Pub. 2 2018 Issue 1

CASE HISTORY: Death from Acute Oxycodone Intoxication Results in Large Settlement I n 2011, a family practice physician assumed care of a 42 year-old male patient. The patient had a history of a left knee arthroscope and fracture of the right ulna. In addition, the patient reported a major depressive disorder, panic attacks and ADHD which were being treated by a psychiatrist. The patient presented for his first appointment complaining of pain following a recent orthopedic surgery to repair his right ulnar fracture. He explained he had been taking ibuprofen and Vicodin (hy- drocodone and acetaminophen) but had run-out and was experiencing insomnia due to pain. He was scheduled to see his orthopedic surgeon the next week. The patient also complained of nausea due to the Adderall, which he was taking to ameliorate his ADHD symptoms. The physician prescribed 90 Vicodin tablets with instructions to take one tablet three times a day, as needed and Phener- gan (promethazine) one tablet per day, as needed for nau- sea. The physician further instructed the patient to only ob- tain pain medication from him, not to exceed the prescribed dose of three times a day, and the plan included weaning the patient off the Vicodin the next month. Over the next four years the patient was seen almost every month or two with an ongoing diagnosis of chronic pain in his right wrist as a result of the ulnar fracture. During this time the patient experienced several significant family issues including a contentious divorce and loss of custody of his children. In addition, his employment status changed and he lost his health insurance. He was unable to continue care with his psychiatrist. At almost every visit he was prescribed Vicodin or Percocet (oxycodone and acetaminophen). Additional medications prescribed by the family physician included temazepam, lorazepam and a variety of antihistamines. During this four year period, the family physician and patient had several discussions regarding referral to a pain management specialist. However, the patient consistently refused the referral. In early 2015, the patient was seen for a routine visit. He was experiencing several social stressors and was starting a new job. He reported continued insomnia which he managed by alternating trazodone and zolpidem each night. The patient was back under the care of a psychiatrist. The physician “advised caution w/ meds” and recommended he continue seeing his psychiatrist. Six days after the visit the patient was found in his home, unresponsive, lying on his couch. The time of death was estimated to be four days prior to the discovery of his body. There was no suicide note and no other evidence of a deliber- ate overdose. The post-mortem blood test was positive for oxy- codone and its metabolites, noroxycodone and oxymorphone. 1 The oxycodone levels measured by the medical examiner were consistent with a lethal dose. Blood tests also were positive for lorazepam, zolpidem, norchlorcyclizine, diphenhydramine, dox- ylamine, and promethazine. However, these drug levels were either normal or not extraordinarily high. The cause of death was reported as acute oxycodone intoxication. 33 |