Anna Nicole Smith's psychiatrist

On the surface, it seems she over-prescribed. However, on looking deeper, physicians are often caught between two unpalatable options:

“On the one hand, if they prescribe too much medication for a patient “¦ they could be in trouble, even [facing] criminal prosecution,” Johnson said.
But there has also been a movement in health care to provide more adequate pain management and mental health management for patients.
“So if they prescribe too little, they could be subject to malpractice,” Johnson said.
“It is a double-edged sword,” Doering said. “At the same time these medicines control pain and disease, they have some potential for side effects and other risks to health.”

Comments

Anonymous
“”So if they prescribe too little, they could be subject to malpractice,” Johnson said.”
You have to be kidding. You’re defending this guy, Kevin? You’ve reached new lows in your defense of all things doctors do.
Kevin
I’m not defending anyone. I am simply stating that physicians are sometimes in a quandary when treating difficult conditions that blurs the line between over-prescribing and appropriate alleviation of symptoms.
Thanks,
Kevin
Anonymous
This psychiatrist finds that patients who have prior extensive polysubstance abuse histories often have anxiety and agitation that simply do not respond to usual dosages of the usual drugs. It is common for them to require prodigious dosages of 5 or 6 meds to achieve acceptable (to them) control of their anxiety and dyphoria. This is especially true with past use of ecstacy and LSD which can cause irreversible changes in the serotonin regulatory systems so critical to mood regulation and the target of many of our pharmacological interventions.
This situation also develops even when the aggresive polyphamacy doesn’t really help because people who have plied themselves with drugs on a regular basis to self-regulate their emotional states do not tolerate temporary dysphoria and demand insant relief when uncomfortable. The result is addition of med after med by the physician attempting to satisfy this demand. The physicians job however often is to say “No” and teach the patient some patience with their own mood swings and regulate meds for optimal long-term function, not the mood of the moment. It is especially hard to resist these demands when the physician is flattered that a VIP patient has chosen them. In our celebrity culture, the docs too are often not above manipulation and unconsciously accept the cultural assumption that these are special people who deserve special priveleges and special treatment.
These types of patients need a certain kind of doctor, someone who is at least something of a curmudgeon who is above manipulation. One who doesn’t give a rat’s *ss who they are. Of course what happens when the VIP patient gets this sort of doctor, who, unlike all the other *sskissers tells them “No” and just how the cow ate the cabbage, they bad-mouth them and find someone more compliant.
Which more applies here? Clinically intractable symptoms or star-stuck doctor? I can’t possibly have enough information to have an opinion on that. It is beyond regulatory “fixes” because these are “special people” for whom the rules don’t apply. OJ proves that in the extreme. All regulatory fixes achieve is to deprive tens of thousands of other tough cases of needed treatment.
One things that bothers me about the reaction to these kinds of cases is the assumption that if someone dies either of a psychiatric illness or of it’s treatment, that the treatment was wrong. That is a cultural assumption that does not bear up under more than superficial scutiny, but our culture, especially the blogosphere, is not given to anything more than superficial logic. It is in fact entirely reasonable, ethical, and medically appropriate to make risky decisions to provide (or deny) psychiatric treatment when there is a sufficient potential payoff for the risk. If a dangerous cocktail to a subset of very treatment resistant patients kills 1 in a 100, but 50 in a 100 a tolerable reasonable existance otherwise unattainable, I can promise you that nearly everyone of those people would chose that risk and it is reasonable. If denying a chronically manipulative “I’m suicidal” hospital abuser his hundredth admission to the hospital despite his threats carries a certain risk of tragedy but offers the only reasonable hope of breaking the behavior pattern, then it is worth it.
Anonymous
Chloral hydrate?? Do you know ANYONE who still prescribes chloral hydrate for this type of situation? This doc wasn’t afraid of being sued, she was afraid of losing her cash cow of a patient.
Linsey
I’m shocked that you’re defending this. There is a point where you have to provide sufficient treatment, but this psychiatrist went way past that. There’s no question about it. I’m frankly disgusted that you would compare people who truly are suffering and are not receiving sufficient treatment to a celebrity who got whatever she wanted. I’ve read Anna Nicole Smith’s autopsy report, and here is a list of what was in her system:
A. Toxic/lethal drug:
Chloral Hydrate (Noctec) 1.Trichloroethanol (TCE) 75ug/mL (active metabolite) 2.Trichloroacetic acid ( TCA) 85ug/mL (inactive metabolite)
B. Therapeutic drugs :
1. Diphenhydramine (Bendaryl) 0.11 mg/L
2. Clonazepam (Klonopin) 0.04 mg/L
3. Diazepam (Valium) 0.21 mg/L
4. Nordiazepam (metabolite) 0.38 mg/L
5 Temazepam (metabolite) 0.09 mg/L
6. Oxazepam 0.09 mg/L
7. Lorazepam 22.0 ng/mL
C. Other non-contributory drugs present (atropine, topiramate, ciprofloxacin, acetaminophen)
Is there really any excuse for this?
RJS
Well said, Anonymous 10:17.
Anonymous
“I’m not defending anyone. I am simply stating that physicians are sometimes in a quandary when treating difficult conditions that blurs the line between over-prescribing and appropriate alleviation of symptoms.”
You picked a piss poor example to make your point with.

Anna Nicole Smith’s psychiatrist

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