This case involves a college student who died from an opioid overdose. The student had undergone surgery after a sports-related injury, and was prescribed opioids for pain relief. The student became addicted after taking the opioids for a few months and later went in for addiction treatment. The student was prescribed the maximum narcotic dose on the first day of treatment, and the doctor increased the student’s dosage the next day. The student suddenly passed away the following evening from opioid poisoning. A Medical Toxicology expert was sought to discuss the proper dosage levels for narcotics patients.
Question(s) For Expert Witness
- 1. What are the proper steps during the initial intake process for new patients like the one described above?
- 2. How do you determine when to increase dosage levels of narcotics for such patients?
Expert Witness Response E-068745
I’m Board Certified in Addiction Medicine, Medical Toxicology and Board Eligible in Internal Medicine. Major components of my practice including treating opioid dependence, toxicity related to opioids, and complex pain/addiction issues in the hospital and clinic setting. I’ve been Director of Toxicology at a large university medical center for 6 years now and Medical Director for a large Outpatient Treatment program for nearly as long. I have published and lectured extensively on opioid-related topics. Most recently I was a 2nd author of a paper which discussed methadone use. I have consulted on numerous methadone-intoxicated patients, treated them at bedside, and consulted indirectly for a methadone clinic providing feedback/expert assistance and advised on dosing. I have not prescribed methadone for a patient that has resulted in a fatality –I have cared for methadone overdoses in the hospital.
Methadone-related questions are very common in my clinical and academic practice. Intake into an opioid treatment program involves a series of patient assessments, exams, interviews, a drug screen, and other information gatherings. Some of the initial intake is program specific (e.g. day/time intake and dosing of methadone). Regulations are based on federal guidelines but also subject to state/additional regulation/oversight depending on locale. Most important is a careful patient assessment. Methadone prescription is either for dependence treatment (which is very strict and must follow specific protocol) or for pain management (which results in many more overdose deaths than the clinic use for dependence). In this patient, the prescription involves treatment of dependence — pain control may be a secondary outcome, though dosing would not be changed to suit pain control.
Methadone titration involves careful patient assessment and compliance with federal guidelines regarding the rate that methadone can be increased. There are limitations. Dosing on day 1 is limited to 30 mg (increase to 40 mg –one additional 10 mg dose x 1) and then 5 mg every 2 days (or 10 mg over 4 days) increases maximum as titration up occurs.