Editor’s Memo from March, 2016
By Forest Tennant, MD, DrPH
For many years, I’ve had my two local papers, The Los Angeles Times and San Gabriel Valley Tribune, delivered to my door early each morning. The San Gabriel Valley is just east of downtown Los Angeles and consists of two-dozen bedroom communities.
Both newspapers delivered a shock on the morning of March 2, 2012. The front-page headline read, “Rowland Heights Doctor Faces Murder Charges for Prescription Drugs.”1,2 On February 5, 2016, Hsiu-Ying “Lisa” Tseng, DO, was sentenced to 30 years to life in prison for the murder of 3 young men who fatally overdosed while under her care.3
The murder conviction of Dr. Tseng for prescribing a deadly concoction of medications is a first in the United States. Due to this landmark event, Practical Pain Management wants all pain practitioners to know the sorry facts and lessons about this case. Above all, this case does not reflect the legitimate practice of medicine and the prescribing of opioids and other controlled drugs to bona fide pain patients.
Since I live and practice in the community of West Covina, which abuts Rowland Heights to the south, and Dr. Tseng’s trial and sentencing were held in Los Angeles, I’ve been able to follow this case and collect the news reports that it has generated.
Dr. Tseng, 46, who was a general practitioner, is among a small but growing number of doctors charged with murder for prescribing opioids that killed patients. A Florida doctor was acquitted of first-degree murder in September, 2015.3
Dr. Tseng was officially charged with murder of 3 young, single men: Vin Nguyen, 29, of Lake Forest, California; Steven Ogle, 25, of Palm Desert, California; and Joseph Rovero, III, 21, an Arizona State University student from San Ramon, California.
Dr. Tseng was reported to have written more than 27,000 prescriptions over a 3 year period, starting in January 2007. She saw patients at a rate of about 25 a day, and wrote prescriptions primarily for alprazolam (Xanax), oxycodone (Oxycontin), hydrocodone/acetaminophen (Vicodin), and amphetamine/dextroamphetamine (Adderall)—all highly abused medications. She initially came to the attention of authorities when some pharmacies noted non-standard prescriptions being presented by questionable patients.
Accompanying the original 2012 news report was this statement by Los Angeles District Attorney Steve Cooley: “There were deaths directly as a result of her prescribing medication that was probably not needed at all, to feed someone’s habit. Her incredible greed was exhibited by prolific dispensing of literally thousands upon thousands of dangerous drugs.”4
I was impressed by Cooley’s statement as I have personally known him for many years and even testified as an expert witness in some of the DA’s cases. He’s not a prosecutor with a vendetta against physicians or pain patients, so I knew his statement represented that something bizarre was happening.
Dr. Tseng was 42 years of age when she was arrested. She graduated from Michigan State University of Osteopathic Medicine, and was licensed in 1997. In 2005, she opened her clinic in a strip mall on Fullerton Boulevard, a very busy street, in Rowland Heights. The clinic’s name was Advanced Care AAA Medical. She surrendered her medical license in 2012 after her arrest and incarceration.
Incredibly, at the time of her arrest, Dr. Tseng was affiliated with 14 hospitals in the Greater Los Angeles area. Almost all the hospitals ranked her in the “top 25%” of physicians. An interesting questions is why did she have all these hospital affiliations and what did she do to receive such positive ratings? Did any of these hospitals bother to check her practice?
She has two young children and expressed this opinion in a public letter before her sentencing: “I now realize that personal problems—undiagnosed depression, hoarding, and difficulty juggling work and children—interfered with her abilities to be a good physician.”3
Between 2007 and 2010, Dr. Tseng’s tax returns showed that her practice took in $5 million. According to court documents and press reports, she kept few records, and seldom performed a physical examination. Prescriptions of medications were issued pretty much on the patient’s request, which undercover law enforcement agents documented.
Even though Dr. Tseng was convicted of murder of only 3 young men, other deaths occurred in her practice. Three young men under age 30 overdosed and died in 2007 and 2008: Mathew Stavron, Ryan Latheau, and Nathan Kenney. It appears that her practice catered to young people who were clearly abusing and misusing medications.
During the trial, it became evident that these patients drove long distances to her clinic and apparently all paid cash for prescriptions. She rarely performed a physical examination or documented a bona fide need for opioid analgesics and other drugs. Most clinic visits resulted in prescriptions for at least
2 of these 4 drugs: Oxycontin, Adderall, Xanax, and Vicodin.
She received numerous reports from families, pharmacists, and coroners about her patients abusing and selling drugs. She was even notified about patient deaths before the 3 fatalities of which she was convicted. Apparently, she ignored all or at least the majority of these 3rd party reports of inappropriate use of her prescriptions.
The Community Setting
This case has been particularly perplexing to the pain practitioners who function in close proximity to Rowland Heights. I personally had never heard of Dr. Tseng and was shocked that she could essentially run a “pill mill” for so long.
