RECORD OF INVESTIGATION INTO DEATH
Coroners Act 1995
Coroners Regulations 1996
I, Stephen Raymond Carey, Coroner, having investigated the death of
WITHOUT HOLDING AN INQUEST
FIND THAT :“the deceased” died in 2005 in Southern Tasmania.
The deceased was born in Hobart and was a single male who was in receipt of a disability pension at the time of his death.
I find that the deceased died of a drug overdose (multiple drugs) contributed to by lung disease that disease having been caused by a history of intravenous drug use.
At the time of the deceased’s death he was not being treated by a medical practitioner.
CIRCUMSTANCES SURROUNDING THE DEATH :
The deceased had a history of illicit use of drugs dating back to his teenage years. He had commenced the Methadone program on 3 June 1997, at that time giving a history of having been injecting prescribed morphine (MS Contin and Anamorph) for about four years. This suggests his injecting began in or about 1994 when the deceased was 17 years of age.
The deceased was transferred from the care of a general practitioner, who was overseeing his involvement in the Methadone program, to the supervision of the Alcohol & Drug Service for the prescription of Methadone in May 2001. His behaviour, including actual drug seeking and threatening violence, deteriorated over the four years he was treated by the Alcohol & Drug Service. His behaviour reached the stage that his treating medical practitioner at Alcohol & Drug Service (Dr Susan Sheehan) did not feel able to meet him without the presence of security guards. By letter dated 5 November 2004 his place on the Methadone program was cancelled in accordance with the Tasmania Methadone Policy 2000 which states at para 9.2:-
“Violence or threat of violence against staff or patients…….may result in the involuntary removal of the patient from the program.”
Rather than abruptly ending his dosage, arrangements were made for the deceased to continue to access Methadone on a daily basis but with a gradually reducing dosage from the usual of 110 mg per day and with no access to take-away doses. His dosage was reduced by 5 mg every week until his dosage was 45 mg and it was then to be reduced by 5 mg every two weeks until he was on 20 mg. From 22 February 2005 he was permitted to take one take-away dose per week. Whilst on the Methadone program the deceased had also been prescribed Benzodiazepines and the prescription of these remained unchanged throughout this period of Methadone reduction. Appointments were made for the deceased to attend other care providers within the Alcohol & Drug Service in order to provide support to him throughout this process but the deceased failed to attend such appointments.
On 12 April 2005 the deceased received his last dose of Methadone as he decided to abruptly exit the program. Following discussion between Dr Pitt, the deceased’s treating general practitioner, and Dr Sheehan at the Alcohol & Drug Service the deceased’s medication was changed from Serepax (Oxazepam) to Diazepam (Valium) in order to help minimise withdrawal symptoms. His last prescription was for Serepax 20 mg (by two at night) as the change to Mogadon (Nitrazepam) to assist sleep had caused headaches and Diazepam 5 mg (by three per day) to be collected on 15 May 2005. This prescription was for ten days of medication. During the period that he was being provided this medication by Dr Pitt it was also suspected that the deceased had been “doctor shopping” seeking other medication and one general practitioner on or about 18 April 2005 prescribed him Xanax (Alprazolam) (50 tabs).
On the evening of 22 May 2005 the deceased was left at home by his mother who was to attend a social function and stay the evening at her partner’s residence. The deceased complained that he was feeling unwell but the deceased’s mother, was not any more concerned than normal given the deceased’s previous medical history. In this regard he had suffered, for some years, cyclical vomiting, stomach pains and constipation. In more recent times he had been complaining of muscle spasms due to his Methadone dose reduction and eventual cessation of Methadone. The deceased gave his mother no reason not to go out that evening. When she returned the next morning at approximately 10.30 am she found the deceased slumped on the floor, she called an ambulance and commenced CPR. These procedures were continued by ambulance officers upon their arrival but efforts were discontinued after a period upon assessment by the ambulance officers that the deceased was dead.
