's office said at the time that the direct connection between a doctor's prescription and a patient's death is difficult to prove.
Prescription drug abuse is so great in the U.S., some agents who once chased Mexican and Colombian drug traffickers are now investigating doctors who push pills illegally, said Payne, the DEA spokesman. But doctors are only one part of the problem.
"We go after the biggest and most egregious cases," Payne said. "We have to hit the problem at every level. But it's really hard to make an impact when there are so many links in the chain."

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[IDBasco]

I look at this kind of stuff and think that it can't be long before malpractice suits for wrongful death or something similar start popping up. And not long after that there will be a spike in malpractice insurance. Followed by fewer people wanting to do pain.

Just ponderings, I guess.

 

[lobelsteve]

She OD'd a few people and was not sanctioned by the DEA or the medical board. So she kept OD'ing people. Reap what you sew. Bet she is not trained in pain.....

Also, where were the DEA and medical board to step in and stop this nonsense after she OD'd the first patient. Is that not the job of the investigative branch of a licensing board.

I welcome prosecutions like this. It will further restrict opiate prescribing to folks who may know how to do it better.

Bring on all the REMS for all opiates. 9 days until Fentora/Actiq goes Rx to REMS provider only. We need hydrocdone schedule 2, codeine schedule 3 and limited to #1800mg per month (due to most of it in cough syrup these days).

Make BZD limited to Psych only.

The war on drugs could come out of the jungle and shed some light on doctors everywhere. And then all we need is DA's who can get their heads out of their asses (not Atlanta) and take down rogue docs.

 

[Aether2000]

The DEA doesn't have the legal authority to investigate or act on substance abuse by patients but can act if the medication is prescribed for an illegitimate purpose (not medically indicated). This is a difficult thing for the DEA to determine since they are frequently relegated to focusing on the number of pills being prescribed that is touted as evidence of wrongdoing. Frequently, the number of pills being touted in sensational cases in the press are actually within the normal limits of prescribing. The DEA engages the medical boards to determine medical legitimacy of prescribing, and the medical boards frequently have not specified the requirements for physicians. Because of DEA pressure on the boards to act, the boards may select a physician to make an example of him to curtail prescribing of opioids without ever having to do their job by specifying the expected requirements for such prescribing.
I agree with Steve: hydrocodone should be schedule II, benzodiazepines should certainly not be permitted to be prescribed by PCPs and probably no one else other than psychiatrists. We do not have a codeine problem anymore where I live due to the readily available more potent drugs shared within families and on the street.

 

[Louisville04]

I look at this kind of stuff and think that it can't be long before malpractice suits for wrongful death or something similar start popping up. And not long after that there will be a spike in malpractice insurance. Followed by fewer people wanting to do pain.

Just ponderings, I guess.

When reimbursements go down for pain procedures, fewer people will want to do pain.

I agree with Steve: hydrocodone should be schedule II, benzodiazepines should certainly not be permitted to be prescribed by PCPs and probably no one else other than psychiatrists. We do not have a codeine problem anymore where I live due to the readily available more potent drugs shared within families and on the street.

At my old VA, the PCP's would always prescribe hydrocodone vs oxy, morphine, methadone, fentanyl since you could write for refills. My new VA the PCP's will not prescribe hydrocodone. The strongest medication prescribed is Tylenol #3. If they need something stronger, they are referred to the chronic pain clinic.

What about benzo's for anxiety prior to a MRI or as a muscle relaxant after failing the usual meds (cyclobenzaprine, methocarbamol, etc.)?

 

[lobelsteve]

When reimbursements go down for pain procedures, fewer people will want to do pain.



At my old VA, the PCP's would always prescribe hydrocodone vs oxy, morphine, methadone, fentanyl since you could write for refills. My new VA the PCP's will not prescribe hydrocodone. The strongest medication prescribed is Tylenol #3. If they need something stronger, they are referred to the chronic pain clinic.

What about benzo's for anxiety prior to a MRI or as a muscle relaxant after failing the usual meds (cyclobenzaprine, methocarbamol, etc.)?

Reasonable use of BZD: situational anxiety. QTY limit #5.
Ok for my wife for getting on an airplane, ok for my patient getting an MRI.
Ok for me- never.

 

[Aether2000]

Unfortunately, the VA system is contributing to substance abuse, if not death of patients due to their separatist mentality. The VA docs in my region are told not to check the states prescription drug database because the administration deems this to be a "violation of patient confidentiality". None of the VA prescriptions for opioid narcotics are entered into this database. So we have a situation where VA patients can be seen in the VA pain clinics and also in private pain clinics, and neither one would have any way of knowing the patient is massively double dipping. VA docs (and military) do not have to be licensed in the state they practice, unlike all other physicians. They are not subject to state medical board regulations since they are not licensed to practice in the state. This also is a red flag for potential issues regarding overprescribing of opioids.

 

[VA Hopeful Dr]

She OD'd a few people and was not sanctioned by the DEA or the medical board. So she kept OD'ing people. Reap what you sew. Bet she is not trained in pain.....

Also, where were the DEA and medical board to step in and stop this nonsense after she OD'd the first patient. Is that not the job of the investigative branch of a licensing board.

I welcome prosecutions like this. It will further restrict opiate prescribing to folks who may know how to do it better.

