Medication Missteps

As more details about the late Supreme Court Chief Justice William Rehnquist's battle with prescription medication have emerged, they have focused new attention on how doctors prescribe and monitor people who take potentially addictive drugs.

Declassified documents released by the FBI this week paint a picture of an esteemed and learned man who nonetheless fell prey to a long-term debilitating habit while he was a Supreme Court justice during the 1970s. In 1981, five years before he became chief justice, Rehnquist was admitted to George Washington University Hospital for a month in order to be weaned off prescription drugs. During his hospital stay, according to the documents, Rehnquist experienced paranoid delusions and tried, at one point, to escape from the hospital in his pajamas. Shortly before he underwent the treatment his family described him as having a longstanding problem with "slurred speech."

And no wonder. The FBI reports that Rehnquist was already taking the powerful hypnotic ethchlorvynol—marketed as Placidyl—to treat insomnia when, in 1972, he came under the care of a Capitol Hill doctor (whose name was redacted from the report). Subsequently, Rehnquist's dose of the powerful drug as much as tripled to 1,500 milligrams per day. He began taking a pill before retiring and a pill if he woke once or twice during the night. At the same time, the jurist was also taking Darvon, a narcotic, and Tylenol 3, prescribed by another physician to treat chronic back pain.

Back then, prescription drug abuse was nowhere near the problem it is today. There are simply more drugs available now, says Dr. Nora D. Volkow, executive director for the National Institute of Drug Abuse, and physicians often lack the training to properly administer them. "Doctors don't know how to evaluate patients and they don't know how to get honest responses from them about their drug use," she says. Although increased public awareness has helped— former First Lady Betty Ford famously opened her clinic in 1982—for the most part, says Volkow, patients often mistakenly assume that if a doctor is prescribing a drug then "they can't get addicted." According to the U.S. government's 2004 National Survey on Drug Use and Health, the most recent study available, 6 million people—some 2.5 percent of the population over the age of 12—have abused prescription drugs.

Physical dependence is not always a sign of addiction. Dependence indicates that an individual has been exposed to a drug at high enough doses for long enough to develop a tolerance for it. Addiction is a neurobiological syndrome that can include physical dependence, but is characterized by craving, loss of control and compulsive use—even when the users knows it is causing them harm. Addiction is typically treated with behavioral intervention, drug treatment in the case of methadone, or a combination. Although it is not clear if Rehnquist's drug problem affected his judgment, doctors who treated him told the FBI that toxicity from Placidyl might result in blurred vision, slurred speech and difficulty in moving.

In the FBI report, the doctor who helped Rehnquist get off drugs said the justice's family blamed the prescribing physician and the pharmacist and suggested that they were intimidated by high-ranking government officials. Dr. Russell Portenoy, chairman of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York, says Mrs. Natalie C. Rehnquist may have been right. With an estimated 70 million Americans in chronic pain, Portenoy believes that every kind of doctor—including primary care physicians—should know how to identify patients who may have addictive tendencies and intervene if they think their patient has developed a problem. Warning signs? When patients up the dosage rates without medical supervision, experience cravings or get prescriptions from a variety of physicians (a practice known as doctor shopping.)

But Portenoy knows it's not easy—especially with a VIP. "I have some sympathy for the doctor" who was treating him, he says. "The doctor realizes that an esteemed scholar, a person of high personal wealth or a head of a major corporation has been engaging in significantly problematic drug-related behavior," such as Rehnquist exhibited. "The reality is, it can be difficult for a physician to handle." Unfortunately, what was true 30 years ago is still true today.