Many colleagues struggled to square the brazenness of Salerian’s conduct with the thoughtful physician they thought they knew. But clues to another side of the doctor—explosive, attention-craving, defiant—were hidden in plain sight.
In his first year as a resident at GW, Salerian openly mocked a renowned expert on narcissism, who later bristled to the program director, “Where do you get your residents?”
At the Metropolitan Psychiatric Group, Salerian needled what he called his “lily-white colleagues” by treating psychotics, schizophrenics, blacks, and the poor—people who deviated from the stock clientele of affluent women suffering what he dismissively dubbed “Bethesda Wife Syndrome.”
The board exams in psychiatry are a mark of professional distinction. But Salerian failed them and never tried again: “I began disagreeing with psychiatry,” at least as currently practiced, he says. “It slowly began occurring to me how different my thinking was.”
Salerian saw his reputation for controversy as the calling card of an original mind. He sought patients whom other colleagues couldn’t handle or wouldn’t touch, then gave them treatments other doctors wouldn’t. In the 1980s and early ’90s, when most psychiatrists were still analyzing patients on couches, he began prescribing newly approved drugs in unorthodox combinations, in search of experimental, “off label” treatments, sometimes for conditions outside his field.
His willingness, even eagerness, to prescribe exotic drug cocktails endeared him to many patients, particularly those in the grips of despair. A Chevy Chase woman whose brother is bipolar says they’d visited specialists in DC and New York before a doctor referred them to Salerian in 2000. For years, her brother refused pills that doctors said he needed to get better. Salerian was the first to break through. He patiently explained how the brain worked, never charging for the extra time, and drew sketches showing how pills helped. “From our family’s perspective,” she says, “Dr. Salerian saved a life.”
But his pharmaceutical cocktails made even his admirers nervous. “They were very unusual combinations of medications,” says Carl Gray, a Rockville psychiatrist who sent Salerian some of his toughest patients.
Laurence Greenwood, a psychiatrist in Prince George’s County, remembers seeking out Salerian for advice about a relative with intractable schizophrenia. Salerian suggested the stimulant Ritalin, an ADHD drug traditionally thought to aggravate psychosis. The relative’s doctor balked: He wasn’t comfortable turning his patient into a test subject. “Nor would I have been as a doctor, because as a doctor I’m being cautious,” Greenwood says. “But as a patient, a family member, where the quality of life of a whole family is being severely disturbed by the patient’s suffering, it would be a very reasonable thing to try. In a sense, I wish I had Alen’s courage.”
Bernard Vittone, who directs a prominent mental-health clinic in DC’s Foggy Bottom and has known Salerian for decades, puts it another way: “He has some traits you could view as being admirable or very reckless.”
• • •
After the Hanssen affair, George Washington University cut Salerian loose and the Psychiatric Institute declined to renew his hospital privileges. He and the drug companies whose pills he promoted parted ways.
The Maryland medical board issued an excoriating ruling that accused Salerian of “gross” ethics violations in the Hanssen case. The doctor, the board wrote, seemed to have “a perception of self so grandiose as to raise concerns about his judgment.” Remarkably, the Maryland and DC medical boards let Salerian off with a reprimand and fines of just $8,500.
The ruling barely broke his stride. Salerian remained a regular on Channel 9 and kept up a busy practice, where patients who remembered his TV appearances now felt they were in the hands of a highly sought-after psychiatrist.
But things were getting strange. In 2003, Salerian self-published a glossy book of cartoons called Honest Moments With Dr. Shrink. Though pitched as a satire of psychiatry, the cartoons—pastel-crayon doodles that call to mind a grade-school art fair—were at best cryptic, at worst racially charged and sexually vulgar. “Doc, please help me find my G spot,” a woman shaped like an eel says on the first page. “Who saw it last?” says Dr. Shrink, who’s drawn in the shape of a refrigerator.
Honest Moments was followed by a Salerian line of vitamins. Then came a deepening preoccupation with John F. Kennedy’s assassination, research trips to Dealey Plaza, and a torrent of more than 200 JFK-inspired paintings that he exhibited in Dallas and DC.
Salerian found another canvas for his creative impulses on the lawn outside his office. Pronouncing the landlord’s landscaping “bland,” he turned the empty sod into a statue garden, complete with a rooster figurine, a fountain ringed by 24 lion heads, and a giraffe he named after his son Justin. He told the Washington City Paper at the time that the installation was a whimsical welcome mat meant to “make neuropsychiatry accessible.”
Inside Salerian’s office, however, some longtime patients felt unsettled. A Maryland woman recalled her unease when a large oil painting depicting a nude couple in the throes of coitus went up in the waiting room. Once-brisk appointments turned into drawn-out bull sessions about the doctor’s art and his latest JFK findings. “When you went to see Dr. Salerian, you took the whole day off,” one patient says.
The most extraordinary shifts were inside the exam room. A growing number of patients were traveling great distances for another new sideline: addictive narcotic painkillers such as OxyContin, methadone, and Fentanyl.