Bring on all the REMS for all opiates. 9 days until Fentora/Actiq goes Rx to REMS provider only. We need hydrocdone schedule 2, codeine schedule 3 and limited to #1800mg per month (due to most of it in cough syrup these days).

Make BZD limited to Psych only.

The war on drugs could come out of the jungle and shed some light on doctors everywhere. And then all we need is DA's who can get their heads out of their asses (not Atlanta) and take down rogue docs.

I actually wouldn't mind (as an FP) a limit on milligrams of morphine equivalent per month

 

[PinchandBurn]

If you put a restriction on what Primary Care MDs can write, they will try to 'dump' all their opioid Rxing on you. I do not think that's what we want. Your clinic would be bogged down with Opioid Rxing/Refilling instead of doing procedures and treating legitimate sufferers of pain.

I think PCPs SHOULD be able to write for opioids. However, maybe they need to consult a Pain Physician atleast 1-2 a year,etc. The pain physician should determine if the opioid Rxing is reasonable and/or if there are other treatment modalities available for the patient to reduce the opioid burden (adjuvants, procedures, PT, TENS,etc). Additionally, at that time a Urine Tox,etc can be down.

Why would you want to bog down your clinic with just refills on these shedule 2's every month? If patients are stable on them, no reason for PCP not to write for them.

 

[lobelsteve]

If you put a restriction on what Primary Care MDs can write, they will try to 'dump' all their opioid Rxing on you. I do not think that's what we want. Your clinic would be bogged down with Opioid Rxing/Refilling instead of doing procedures and treating legitimate sufferers of pain.

I think PCPs SHOULD be able to write for opioids. However, maybe they need to consult a Pain Physician atleast 1-2 a year,etc. The pain physician should determine if the opioid Rxing is reasonable and/or if there are other treatment modalities available for the patient to reduce the opioid burden (adjuvants, procedures, PT, TENS,etc). Additionally, at that time a Urine Tox,etc can be down.

Why would you want to bog down your clinic with just refills on these shedule 2's every month? If patients are stable on them, no reason for PCP not to write for them.

Pinch. You are wrong. You would be inundated with level 4 new patient visits where you decide the current regimen is or is not working, is or is not appropriate, and then decide what to do about it. You would not be obligated to Rx. The job is not to write or not write Rx- it is to try and help the patient and out colleagues. If it ain't right , make suggestions how to fix it. If you want to get the due diligence and take over care- then it's your patient. If you review the record, examine the patient, and decide nothing for you to do other than make recommendations- then it's a single visit consult. No skin of your back, no time wasted, just another visit.

We have no obligation to write prescriptions. We have an obligation to write prescriptions when, where, and why, and for what we feel will be useful in increasing patient's functional status.

 

[Jcm800]

yeah, cuz that happens....

 

[nwbgn]

I think PCPs SHOULD be able to write for opioids. However, maybe they need to consult a Pain Physician atleast 1-2 a year,etc. The pain physician should determine if the opioid Rxing is reasonable and/or if there are other treatment modalities available for the patient to reduce the opioid burden (adjuvants, procedures, PT, TENS,etc). Additionally, at that time a Urine Tox,etc can be down.

I don't know about the other pain docs out there, but I don't always find that I can fully come to a conclusion about whether a patient's medication regimen is appropriate on a first visit. Even if a patient referred to me by their PCP claims they take hydrocodone 3 times a day for the past several months, how do I know whether they have been taking it correctly throughout this time? Often times they tell me they have been taking it "every 4-6hrs like it says on the bottle doc!" Despite requesting records, I doubt I am always getting the entire scoop on whether the patient has requested early renewals, has a history of drug abuse, etc. because the patient holds back info or it is not documented/conveyed by prior physician. It will sometimes come out in one way or another (tox, prescription monitoring, etc) months after first see them. I see it all the time...

 

[hyperalgesia]

Unfortunately, the VA system is contributing to substance abuse, if not death of patients due to their separatist mentality. The VA docs in my region are told not to check the states prescription drug database because the administration deems this to be a "violation of patient confidentiality". None of the VA prescriptions for opioid narcotics are entered into this database. So we have a situation where VA patients can be seen in the VA pain clinics and also in private pain clinics, and neither one would have any way of knowing the patient is massively double dipping. VA docs (and military) do not have to be licensed in the state they practice, unlike all other physicians. They are not subject to state medical board regulations since they are not licensed to practice in the state. This also is a red flag for potential issues regarding overprescribing of opioids.

The VA is a political organization run by politicians obsessed with pt "satisfaction". We are not allowed to put pt information into an external DB although we are now allowed to retrieve info from the state DBs (because Obama waved his hand).

Honestly though, in my limited experience (2 VAs), I haven't observed opioid overprescribing is WORSE in the VA than in PP. VA docs are not as worried about prosecution or discipline but they are also not enticed by having a line of patients either. There is certainly no incentive to accept challenges and the potential headaches that go with them...

 

[Aether2000]

In my region, the VA docs have been specifically prohibited from checking the state databases. The complete disconnect between VA prescribing and private clinic prescribing has caused patient overdoses when patients are being seen surreptitiously by both entities with both sets of physicians operating blind due to policies of the VA. The VA policies are leading to overdose and death. VA docs do not answer to state boards and the oversight of their prescribing by the administration is practically non-existent. It is not the fault of the VA docs....they are cogs in a wheel, but the VA system is responsible for patient injury, and they take no responsibility for the ramifications of their policies.

