The last week hasn’t been a very uplifting one for psychiatrists who pay attention to the news. For as much as we complain about shrinking reimbursements, the undue influence of Big Pharma, and government meddling in our therapeutic work, we psychiatrists now have two new reasons to be concerned.
And, maybe, to lawyer up.
I. APA Threatens Blogger
Most readers who follow this blog will certainly have seen this story already, after first being reported in Allen Frances’ Psychology Today blog. So I know I’m just preaching to the choir here, but frankly, in my opinion, this story cannot receive too much attention.
As you probably know, American Psychiatric Publishing, a branch of the APA, threatened to sue a British blogger, Suzy Chapman, for her blog “dsm5watch.” They argued that the use of “dsm5” in her blog title constituted trademark infringement. She has moved her content to “dxrevisionwatch” and describes her reasons for doing so here.
I had been following the “dsm5watch” blog since February 2011 via my RSS feed, and have linked to its content in some of my posts. It was first launched way back in December 2009. I thought it was a fair, balanced way for readers to keep abreast of the DSM-5 development process (for a while, I actually thought it was published by the APA!!). Granted, many of the posts were about CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis), and the blog often mentioned the DSM-5 controversy, but nothing that hadn’t been published anywhere else.
In my humble opinion, shutting it down was simply a misguided, heavy-handed move by the APA. Why “misguided”? As psychotherapist and author Gary Greenberg wrote in his blog Thursday, “the APA is a corporation that, like any other, will do anything to protect itself from harm…. And it spends a lot of time imagining dangers.”
Suzy Chapman, congratulations, you are the “bad object” of the APA’s paranoid projection.
This entire fiasco has the potential to become a huge embarrassment to the field of psychiatry. I guess I can understand why the APA might wish to protect its intellectual property, but the idea of “picking on the little guy”—especially when the “little guy” is simply keeping readers informed about developments in our field of (supposedly) intellectual, scientific endeavor—makes me ashamed to think that these men and women speak for me.
II. Patients Sue Doctors for Creating “Valium Addicts”
This article, too, has made the rounds on several blogs and news sites, and while it was published in a UK tabloid well-known for several anti-medication stories in the past, I think the message it sends is an important one.
Benzodiazepines, or “benzos” (which include Valium, Xanax, Klonopin, and Ativan), are some of the most widely prescribed drugs in the US and Great Britain, and among the most addictive. Tolerance to the anxiolytic effects of benzos develops very rapidly, so people often request higher doses; but overdose can be deadly due to respiratory depression, and the withdrawal syndrome—which can include seizures and delirium—can also be life-threatening.
Benzos have been popular since the 1960s. They replaced the barbiturates, made popular by the Rolling Stones as “Mother’s Little Helpers” back in 1966. Their rapid onset and calming effect—much like that of alcohol—and their ability to potentiate the effects of other drugs, like opiates, often leads to use, abuse, and addiction.
[Not to get too tangential here, but last week’s episode of “Real Housewives of Beverly Hills” (hey, it’s one of my wife’s favorite shows, and we have only one TV) featured Brandi in a Xanax-and-alcohol-fueled daze, enjoying a mai tai with her girlfriends at a Lanai resort. Oh, and she had trouble keeping her right nipple in her cocktail dress. Is it any wonder why people request benzos by name???]
Anyway, to get back on track: Benzos are effective drugs. And their utility and versatility—not to mention their street value—gives them a cachet that’s hard to exaggerate. More importantly, the potential dangers, which are compounded in patients with a high tolerance, mean that they really should be prescribed for very short intervals, if at all.
But the responsible use of benzos requires effort on behalf of the prescriber. It takes time to explain to the patient the risks of tolerance and withdrawal. It also takes time to teach other methods of managing anxiety. Doctors (and, increasingly, patients) just don’t have that kind of time—or don’t want to find it. Moreover, they (we) find it difficult to say “no” to patients when they describe something working so well.
Hence, it’s not uncommon for doctors to see patients taking 4 mg of Xanax or 8 mg of Klonopin daily, and still complaining of anxiety or restlessness or “jitteriness” and asking for more. Patients on these regimens rarely want to stop them (even when told of the long-term dangers), and when they do, the withdrawal process is not one to be taken lightly. (The Ashton Manual—available online—is the authoritative resource for managing benzo withdrawal.)
