Double up leads to death from opioid toxicity


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Two doctors have been implicated in the death of a 79-year-old man after he was administered morphine, despite having taken leftover Endone tablets prescribed to his late wife

In August 2014, a NSW man died in the Intensive Care Unit of a south Sydney hospital after being given doses of morphine that an inquest has deemed “not appropriate” by his treating practitioners.

While the doctors have been implicated in his death, the case also signals the importance of increasing awareness surrounding unused medications in the home.

Following a leg injury, the patient had been initially treated with Celebrex, Lyrica and cortisone injections.

There was no evidence that the GP’s prescription of these medications were in any way inappropriate, the inquiry found.

However in the leadup to his death, the patient had been experiencing increasing pain, and had begun using Endone tablets.

The coroner suspected the likely source of the Endone was unused medication that had been prescribed to his late wife – who had passed away from ovarian cancer – and left in their home after her death in April 2013.

It was discovered that the patient had taken a tablet of Endone in the evenings of the 21 and 22 August 2014, and on the morning of 23 August.

Furthermore, a part-used packet of Endone had been left on his bedside table by his daughter, and it was unknown whether the patient had taken more of the tablets himself.

On 23 August, the GP’s husband, a nearby radiologist, attended the patient’s home and injected him with two doses of morphine, likely being 30mgs and 20mgs respectively.

The patient’s GP had allowed her husband to access her supply bag in order to obtain the morphine.

Following this, on the morning of 24 August, the patient’s daughter found him in lying unconscious in his bed and rang for emergency services.

He was found to have suffered respiratory arrest consistent with opioid toxicity and suffered further cardiac arrests in the hospital.

He died the following day, on 25 August.

During the February 2018 inquest, NSW Deputy State Coroner Elizabeth Ryan ruled that the patient had died in circumstances where morphine with which he had been injected interacted with the oxycodone tablets he had taken in the days earlier, causing cardio-respiratory arrest.

It was not possible to determine from the toxicology results how much of the oxycodone he had actually ingested – however, neither the oxycodone nor the morphine was found in potentially lethal concentrations.

The opinion of an expert witness was that although each of the two drugs was found in only therapeutic concentrations, the effects of the two when combined would have been additive.

Another expert stated that the second injection of morphine would have been ‘highly likely’ to cause progression from sedation to respiratory suppression.

The coroner said she had reasonable grounds to believe the evidence given in the inquest may indicate a complaint could be made about the treating doctor and the GP concerning their care and treatment of the patient during the period 22 to 24 August 2014.

It is not clear whether the doctors knew that the patient had been taking oxycodone tablets before administering the morphine.

Experts concurred that administration of opioids at the patient’s home was a “riskier undertaking” than in a hospital setting.

“On the basis of … earlier signs, as well as the factors referred to [of the patient’s] age, his status as an opioid naïve patient his simultaneous use of another opioid, and the absence of any patient safety mechanisms to monitor his response to the morphine doses, the two expert witnesses concurred that the dosages were inappropriate,” the coroner ruled.

Both doctors have been referred to the Medical Council of NSW.

The coroner also expressed her sympathy for the patient’s family, who continue to be “deeply distressed” by his loss.

Consumers should be aware that unused, unwanted and leftover medicines in the home can be dangerous in the wrong hands and should be returned to the pharmacy, according to the Return of Unwanted Medicines Project.

According to a recent survey published in the Australian Health Review, 75% of respondents held on old medicines “just in case they needed them again”, while 9% kept medicines “to give them to family or friends if they needed them”.

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