 

[lobelsteve]

In my region, the VA docs have been specifically prohibited from checking the state databases. The complete disconnect between VA prescribing and private clinic prescribing has caused patient overdoses when patients are being seen surreptitiously by both entities with both sets of physicians operating blind due to policies of the VA. The VA policies are leading to overdose and death.

Might be a cost containment strategy. Jk.

 

[Aether2000]

lol...never thought of that.

 

[neuropathic]

If you put a restriction on what Primary Care MDs can write, they will try to 'dump' all their opioid Rxing on you. I do not think that's what we want. Your clinic would be bogged down with Opioid Rxing/Refilling instead of doing procedures and treating legitimate sufferers of pain.

Disagree. I cannot understand why people called themselves pain specialists, but tell patients they don't want to prescribe pain medications. It's like you called yourself a math professor, but you are going to teach your students algebra only and not anything else. Pain specialists should offer all the options. Not all pain patients need procedures and sometimes it is appropriate to use pain medications instead of injections.

While I agree that "Dr". Lisa Tseng committed gross negligence, unethical and should not be a doctor, I think it is wrong to put her in jail. She may have overprescribed and prescribed without legitimate medical reasons, you can't control what patients do once they get the prescription.

 

[lobelsteve]

Disagree. I cannot understand why people called themselves pain specialists, but tell patients they don't want to prescribe pain medications. It's like you called yourself a math professor, but you are going to teach your students algebra only and not anything else. Pain specialists should offer all the options. Not all pain patients need procedures and sometimes it is appropriate to use pain medications instead of injections.

While I agree that "Dr". Lisa Tseng committed gross negligence, unethical and should not be a doctor, I think it is wrong to put her in jail. She may have overprescribed and prescribed without legitimate medical reasons, you can't control what patients do once they get the prescription.

She was a drug dealer and was not acting as a physician. SHe sold drugs for money via an Rx pad and a license.

1. Jail 5 years
2. Forfeiture of all unlawfully gained assets
3. Loss of medical license x5 years
4. Loss of DEA registration (forever)
5. Consideration of revocation of MD or residency training certificate from her school/program.

 

[Ducttape]

Disagree. I cannot understand why people called themselves pain specialists, but tell patients they don't want to prescribe pain medications. It's like you called yourself a math professor, but you are going to teach your students algebra only and not anything else. Pain specialists should offer all the options. Not all pain patients need procedures and sometimes it is appropriate to use pain medications instead of injections.

While I agree that "Dr". Lisa Tseng committed gross negligence, unethical and should not be a doctor, I think it is wrong to put her in jail. She may have overprescribed and prescribed without legitimate medical reasons, you can't control what patients do once they get the prescription.

First, i call myself a pain specialist but i reframe from writing OPIOID pain medications at almost all costs.

Why? because there is almost no evidence based medicine that strongly suggests that chronic opioid therapy improves long term outcomes or quality of life. Why would i recommend a medication or prescribe a medication that doesnt lead to improvement? That isnt even factoring complications of therapy.

Now there are of course situations where this is not an issue, such as short term postoperative pain and palliative terminal care.

Using your math teacher analogy, i dont know any math professor that has to teach their students that 1+1=2. And only few professors teach chaos theory to their students, unless that is their specialty.

 

[PinchandBurn]

First, i call myself a pain specialist but i reframe from writing OPIOID pain medications at almost all costs.

Why? because there is almost no evidence based medicine that strongly suggests that chronic opioid therapy improves long term outcomes or quality of life. Why would i recommend a medication or prescribe a medication that doesnt lead to improvement? That isnt even factoring complications of therapy.

Now there are of course situations where this is not an issue, such as short term postoperative pain and palliative terminal care.

Using your math teacher analogy, i dont know any math professor that has to teach their students that 1+1=2. And only few professors teach chaos theory to their students, unless that is their specialty.

agree with above.

Additionally, one can write for adjuvant meds, do procedures, PT, psych referrals,etc. Opioids do not need to be the first line of treatment for chronic pain as there is limited data for it.....aside perhaps tramadol. I very rarely write for opioids.

Secondly, yes I think Dr. Lisa probably did something she shouldnt have. However, if you think about the embarrassment and the public humility that she has undergone thus far, I think it's fair to say she's learned her lesson.

At the end of the day, she's a physician. What people easily forget in these instances is that she probably did help a LOT of people in her career (during her pre med days, medical school days, residency years). What other career on the face of the earth has almost 10+ years of free philanthropic training before earning a legitimate paycheck? Jail time and 'murder' charges are somewhat extreme. The medical profession/board should deal with her NOT civil attorneys that want to find a scapegoat to crucify.

Cases like this will just do one thing. It will make physicians completely averse to writing ANYONE oral opioid medications. The pendulum will swing that way.

 

[Aether2000]

If we are talking pain therapies and EBM:
-There is weak to moderate evidence injections give short term relief only and strong evidence they do not work for long term relief
-There is weak evidence to support RF
-There is weak to moderate evidence to support SCS
-There is weak evidence to support PT in limited situations
-There is weak evidence to support adjunctive non-opioid medications in the treatment of pain
-There is moderate evidence that chiropractic is useful for chronic pain

So if you compare opioids with all the other therapies, the evidence is really not much different than what is being used in pain medicine.