Do I believe it’s fair to sue doctors who turn their patients into “benzo addicts”? That’s a difficult question, particularly because of the tricky nature of the word “addict.” If we instead talk about making patients physically dependent on benzos, then the question can be reframed as: Should we blame doctors for creating a physiological state in a patient which has the potential to be life-threatening if not managed properly?
Before answering “Hell yes!” it must be understood that just about everything we do in psychopharmacology (if not all of medicine) “has the potential to be life-threatening if not managed properly.” The real issue is, how likely is an adverse outcome, and how well does the doctor manage it? Of course, there’s also the question about whether the patient bears any responsibility in the overuse or abuse of the drug. But even if a patient knowingly takes more than what is recommended and the doctor knows this, it is the doctor’s responsibility to respond accordingly.
In my book, there’s no excuse for the indiscriminate prescribing of benzodiazepines. There’s also no excuse for abruptly discharging a heavy benzo user from one’s practice, or “dumping” him on a public clinic or detox facility. (Trust me, this happens A LOT.) Whether a doc should be sued for this is not my area of expertise. However, I think it is good that attention is being drawn to what is, in the end, just bad medicine. Hopefully the systems in place that foster this sort of care—inadequate medical education, poor reimbursement for therapy, emphasis on medication management, and arbitrary insurance-company regulations that limit access to more effective treatment—can be changed soon.
But I’m not holding my breath. I’m calling my attorney.
Thank you for helping to spread Suzy Chapman’s story.
Now, as to benzos: Try this thought experiment:
You wake up today and benzos are available OTC. They always have been. They were banned briefly in the 20’s but it just didn’t work out – too much organized crime.
You have to be 18 to purchase benzo’s. There are stiff, enforced penalties for driving intoxicated on benzos.
Everybody knows the dangers. Everybody. Children are taught to take benzos in small quantities, and for very short periods only.
AH, but benzos are DIFFERENT! You shout. No they’re not.
I think the point you are making Rob absolutely spot on! Instead we have Doctors who like to prescribe benzos and than pull the rug out from under your feet.
Rob, You stated “Everybody knows the dangers. Everybody.”
That statement is so ridiculous… You just aren’t too bright, are ya! That makes you sound like an educated fool,,, or maybe an uneducated fool,, whichever, pick one. A fool is a fool.
Ad hominem as a substitute for argument?
I actually have a regimen I devised. I was prescribed valium as needed. But I saw Dr. Drew on TV say that no one should take benzos for more than five days…What does that mean? 5 days a week, year, month? I made it mean a month for me. If I need something regularly, then I also have a prescription for beta blockers that I can take more long term. But I devised that schedule on my own. Two doctors have prescribed me benzos and neither discussed risks or addiction potential with me.
I don’t know that I agree with Rob about making Benzos over the counter…but I do agree with him that everyone should be well informed of the dangers. I think that is one thing we can thank Amy Winehouse for. I remember when she died of “alcohol withdrawal,” Dr. Drew thought that sounded like BS. And then he said he was glad that more attention was being brought to the dangers of alcohol withdrawal, but people who die from alcohol withdrawal do not die like Amy Winehouse did. He also thought there were drugs involved. Obviously, Dr, Drew needed to keep his opinions to himself. But he called it before anyone else did. She chased librium with alcohol, so he was right. And then Dr. Drew got appalled when he found out she had been on the drug for 2 months (I think it was), so she could detox from alcohol addiction–which he thought was way too long.
But here was the scary thing for me. People didn’t get how dangerous the librium was. Her dad went on TV and stuck up for her by saying drugs were not involved in her death, there was only librium in her system, that’s normal for someone detoxing…It’s really shocking how little the Winehouse family knew about addiction. They thought she was on them so she could safely withdraw, and they didn’t see the addiction potential. Even her fans were saying, “See it was librium in her system! Drugs didn’t kill her! Librium is used to discontinue drugs!”
Sigh. Maybe with her death (loved that singer), people are better informed. It’s just sad that her death prompted this, and it wasn’t the effort of doctors to inform the public.