Why? Pain practitioners in my city know each other. In my town of West Covina, no physician could possibly operate a storefront prescribing Oxycontin and other medications for illegitimate purposes for very long. Physicians and our surrounding medical establishments would not tolerate such behavior and would immediately notify law enforcement, including our local police department.
Unfortunately, an objective analysis of Rowland Heights is one of the sorry messages in this debacle. Rowland Heights is a new, unincorporated conclave of a tight knit Asian-immigrant community. There is no police department, city hall, hospital, or mayor.
Besides the Dr. Tseng matter, this community recently made national headlines for a different, but equally tragic event. Three teenagers from China were sentenced to prison for brutally beating 2 teenage girls. The beating included burning their breasts. The apparent motive was that the girls didn’t show “proper respect.”5 The 3 teenagers were called “parachute kids,” which refers to young people sent alone by their parents to America to attend school.
Perhaps I sound defensive, but I do not believe Dr. Tseng could have carried out her practice in any of the communities that surround Rowland Heights. I truly believe that a normal, incorporated city would have stopped Dr. Tseng long ago.
A Message for Pain Practitioners
The case of Dr. Tseng highlights the deadly results of “pill mills,” when prescriptions for pain medications were being written by unscrupulous physicians without patient assessment or review. The good news is that a recent study showed that the rate of opioid prescribing in the United States stabilized between 2010 and 20126 coupled with a decline in the rate of deaths from overdose.7
These trends corresponded with the release of the reformulated abuse-deterrent version of Oxycontin, as well as an increase in physician and patient education efforts, prescription Take Back days, use of prescription drug monitoring programs (PDMP), and law-enforcement efforts to shut down questionable prescribers and clinics.
The bad news is that coinciding with efforts to reduce prescription-opioid abuse and overdose, overdoses caused by street drugs, such as heroin and synthetic fentanyl, have increased. According to national surveillance data, 914,000 people reported heroin use in 2014, a 145% increase since 2007, and deaths due to heroin overdose more than quintupled, from 1,842 deaths in 2000 to 10,574 deaths in 2014.8
Physicians need to practice “due diligence” before prescribing opioid medications. This includes obtaining a urine drug screen (repeated at random intervals at follow-up visits), checking your state’s PDMP to review the history of the patient’s prescriptions for controlled substances, and taking a careful history of smoking, alcohol, and other drugs of abuse, incarceration, and income source (and document in the medical record).
Finally, if dealing with chronic pain, it is important to request old medical records, and then followup to be sure they have arrived. I also recommend all practitioners review the importance of Universal Precautions, as outlined by Gourlay and Heit.9 The 10 principles include:
- Diagnosis with appropriate differential diagnosis
- Psychological assessment including risk of addictive disorders
- Informed consent (verbal or written/signed)
- Treatment agreement (verbal or written/signed)
- Pre-/post-intervention assessment of pain level and function
- Appropriate trial of opioid therapy ± adjunctive medication
- Reassessment of pain score and level of function
- Regularly assess the “Four As” of pain medicine:
- Adverse Reactions
- Aberrant Behavior
- Periodically review pain and comorbidity diagnoses, including addictive disorders
For primary care physicians, it is also important to triage pain patients, as suggested by Gourlay and Heit (Table 1).9 For a primer on Substance Use Disorder, please read Dr. Cosio’s article.
For the first time, a physician in the United States has been convicted of murder for prescribing abusable drugs to patients who overdosed and died. The doctor practiced and prescribed drugs in a bizarre manner in a non-typical community, which apparently didn’t know or didn’t care. No physician who is conscientiously treating pain patients by taking a history, performing a physical examination, and developing a treatment plan need be intimidated by this case. It simply was so far out-of-line and deplorable that it has little connection to normal pain practice.
- Girion L, Glover S, Brown-Potts H. Doctor charged in fatal prescription overdoses.LA Times. March 1, 2012.
- Day B, Update: Rowland Heights doctor accused of murder following patient’s overdose deaths.San Gabriel Valley Tribune. March 2, 2012.
- Gerber M. Doctor convicted of murder for patients’ drug overdoses gets 30 years to life in prison.LA Times. February 5, 2016. http://www.latimes.com/local/lanow/la-me-ln-doctor-murder-overdose-drugs-sentencing-20160205-story.html. Accessed February 29, 2016.
- Gregory J, Michaelson E. Rowland Heights doctor faces murder charges for prescription drugs.Eyewitness News (ABC 7). March 2, 2012.
- Gonzales R. Chinese teens sentenced in brutal Rowland HeightsSan Gabriel Valley Tribune. February 16, 2016.
- Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, S., 2007–2012. Am J Prev Med. 2015 Sep;49(3):409-13.
- Decline in drug overdose deaths after state policy changes — Florida, 2010–2012. MMWR Morb Mortal Wkly Rep. 2014;63:569-574.
- Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016; 374:154-163.
- Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient. Pain Med. 2009;10(suppl 2):S115-S123.