 

[Ducttape]

I would agree with caveats. Opioid therapy is "different".

At best, Cochrane suggests weak evidence for opioid in nonmalignant pain in a certain population. They noted a fairly high rate of patients that could not tolerate the therapy, however, so this was factored in only as "well-selected patients... Small risk of side effects"

Second, all of those other therapies you mention we know and inform patients provide short term pain relief. That is generally not the expectation when we begin opioid therapy in chronic pain patients.

I do an epidural, I tell the patient 10-12 weeks reduced pain is the expectation. Starting opioids, I tell them that, barring side effect or lack of functional improvement, they know it is for years.

Finally, stopping a therapy usually doesn't cause significant side effects, of course. Well, besides opioid therapy...

 

[powermd]

Disagree. I cannot understand why people called themselves pain specialists, but tell patients they don't want to prescribe pain medications.

As a pain specialist, it appears to me that the "evidence" has not yet caught up with the realities of interventional or medication based management.

All research in pain is fraught with biases that make it difficult to believe results that don't square with the clinical realities we see every day. An excellent case in point would be the Buchbinder vertebroplasty study. Great procedure, poor study. I suspect that many studies are hurt by the simple fact that few patients in genuine pain are willing to risk being assigned to a control group. Studying pain is quite different than studying diseases without noxious symptoms like hypertension or hypercholesterolemia.

The reality of clinical medicine is that proper patient selection matters more than anything if you're hoping to achieve a specific result. There's plenty of variability among clinicians in their ability to select patients properly for treatment. The variable nature of pain problems, and the patients themselves don't help matters.

In my experience, among patients presenting to a pain clinic and desiring opioids, the results are terrible. I suspect that the better candidates never make it to my clinic because they do fine on moderate doses prescribed by PMDs. I'm afraid to start opioids on anyone because I don't want the word to get out that I prescribe, thereby inviting a mile long line of bad-candidate dumps. This leads to an almost equally long line of disappointed f-bomb laying jerks who will drag my name through the mud online and when they see their referring doctor again. Better to assist PMDs on a consultative basis and avoid this mess entirely.

I've spent a year at my current practice, and I can say it works out exceedingly well. I can't remember my last "bad" patient encounter where some jerk flew off the handle when he didn't get his "medicine".

 

[hyperalgesia]

What if we stop trying to "control" narcotics and just let people buy whatever they can afford? No monitoring programs. No police work for docs. Just a strong warning label, advertising limits, no selling to kids, etc. Like cigarrettes.

Seems like what we are doing with tobacco is really working. But what we're doing with narcs is really not working at all...

This idea of big-brother monitoring programs, placing blame for pt's drug abuse on policies and docs (rather than the pt) is making me uncomfortable.

Don't get me wrong, I agree that docs that abuse their position should be prosecuted. I just think we might do better by not allowing the doc to be in the position of gatekeeper/constable in the first place. People are inherently too frail.

 

[mid|ine]

Rovero's mother, April, said her son had prescriptions filled for 90 tablets of oxycodone, 90 tablets of the muscle relaxant Soma and 30 tablets of the anti-anxiety medication Xanax. An autopsy found the younger Rovero died from a mixture of alcohol and moderate to trace levels of the three drugs Tseng gave him.

While more then i would rx this is far from outside the standard of care. I see rx from pcps all the time. Also looks like death was more due to etoh.

 

[jettavr6]

While I agree that "Dr". Lisa Tseng committed gross negligence, unethical and should not be a doctor, I think it is wrong to put her in jail. She may have overprescribed and prescribed without legitimate medical reasons, you can't control what patients do once they get the prescription.

We heard about this lady while I was in fellowship at USC, which isn't very far from where she practiced. She sold prescriptions; over 20 a day. This puts her in the category of being nothing less than a drug dealer and they usually do time in the county lock up. I don't agree with the murder charge and I doubt that it will stick.

 

[lobelsteve]

While more then i would rx this is far from outside the standard of care. I see rx from pcps all the time. Also looks like death was more due to etoh.

I write opiates. Selectively. Some times high doses. But I do not write BZD or Soma.
I have 5 patients under the age of 30. 2 are high risk. THey see me more frequently and I keep tabs on them using appropriate tests, paperwork. I assume some risk as does the patient. Informed consent and agreement for treatment. All 5 of these folks are in school and/or working FT. They now have stability in their lives and I'm watching to make sure things stay positive. Easy enough to put down the pen if something doesn't seem right.

 

[mid|ine]

This is a MURDER charge. While I dong agree with her medicine it hardly amounts to murder. And 20-30 scrips per day is nothing like classic pill mills.

 

[PinchandBurn]

If we are talking pain therapies and EBM:
-There is weak to moderate evidence injections give short term relief only and strong evidence they do not work for long term relief
-There is weak evidence to support RF
-There is weak to moderate evidence to support SCS
-There is weak evidence to support PT in limited situations
-There is weak evidence to support adjunctive non-opioid medications in the treatment of pain
-There is moderate evidence that chiropractic is useful for chronic pain

So if you compare opioids with all the other therapies, the evidence is really not much different than what is being used in pain medicine.

major difference between all those things you've listed above and opioids is this. You can physically see/oversee interventions, PT, chiropractics,etc. You have control over them.