The lawsuit over benzodiazepines is one that involves holding the medical profession accountable.
And civil courts (in some cases, criminal courts) are an appropriate way to do so.
The lawsuit against the blogger is the classic case is about power and control, and keeping someone from presenting the facts.
The common denominator for both of these cases is harm. In the case of benzodiazapines, it’s an attempt to limit harm by holding practitioners accountable. In the case of the APA against a blogger, it’s an attempt by a powerful group to prevent harm by limiting speech… by stopping someone from presenting the facts.
The benzo case makes perfct sense.
The blogger versus the APA is nonsense.
Two more quick points –
1) Medical practitioners are licensed. They are regulated by the states in which they practice. As it should be.
2) The blogger’s speech is political. It is, in the truest sense, “free speech.” Here’s why: The DSM labels have legal implications. They restrict people, take freedom away… For instance, try getting a pilot’s license after an ADHD label; try joining the military after a label of severe mental illness… There was an attempt a few years back to take away the right to vote in Virginia based upon a psychiatric label, and of course there is the constant threat in many states of “forced outpatient treatment” . Political speech is “free speech” and cannot be restricted. Going after the DSM task force with a blog is free speech. Period.
Duane, I agree with you. Free speech, by law, cannot be silenced. Someone wrote elsewhere that if Suzy Chapman wanted to challenge the SLAPP lawsuit, she’d most likely win, for that reason. But she was bullied (for lack of a better word) into jumping ship.
As far as the benzo case goes, I agree with you there, too. But let me play devil’s advocate for a moment. Setting aside what we might learn on some future date about the long-term effects of our treatment, the “community standard” in medicine is generally accepted as the standard for negligence (see Bolam vs Friern Hospital, 1950s). Despite what you and I (and Mara, and Dr. Drew, and the late Amy Winehouse, now) know about benzos, the standard of care is, unfortunately, long-term benzo use. Not that I agree with it, but that’s the way it is. And most people don’t die. Of benzo misuse, that is.
The reason plaintiffs are filing class action suits against makers of branded drugs like Seroquel and Risperdal is because (a) they allege the adverse effects of those drugs were deliberately hidden from doctors, and (b) those drug companies have very deep pockets. Benzos are different because (a) no drug company “markets” them anymore, docs learn about them from textbooks and peers, and (b) they’re generic, so no manufacturer worth suing. Hence, patients sue the doctors instead.
Should patients sue the prescribers of Risperdal and Seroquel, instead of Janssen and AstraZeneca? Interesting question.
(Addendum: I should point out here my wife is employed by Bristol-Myers Squibb, maker of Abilify.)
I suppose the question will likely soon be answered.
Doesn’t the fact that benzos are scheduled drugs tip people off to the addictive potential? I find it kind of hard to believe that most patients would be unaware of this.
Any doc who makes an assumption like this instead of providing information should be sued. It’s their area of expertise, not the patients. Informed consent should be informed.
As someone who follows Suzy Chapman because I have ME I am glad to see this subject getting aired so widely.
But as ME causes muscle spasm I will not be giving up my Vallium any time soon – they are the only thing that allow me to sit upright at all.
Many years ago I was prescribed tincture of Opium, as an attempt to help my completely debilitating and dsiabling trigeminal neuralgia pain (that was constant as well as triggered – for those who know about tn). The amount was for an 8 ounce bottle. It was up to me to use it in the way prescribed, I think it was one teaspoon every 4 hours (many many years ago but my best example I think.) I could take more, knowing that opium can be addicting. My doc could warn me but he could not stand by me day and night to make sure I did not abuse it. (It did not help, took one teaspoonful and it turned out I was highly allergic to it. Never did decide if the mouse I swore i heard scratching all night was a result of a mouse of the combo of benadryl and opium.)
If the doc responds to the complaint : “I am still jittery” with additional scripts for the drug or keeps telling you to up the dose that sounds like malpractice but if you have made me aware of the dangers – and the pharmacist should also be keeping an eye on my refills and advising me on the possible risks (is he then liable also?) – I do not see where your legal liability lies. Knowing you are addicted then dumping you, that may be a legal liability.
