A coroner has recommended amended training on medicines which affect the central nervous system, after the death of a man from mixed drug toxicity
Victorian coroner Leveasque Peterson has recommended that the Department of Health review and amend SafeScript training for health professionals to include additional advice and training, about exploring with their patients the effects of medications not recorded in SafeScript which affect the central nervous system – such as antidepressants and antipsychotics – which in combination increase the risk of harm.
Coroner Peterson also recommended amended training on discussing with patients prescribed with quetiapine the details of its use, time of dosing and risks in combination with other medicines; and educating patients about the risk of accidental overdose with dosing routines and combinations of high risk medicines, even if prescribed.
She also recommended amended training on educating patients using multiple sedating medicaitons about the implications of alcohol use, due to the central nervous system depressive effect.
This month Coroner Peterson handed down her findings regarding the death of a 38-year-old man from mixed drug toxicity, including alcohol, codeine, benzodiazepines and quetiapine.
The man, a talented and well-liked sportsman who was described as having a “very driven personality,” also had a long history of anxiety dating back to high school.
Over the following years he received treatment and was prescribed diazepam, quetiapine and sertraline for severe anxiety and suicidality.
The Coroner heard that after the man married his wife in 2016 and the pair bought their first home, it became apparent that he was overusing codeine products, partly to help manage his anxiety.
He sought help and told his psychologist that “due to sporting injuries he had been taking over the counter pain medications” and his wife had become concerned about how much he was taking.
He said he had stopped taking it and wanted to rebuild his wife’s trust in him. He worked on cognitive behavioural therapy for anxiety and his relationship improved, and soon the couple were expecting a child.
In 2018 he was referred to a private psychiatrist and diagnosed with Tourette Syndrome and residual symptoms of PTSD, as well as severe anxiety.
This psychiatrist continued sertraline, reduced the level of quetiapine and introduced haloperidol to manage “tics” associated with Tourette’s Syndrome.
In June 2018, the man went to see a new GP for the first time.
He requested diazepam for increased anxiety after losing his job and feeling overwhelmed by new parenthood.
He also claimed that his wife had lost his script for Panadeine Forte, which he said was prescribed to manage pain in his hand from a sports injury.
He told the new GP that 25 tablets of diazepam lasted him 90 days, but felt he needed more; the GP felt this was appropriate and prescribed diazepam 2mg as well as Panadeine Forte, but only on the understanding that the patient not lose his script again.
The next month he went back and again asked for Panadeine Forte prior to hand surgery, which the doctor prescribed, telling him to use it only for breakthrough pain.
Days later, his psychiatrist realised that the man appeared to be addicted to Endone, and was accessing it from two different doctors, as well as having “some interest in diazepam,” the coroner noted.
At around this time, the patient’s wife suspected that he was “’doctor shopping’ again,” the coroner noted.
In late July 2018, the man again consulted the new GP, saying his anxiety had worsened into daily panic attacks and worry about losing his job, and that he was taking more of the medication than previously and needed it to “help calm his nerves”.
While the GP agreed to prescribed diazepam and Panadeine Forte, he asked the patient to return in a week to discuss long-term use of benzodiazepines and pain issues. The patient did not return for four weeks.
According to SafeScript records, during the month of July 2018 the patient consulted 14 prescribers and was able to access 700 Panadeine Forte tablets and 308 diazepam 5mg tablets from nine pharmacies.
SafeScript records show that during August 2018, the man consulted six prescribers for codeine and diazepam, and accessed 140 Panadeine Forte and 250 diazepam 5mg tablets from six pharmacies.
The next month, his wife found hidden codeine tablets in his car. The man denied dependence on the drug and “diminished the period he had been using it,” Coroner Peterson noted.
He again went to the GP, who this time discussed the risks of dependence and tolerance to codeine, advising him on withdrawal and how to come off codeine onto a lower acceptable dose.
The patient agreed to try pregabalin and Celebrex and was given scripts for pregabalin 25mg and Panadeine Forte.
