Virginia – Family Medicine – Long History Of Narcotic Seeking Behavior And Pattern Of Abuse

From 12/01/2010-12/03/2010, a 31-year-old-man with schizophrenia and bipolar disorder was hospitalized.  During the hospitalization, a psychiatric consultation revealed that the patient had a significant history of “drug seeking behavior (primarily opiates) and significant paranoid thinking.”  It was noted that since July 2010, the patient had presented to the emergency department at least 11 times, “most all of which where he is complaining of pain and seeking some type of medication.”

He had stuck a nail in his ankle and stabbed himself in the thigh in two separate instances, which the mother believed were performed to obtain more pain medications.  He had obtained pain medications from other family members.  The mother confirmed that he had a “severe drug problem.”

It was also documented that the patient had at least 10 prior psychiatric hospitalizations for the diagnosis of mixed personality disorder (mainly paranoid) and severe opioid dependence.  It was noted that the patient was unlikely to take his prescribed psychotropic medications.

On 6/27/2011, the patient’s PCP stated that another physician, who was managing the patient’s pain, refused to prescribe him further narcotics given that his urine drug screen was negative for hydrocodone, which the physician had been prescribing him.

On 7/24/2011, the patient presented to an emergency department for treatment of a re-opened gunshot wound in his right calf.  It was documented that the patient had recently been hospitalized at another hospital for an overdose of barbiturates and opiates (which required intubation).

On 10/17/2011, a pain management specialist declined to accept the patient given the patient’s “PMP and UDS results, as well as his record including violent behavior and 2 self-inflicted gunshot wounds…These results and behaviors are highly suggestive of a substance abuse disorder.  I would recommend that he be evaluated and treated for addiction…He also likely has rebound headaches given his multiple daily doses of controlled substances.  Weaning of the controlled substances would address the rebound headache issue…[and] would be safer from a potential overdose perspective…[F]rom my review of the record, I am very concerned that treatment for his pain would be unsuccessful without first addressing the addiction issue.”

From 2/09/2012 to 2/25/2012, the patient was hospitalized was treated for recurrent infection of his right leg gunshot wound.  It was documented that “[u]ltimately, it was felt he had a significant component of pain [medication] seeking behavior…Ultimately, we have recommended to him that he taper and stop all of his pain meds over time.  If he cannot do that, I have recommended to him that he seek treatment for substance abuse.”

On 1/6/2012, the surgeon treating the patient’s non-healing gunshot wound was contacted by a pharmacist who reported that the patient was receiving prescriptions for oxycodone/acetaminophen from his PCP at the same time the surgeon was prescribing the medication for him.  On 1/25/2012, the patient’s PCP refused to see him anymore after he caused a scene in the waiting room and broke his crutches when his PCP would not write for further narcotics.

The patient reported to the surgeon that his pain medications had been stolen on 2/01/2012 and again on 3/21/2012.

On 3/23/2012, the patient first visited the family practitioner, who subsequently prescribed large quantities of narcotics despite his prior history.  The family practitioner testified that she initially did not know of the patient’s prior history.  When she knew of his history, she testified that she wanted to gain the patient’s trust first and then she planned to taper the patient off of narcotics.

From March 2012 to August 2015, the family practitioner prescribed fentanyl patches, oxycontin, hydromorphone, Fioricet, and alprazolam for chronic pain from the self-inflicted gunshot wound to the right lower leg, neuropathic pain of the right leg, chronic headaches, chronic left ankle pain, and anxiety.

On 03/29/2013, the family practitioner entered into a controlled substance agreement with the patient.  Once executed, the patient failed to enforce provisions of the agreement, such as performing urine drug screens or performing pill counts consistently.

On numerous occasions, the family practitioner documented that the patient reported that his brother, sister, roommate, friends, or others had stolen his pain medications.  The family practitioner failed to require a police report proving these alleged thefts and routinely replaced the prescriptions for these stolen medications.

On 4/11/2012, the patient reported that he had run out of his hydromorphone early because he was carrying it with him in the car when the pills fell out of his coat pocket into the back seat.  In other instances, he reported that he had lost his pill bottles.

On 6/15/2012, his bottle of hydromorphone again went missing.  The patient asserted that his roommate (who allegedly suffered from AIDS) was in possession of the pain medications with blood covering the roommate’s hands as well as several of the pill bottles.  He said he could not find the bloody bottle of hydromorphone.  When the family practitioner refused to prescribe hydromorphone, he reported that even if he could find the bottle of hydromorphone, he would be afraid to take it, given the risk of HIV exposure.