Once anyone gives a patient opioids, you've lost 'control'. As someone mentioned in the original article, the patient can take the 30 day supply all at once and OD himself/herself. Sure we can all predict the 'typical' people that would do this and avoid giving them meds (patients with documented uncontrolled psychopathology). However, say a woman has a bad day at work, gets fired, or for X reason, decides to take all those pills in one day to commit suicide.....it's out of the MD's hands.

Murder charges and jail time is a big deal. None of us know the whole story. But let's just assume she wasnt just handing out pills and that one of these emotionally labile patients as I mentioned above decided to 'off " herself/himself. Is that the MD's fault? Should she really go to jail for that?

 

[bedrock]

If we are talking pain therapies and EBM:
-There is weak to moderate evidence injections give short term relief only and strong evidence they do not work for long term relief
-There is weak evidence to support RF
-There is weak to moderate evidence to support SCS
-There is weak evidence to support PT in limited situations
-There is weak evidence to support adjunctive non-opioid medications in the treatment of pain
-There is moderate evidence that chiropractic is useful for chronic pain

So if you compare opioids with all the other therapies, the evidence is really not much different than what is being used in pain medicine.

I'd say there is better than "weak" evidence to support RF (when patients are properly selected)

 

[emd123]

If a patient dies from a dangerous incompetent doctor who commits negligence, the doctor should be liable for negligence and his/her license should be pulled. The jump to criminal charges should be reserved for cases where the doctor had intent. It is a slippery slope. This is political, and they are trying to create a chilling effect on the prescribing of all opiates. I am sure that such cases will create a chilling effect on prescribing. As to whether or not it will suppress underground drug trade at all, I am very skeptical.

Bad doctors should be stopped, and pill mills should be shut down, there's no doubt, but here's the problem. Any chronic pain patient that is on long acting opiates will have a blood opiate level that will appear "in the toxic range" compared to the general population. They could be wide awake, alert, talking and nowhere near overdose, yet draw a serum opiate level and it'll come back "very high", or with some numerical version of such. Then, take such a patient who suffers a heart arrhythmia, or has a cardiac arrest for some unrelated reason. Autopsies frequently are inconclusive. So, when the toxicology report comes back several weeks later, and they find "toxic levels" of some opiate, they call it "death by overdose", when in fact it could be totally unrelated. To then trace it back to the doctor and charge murder, seems completely outrageous.

So without commenting on any specific case, and agreeing that dangerous doctors should lose their licenses and perhaps be sued if negligent, I strongly disagree with criminal charges unless there is intent.

I don't think that fellowship trained, or board certified pain doctors have too much to worry about, BUT it is very scary to think that you could be doing everything right, documenting legitimate medical need, examining your patients, drug screening, monitoring patients, discontinuing opiates when patients shows aberrant behaviors, and expending enormous energy standing up to abusers,that you could still be slapped with a murder charge because of something out of your control, or because a patient lies to you. Scary. One doctor who is already stingy with opiates, just got a little bit stingier.

Although, I am very skeptical about the efficacy of long term opiates for many patients, there are some who suffer unbearably and have failed all other options, and need them. Inevitably, this chilling effect will lead to such patients not getting the treatment they need.

Intervention-only, non-narcotic pain practice, anyone?

 

[facets]

There is usually nothing in it for the doctor to prescribe opoids. You have to drug test them, check the state board, put them on a contract, and constantly watch for abusers/diverters who sometimes are so good that your hearts have totally done out to them, only to have them betray you by being cons. There are people who need to be on these medications to have any quality of life. Unless, someone is seeeing 300 patients a day I dont think they could be called pill mills, the FP docs usually see more than this in a day and they are not called "sore throat mills" I think we need need to give the doctor the benefit of a doubt. IMHO too many of us have frankly taken the easy way out by being "intervention only" leaving other specialities to the dirty job of chronic medication management. I'm not saying we should open our panels to all medication managment patients, I had to close mine long ago, but I do some in patients who I believe really need it and do have an improved quality of life, like the 80 y/o lol with spinal stenosis who is too unstable for surgery. Is this benefiting me? He** no! Many of them have cardiac and pulm dz, could die any time from cardiac arrest or resp failure and I could be accused of overdosing them. But I do it anyway. For the crap $40 office visit from MC, no, because if I were in their shoes I would want someone to put my quality of life over covering their butt legally. Sorry but thats the truth as I see it. We all need to take a few of these, sorta to spread the misery

 

[Aether2000]

The evidence of use of RF is very checkered, with some studies showing no benefit at all, while the majority of studies have modest benefits. The Bogduk/Lord procedure is not reproducible in the US using RF (3 hours of RF on a patient) therefore their studies may be deemed not as relevant as we may like.
As for opioid evidence, there are now at least 6 papers showing long term treatment with benefits that are equal to interventional pain procedures with at least as good evidence. That being said, opioids should certainly not be the first therapy employed. PT has become too expensive with each visit costing some of my patients $60 out of pocket due to cost shifting by insurers. The murder charges are not necessarily isolated and increasingly emboldened prosecutors are using the charge against physicians or are weighing it. In Florida, the murder charge is codified into law. A person causes an overdose death, they may be charged with murder. Predictably, the number of illegitimate and legitimate clinics prescribing opioids is rapidly diminishing since there is now a very real risk of criminal charges being filed due to patient behaviors regarding opioids. Patients are going into withdrawal all over the state and are having serious issues finding anyone to prescribe opioids. It will be interesting to see if there are increases in crime with desperate patients now beginning to rob pharmacies or other patients for opioids....