Sue the makers of drugs when they do not give full disclosure of known risks (including addiction or even physical dependence) but it is on me, at the end of the day, whether I take my meds as prescribed or not. If I choose not to and suffer the consequences I only have myself to blame. (Then there is the issue of comparitive negligence. The names of many of these meds, valium for example, are known to the general population to be addictive. You have to have been spending all your life staring at exposed nipples not to have some knowledge about the risks of these meds.
Thanks again, Dr Balt, for your post on this issue.
On January 12, Allen Frances published a follow-up on his “DSM5 in Distress” blog, hosted at Psychology Today:
DSM 5 Censorship Fails
Support From Professionals and Patients Saves Free Speech
“Last week I described the plight of Suzy Chapman, a well respected UK patient advocate forced to change the domain name of her website by the heavy handed tactics of the publishing arm of the American Psychiatric Association. The spurious legal excuse was commercial protection of the ‘DSM 5’ trademark; the probable intent was to stifle one of the internet’s best sources of DSM and ICD information. This bullying could not have come at a worse time – just as final decisions are being made on highly controversial DSM 5 proposals and with the third and final draft due for release this spring. This is precisely when a ragged and reckless DSM 5 can most benefit from the widest and most open discussion…”
Read follow-up blog here:
“Suzy Chapman, congratulations, you are the “bad object” of the APA’s paranoid projection.”
:o) I’ll have it printed on a T shirt.
William Heisel has published a two part report, here, on “Reporting on Health”:
Part One, February 27, 2012
Slap: American Psychiatric Association Pressures Brit DSM5 Blogger Suzy Chapman
Part Two, February 29, 2012
Slap: American Psychiatric Association Targets One DSM5 Critic, Ignores Others
[…]Two New Ways To Get Sued « Thought Broadcast[…]…
I want to respond to:
“Patients on these regimens rarely want to stop them (even when told of the long-term dangers)”
This patient (me) was never told of the long-term dangers. Nor was my father who was present with me when I was prescribed Ativan.
This patient (me) has never been able to convince *psychiatrists* of the long-term dangers.
This patient (me) wants to stop the medication.
I was prescribed Ativan to take daily (2 mg) when I was 14 years old for anxiety. I am now 29 and take twice the dose I was originally prescribed. I am on two other psychiatric drugs I am trying to withdraw from before I start withdrawing from Ativan.
I don’t necessarily want to sue (I’d rather the psychiatrist pay back my school system for all the money they spent on my education that I now cannot remember like so much of the rest of my life). I am sick of the twilight zone I live in though where doctors don’t understand these medications as well as the patients trying to get off of them. The Heather Ashton manual you have mentioned? I have never been to a doctor who would even entertain the idea of looking at it. The doctors I have seen think you can withdraw from benzos within a matter of days or weeks or go in patient. I have had psychiatrist who believe the same medications used to treat opiate addiction would be suitable for benzodiazepine withdrawal. There is a simple and blunt problem: the psychiatrists I have known (and there have been a lot because they are transient, constantly quitting and finding other jobs or being fired, etc.) are not intelligent, or at the least intellectually curious. Most of them have difficulty speaking English. I don’t know if it’s the same everywhere in the country, but I live in southeastern Virginia. The psychiatrists I have seen have received degrees in the Caribbean or Pakistan. I am not xenophobic, but there is some sort of dearth of interest in psychiatry that attracts lesser qualified FMGs to this field.
I have never encountered a psychiatrist who has wanted to lower my dose of anything, quite the opposite. I have never found one who would agree to a Valium cross taper either. They usually chuckle and say, “Oh, no, no, you can’t be on both!” I have to try to explain that my intention is to go off the meds, but they can’t even conceive of the notion you would use one medication to go off another. I would have better luck explaining this to their secretaries who seem to be the ones doing any sort of intelligent interaction.
I work in tech support being paid a bit more than minimum wage. The knowledge base I am required to have is much larger than the sum of what a psychiatrist needs to know to prescribe or decide not to prescribe medications. If your one job is to know about medications, how they work, and when they shouldn’t and shouldn’t be prescribed, I get pretty angry when no one in the profession seems to be doing those simple tasks. I recently asked my psychiatrist about my withdrawal from Seroquel and had a question about its effect on histamine receptors. She squirmed in her seat. She has no idea how these drugs work.
