Coroner calls for state health department to review rationale for excluding pregabalin from SafeScript, following the death of a Victorian man
The Victorian coroner has called for a government review into the rationale for excluding pregabalin from the state’s real-time prescription monitoring scheme, SafeScript, following a man’s death from mixed drug toxicity.
Phillip James King, 52 years old at the time of his death, suffered from severe neuropathic pain after being diagnosed with multiple sclerosis in 2008.
He also suffered from chronic neck and back pain, chronic left knee pain, and chronic depression and anxiety.
Mr King was found deceased by his wife in his home on 22 December 2017.
He had sent a text message to his solicitor the night before which amounted to a “suicide note”.
Toxicological analysis of Mr King’s post-mortem blood detected presence of fentanyl, tramadol, diazepam and its metabolite nordiazepam, pregabalin, sertraline and traces of paracetamol.
The detected drugs were consistent with excessive and potentially fatal use, said the toxicologist, and the combination of drugs could cause death in the absence of other contributing factors.
Following an investigation of Mr King’s prescription and dispensing history, Victorian coroner Audrey Jamieson said she was “particularly concerned” by the number of drugs required to address Mr King’s pain levels, his admission to misusing pregabalin, and the number of drugs identified in his post-mortem toxicology.
During the six-month period prior to his death, Mr King was dispensed 550 tablets of diazepam—or three tablets per day—an amount Ms Jamieson called “questionable” in her finding without inquest.
He also accessed 672 tablets of pregabalin in the six months prior to his death—which was more than his recommended dose of two 150mg tablets daily and one 75mg tablet daily.
“Clearly, Mr King was accessing more pregabalin than therapeutically indicated by his treating doctor,” found Ms Jamieson.
“This appears to be facilitated, at least in part, by there being at least two different clinics involved in prescribing the pregabalin.”
Investigations also showed Mr King was prescribed 30 days’ supply for fentanyl within a six-day period.
Ms Jamieson said it was unclear whether Mr King truly required oxycodone, fentanyl, tramadol, pregabalin and possibly sertraline to treat his pain effectively.
“Mr King’s intentional overdose is emblematic of the need for a real-time prescription monitoring system that covers all prescribed drugs,” she said.
“The Victorian real-time prescription monitoring system does not cover pregabalin or sertraline, but both were relevant in Mr King’s death.”
The coroner recommended that the Victorian Department of Health and Human Services review the rationale for excluding pregabalin from the real-time prescription monitoring scheme.
Medicines currently monitored by SafeScript include:
These medicines were determined based on a study, conducted by Austin Health, of local and international research which informed recommendations from the SafeScript Expert Advisory Group.
Earlier this year, the Victorian Department of Health and Human Services commissioned an update of the literature review to determine if there was any significant new evidence of harm associated with medicines not currently monitored in SafeScript.
This review looked at pregabalin, as well as tramadol and olanzapine.
Following the review, the SafeScript Expert Advisory Group did not recommend any new medicines be added to the list of those currently monitored.
“In the case of pregabalin, the literature review found evidence of harm only when pregabalin was used in combination with opioids or benzodiazepines, not when prescribed on its own,” said the Department of Health and Human Services.
“Overall, the scale of harm for these medicines considered in the 2019 review was not at the same level compared to medicines currently monitored in SafeScript.
“While no additional medicines will be included in SafeScript at this stage, the department will continue to closely observe data and review any new evidence of harm for the medicines considered in the 2019 review and indeed any medicine not currently monitored.”