Jackson Case Highlights Medical Ethics

Jackson Case Highlights Medical Ethics

Two prominent doctors in the field of pain management reflect on the malign influence of celebrity.

From 2001 to 2005, unintentional overdose deaths due to prescription drugs increased 114 percent.Ieva Geneviciene

The King of Pop and the World's Greatest Womanizer have more in common than you might think.

Michael Jackson's death last month, like that of Howard Hughes in 1976, revealed the hidden side of a famously reclusive figure, one that involved elaborate schemes to obtain prescription drugs. Both men began a regiment of painkillers after an accident: Hughes' plane crash in 1946 and Jackson's burn on the set of a Pepsi commercial in 1984. Over time, each developed a tolerance for narcotics that enabled them to consume otherwise lethal doses.

What followed the death of Hughes, like many others each year, may very well follow Jackson's death: a criminal trial against one or more of the pop singer's doctors. Hughes' case wasn't the first and Jackson's certainly won't be the last. Such cases invariably shine a spotlight on medical ethics and the influence of celebrity.

The investigation in the Jackson case has so far focused on the star's personal cardiologist, Dr. Conrad Murray, who was present when Jackson died.

Dr. Forest Tennant served as an expert witness in the 1978 case against Dr. Wilbur Thain, who was accused of illegally prescribing Hughes, and the case in 1981 against Dr. George Nichopoulos, who was charged with over-prescribing Elvis Presley, Jerry Lee Lewis and seven others. Both doctors were acquitted of criminal charges and kept their medical licenses. A medical board later sanctioned Nichopoulos, dubbed "Dr. Nick" by the press, for ethical violations.

"Famous people like Jackson, Howard Hughes or Elvis Presley had enough money, enough privacy and severe enough medical problems that they had the need to have physicians at their beck and call," said Tennant, who treated his own share of famous people over the years as a Los Angeles physician and former medical director for the National Football League. "The willingness of physicians to take on this role, in my experience, is tantamount always to having to violate ethical standards."

For a physician to be convicted of criminal wrongdoing, the prosecution must prove that the doctor willfully over-prescribed drugs or knew that prescriptions were falsified. For instance, California authorities earlier this year charged two doctors who cared for actress and model Anna Nicole Smith, who died of a drug overdose in 2007, in part because the doctors allegedly wrote prescriptions for Smith under pseudonyms.

"When physicians get put in these positions, corners are going to be cut," Tennant said. "It's pretty obvious right now these things happened in the Jackson case."

How else to explain at Jackson's bedside bottles of the anesthesia drug Diprivan (brand name Propofol), which under normal circumstances doesn't leave the hospital?

"It's absolutely out of this universe," said Dr. Lynn Webster, who publishes a guide for practitioners called Avoiding Opioid Abuse While Managing Pain and is on the board of Zero Unintentional Deaths, which works "to eliminate the harm and unintended deaths associated with prescription pain relievers." Webster said for a patient to reasonably require Diprivan as a painkiller, he would have to be terminally ill and paraplegic.

"If what I hear out of the news is remotely correct, this is an individual who has become really addicted to multiple medications and cannot escape this without continued feeding of near lethal levels of medications," Webster said. "The window between what Michael wanted or felt like he needed and death was probably very narrow."

Unlike the Hughes case, the legal and regulatory machinery in the aftermath of Jackson's death has yet to complete its mission. Still, some clues can be divined from various media reports. According to TMZ.com, a former Jackson bodyguard told investigators that Jackson was taking 10 Xanax pills per night. The same bodyguard said at one time Jackson might have taken 30 to 40 pills per night of the anti-anxiety medication.

"There is no one who should ever have 10 Xanax a night even if that's the only thing he's taking," Webster said. Press reports following a search of Jackson's home also indicated he was taking a host of other painkillers including Demerol and Oxycontin, some in his name, others without labels or under different names. Assistants were said to obtain drugs from multiple pharmacies.

In 1978, the trial against Thain revealed similar plots by Howard Hughes. The subject line of a 1958 "operating memorandum" submitted as evidence in the trial and obtained courtesy of Tennant says, "Instructions from HRH regarding securing and processing prescriptions."

