Risk Management Tools & Resources


CASE STUDY: Patient Overdoses and Dies After Inappropriate Opioid Prescribing

CASE STUDY: Patient Overdoses and Dies After Inappropriate Opioid Prescribing

Case Details

The patient was a male in his late thirties with a history of significant orthopaedic injuries and a previous narcotic and heroin dependency. He presented to the emergency department (ED) at a rural critical access hospital with complaints of low back pain radiating down both legs. He was diagnosed with muscle spasms, treated with non-narcotics, and referred to a family medicine physician.

The patient visited the family medicine physician, Dr. R, and was treated for several weeks without opioids. Dr. R then ordered an MRI, referred the patient to a neurosurgeon, and provided a prescription for 5 days' supply of diazepam and acetaminophen/hydrocodone.

Several days later, the patient went for the MRI, but complained of pain so he was given meperidine. Later that day, the patient went to another clinic requesting a refill of his narcotics, but was denied. The day following the MRI, the patient returned to the ED and stated that the meperidine he had received the previous day resulted in the first rest he'd had in 5 days. However, he was again treated with non-narcotics.

Two days later, the patient called Dr. R's office and stated that he'd had a fight with his girlfriend and she had flushed all of his medications down the toilet. Dr. R authorized a
5-day replacement supply. The following day, the patient came to Dr. R's office complaining of additional pain in his shoulder. Dr. R refilled the patient's narcotic prescriptions for 2 weeks (diazepam, acetaminophen/hydrocodone) and also prescribed hydrocodone/ibuprofen for breakthrough pain.

Two days after that visit, the patient was found dead in a hotel room. Toxicology revealed that he died of an overdose of diazepam and hydrocodone. The patient's family filed a malpractice suit against Dr. R alleging improper management of the patient's medication regimen. The case was settled with Dr. R's consent.


A number of risk management issues contributed to this case. First, Dr. R's practice did not have a thorough policy/protocol for medication prescribing. In the absence of such guidance, the doctor was relying on his own judgment to determine whether he should fulfill the patient's request. A policy that clearly stipulated how to handle requests for refills, requirements for physical evaluation, timeframes for refilling high-alert medications, and situations that require further evaluation could have helped guide the clinical decision-making process regarding the patient's medication regimen.

Second, Dr. R's documentation showed no evidence that he discussed the risks of the medication with the patient, provided any patient educational materials, or used a pain management contract with the patient. Informed consent and patient education are an essential part of patient-centered care, particularly in situations in which providers are prescribing narcotics for pain relief. The side effects of these medications and potential for adverse outcomes should be thoroughly discussed with patients, and these discussions should be clearly documented in patients' health records. Pain management contracts also can be used to educate patients about expectations related to their medications and to reinforce the provider's commitment to ethical prescribing.

Third, the patient in this case exhibited signs of drug-seeking behavior. He had a history of narcotic and heroin dependency, complaints of chronic and widespread pain, and he presented on multiple occasions within days seeking refills due to destroyed pills or increasing pain. These factors were red flags for potential addiction and drug seeking. Knowing that the patient had a complex history and various pain issues, Dr. R would have been wise to refer the patient to a pain management specialist for further evaluation and treatment. Failure to do so left Dr. R responsible for managing a complex clinical situation that was outside of his scope of expertise.

In Summary

Healthcare providers have an ethical, professional, and legal responsibility to appropriately prescribe controlled substances. However, managing patients who have chronic pain can be challenging, and simple, clear-cut solutions are not always available.

Although approaches to pain management and opioid prescribing are not
one-size-fits-all, providers can use various strategies to reduce risk, such as implementing detailed prescribing policies, checking prescription drug monitoring programs, conducting thorough informed consent discussions, providing patient education verbally and in writing, documenting efforts made to inform and educate patients, using pain management contracts, and seeking referrals and consultations for complex cases.

Implementing these safeguards can help better engage patients in their care, reduce the risk of adverse patient outcomes, and potentially limit liability exposure.

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