The same day he saw his psychiatrist and told him he had ceased painkillers after going “cold turkey” for 10 days. He reported his tics were controlled with 1.5mg haloperidol and 300mg quetiapine.
Later in September 2018 he saw his GP with a statutory declaration saying his car had been broken into and his scripts for diazepam and Panadeine Forte had been stolen.
Not suspecting doctor shopping, the doctor re-prescribed the medicines.
According to SafeScript, that month the man consulted four prescribers for codeine and diazepam and accessed 420 Panadeine Forte tablets and 300 diazepam 5mg tablets from five pharmacies.
In October 2018, his wife suggested a trial separation.
That month the man told his GP that he had refractured his right hand playing cricket, and been seen in hospital for further surgery. He reported that he was on 10 Endone 5mg tablets a day but felt painkillers were “not doing much”.
The GP asked more questions and the patient admitted to taking Panadeine Forte at significantly higher than prescribed rates, estimating it was about 15 tablets a day.
He admitted he “probably had a codeine addiction” and the doctor commenced a safe weaning plan for codeine with the man, with a plan to address his benzodiazepine dependence after he had been weaned from codeine.
The GP prescribed codeine-only tablets 30mg at 14 tablets daily (420mg daily), to be reduced
by two tablets every two weeks, and diazepam 5mg one tablet daily as required at the same
Later in October 2018, the GP received a letter from the PBS informing him that his patient had been seeking benzodiazepines from multiple prescribers.
He consulted with the patient, who admitted to taking “five to six tablets of diazepam daily” and was candid about his need to stop using codeine. The doctor realised he had not prescribed enough codeine to effectively wean over the predicted period, and increased the script, with the aim of his patient ceasing codeine in six weeks.
He also discussed the patient’s obtaining multiple drugs of dependence from different GPs and the pair agreed that the GP would become his single prescribing GPs for these medications.
An agreement set out the conditions, current dose and weaning plan for codeine, and a nearby Chemist Warehouse was nominated as the dispensing pharmacy, though on one occasion in November a one-off pickup was allowed from a pharmacy in a town north of Melbourne where the man was staying.
The man’s current dose of codeine 30mg was recorded as 12 tablets per day (360mg daily), with the aim of weaning to 10 tablets per day, followed by a further weaning of two tablets per week until ceased. He was not to begin weaning diazepam until he had come off codeine.
According to SafeScript records, during the month of October 2018 the patient consulted seven prescribers for codeine and diazepam, and accessed 132 Panadeine Forte tablets, 500 codeine phosphate 30mg tablets and 300 diazepam 5mg tablets from six pharmacies.
In November 2018 the patient admitted to having difficulty sticking to the weaning plan and a new written agreement was signed, slowing the rate of weaning.
At around this time, the psychiatrist was notified by DHHS that the man was overusing diazepam and sourcing it from multiple prescribers.
The patient’s sister telephoned him to raise concerns about her brother’s behaviour and addiction to oxycodone and doctor shopping for diazepam and codeine.
When the psychiatrist asked his patient about this, the man admitted to abusing oxycodone and benzodiazepines for several years but refused to provide the names of the prescribers he had seen.
The psychiatrist added 50mg desvenlafaxine to the man’s regime and registered with SafeScript, telling his patient to limit the prescription of diazepam to 10mg daily only, with only weekly pickups, which the man was “reportedly not happy with”.
In mid-November his GP observed that he was not coping and was unable to wean off medicines, and he admitted to his psychiatrist that he had not contacted addiction services to which he had been referred.
According to his psychiatrist, at this time the man was being prescribed weekly pickup dose of 10mg diazepam, 300mg quetiapine, 200mg sertraline, 1.5mg haloperidol and 50mg desvenlafaxine.
This was to be the last time the man saw his psychiatrist.
Later in November, he went to see his family GP, who provided a script for quetiapine 300mg (60 tablets) once daily as well as diazepam 5mg (50 tablets) three times daily, with no repeats.
According to SafeScript he still had two remaining scripts for quetiapine from the psychiatrist.