"When the call comes in to the office following the doctor's call to Mrs. Hughes and it is something that can be telephoned in, then OK," the memo reads. "Try to prevail on the doctor not to require a confirmation of the prescription. It would be well to put the prescription in Mrs. Melba Doss' name, as Mrs. Hughes would like that better than using another name she doesn't know."

Webster sympathized with doctors who get lured into the world of celebrity. "It's unfortunate because physicians can sometimes get pulled into situations like this that seem to be very exciting because of the people they are working with, and they forget the principles they are supposed to follow," he said.

Based on media reports, Jackson saw more than a dozen doctors since 1993. The Los Angeles Times quotes a longtime Jackson associate as saying the pop singer had little trouble finding a doctor who would prescribe drugs.

"They rotate in and out," the article quoted the source, who requested anonymity. "There were a lot of doctors over the years. ... They liked to be known as Michael Jackson's doctor."

Investigators in recent weeks subpoenaed medical records from multiple doctors who treated the singer, including Dr. Arnold Klein, Jackson's dermatologist for nearly 25 years.

Webster advises doctors who prescribe controlled substances to maintain detailed medical records and visit personally with patients to closely monitor their condition. "All of us get fooled, but the good physicians are always on guard for individuals who are out there to try and deceive them. For somebody to be deceived for 10 years would be extraordinary."

And of course, such abuse is not solely the province of celebrities. More than 8,500 Americans died from prescription drug overdoses in 2005, the latest year figures were available, according to the Office of National Drug Control Policy. From 2001 to 2005, unintentional overdose deaths due to prescription drugs increased 114 percent.

Public policy and drug enforcement actions over the past decade to combat abuse of painkillers have led to prescription drug monitoring programs in 33 states, including California. The programs work by tracking prescriptions of controlled substances through pharmacies.

To avoid detection, doctors might stockpile drugs in their office. Using aliases and diverting drugs from other patients are difficult to detect. And doctors might choose to skimp on the note taking in the name of privacy, especially when it comes to extremely reclusive figures such as Jackson and Hughes.

Their deaths took place in far different eras more than 30 years apart, but the issues remain the same when doctors succumb to the influence of celebrity. Early autopsy results said track marks scarred Jackson's arms. The autopsy of Hughes revealed a much more shocking detail: Five glass syringes, used to inject codeine, were found embedded in his upper and lower arm.

Warren Zevon's The Wind "sardonic wit and blazing intelligence"

Warren Zevon's The Wind

Warren Zevon was an American singer-songwriter known for his "sardonic wit and blazing intelligence" which he incorporated into his music. Some of his well known songs include "Werewolves of London", "Roland the Headless Thompson Gunner", and "Lawyers, Guns and Money". In 2002, Zevon was diagnosed with mesothelioma. He refused any treatment and started on his final album The Wind.

The Wind features guest appearances from several of Zevon's close friends (Tom Petty, Bruce Springsteen, Don Henley to name a few). The making of the album was made into a documentary for VH1 entitled, Warren Zevon: Keep Me In Your Heart.

When I first heard The Wind, I knew it was Zevon's final album, made while he was dying, and so I listened to it differently than I would other albums. It seems to frequently refer to Zevon's illness (but maybe that's just me). Some songs seemed to contain a lot of regret.

Included on the album is a cover of the Bob Dylan song "Knockin' on Heaven's Door". (Not hard to see how this one relates to dyint.) Another song, "Disorder in the House" (recorded with Bruce Springsteen and winner of a Grammy for Best Rock Performance by a Duo or Group With Vocal), is about a house coming apart and falling down. It starts with the lines:
Disorder in the house
The tub runneth over
Plaster's falling down in pieces by the couch of pain

It ends:
Disorder in the house
All bets are off
I'm sprawled across the davenport of despair
Disorder in the house
I'll live with the losses
And watch the sundown through the portiere

Below is "Keep Me in Your Heart" also from The Wind.

Shortly after his diagnosis, in 2002, Zevon appeared on The Late Show with David Letterman as the only guest for an entire hour (most of the appearance can be seen on You Tube). Zevon was a frequent guest on The Late Show. When discussing his cancer, Zevon says,"I might have made a tactical error in not going to a physician for 20 years. It was one of those phobias that really didn't pay off." Later on, Letterman asks Zevon if he knows something about life and death that Letterman doesn't know. Zevon responds, "Not unless I know how much you're supposed to enjoy every sandwich." (The line "enjoy every sandwich" then became one of Zevon's more famous lines.)