 

[newdude2009]

She was a drug dealer and was not acting as a physician. SHe sold drugs for money via an Rx pad and a license.

1. Jail 5 years
2. Forfeiture of all unlawfully gained assets
3. Loss of medical license x5 years
4. Loss of DEA registration (forever)
5. Consideration of revocation of MD or residency training certificate from her school/program.

To be honest, these are all allegations. Nothing has been proven about her. The media and courts love to vilify doctors, so be careful judging this doc because the next case of gross negligence could be you.

 

[lobelsteve]

In my region, the VA docs have been specifically prohibited from checking the state databases. The complete disconnect between VA prescribing and private clinic prescribing has caused patient overdoses when patients are being seen surreptitiously by both entities with both sets of physicians operating blind due to policies of the VA. The VA policies are leading to overdose and death. VA docs do not answer to state boards and the oversight of their prescribing by the administration is practically non-existent. It is not the fault of the VA docs....they are cogs in a wheel, but the VA system is responsible for patient injury, and they take no responsibility for the ramifications of their policies.

To be honest, these are all allegations. Nothing has been proven about her. The media and courts love to vilify doctors, so be careful judging this doc because the next case of gross negligence could be you.

That's cute. But you are ignorant. Pm for details as to why. I've said too much for the forum.

 

[neuropathic]

Just to echo a lot of what were said by many of the expert forumers, I think this case should be followed closely across the nation. I honestly cannot convict her of murder if I am one of the juries. You think Conrad Murray is less guilty than her? Conrad was covicted of involuntary manslaughter, not murder.

Revoke her license for sure. And if there is ever a chance for her to get her medical license back, never issue her a DEA license. Make her do community service and give talks about the danger of drugs and addiction. Her life and career are practically destroyed. Save a spot in jail for someone else.

 

[specepic]

Pinch. You are wrong. You would be inundated with level 4 new patient visits where you decide the current regimen is or is not working, is or is not appropriate, and then decide what to do about it. You would not be obligated to Rx. The job is not to write or not write Rx- it is to try and help the patient and out colleagues. If it ain't right , make suggestions how to fix it. If you want to get the due diligence and take over care- then it's your patient. If you review the record, examine the patient, and decide nothing for you to do other than make recommendations- then it's a single visit consult. No skin of your back, no time wasted, just another visit.

We have no obligation to write prescriptions. We have an obligation to write prescriptions when, where, and why, and for what we feel will be useful in increasing patient's functional status.

I almost never refuse a consult, but I can quickly discern the pt's who will be trouble from the records, and most chronic opioid pts are trouble (esp young ones). A few are not, which is why I see them first, and do a good assessment before passing judgment. That being said my spidey sense is rarely wrong. You see them, give your rec's, they either start trouble on the spot, or then you get phone calls every other day, that the non-opioids/inj/PT/psych "aren't working". They try to wear you down like one of my toddlers wanting to watch elmo for fifth time. I can see why some people do block shops. I do not b/c imho we are the only ones who are trained to do it right, but it is a PIA many times.

I would say 25% or less of those I extend an olive branch to are still compliant at a year. Amazing. I have a chronic pain RN who helps me out with further interviews, testing, etc. which really helps catch the problem pts.

 

[Aether2000]

As for the VA: I spoke with the guy in charge of the section yesterday. It is a problem the VA is fighting here....may be regional, but it is still a problem.
As for opioid screening: we do refuse consults. We look at the state prescription drug database and review all records from physicians that have prescribed opioids over the past 6 months, and only then will we see a consult if it appears the potential patient has seen other pain physicians, and if they have aberrant behaviors, then we just say no. It saves a lot of headaches. For awhile we tried screening, then telling the referring physician we would see the patient for non-opioid therapy only if there were aberrancies in the chart but frequently the patient would simply no show. Therefore, being in the twilight of my career, I can afford to be extremely selective. Of those that are prescribed opioids in my program, we lose around 5-10% per year due to substance abuse or drug diversion in a tightly controlled program with UDS and pill counts and strict rules.

 

[knoxdoc]

I think the VA thing is regional. EVERY patient seen at our local VA is on vitamin O, regardless of diagnosis, unless they sign a consent absolving the VA of any responsibility if the patient dares to venture through life without full mu-receptor saturation.

 

[PinchandBurn]

I'd say there is better than "weak" evidence to support RF (when patients are properly selected)

agree with Bedrock


I think RFA , for properly selected patients, is one of the BEST procedures that we have.