SafeScript records showed that he was being dispensed quetiapine more frequently than would appear warranted from his prescription, being dispensed 60 tablets of quetiapine 300mg on 11 September 2018, 5 October 2018, 20 October 2018, 10 November 2018, 22 November 2018 and 18 December 2018 from a prescription with five repeats provided by the psychiatrist, and on 28 December 2018, 22 January 2019, 4 February 2019, 26 February 2019 and 11 March 2019 from a prescription with five repeats provided by the family GP.
During November 2018, the man consulted five prescribers to get 270 Panadeine Forte tablets, 410 codeine phosphate 30mg tablets and 388 diazepam 5mg tablets from nine pharmacies.
Meanwhile the GP continued to prescribe in accordance with the weaning plan, also prescribing zolpidem to help the man sleep.
In December 2018 he inventoried the man’s medicines and found he was over-using diazepam, and replenished the supply, telling him that if it happened again he might have to commence daily pickup.
That month the patient had his last appointment with his psychologist, to whom he admitted relying on alcohol to control his anxiety and refusing drug and alcohol counselling, saying he did not have a problem.
He last saw the family GP in mid-December 2018, when he was prescribed diazepam 5mg twice daily, no repeats.
He went to the new GP on the 21st, saying he had lost 50 tablets of diazepam.
The doctor believed this and agreed to provide once-off permission for early dispensing.
During the month of December 2018 the man consulted four prescribers and accessed 250 Panadeine Forte tablets, 220 codeine phosphate 30mg tablets, and 280 diazepam 5mg tablets from five pharmacies.
In January 2019 the new GP was contacted by the pharmacy in the town north of Melbourne where the patient had stayed in November 2018.
The pharmacy advised him that the patient had recently acquired 200 codeine 30mg tablets, from a previously unfilled script written by the doctor in October. The new GP asked the pharmacy not to dispense to him again until he had spoken to the patient.
When confronted, the patient said he “could not control himself” after receiving a large quantity of codeine.
The GP checked SafeScript and “identified that [the man] had been trying quite hard to keep within the weaning limits” and decided to continue the weaning plan, tightening dispensing controls for weekly pickups.
From this point, SafeScript identified a “marked” reduction in the man’s access to drugs of dependence. He obtained his weekly supplied of codeine from the northern pharmacy, which held copies of the letters about the weaning plan, as did the Chemist Warehouse.
In January, the man’s wife told him she wanted to make the separation formal. He made comments about ending his life, and concerned, his wife contacted his siblings and arranged a welfare check.
Police found him behind the wheel and he returned a positive reading of 0.054 grams of alcohol per 210 litres of breath. He lost his licence for three months.
When his sister collected his car the day after he was released from custody, “she found multiple empty packets of codeine and benzodiazepine medicines in the vehicle”.
He again told his new GP that he was having trouble weaning, and due to his mental health issues the GP allowed him five codeine 30mg tablets a day until he was ready to try weaning again.
He also disclosed that that he did not feel the antidepressant sertraline was working,
and wanted to try more desvenlafaxine. He also agreed to stop zolpidem.
SafeScript records show that throughout January 2019, the man consulted only his new GP for codeine and diazepam, and only used two pharmacies.
In February, he lost his job, blaming anxiety for his loss of concentration, though his doctor suggested this should also be attributable to his ongoing use of high doses of benzodiazepines and codeine.
Later that month he saw the new GP again, saying he had used an additional 20 codeine tablets above the prescribed amount over two days, after spraining his ankle.
“He also explained that currently, the pharmacy were allowing him script quantities all at once.”
In March 2019, he had a new job, and been able to keep his codeine and diazepam intake stable.
The GP prescribed one to two tablets of zolpidem 10mg for insomnia.
The patient then filled a prescription of zolpidem 10mg (28 tablets), diazepam 5mg (100 tablets) and codeine phosphate 30mg (80 tablets) as prescribed at the pharmacy in the northern town.
Days later, he filled a script of quetiapine 300mg (60 tablets), prescribed by his family GP with one repeat, as well as zolpidem from his new GP, at a different pharmacy.
In mid-March 2019, he was found dead at his home, with a large number of prescription medication packages found in his bedroom.