Implements on or about the deceased’s body when he was found are indicative of intravenous drug use and at autopsy dried vene puncture marks were noted in both groins of the deceased. A post mortem blood analysis established that a number of drugs were present, including Methadone and Benzodiazepines. Based upon the deceased’s history and the circumstances in which he was found, it is a reasonable inference that he has injected those drugs. There is nothing in the findings of the police investigation to suggest that the drugs were other than self administered and that there are no suspicious circumstances.
A contributing factor to the deceased’s death was that he suffered an undiagnosed lung disease. The findings upon microscopic examination of the lungs are:-
“…..numerous focal granulomata around vessels, which appear thick-walled. The granulomata contained foreign body giant cells and abundant refractile foreign body material.”
This foreign body granulomata formed as a result of habitual IV drug use due to the impurities in such administration. The administration of drugs such as Methadone and benzodiazepines have the effect of impairing respiration, which would have been further aggravated by the presence of the lung disease.
RECOMMENDATIONS AND COMMENTS:
A number of issues have been raised by this investigation. Firstly, "the deceased's mother" complains that her son was not given appropriate medical care and attention during the period he was reducing his Methadone, blaming Dr Sheehan at the Alcohol & Drug Service for refusing to treat him during this period and other doctors for being influenced by her in decisions they made about treating the deceased. She also complains that information provided to patients and families concerning the Methadone program is deficient and that Methadone is too easy to obtain.
The police investigation raised a concern as to the significant level of abuse of Methadone and Morphine within this State.
I have made some enquiries on these issues and will make some comments, however this is not an appropriate venue to fully canvass all aspects of the Methadone program within this State. I note that in November 2006 Statewide Specialist Services, a division of the Department of Health & Human Services, announced a review of Alcohol, Tobacco and other Drug Treatment Services within Tasmania and such review is a more appropriate vehicle to air a number of the concerns raised herein.
Insofar as the concerns of the deceased’s mother are concerned, I comment and conclude as follows:-
I accept as reasonable the decision taken by the Alcohol & Drug Service to have the deceased involuntarily removed from the Methadone program. It is apparent from the material provided to me that there had been significant behavioural problems with the deceased while he was on the program. Eventually due to threats of violence, including death threats made to Dr Sheehan and other staff at the Alcohol & Drug Services, the decision was made to remove him from the Methadone program. At that stage a rapid dose reduction or immediate cessation of treatment may have been warranted, however the deceased was given the opportunity to undergo a gradual dose reduction. Other support services were offered to the deceased but he failed to avail himself of these services. The deceased was advised to consult a general practitioner who might oversee his condition during the Methadone dose reduction program. Dr G Pitt contacted Dr Sheehan after the deceased attended upon him and requested Xanax as part of his treatment. He was quite appropriately given details of why the deceased had been removed from the Methadone program and provided with advice as to the deceased’s probable symptomatic medication requirements. He was also advised that the deceased was on probation in respect to an offence of negligent driving committed by the deceased while he was under the influence of Xanax. At the time of that offence the deceased had swapped with some other person his prescribed Mogadon medication for the Xanax.
On the material available to me I am not persuaded that any criticism of Dr Sheehan or of the Alcohol & Drug Service is warranted in respect to their treatment or care of the deceased. He had initially been transferred to their care from private care due to his violent behaviour. His behavioural problems continued and he did not take up the opportunity for other care and treatment options that were offered to him. His behaviour eventually caused a decision to be made that it was unsafe to treat him in a community alcohol and drug service. There was a foundational basis for this decision and I do not question it.
- In this case the deceased had ceased his entitlement to Methadone a number of weeks prior to his death yet this substance was detected at post mortem. Obviously he had obtained Methadone illicitly. It has not been determined whether this Methadone was obtained in the form of syrup (for the treatment of opioid dependency) or tablet form (for analgesia). If it was in the form of syrup then a take-away dose prescribed for another person has been provided to the deceased. This possibility raises concern about the practice of providing take-away doses that might then be used illicitly. I sought advice as to this practice.
