This case involves the treatment of a 66-year-old female for injuries she sustained from a fall in her home. The woman fell down ten stairs and suffered chronic back pain as a result of the incident. Because the woman was unable to return to work, she also developed severe depression. The patient saw specialists in neurology, psychiatry, and pain medicine for symptom management. Over the course of her treatment, the patient was maintained continuously on 22 drugs. In spite of the volume of medications the patient had been prescribed, she received very little monitoring from any of her specialists. The woman suffered incidents of altered mental status but was never admitted to the hospital for evaluation. The patient was later found unresponsive and expired. It was determined that the cause of death was intoxication due to the combined effects of her antidepressants and her pain reliever.
Question(s) For Expert Witness
- 1. Do you routinely treat patients with lower back pain and injuries?
- 2. What protocols or programs are in place to prevent fatal drug interactions?
Expert Witness Response E-049440
I am a pain medicine specialist and treat similar patients with this complaint in the outpatient portion of my practice. I see at least 20-30% worker’s compensation patients, and at least 65-75% of my patient population in pain management is for lower back and other musculoskeletal-related conditions and injuries. There are several protocols now in place and multiple standards of care. Overall, we use urine toxicology with regard to controlled substances to assure correct usage, we have iSTOP across many state lines to assure only 1 provider for specific controlled substances (although this was not established by the states involved during the timeline in the vignette). Much of the issues here rely on adequate history taking and knowledge of these medications, which have numerous interactions, as well as black box warnings. Many electronic medical records that also include prescribing in the function will have warnings and hard-stops for interactions of various medications.