The doctor appears to have embraced the drugs soon after Cacheris fired him from the Hanssen case and just as the first major news stories about OxyContin’s dark side broke. The pill, approved by the Food and Drug Administration in 1995, was the first made of pure oxycodone, a powerful derivative of the opium poppy. It was formulated to dissolve in the body over 12 hours, but people found they could ingest the oxycodone all at once by crushing the pill and then snorting or injecting it. The euphoria gave the drug street value and the nickname “hillbilly heroin.”
Narcotic painkillers, typically prescribed to cancer patients and others in severe physical pain, have no FDA-approved psychiatric uses. But Salerian wanted to blaze a new frontier. “I have prescribed OxyContin to more than 200 of my patients, and none of them has become addicted,” he boasted in a 2002 op-ed in the Indianapolis Star. He said he’d used the drugs to treat not just physical pain but also depression.
It had been at least a half century since doctors had tried anything of the kind. Though physicians in the 1800s had given opium derivatives such as morphine to people with “melancholia” and other ailments, by the 1950s scientists had produced the first class of modern antidepressants. They were more effective and had fewer side effects than opiates and were not addictive. To tout opiates for depression now would be somewhat like prescribing arsenic and mercury for syphilis, decades after the invention of penicillin.
• • •
Salerian’s faith in the power of painkillers springs from something he calls the Salerian Theory of Brain. This “new paradigm,” he wrote in a non-peer-reviewed medical journal, would do to the foundations of modern psychiatry what Galileo did to “Ptolemaic assumptions about the celestial movements.”
The theory’s narcotics bit goes something like this: Endorphins, our bodies’ natural opiates, are necessary for healthy brain chemistry and good mood. People with too few endorphins—a group that in Salerian’s view includes drug addicts—can get right, he believes, by taking super-sized doses of manmade opiates like OxyContin.
As his colleague Bernard Vittone put it, Salerian was “operating in universes I’ve never even seen.”
Yet the doctor had nearly absolute faith in his patients. Though he often prescribed OxyContin at three times the recommended doses, he refused to subject patients to common safeguards against abuse and dealing. “Any doctor who creates these monkey, Mickey Mouse forms and forces you to give drug urines,” he told an internet radio show, “is actually raping Hippocrates.”
The test subject for his opiate cure, Salerian says, was a severely depressed, drug-addicted railroad worker named Paul. Over a series of hospitalizations in the mid-1980s, Salerian used conventional methods to wean Paul off an addiction to Fiorinal, a non-opioid painkiller and muscle relaxant.
But in the 1990s, after traditional depression treatments failed, Salerian says he ceded to Paul’s request for Percocet, a narcotic painkiller. Salerian rhapsodized about the results. Though forced into a disability retirement, Paul discovered true pleasure in a new car and in vacations with his wife, Salerian insists. (Paul’s wife disputes Salerian’s account.) All the same, in the spring of 2001, Salerian added another pill to Paul’s drug cocktail: OxyContin. The next year, another: Fiorinal, the very drug Salerian had detoxed Paul from a decade and a half earlier. Paul grew addicted again, this time to the active ingredient in OxyContin. In 2004, his wife filed a complaint with the DC medical board about Salerian’s narcotics experiments, but it didn’t do her any good. She became a widow in 2005, when Paul bled to death from an undiagnosed intestinal ulcer.
Four years later, in January 2009, the DC medical board said there wasn’t sufficient evidence of misconduct and dismissed the case. Salerian, who spent $750,000 on an elaborate defense, says he took the ruling as both exoneration and endorsement. He changed the name of his practice to the Salerian Center for Neuroscience and Pain and felt that his scientific revolution was finally under way. “It was a dream,” he said later. “My march began.”
By February 2010, another patient was dead.
Patrick Kennedy—or Paddy, as his family called him—was a quiet but playful kid who began taking illegal drugs his sophomore year at Bethesda–Chevy Chase High School. In college he grew depressed and worried he might be succumbing, as had his mother, to schizophrenia.
His elder brother took Paddy, then 20, to see Salerian, with whom their family had had good experiences in the past. Salerian gave Paddy an on-the-spot diagnosis of obsessive-compulsive disorder, attention-deficit disorder, and phobia—and a prescription for methadone, a narcotic approved only for chronic physical pain and for heroin maintenance and detox therapy.
Because it can slow breathing, the medical rule of thumb for methadone is start low, go slow. Salerian wrote Paddy a dose above the manufacturer’s guidelines, believing it would boost his dopamine, a neurotransmitter that helps regulate motivation and pleasure-seeking.
The day he took his first pill, Paddy sent his family an effusive e-mail. “Dr. Salerian has given me new hope,” he wrote.
Two days later, his father, Steven Kennedy, an editorial consultant, cooked a dinner of beef-and-barley soup and settled onto the couch with his son for an episode of House, the TV drama about a drug-addled doctor with a genius for diagnosis. Before the show was over, Paddy complained about his vision. “My eyes feel out of focus, Dad,” he said and went to bed.
When Paddy was still in bed at 11 the next morning, his father went in and found his son’s body pale and rigid. Blood had pooled in purple blotches under his skin, a sign he’d probably been dead for hours. Detectives counted the remaining methadone pills: There was no indication he’d taken more than prescribed. The Virginia medical examiner ruled the death an accidental overdose.