On 7/5/2012, the pharmacist called the family practitioner stating that the patient had consumed 40 tablets of hydromorphone in just three days.  The patient complained that the pharmacist had only given him 40 out of 180 prescribed on 06/29/2012 and requested that the family practitioner provide him with another script.  The family practitioner’s nurse practitioner then provided the patient with a prescription for 50 tablets of hydromorphone.

On 10/25/2012, another physician in the family practitioner’s practice saw the patient and noted that the patient was being prescribed “unbelievable doses of opiates along with benzos.”

On 6/12/2013, a blood serum drug test was negative for hydromorphone.  On 7/22/2013, the patient explained that he had stopped the hydromorphone 1-2 days prior to the blood test done on 06/12/2013.  He stated that he failed to inform the family practitioner of this at his last visit because he thought the medication would still show up in his blood and he did not want the family practitioner to be mad at him for not taking his hydromorphone exactly as prescribed.

On 7/19/2013, he reported that he had run out of a month’s supply of hydromorphone and alprazolam prescribed to him on 06/12/2013 with fill dates of 06/30/2013.  Despite the evidence, the family practitioner noted that she would “give him the benefit of doubt and am refilling his meds. for 1 month.”

On 8/1/2013, the patient’s mother told the family practitioner that the patient believed others were stealing his medications secondary to his schizophrenia.  The family practitioner and mother agreed that the mother would dispense medications to the patient.  On 01/10/2014, the patient reported to the family practitioner that his mother had given back his medications to manage himself.

On 8/16/2013, the family practitioner authorized an early refill given that the patient said his fentanyl patches were falling off, requiring him to increase his hydromorphone usage.

On 11/14/2013, the family practitioner watched a video where the patient secretly recorded his sister stealing a pain patch off of his desk.  The patient declined to call the police as recommended by the family practitioner and said her sister had gone into treatment.

On 5/1/2014, the patient received hydrocodone/acetaminophen from his dentist.  The family practitioner prescribed the patient more of the same and gave him early scripts for hydromorphone and fentanyl.

On 6/4/2014, the patient reported that he had been hospitalized at a psychiatric facility.  His mother admitted that she did not want to manage his medications because the patient kept pestering her for them.

On 6/4/2014, the patient was hurting more than usual and could not take extra medication given that his mother had taken back control.

On 7/9/2014, the patient informed the family practitioner that her mother had not given him any fentanyl patches and he was taking extra hydromorphone in response.  The mother had left a message if her son could take an extra hydromorphone pill per day.  The family practitioner responded by admonishing the patient not take take an extra hydromorphone per day and prescribed him more fentanyl patches.

On 8/25/2014, the patient was taken to the emergency department after the family practitioner had written prescriptions for hydromorphone (#540), Fioricet (#360), and fentanyl patches (#45) and after the patient had misused these medications.

On 09/25/2014, the family practitioner prescribed further narcotic medications, noting that “this will be [the patient’s] last chance to show his responsibility.”

Despite a pattern of abuse, the family practitioner continued to prescribe narcotics to the patient and in response to the patient’s self-titration upward due to increased pain, she increased the daily dosage of hydromorphone.

On 6/18/2015, the patient reported that he had increased his consumption of hydromorphone to two pills every 6 hours.  He justified this increase, saying he would experience suicidal ideation and hallucinations if he failed to do so.  In response, the family practitioner noted that she did “not believe that he is abusing the meds.  I believe that his pain is uncontrolled.”

On 7/2/2014, the patient reported acute withdrawal symptoms and suicidal thoughts due to being out of hydromorphone for 12 days.  The pharmacy had refused to fill the early hydromorphone prescription the family practitioner had given him on 06/28/2015.

The family practitioner testified that she took over care of the patient’s pain management given that other physicians would not and the surgeon did not know what to do with him.

She testified that the patient absolutely refused to see mental health providers during the treatment period.  She said that the reason she did not threaten to cut the patient off from his narcotic regime was that she wanted him to buy into the treatment plan.

Based on her treatment of this patient and another, the family practitioner was reprimanded.  She was prohibited from treating any patients with chronic pain starting 30 days after the order.  Within twelve months of the order, she was to provide proof of completing 15 credit hours in the subject of pain management and 8 hours in the subject of recognizing addiction.

State: Virginia

Date: September 2016

Specialty: Family Medicine, Pain Management, Psychiatry

Symptom: Pain, Psychiatric Symptoms

Diagnosis: Drug Addiction, Drug Overdose, Side Effects, or Withdrawal

Medical Error: Improper medication management

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

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