Warren Zevon died September 7, 2003, less than two weeks after the release of The Wind on August 26th.

New Twitter Research: Men Follow Men and Nobody Tweets - Conversation Starter - HarvardBusiness.org

New Twitter Research: Men Follow Men and Nobody Tweets

Twitter has attracted tremendous attention from the media and celebrities, but there is much uncertainty about Twitter's purpose. Is Twitter a communications service for friends and groups, a means of expressing yourself freely, or simply a marketing tool?

We examined the activity of a random sample of 300,000 Twitter users in May 2009 to find out how people are using the service. We then compared our findings to activity on other social networks and online content production venues. Our findings are very surprising.

Of our sample (300,542 users, collected in May 2009), 80% are followed by or follow at least one user. By comparison, only 60 to 65% of other online social networks' members had at least one friend (when these networks were at a similar level of development). This suggests that actual users (as opposed to the media at large) understand how Twitter works.

Although men and women follow a similar number of Twitter users, men have 15% more followers than women. Men also have more reciprocated relationships, in which two users follow each other. This "follower split" suggests that women are driven less by followers than men, or have more stringent thresholds for reciprocating relationships. This is intriguing, especially given that females hold a slight majority on Twitter: we found that men comprise 45% of Twitter users, while women represent 55%. To get this figure, we cross-referenced users' "real names" against a database of 40,000 strongly gendered names.

Even more interesting is who follows whom. We found that an average man is almost twice more likely to follow another man than a woman. Similarly, an average woman is 25% more likely to follow a man than a woman. Finally, an average man is 40% more likely to be followed by another man than by a woman. These results cannot be explained by different tweeting activity - both men and women tweet at the same rate.

These results are stunning given what previous research has found in the context of online social networks. On a typical online social network, most of the activity is focused around women - men follow content produced by women they do and do not know, and women follow content produced by women they knowⁱ. Generally, men receive comparatively little attention from other men or from women. We wonder to what extent this pattern of results arises because men and women find the content produced by other men on Twitter more compelling than on a typical social network, and men find the content produced by women less compelling (because of a lack of photo sharing, detailed biographies, etc.).

Twitter's usage patterns are also very different from a typical on-line social network. A typical Twitter user contributes very rarely. Among Twitter users, the median number of lifetime tweets per user is one. This translates into over half of Twitter users tweeting less than once every 74 days.

At the same time there is a small contingent of users who are very active. Specifically, the top 10% of prolific Twitter users accounted for over 90% of tweets. On a typical online social network, the top 10% of users account for 30% of all production. To put Twitter in perspective, consider an unlikely analogue - Wikipedia. There, the top 15% of the most prolific editors account for 90% of Wikipedia's edits ⁱⁱ. In other words, the pattern of contributions on Twitter is more concentrated among the few top users than is the case on Wikipedia, even though Wikipedia is clearly not a communications tool. This implies that Twitter's resembles more of a one-way, one-to-many publishing service more than a two-way, peer-to-peer communication network.

Bill Heil is a graduating MBA student at Harvard Business School, and will start at Adobe Systems as a Product Manager in the fall. Mikolaj Jan Piskorski is an Assistant Professor of Strategy at HBS who teaches a Second Year elective entitled Competing with Social Networks. Bill undertook research for parts of this article in the context of that class.

i Piskorski, Mikolaj Jan. "Networks as covers: Evidence from an on-line social network." Working Paper, Harvard Business School.
ii Piskorski, Mikolaj Jan and Andreea Gorbatai, "Social structure of collaboration on Wikipedia." Working Paper, Harvard Business School.

New Twitter Research: Men Follow Men and Nobody Tweets - Conversation Starter - HarvardBusiness.org

Eat It to Save It - Idea of the Day Blog - NYTimes.com

Eat It to Save It

Today’s idea: Farm biodiversity is disappearing, so we should eat endangered crops and livestock to boost demand for them and thereby save them from extinction, an article says.