And if I don’t know something at my job, I have to look it up. If a psychiatrist doesn’t know something, they say something that they think will sound right, examples I’ve heard include, “I don’t think the season is right to make a drug change. I usually have better luck with patients changing medication in winter.” Or: “Those studies are about British Ativan. In the United States Ativan isn’t nearly as addictive.”
Look at the fact that there are web-site by patients designed to help patients persuade their doctors to help them taper:
What does that say to you about the problem?
I have never met anyone online through support communities who has withdrawn with the encouragement or advice of their doctor. It is addicts helping addicts. The problem is ignored by the US government, and it’s ignored by psychiatry from what I can tell.
Even the author of this post acknowledges the best guide for withdrawing comes from Professor Heather Ashton, who is not a psychiatrist.
Wouldn’t the field of psychiatry like to take credit for something besides writing a new DSM? I’d be grateful if they’d try to help solve some of the serious life problems they have caused for their consumers. Not help for the original situation—repair of the damage.
I have been on Konopin for nearly seven years for debilitating panic attacks and agraphobia. I also recently got diagnosed with ADHD. Before I took this drug, not to say that all benzos agreed with me because I had an adverse reaction to Xanax, fell dull and heavy with valium but Klonopin – to put it mildly – saved my life, allowed me to hold a decent job, allowed me to walk in an open atmosphere without fear, panic and continuous running to emergency hospitals for embarassing dismissals and contemptuous sighs of “panic (taking up precious hospital resources) attack”. That being said, I knew it was addictive because of my Internet research. I knew and now I especially know that I’ll be on it for the rest of my life. But never, never did any doctor explain the addictive qualities of Klonopin or how I might taper down sometimes and how that could be managed. Sometimes, when I was doing better, I would bring up the topic of cutting down weekends when not working. Well, I paid the doctor his/her fee for allowing me to do all the research grunt work. I have never had a Pschy who took health insurance. They do what they want, including asking me to go fishing, or telling me about their bad childhood, or whatever .. I ignore it and diagnose myself.
When will this contemptuous group of professionals ever become monitored or managed or watched. Because they are self-employed and, for the most part, never take health insurance, and work on their own in their private offices, they get away with much. And we poor sick individuals suffer the consequences.
I cannot tell you how much I appreciate your article on benzos. Here’s my story I’ve been with the same woman 23 years here in Hermiston Oregon we have a mental health facility called lifeways Mental Health Services in which my wife has been a client for many years I have repeatedly told their staff and prescribers that my wife cannot take klonopin without abusing it Klonopin has a paid a huge role in my life repeatedly going back to prison at one point I got so frustrated I went to OfficeMax and have them make me up $18 sign that red lifeways keeping people addicted to drugs I spent two weeks in the hot summer sun or on the sidewalk in front of lifeways Mental Health Services Good Shepherd Hospital is just across the street so I had many nurses and if you doctors stopped by and asked me what was going on I told them my story all of them were supportive shortly after this my wife went back to prison for 3 years evidently medical staff didn’t believe my wife should be on this drug either for they spent many months close to your Weiner or off Klonopin however my wife only lasted about 6 months before she went back into lifeways and said give me Klonopin and walk out with the prescription as you well know benzos Luther affecting this in a short. Of time so in just a few weeks my wife monthly Supply only gets her through a week or two so she’s out on the street looking to buy Klonopin from people that go to lifeways and get Klonopin for the sole purpose of selling it on the street. A few months ago I contacted Ellen pinney Oregon’s medical ombudsman I told her a little bit about my story she asked me to write down my wife complete history regarding Klonopin so I made my best effort to condense 23 years into a 6-page letter and send it to her I also sent it to Oregon Board of Nursing and a few other government agencies. Klonopin is killing my wife and has destroyed my marriage. If you would care to read my 6-page letter I would definitely fax it to you again thank you so much for your article and keep up the good work sincerely Ed Weems
[…] else. Additionally if the disbelieving doctor was the original prescriber, self preservation and fear of litigation may play an additional part in remaining blind to the patient’s […]