Michael Jackson’s death has spawned speculation about its cause and how it might have been avoided. Moreover, there is pressure to find someone to blame for his death. I’ve waited to write about this sensational story until there were more facts and an opportunity to write about this tragedy from a physician’s viewpoint. Physicians and other practitioners with legitimate access to controlled substances face pressure from patients who seek drugs for legitimate pain relief and from others whose insatiable demands for medication attempt to effectively self-prescribe more and more analgesic drugs at increasing doses. Resourceful patients who are outpatients may employ multiple practitioners and keep them in the dark regarding their full drug regimen, or may decide to ignore dosage and other instructions. Nevertheless, when there is a tragedy, there is usually a search for someone to blame, and the Jackson case is no exception. Treating a problem patient involves protecting both the patient and yourself. Read the full article and contribute your own thoughts on this troubling subject:

Enter the Feds

With the sensational media coverage of the Michael Jackson case, it was only a matter of time before the Feds (DEA) decided to get involved and scrutinize the physicians and other practitioners involved in his care, the drugs that were prescribed or otherwise used by or provided to him, and to second-guess whether any of them were inappropriately prescribed for or provided to him.

According to an early news report, registered nurse Cherilyn Lee told an Associated Press reporter that Mr. Jackson repeatedly pressured her to give him the intravenous anesthetic Propofol to help him to get to sleep and sleep through the night, an extreme request that the nurse understandably refused.

Protecting Both the Patient and Yourself

Whenever you are pressured by a patient to administer or provide drugs for pain relief that exceed the dosage you consider safe under the circumstances and setting you prescribe and reasonably can assume they will be used, you need to take precautions both to protect the patient and to limit your professional liability. Depending on the circumstances, these precautions may include:

• Moving the patient to a hospital setting, if appropriate
• Ordering lab tests to see what’s really going on
• Referring the patient to appropriate specialists for diagnosis
• Consulting the patient’s other physicians, if the patient will disclose them
• Limiting prescriptions to a total quantity small enough to limit abuse
• Writing “no refill” prescriptions to limit abuse
• Bowing out of a case gracefully if the patient is non-compliant and uncooperative.

Admit that You Cannot Manage the Unmanageable

As physicians, it’s important to consider the needs of your patient, alongside their personality when prescribing drugs that are potentially addictive or have high potential for abuse – whether they are simply in pain, or seeking drugs for other reasons. Early press reports paint a picture of Michael Jackson as a drug-seeker in chronic pain, who would seek out ever stronger drugs and pressure practitioners to give them to him without regard to the possible consequences.

Proper pain management protocols can help prevent such extreme behavior in patients that are actually managed on a consistent basis – patients who self-medicate on an ad-hoc basis and decide their own doses and frequencies of medication walk a dangerous and unmanaged path. If you cannot modify this kind of patient’s behavior and verify that the patient is complying with your pain management program, then you either need to get the patient to move to a setting where they can be actively managed, such as a hospital, or admit that you have an unmanageable, self-destructive patient, a case that you are unable to manage, and you need to bow out of the case as quickly and as gracefully as possible.

A Formula for Reducing Your Risk

Addicts and recreational drug users will present themselves to you from time to time as new outpatient pain management patients that may or may not be referred to you by another physician. Identifying them and differentiating them from patients who need relief from pain originating from an underlying medical condition can be made easier or more difficult, depending on whether your intake policy requires a prior diagnosis and existing course of treatment for that condition by a referring physician with whom you consult to verify the legitimacy and appropriateness of the referral. You also need to periodically verify that the patient is still being managed and treated by the referring physician. Limiting your intake to verifiable cases under continued management by the referring physician will limit your risk and will provide a better exit strategy where you can refer the patient back to the referring physician for re-evaluation when you feel it is appropriate. No strategy is foolproof, but if you have a medically sound policy and procedures in place and a dishonest patient subverts them, at least you can demonstrate that you exercised due diligence.

I invite you to add your own comments and ideas below. Note that all comments are manually moderated to maintain the professional tone of this publication and therefore do not appear instantly.