Tamas Dezso for The New York Times With succulent pork back in demand, the Mangalitsa pig of Hungary made a comeback.

Food | You like heirloom tomatoes, right? The same sort of determined breeding that goes into those could preserve disappearing strains of pigs, turkeys, cows and all manner of crops, writes Emily Badger in Miller-McCune magazine — if there were sufficient consumer demand.

“But today, 99 percent of turkeys eaten in America come from a single breed, the Broad-Breasted White,” she writes. “More than 80 percent of dairy cows are Holsteins and 75 percent of pigs come from just three breeds.” Same holds for fruits and veggies, she says; while there used to be 15,000 varieties of apple, there now are 1,500.

“In an era when many problems — deforestation, climate change, water shortages — have been caused by human over-consumption, here is a problem of under-consumption,” Badger writes. “Biodiversity is disappearing precisely because people no longer consume it, and if we would just eat endangered crops and livestock now, restoring their role in the food supply, we could save them from extinction.”

And who knows? The preserved breeds might be better suited to whatever climate change has in store, before they become dinner. [Miller-McCune]

Eat It to Save It - Idea of the Day Blog - NYTimes.com

Avoiding Opioid Abuse While Managing Pain

Avoiding Opioid Abuse While Managing Pain

Reviewed by Frederick W. Burgess, MD, PhD, Clinical Associate Professor of Surgery (Anesthesiology)

Frederick W. Burgess, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island; Rhode Island Hospital, Providence, Rhode Island;

Disclosure: Frederick W. Burgess, MD, PhD, has disclosed no relevant financial relationships.

Avoiding Opioid Abuse While Managing Pain.
Lynn R. Webster, MD and Beth Dove. Sunrise River Press Copyright: 2007 Pages: 202 ISBN-13 978-0-9624814-8-2 Price: 24.95 US Dollars

Opioid analgesics represent one of our earliest and most effective therapeutic classes of medication. Despite their recognized efficacy, the opioids have historically been subjected to periods of widespread availability and abuse, followed by periods of excessive governmental restriction and legal oppression. Medical professionals have struggled, and still struggle, to determine the proper balance between the potential for opioid abuse and the need for compassionate analgesia.

Dr. Lynn Webster, a distinguished researcher and clinician specializing in pain medicine and psychiatry, and his associate, Beth Dove, a medical writer, have created a very useful compilation of information relating to the issues of pain treatment and the potential for opioid abuse and drug diversion in their text: Avoiding Opioid Abuse While Managing Pain. Dr. Webster is a recognized leader in the field of pain medicine and is noted for significant contributions to the pain medicine primary literature. Their text deals with a very timely topic, of considerable interest not only to pain medicine specialists but of great clinical relevance to primary care physicians engaged in the treatment of patients suffering from persistent pain conditions.

Avoiding Opioid Abuse While Managing Pain offers a concise overview of the overlapping issues of opioid abuse, the neurobiology of addiction, the assessment and monitoring for opioid abuse, and the legal ramifications of opioid prescribing. The text is concise, easy to read, and well organized. Numerous tables, figures, and graphic illustrations are included, emphasizing important points and pathways in addition to the reproduction of several diagnostic screening tools. Unfortunately, some of the graphics appear to have originally been designed as color slides and lose some of their clarity when reproduced in gray-scale for the text.

Webster and Dove open the book by defining many of the terms specific to addiction and drug dependence. The first chapter highlights the recent upsurge in prescription opioid abuse and accidental prescription drug overdose deaths, which appears to correlate with, but cannot be directly attributed to, the increased prescribing of opioid analgesics.

Based on current data, the greater availability of prescription opioids within the community may be providing increased opportunity for opioid diversion. One important point emphasized by the authors is that abuse and addiction are not synonymous; opioid abuse may be medically appropriate, in the sense that the patient may be using the medication to self-treat pain, but it qualifies as abuse if the medication was not prescribed to this individual.

For example, many teenage girls will use hydrocodone obtained from parents or friends to self-medicate a headache. They are not addicted or abusing it in the sense of “getting high,” but simply using it to relieve their headache pain. However, from a strictly legal standpoint, this type of use is regarded as drug abuse. Much of the data published on this topic has used this type of definition. It tends to inflate the numbers of college students “abusing” drugs, but it is the accepted definition.