Police officers located “empty alcohol containers and numerous prescription medication packs and boxes” in the man’s home and car.
“The medications included diazepam, rivaroxaban, codeine phosphate, zolpidem, desvenlafaxine, quetiapine, sertraline and haloperidol,” the Coroner noted.
“Many of the medication packs were empty, but there was one full box of sertraline, one box of sertraline with one tablet missing, one box of desvenlafaxine with six tablets missing and a bottle of
haloperidol was approximately one-third full.”
“Toxicological analysis of post-mortem samples identified the presence of ethanol (0.06 g/100mL), quetiapine, codeine, desmethylvenlafaxine, sertraline, zolpidem and benzodiazepines diazepam, nordiazepam, temazepam and oxazepam.
“The drugs detected were consistent with excessive and potentially fatal use, and the combination of drugs may cause death in the absence of other contributing factors.”
The Coroners Prevention Unit had found the new GP’s prescribing was appropriate and that the patient appeared to have developed a “meaningful and therapeutic” relationship with him, engaging in a plan to stop substance abuse and manage his anxiety.
But it noted that one of the complexities in the case was that the man “compartmentalised his treatments,” nominating his family GP as his usual GP to his psychiatrist – perhaps intentionally, to keep his current addiction treatments separate, or perhaps because he saw their management of his mental and physical health as separate from his addiction.
It also noted that while he had trusted his new GP, he had not discussed the fact that he had been prescribed quetiapine, which he had sourced from the family GP.
The CPU said that while the prescribers could have been more proactive, no prescriber could be confident at the time that SafeScript “presented a complete picture”.
“The CPU noted that SafeScript is now mandatory and should provide practitioners and pharmacists with information so they can more easily identify other practitioners involved in a patient’s care,” Coroner Peterson said.
“However, there are limitations to this, as SafeScript would not have informed other practitioners of [the man]’s treatment in hospitals, or providers who were prescribing medications other than the 27 medicines monitored through Safescript.”
The CPU said the man was “vulnerable to using other more accessible and sedating substances with which to self-medicate any increase in his anxiety, be it from his mental disorder or from the anxiety associated with the reduction in use and restricted access, including the rescheduling of over-the-counter codeine products to prescription only in February 2018. Such substances could include other medicines he had access to (such as quetiapine) and alcohol.”
It noted that the toxicology report had identified the presence of quetiapine at ~9.1 mg/L.
He had continued to be dispensed quetiapine at regular intervals until his death, with an average daily dose of about three tablets or 1050mg daily, “well above the recommended daily dose”.
“CPU noted that the adverse effects of quetiapine include sedation, cardiac and QT Interval changes and risk of sudden death, seizures, venous thromboembolism, and physical health comorbidities including weight gain and hypercholesteremia and the prescribing of it should also require routine physical health monitoring.”
The CPU also considered that there was a suboptimal level of coordinated care and clinical communications.
But this was “heavily influenced” by the man’s “misrepresenting his situation, not being transparent about medications, who he was consulting, what scripts he was accessing and compartmentalising his care”.
“The introduction of SafeScript… and the rescheduling of over-the-counter codeine products are policy responses that should reduce the likelihood of iatrogenic addictions,” the Coroner said.
“SafeScript has been a vital tool for prescribers and dispensers to identify and intervene to prevent excessive use of prescribed drugs, use of contraindicated drug combinations, prescription shopping and other issues that emerge from poor coordination of care.
“The use of SafeScript should prevent the set of circumstances in which [the man] was enabled to develop addictions to codeine and benzodiazepines.”
“As part of their review, the CPU identified that there may be further opportunities to utilise SafeScript and its associated educational resources to provide further advice and information to prescribers, dispensers, patients and their families about the short term risks of opioid and benzodiazepine use.
“I agree with this assessment, and consider that there is an opportunity to increase patient safety.”
The Coroner directed that a copy of the finding be sent to both the RACGP and Pharmaceutical Society of Australia, as well as the medical clinics and pharmacies involved in prescribing and dispensing addictive medicines to the man in the six months up until his death.