In principle Methadone maintenance is intended to be a supervised dosing program which would require a patient to attend a pharmacy 7 days per week, 365 days a year. However a practice has developed to allow some patients to minimise their visits to the pharmacy by allowing take-away doses up to a maximum of three doses per week. The reasons for this are varied but may be in order to support a patient in endeavours to obtain or maintain employment, ease travel burdens, address family commitments or allow short term holiday or recreational wishes. It is accepted that a proportion of these take-away doses are diverted and sold to others. The prescription of take-away doses is a clinical decision made by the prescribing doctor. The Alcohol & Drug Service believe the take-away approval rate within Tasmania is too high, however it is accepted that individual general practitioners come under great pressure from Methadone patients who can be extremely persistent, creative and exhausting. Patient anger in these circumstances may also become an issue.
I recommend that if the Alcohol & Drug Service believe that the rate of prescription of take-away doses is too high then steps ought be taken to reduce it. Options that may be considered are to establish explicit and rigorous rules concerning access to take-away doses, or that request for take-away doses be sanctioned by an expert panel independent from the prescriber. There also seems a need to provide appropriate monitoring and, if necessary, support to prescribing general practitioners. What must be achieved is a balance between the encouragement of rehabilitation by providing take-away doses and the opportunity to divert these doses for illicit use.
- There is also concern as to the use of Methadone in combination with prescribed opioids and/or benzodiazepines. Prior to 1990 the use of opioids was restricted to terminal and acute conditions. Morphine was therefore relatively rare in the community and diversion and abuse was infrequent. With the advent of long-acting forms of morphine, eg MS Contin, clinical practice changed to allow prescription of such drugs in cases of chronic pain. I am advised that the prescription of these agents by Tasmanian General Practitioners is at a level significantly higher than the National average. I am also advised that the injecting of prescription narcotics is a prevalent practice within Tasmania. It seems appropriate that some consideration ought be given to addressing the reason for and the problems created by the greater availability of these drugs within the community.
Medical practitioners are free to prescribe narcotic drugs in the course of medical practice, consistent with clinical policies for non-drug dependent patients for up to two months. The Alcohol & Drug Dependency Act 1968 then requires the prescriber to obtain an authorisation from the Secretary of the Department of Health & Human Services if they wish to continue prescribing. Such applications may be assessed in accordance with established guidelines or by independent expert assessment. In addition, the dispensing of a narcotic agent is required to be reported by pharmacies to the Pharmaceutical Services Branch on a monthly basis. This process allows for the identification of prescribing without authorisation. This monitoring system however has a number of limitations due to there being no reliable patient identification system (Medicare patient numbers are not permitted to be used for this purpose) and time delays in the process. Given both the documented and anecdotal evidence concerning the misuse of prescribed narcotics in this State I recommend that the mechanisms in place to monitor the instances of prescription be improved in order to allow timely and accurate identification of any indications of inappropriate or unauthorised prescription or any other circumstances that may be of concern.
However given the subjective nature of many instances of chronic pain a key issue would seem to be the development of better mechanisms to select those patients who are suitable for treatment with narcotic drugs and to exclude those patients who receive little or no therapeutic benefit or who present a risk in regard to diversion, misuse or abuse.
I am advised that a project is presently underway involving the Department of Health & Human Services and the Division of General Practice to develop a Code of Practice for the prescribing of narcotic drugs and for a formalised template for the management of chronic pain. The intention is that the latter will become the basis of an application for authorisations to prescribe a narcotic on and ongoing basis. I commend this project.
I also recommend that there be established some form of medical review body to carry out quality and safety review of cases involving patients at high risk of fatal drug abuse and instances of patient death involving use of prescription narcotics. Such assessments could provide ongoing review of clinical practice involving the prescription of narcotics.