In the next chapter, the authors provide a general review of the current research on the neurobiology of addiction. The information presented cites many of the current developments in our understanding of addiction, but it may leave the reader more confused than enlightened. The problem is not with Webster and Dove's presentation; rather, it reflects the current lack of a unifying theory of addiction. Considerable advancements have been made in the field, but the manifestation of addiction is a complex mix of various genetic elements, environment, and drug-specific effects.

Webster and Dove go on to examine patient-specific behaviors as indications of opioid abuse patterns. Medication use behavioral patterns must be assessed and charted, much as any sign or symptom, and used to evaluate treatment response. The concept of a “trio-diagnosis” is proposed to account for the interactions between pain, psychiatric disease, and substance abuse.

The authors note that no single medical or mental health condition can be addressed independently and have a reasonable expectation of success. Comorbid diagnoses of substance abuse and psychiatric disease and pain are frequently manifested among patients with low back pain and in many other pain conditions. The 3 are often interrelated and may require the involvement of other medical specialists to obtain the best response. Simply prescribing an opioid to relieve pain has the potential to aggravate the other coexisting conditions.

Chapters IV and V of Avoiding Opioid Abuse While Managing Pain are devoted to identifying and assessing the risk factors that may contribute to opioid abuse. There is no single risk factor or screening tool that will uniformly identify a patient as a poor risk for opioid therapy. The main value of assessing these risk factors and applying an assessment tool lies in identifying which patient will require the greatest amount of supervision and careful ongoing monitoring for substance abuse.

Webster and Dove also present the advantages and limitations of several screening tools. They note that many of the early screening tests employed were specifically designed to diagnose alcohol or substance abuse and were not intended to assess patients employing opioids for pain. However, several new opioid-specific screening tools, such as the Opioid Risk Tool, the Screening Instrument for Substance Abuse, and the Prescription Drug Use Questionnaire, are reasonably fast and easy to administer. These tests will be useful in aiding physicians in developing a risk assessment protocol for their practice situations, to stratify patients according to their potential liability for addiction and substance abuse. As the authors point out: “the goal is not to deny pain treatment to any patient, but to set and maintain a level of monitoring proportionate to the individual's risk.”

Chapter VI provides a number of specific methods for monitoring patients treated with opioid analgesics. Several factors are essential to avoid opioid abuse and diversion, some as simple as meticulous record keeping, a comprehensive history and physical assessment, continual re-evaluation and documentation of response, or lack thereof, and the use of an informed consent and treatment agreement signed by the patient. It is important to spell out the risks of chronic opioid therapy to the patient, provide standards of behavior relating to medication use, and delineate the patient's obligations to adhere to the agreed treatment protocol.

This chapter also delineates recommendations for monitoring and prescribing guidelines dependent on the perceived risk of opioid abuse/diversion risk for individual patients. It is essential that physicians prescribing opioids accept responsibility for both treating pain and avoiding harm that may be associated with their patients' abuse or diversion of opioid analgesics. Ethically and legally, the physician has a societal responsibility to evaluate and continually monitor for inappropriate opioid use.

The concept of a balanced approach to pain treatment and substance abuse is further elaborated in the next chapter. The perceived and real competing interests between appropriate pain treatment and the governmental focus on the war on drug abuse continue to inspire fear of prosecution among physicians.

The recent struggles between the pain medicine community and the Drug Enforcement Agency on how best to obtain balance have not provided a sense of confidence in the community. The authors have attempted to provide a guide to avoid legal scrutiny, but, realistically, there are no rigid criteria that can be uniformly applied to guard against it. Once again, the use of careful monitoring and documentation is the best approach. The book concludes with an overview of future directions targeting drug development and pharmaceutical delivery systems designed to minimize abuse potential.

Webster and Dove's Avoiding Opioid Abuse While Managing Pain will be a useful addition to the bookshelves of any physician or other healthcare provider engaged in the care of patients treated with opioids for persistent pain conditions. Increasingly, primary care physicians are responsible for treating patients with opioid addiction and persistent pain. This text will provide the necessary tools to develop treatment protocols for monitoring and documenting a careful program to assess the efficacy of chronic opioid therapy and minimize opioid abuse.