Local pharmacists and GPs attempted to curb the drug-seeking behaviour of a patient, but it wasn’t enough to save her life
A coroner recently investigated the case of a 33-year-old Victorian woman who died on 7 July 2018 from mixed drug toxicity.
The woman had a complex and extensive medical history since her teen years, including a chronic pain condition.
From 2013 she began attending a local clinic, and at that time, she was identified under the Prescription Shopping Program for having seven prescribers for diazepam.
At the commencement of their therapeutic relationship, her primary GP said he communicated with eight local GPs to ensure she was not receiving further prescriptions there, as well as local pharmacies. Prescriptions he wrote were provided on a weekly basis.
“We had multiple disagreements in our doctor-patient relationship, usually when I declined to provide early prescriptions or challenged her on discrepancies in her history,” he told the Coroner’s Court of Victoria.
In May 2017, the woman underwent surgery after which she was treated with oxycodone for a month. The following month, she was admitted to hospital following an apparent overdose of Mersyndol Forte, Endone, zolpidem, diazepam and mirtazapine. She denied suicidal intent.
Following this she was prescribed pregabalin but her diazepam dose was reduced.
All medications were prescribed with limited amounts and weekly pickups at a regular local pharmacy.
In November 2017, her primary GP discovered from the Prescription Shopper Program that her prescribing from specialists was increasing. Over the next few months, he communicated with them to limit this additional prescribing.
On 9 May 2018, he prescribed her pregabalin 75mg capsules. A few days later, a second GP at the same clinic prescribed her pregabalin 150mg capsules. On 23 May, her regular GP changed her dose back to 75mg given previous prescriptions had frequently been “lost” or “misplaced”.
On 24 May, she was reviewed by a different GP at the clinic yet again, from whom she requested more pregabalin. This doctor refused her request and recommended any increase in dosage should be discussed with her primary GP.
Thirty minutes after this consultation, he received a call from a local pharmacist who reported that she had presented to the pharmacy requesting a box of pregabalin, stating she had lost her tablets.
The GP advised the pharmacist that no extra pregabalin tablets should be provided to the patient.
All this occurred over the backdrop of several health issues for which the woman required medical care.
On 31 May, the primary GP received a call from a pharmacy an hour away from the clinic advising him that the patient had presented with a prescription for pregabalin dated 30 May, which had not originated from her usual clinic.
The doctor confirmed the pregabalin should not be dispensed to her.
On 3 June the woman had presented to an emergency department complaining of pain, and had been treated with fentanyl and discharged with a script for pregabalin.
She denied both the hospital script and the pharmacy visit to her primary GP.
Just over a week later, he warned her that if there were any requests for dose escalation, early prescriptions or lost medications, the clinic would terminate prescribing to her. He provided her with her usual prescriptions, all labelled to be dispensed by the one pharmacy.
On 7 July 2018, the woman was found deceased by her mother.
Toxicological analysis of post-mortem samples found the presence of pregabalin, morphine, diazepam, nordiazepam, doxylamine and ondansetron in blood; and morphine, codeine, diazepam, nordiazepam, temazepam, oxazepam, zolpidem, doxylamine and paracetamol in urine.
The elevated level of pregabalin (~51 mg/L) detected in her blood sample was at a level associated with fatalities. Combined with morphine and diazepam, the effects were additive and sufficient to cause death, noted the forensic pathologist.
At the scene, police located empty prescription boxes containing empty blister packs for Dolased Forte, Stilnox and Mersyndol Forte prescribed by a secondary doctor at her regular clinic.
They also found one empty box containing empty blister packs of Lyrica, prescribed by a different doctor and dispensed at a Chemist Warehouse located 15 minutes’ drive from the woman’s local area.
Also located was a receipt from the Chemist Warehouse recording the purchase of the pregabalin, and one box of ondansetron containing four tablets in a blister pack.
Two further empty prescriptions box for pregabalin were found in the garbage bin, each prescribed by different doctors, together with empty blister packs of MS Contin and pregabalin.
Victorian Coroner Darren Bracken commended the efforts of the woman’s primary and secondary GP for their “cautious, thoughtful and caring management”, noting the former’s use of weekly checks with the Prescription Shopping Program and regular contact with other treating medical practitioners and local pharmacists.
He noted that had SafeScript been in effect in Victoria throughout their management of the patient, it would have been of significant value to them.
A PBS patient summary revealed that in addition to prescriptions provided by her primary and secondary GP between May and July 2018, the woman also obtained prescriptions for pregabalin from three other doctors, with a fourth suspected to have provided a private script for the drug.
The number of pregabalin tablets of varying strengths prescribed and dispensed to the woman during this time totalled 412.
However the coroner noted that pregabalin is still not included as one of the drugs monitored in the SafeScript system.
A literature review commissioned by the Victorian government in 2019 found evidence of harm only when pregabalin was used in combination with opioids or benzodiazepines, not when prescribed on its own.
There was no evidence that the woman had been prescribed MS Contin, temazepam or oxazepam, suggesting diversion.
In his findings without inquest, handed down on 28 January 2021, Coroner Bracken reiterated his recommendation that pregabalin be included in the SafeScript scheme in order to prevent deaths in the future, “by drawing the attention of clinicians to excessive prescribing of the drug”.
There was not sufficient evidence for him to find that the woman had deliberately taken excessive amounts of prescribed medication, including pregabalin, with the intent to end her own life.
He urged the Victorian Department of Health and Human Services to re-consider inclusion of pregabalin in the scope of drugs monitored in the SafeScript real-time prescription monitoring scheme.