- The final issue involves the illicit use of benzodiazepines in combination with Methadone. The findings of the 2005 Tasmanian Illicit Drug Reporting System included comment that “There have been increasing reports of consumers injecting combinations of alprazolam and Methadone syrup in the past three IDRS studies, a practice that carries increased risk of overdose, injection related harms and adverse social and legal consequences from the particular disinhibitive affects of this combination.”
Pharmaceutical Benefits Scheme information suggests that prescribing rates for Alprazolam in Tasmania may be twice the National per capita average. Anecdotal evidence suggests a significant problem within Tasmania concerning the hazardous use of Alprazolam. I recommend that there be a review of the prescribing practice for this drug in order to determine if this statistic is correct and if so whether such a rate is appropriate. If necessary, guidelines ought to be developed for doctors concerning the use of Alprazolam and other Benzodiazepines and other strategies identified that might help reduce or minimise the need to prescribe Alprazolam and other Benzodiazepines.
Alprazolam together with other Benzodiazepines are not the subject of any monitoring in the same way as narcotic substances. These drugs are usually prescribed on the Pharmaceutical Benefits Scheme, however Commonwealth privacy laws do not allow the sharing of this information with State authorities. There is no direct method available to identify whether a person is obtaining multiple prescriptions of such drugs from different doctors. I recommend that this issue be raised with the Commonwealth authorities in order to allow identification from their data of instances indicative of the abuse or misuse of prescribed drugs such as benzodiazepines.
The use of Methadone does not provide a cure for an opioid addiction. Patients and their families need to be very mindful of this when entering a pharmacotherapy program. Social and psychological issues will nearly always also have to be dealt with concurrent with the physical issues of addiction. The use of a drug such as Methadone on a maintenance basis assists to stabilise a patient and gives them the opportunity to move from the lifestyle of illicit drug use. Patients who enter a pharmacotherapy program such as the Methadone program need to be fully informed as to the proposed care plan for them and in particular whether it is intended to lead to detoxification or rather proceed as a maintenance program only. It may be timely for the current review mentioned previously, to consider whether open-ended maintenance regimes provide the necessary patient and community benefit or whether all pharmacotherapy ought occur as part of a formal treatment plan having identified steps that progress to detoxification I am aware that the pharmacotherapy program (Methadone program) in Tasmania has for some years been under considerable pressure with very little capacity to accept new patients. However it is apparent that the deceased was provided with a number of opportunities to use other support and treatment services and he chose not to take full advantage of these opportunities. It is also clear that he continued to use other drugs illicitly in combination with his Methadone. An expert workshop on the Induction and Stabilisation of patients on Methadone held on 28/29 January 1999 reported that:-
“A very high percentage of Methadone patients who die during stabilisation have also been using other drugs near, or at the time of their death. In Australia this constitutes greater than 90% of those deaths, suggesting that fewer than 10% were using Methadone exclusively when they died. Other central nervous system depressants are most frequently used with Methadone, including Benzodiazepines, other opiates, alcohol and cannabis.” (www.Health.gov.au. Monograph Series No. 37)
The use of illicit drugs by persons on a pharmacotherapy program raises important issues. I recommend that consideration be given to whether or not persons receiving such treatment should be subject to screening for the use of other drugs. I accept that a balance needs to be achieved between the risk of patients leaving the program and the personal and community consequences of that action on the one hand and on the other, the need to identify those patients who may not be suited to the program or who may pose a real risk of misusing their prescription, eg take-away doses.
Finally, I observe that the provision of pharmacotherapy to a patient whose mood was violent or unpredictable imposes particular challenges. It is unlikely that such persons can be accommodated within the practice of a private general practitioner and consideration needs to be given to whether such persons are excluded from the scheme with the associated personal and community damage that would cause or rather their needs to be developed a facility capable of dealing with such persons.
Before I conclude this matter I wish to convey my sincere condolences to the family of the deceased.
DATED : This 6th day of February 2007.