Is a doctor guilty of malpractice or murder or is the patient responsible for his or her actions when there is a death by overdose?

This is the question that a jury in Los Angeles will have to decide as they are presented the facts in the case of Dr. Lisa Tseng.

The prosecution’s version is that Dr. Tseng handed out opioids like candy without any regard for standard of care. Over the years at least 12 of her patients died from overdoses. She is now standing trial for three deaths. One of the deceased, Joey Rovero, 21 and an Arizona State University student, apparently traveled from Arizona with frat buddies to get a prescription from Dr. Tseng.  He received almost 100 30 mg Roxycodone tablets. The Prosecution says she wrote an average of 25 opioid prescriptions a day.

Dr. Tseng’s defense thus far seems to be that she was trying to care for people with pain, was ill prepared to do so,  and if people take medications irresponsibly then it is not her fault.

Responsible prescribing is the duty of every physician and whether you are giving birth control pills, medication for epilepsy, or treating pain it doesn’t really matter. Some medications are right for some people, and others are not. With opioids, however, you have the added issue of recreational use, addiction, and the Drug Enforcement Agency. As a doctor, I view the special pads for controlled substances as warning lights that are always on, like a seatbelt light during turbulence on an aircraft. Needing to use a special prescription pad helps me to consider every one of these prescriptions just a little more because they do require a greater level of scrutiny.

Some patients will use their opioids recreationally. Let’s be honest, no one snorts birth control pills or gives their water pills to friends at parties. No kids looks in their mother’s medicine cabinet and thinks I have to try that beta-blocker.

Occasional exposures, stolen from a medicine cabinet or for post-operative pain, can nurture addiction (the unwillingness to stop the medication knowing it is causing harm). When life is tough, as it can be, some people turn to chemical coping. Sometimes it was a prescription for chronic pain but the use became concerning and so the doctor stopped the medication, but the patient found a way to keep getting them. Headaches or visits to the emergency department. They became a doctor shopping expert.

Opioids also profoundly impact health even when used appropriately. They can paradoxically make pain worse, cause constipation that can become part of the pain problem, and they have a terrible effect on hormones. I haven’t included sedation as an opioid-specific issue as a lot of drugs have this side effect.

So opioids are a big deal. I was once a far more liberal opioid scribe than I am now. Fifteen years ago we were all “under treating” pain, and so we prescribed more and more opioids. That is what our professional societies told us. I saw almost no one get better or lead a more productive life. I also heard of more lost prescriptions than I can count. Pain scores rarely budged, but doses gradually escalated. I would never keep someone on a beta blocker if it wasn’t controlling their hypertension, so why would I keep someone in an opioid if it wasn’t lowering their pain score? If 240 Norco and 60 OxyContin a month isn’t helping your pain dramatically then you have opioid-resistant pain. Somewhere along the line we confused treating pain with prescribing opioids.

About ten years ago I decided that chronic opioids were not for my practice. The percentage of people in my 15+ year career in chronic pain who have truly benefited from them, meaning a significant reduction in pain scores with a corresponding improvement in functionality, is very small. I have had more patients than I can count with chronic pain tell me, “You know they don’t really work, they just make you care a little less and I’d rather not feel foggy if that is the only benefit.” Those patients typically have a small supply on hand for very bad days.

However, some people end up on chronic opioids for a variety of reasons. While a small percentage truly benefit it is important to remember that we have a health care system where it is easier to get your insurance to pay for back surgery than physical therapy. Most patients with chronic pain are not afforded the opportunity to have their depression optimally managed or their post-traumatic stress disorder treated. In addition, in some pain practices 30 to 50 percent of patients have borderline personality disorders and these patients are very distress intolerant. Every pain is perceived as a 9 or 10 out of 10. It is a very challenging pain to manage.

Add in inadequately (or typically untreated) anxiety and the neuroinflammatory burden of obesity and you start to understand why it is very hard to make a lot of people with chronic pain better, and you see how patients and doctors might turn to opioids. To top it all off, we live in a society where instant gratification is often not soon enough. Many people want surgery to cure pain and are less interested in physical therapy, home exercises, and Feldenkrais. And if they are interested in those things it is unlikely they’d get the time off work to do them!

The best person to manage this group of people who end up on chronic opioids is a board certified pain physician with access to a pain psychologist and a pain pharmacist. But let’s be real and understand this is rare. In addition, talking with people about managing pain pays very little, but epidurals pay great. (Who cares that trials show little benefit!)

So for many people who end up on opioids for whatever reason wind up under the care of their family doctor, internist or gynecologist. This doctor is almost always doing their best to keep the opioids from escalating to minimize harm, but keeping enough on board to prevent their patient from ending up repeatedly in the emergency department where they are at high risk of getting unnecessary therapies and tests and iatrogenic complications. It’s a very hard job.

And so that brings me back to Dr. Tseng and her 25 opioid prescriptions a day.

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

But given how we treat pain, or rather how we don’t really treat pain, in this country I’m not surprised Dr. Tseng exists. I’m actually surprised there aren’t more of her.

Jennifer Gunter is an obstetrician-gynecologist and author of the Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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