 

[Aether2000]

Then we need the studies to support it. To think a procedure works well does little to protect it from being cut by insurers, esp when the insurers have seen such a massive increase in fraud regarding this procedure (performance of PRF and miscoding intentionally as RFTC, use of ultrasound or non image guided medial branch neurolysis, family docs adding a fluoro machine and starting to do the procedure with little training or experience, family docs training other family docs to do this (Empire), etc.
There are also several guidelines out that have found the evidence of efficacy to be lacking, including the American Pain Society Guidelines (Chou) that found the following: For presumed facet joint pain, evidence on efficacy of radiofrequency denervation of the medial branch of the primary dorsal ramus is difficult to interpret. The only trial (n=60) to use
American Pain Society controlled facet joint blocks to select patients and an ablation technique believed to be optimal found radiofrequency denervation to be moderately superior to sham denervation, but baseline differences between groups could invalidate results. Two of three other small (n=30 to 81), higher-quality trials showed no benefits of radiofrequency denervation compared to sham denervation. Interpretation of these results is controversial because these trials used uncontrolled facet joint blocks to select patients and the radiofrequency denervation technique may have been suboptimal in some of the trials (level of evidence: poor).

 

[facets]

Revoke her license for sure. And if there is ever a chance for her to get her medical license back, never issue her a DEA license. Make her do community service and give talks about the danger of drugs and addiction. Her life and career are practically destroyed. Save a spot in jail for someone else.[/QUOTE]

Why don't we just convene a meeting of the Sanhedrin now and turn her over for crucifixation? (It's Lent for some of us)

She is destroyed already. I don't see how she was making any money seeing 30 patients a day, maybe she made a mistake, maybe she is misguided. Has anyone on this forum made a mistake and given opoids to the wrong patient? What-all of you? Put down your stones. All people are capable of redemption.We don't need to pick over her carcass. I believe she is young. She should have her license suspended and she needs reeducation and monitoring. With insurance companies, lawyers, and the government all expecting us to be perfect and by the way, work for nothing, we don't need to be eating our young. Have some compassion for your collegues, she, like all of us, went through a lot of crap to become a physiican but like the rest of us, is not perfect

 

[101N]

Revoke her license for sure. And if there is ever a chance for her to get her medical license back, never issue her a DEA license. Make her do community service and give talks about the danger of drugs and addiction. Her life and career are practically destroyed. Save a spot in jail for someone else.

Why don't we just convene a meeting of the Sanhedrin now and turn her over for crucifixation? (It's Lent for some of us)

She is destroyed already. I don't see how she was making any money seeing 30 patients a day, maybe she made a mistake, maybe she is misguided. Has anyone on this forum made a mistake and given opoids to the wrong patient? What-all of you? Put down your stones. All people are capable of redemption.We don't need to pick over her carcass. I believe she is young. She should have her license suspended and she needs reeducation and monitoring. With insurance companies, lawyers, and the government all expecting us to be perfect and by the way, work for nothing, we don't need to be eating our young. Have some compassion for your collegues, she, like all of us, went through a lot of crap to become a physiican but like the rest of us, is not perfect[/QUOTE]

Oh, my lord, are you suggesting, could it be you alluding to, is this perhaps a tangential
call for the old ways? Bring back the inquisition and let's burn the witch!

 

[PMR 4 MSK]

Bad doctors should be stopped, and pill mills should be shut down, there's no doubt, but here's the problem. Any chronic pain patient that is on long acting opiates will have a blood opiate level that will appear "in the toxic range" compared to the general population. They could be wide awake, alert, talking and nowhere near overdose, yet draw a serum opiate level and it'll come back "very high", or with some numerical version of such. Then, take such a patient who suffers a heart arrhythmia, or has a cardiac arrest for some unrelated reason. Autopsies frequently are inconclusive. So, when the toxicology report comes back several weeks later, and they find "toxic levels" of some opiate, they call it "death by overdose", when in fact it could be totally unrelated. To then trace it back to the doctor and charge murder, seems completely outrageous.

This is not just conjecture. This happened to me. Guy on OxyContin 80 mg TID x 1.5 years, stable, no evidence of abuse. Pt gets in MVA, 4 days later dies in his sleep. Autopsy shows subarachnoid hemorrhage. Blood tox shows high levels of Oxycodone. Cause of death - Oxycodone toxicity. Ignores the SAH. I get sued.

If we are talking pain therapies and EBM:
-There is weak to moderate evidence injections give short term relief only and strong evidence they do not work for long term relief
-There is weak evidence to support RF
-There is weak to moderate evidence to support SCS
-There is weak evidence to support PT in limited situations
-There is weak evidence to support adjunctive non-opioid medications in the treatment of pain
-There is moderate evidence that chiropractic is useful for chronic pain

So if you compare opioids with all the other therapies, the evidence is really not much different than what is being used in pain medicine.

This is the problem I have with pain management as a whole. It goes along with my anecdotal experience. Most everything we do is a guessing game, and the effects are temporary.

You see someone with back pain and some pain in the leg. Maybe it's radicular, maybe facet, maybe SI. You try some meds, they help a little. You do some PT and it helps some, but the pain returns soon after PT is done. You do an ESI and they report 30% improvement. You inject the facets and the pain is another 50% better. One week later, it's back. You inject the SI joints and it's better on the right side, but not the left, but where it was hurting before higher up is now hurting again.

Nothings helps large numbers of people, nothing works long-term.

I think in 10-20 years, we are going to have a completely different approach to pain than opioids and needles.

 

[Socrates25]

California is in such a state of fiscal disaster that its unlikely she will do any jail time, even if she is given the max punishment by law. They have a hard enough time affording to keep violent rapists and murderers in prison, much less a scumbag reckless doc like this bitch. If she does do jail time, I bet it will be only 10% of her sentence.

