Practice of Medicine

Claims Lesson

Overdose Death Results in Allegations of Negligence

August 3, 2015

The Case:

The patient presented to the clinic with complaints of back pain in August.  The physician prescribed Lortab 7.5/500 #36 with one refill. The prescription was refilled in January.  Following the January office visit, the physician saw the patient on six separate office visits between February and August and prescribed a total of six hundred and sixty (660) dosage units of Lortab and ninety-one (91) dosage units of Soma for complaints of pain ranging from a fall in the snow to lifting furniture, to leg and low back pain.

At the last visit in August, the physician documented he advised the patient to start weaning off all pain medications. He prescribed #120 dosage units of Lortab 7.5/500 and #30 dosage units of Soma 350.

Four days later, while traveling out of state, the patient overdosed on prescription medication and died. The medical examiner indicated the death was caused by the effects of multiple drugs.

Over the twelve month treatment period, the physician did not obtain radiological exams, offer other treatment modalities such as trigger point or spinal injections, make a referral to a pain management specialist, or create his own treatment plan. The treatment focused on opiates, muscle relaxants, and antidepressants. Random drug screens were not performed.

Allegations:

The following allegations were made against the defendant physician:

  • The physician breached the standard of care by prescribing excessive amounts of hydrocodone and acetaminophen
  • The failure of the physician to adhere to the standard of care was the cause of her death.

Disposition:

Based on limited defense support, the case was settled for a moderate amount of money.

 

Patient Safety Discussion:

Experts opined the physician’s workup was inadequate to establish a reasonable diagnosis and to determine the etiology of the pain. Further, they noted the physician failed to use a multimodality approach, which includes an opiate sparing regimen, physical therapy, or other therapeutic interventions. Experts also cited the physician’s failure to perform random drug testing. 

According to the Centers for Disease Control and Prevention, drug overdose was the leading cause of injury death in 2013.1Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes.[1]“Of the 22,767 deaths relating to prescription drug overdose in 2013, 16,235 (71.3%) involved opioid painkillers, and 6,973 (30.6%) involved benzodiazepines.”[2]

This alarming number of deaths has prompted many state medical boards to develop guidelines and rules related to managing patients with chronic pain and guidelines for the use of opioid analgesics. The guidelines and laws for pain management and the use of opioid analgesics vary from state to state. Contact your medical board for state-specific guidance. If you hold licenses in more than one state, review the policies in each state for which you maintain active licensure.

The Federation of State Medical Board’s published a model policy that many state medical boards have used as a framework for their treatment of chronic pain and opioid use policies: Below is summary of the guidance.[3]

In the initial work-up, include, at a minimum, a review of systems, a relevant physical examination, laboratory investigations, social history, screening for substance abuse  (including alcohol), and depression. Obtain records from all other providers involved in the patient’s care.

  • Develop the treatment plan early, revisit it regularly, and include individualized goals. The treatment plan should support the selection of therapies, both pharmacologic and nonpharmacologic.
  • Participate in shared decision making with the patient. Discuss the risks and anticipated benefits of chronic opioid therapy.
  • Other risks may include, but not limited to tolerance, dependence, over-sedation, impaired motor skills, and addiction. Pay particular attention to drugs with Black Box warnings. Use of a treatment agreement is recommended.
  • Present opioid therapy to the patient as a trial and carefully monitor for benefit and adverse events.
  • At each visit, monitor the results of the chronic opioid therapy by assessing the “5As” of chronic pain management; Analgesia (reduction in pain), Activity (level of function), Adverse effects, Aberrant substance-related behaviors, and Affect (mood).
  • Perform periodic drug testing to monitor adherence to the treatment plan and to detect the use of any non-prescribed drugs.
  • Seek consultation or refer patients to a pain, psychiatry, addiction, or mental health specialist as needed.
  • The potential benefits and risks should be weighed throughout the course of opioid therapy to determine whether such treatment remains appropriate.
  • Utilize the prescription monitoring program.

[1]Centers for Disease Control and Prevention.Injury Prevention and Control.http://www.cdc.gov/drugoverdose/data/overdose.html.   Accessed July 30, 2015

[2]3Centers for Disease Control and Prevention.Web-based Injury Statistics Query and Reporting System (WISQARS).http://www.cdc.gov/injury/wisqars/fatal.html.  Accessed July 30, 2015.

[3]Federation of State Medical Board.Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain. Washington, DC: July 2013

 

The case report presented is a composite drawn from MagMutual’s case files. Any similarity to a specific case is both coincidental and unintended.

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.