Toxicology Expert Evaluates Role of Opioid Pain Medication in Suspected Overdose

This case involves an older female patient with a history of chronic gastrointestinal disease who had been placed on a number of pain medications prescribed both by her primary care physician and a pain medicine physician. She was found dead in her home from the mix of drugs with no evidence of foul play. A toxicologist was requested to review the patient’s autopsy reports and determine what role prescription medication may have played in her death.

Question(s) For Expert Witness

1. How often do you diagnose or treat patients for pain medication overdose?

2. Are you able to opine on the cause of death after reviewing the records?

Expert Witness Response E-014600

I have treated patients for pain medication overdose as both an emergency physician and as a medical toxicologist. It can be difficult to definitively establish opioid pain medications as the cause of death. Post-mortem blood levels may be useful and can be compared to therapeutic levels and to those found in overdose deaths. The absence of other causes of death may strengthen the case that the death is opioid-related. In patients on chronic opioid therapy, chronic prescriptions for opioids should be limited to a single provider/practice. If two physicians are involved, there should be a valid reason and timely communication between practices/providers is essential. There is no maximum dose for opioids although, evidence-based guidelines recommend limiting total opioid dose as higher doses are associated with an increased risk of death. A morphine equivalent dose of 100 mg/day is considered high dosing and increases risk of overdose death.