The real problem with idiot doctors like this is that the medical boards dont communicate with each other. If you look at the medical board applications, they all ask if you have had your license suspended or revoked in another state. If you lie on that application, it turns out that many state medical boards wont check into it and will assume that you are telling the truth. Of course, they "reserve the right to revoke your license should they find you supplied false information" but thats an empty threat when they are so limited they cant even do basic due diligence on their applicants. In most cases they never discovered you even lied on your app until you get investigated for something else or kill a few more patients in the process.

Bear in mind it took the DEA and the state medical board 3-5 years after she started killing people before they even made the first move against her. Not exactly the bearers of swift justice.

Prediction: she takes a plea deal, gets sentenced to 5 years prison time, does 3 months and is released on probation. 3 years later we hear that she set up shop in Oregon and is investigated again for bad conduct.

 

[Socrates25]

All of this outrage in the public about doctors mistreating pain patients, yet they forget that NURSES can now write for schedule II narcotics in the vast majority of states.

They want to require doctors to take "more training" before scripting narcs, yet they let nurses do it with a ****ty online "doctor of nursing practice" degree. Un****inbelievable.

 

[Mister Mxyzptlk]

What I am seeing now in medical board reviews is that NPs are hiring MDs to "supervise" them. They hire the MD as an independent contractor while the NP owns the clinic.

The problem with that in Texas is that any practice that prescribes narcotics to more than 50% of its patient is deemed a pain clinic and has to register with the state. Also, a pain clinic can only be owned by a doctor. So there are some entrepreneurial NPs out there who are getting their butts fried for owning pain clinics.

The charts are sickening. Patients coming in from Louisiana getting VicoSomaX month after month. No other treatment. No imaging. Nothing. Amazingly every month these patients come back reporting NO side effects, NO need to change dosage, etc.

IMHO if any of these patients O.D. it is manslaughter. Note that when the headlines say "murder" it is usually really manslaughter. I think you can make a case for this in a couple of ways.

Constructive manslaughter (aka ‘unlawful act’ manslaughter) is based on the concept that the malicious intent of a crime also applies to the consequences of the crime. If you intentionally break the law and that act results in the unintended death of someone, the malice of your intended crime is transferred to the death and you get hit with manslaughter. So if you deliberately prescribe narcotics to someone who doesn't need them or who you know is abusing them and they overdose, then the malicious intent of the prescribing also applies to the O.D.

Another possibility is criminally negligent manslaughter where there is a failure to act despite a duty to do so and it results in death. This is more along the lines of professional malpractice, where you have to prove that there was a duty and it was breached. You have to prove gross negligence for this, which is a pretty high hurdle. In the pill mill cases I review I would have no problem testifying against the offenders in this regard.

 

[jsaul]

What I am seeing now in medical board reviews is that NPs are hiring MDs to "supervise" them. They hire the MD as an independent contractor while the NP owns the clinic.

The problem with that in Texas is that any practice that prescribes narcotics to more than 50% of its patient is deemed a pain clinic and has to register with the state. Also, a pain clinic can only be owned by a doctor. So there are some entrepreneurial NPs out there who are getting their butts fried for owning pain clinics.

The charts are sickening. Patients coming in from Louisiana getting VicoSomaX month after month. No other treatment. No imaging. Nothing. Amazingly every month these patients come back reporting NO side effects, NO need to change dosage, etc.

IMHO if any of these patients O.D. it is manslaughter. Note that when the headlines say "murder" it is usually really manslaughter. I think you can make a case for this in a couple of ways.

Constructive manslaughter (aka ‘unlawful act’ manslaughter) is based on the concept that the malicious intent of a crime also applies to the consequences of the crime. If you intentionally break the law and that act results in the unintended death of someone, the malice of your intended crime is transferred to the death and you get hit with manslaughter. So if you deliberately prescribe narcotics to someone who doesn't need them or who you know is abusing them and they overdose, then the malicious intent of the prescribing also applies to the O.D.

Another possibility is criminally negligent manslaughter where there is a failure to act despite a duty to do so and it results in death. This is more along the lines of professional malpractice, where you have to prove that there was a duty and it was breached. You have to prove gross negligence for this, which is a pretty high hurdle. In the pill mill cases I review I would have no problem testifying against the offenders in this regard.

but it didn't seem like this particular doctor was running a pill mill. I don't think she only took cash. She wasn't seeing some crazy amount of patients a day like 50-60. I may be wrong but she seemed like someone just made some bad calls. No matter if do a uds, review records, full exam, imaging, due dillegence, etc- you may still get burned once or twice

 

[facets]

[/B]

but it didn't seem like this particular doctor was running a pill mill. I don't think she only took cash. She wasn't seeing some crazy amount of patients a day like 50-60. I may be wrong but she seemed like someone just made some bad calls. No matter if do a uds, review records, full exam, imaging, due dillegence, etc- you may still get burned once or twice

Exactly my point, and yet people are ready to burn her at the steak. Any one of us could be in her shoes

 

[neuropathic]

Exactly my point, and yet people are ready to burn her at the steak. Any one of us could be in her shoes

Writing Oxycontin, oxycodones, Opana everyday without a legitmate diagnosis, exams, imaging studies? I hope most of us are not in her shoes.