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F or vi years, Brent Slone had relied on opioid medication to tame his agonizing hurting — then he ran out. He raced to resolve the hang-upward over his prescription. He tracked downwardly onetime medical records, he called his pain clinic repeatedly, he fifty-fifty showed upward at the door. Only the final word came downwards: no refills until an appointment almost a week away.
"they denied script im done love yous," Slone, 40, texted his wife on the afternoon of Sept. 12, 2017. He killed himself soon afterward.
In an unusual footstep, his wife and then sued the dispensary and its physicians — a rare legal claiming to doctors over their decisions to reduce patients' opioid doses.
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Her lawyer argued that Slone was neglected by his doctors and his care mishandled by the pain clinic. Since a car crash paralyzed him from the waist down, Slone had been prescribed high-dose opioids and taken them as instructed. But through his providers' carelessness, the lawyer contended, his dose was rashly cut by 55%. When he couldn't become any more medication, he feared days of no relief.
"This is a patient rubber, a patient abandonment case," said the lawyer, Hans Poppe, at the trial, held this August in Louisville, Ky.
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The clinic argued Slone's pain doctors were trying to responsibly treat a patient who was at a precarious moment, 1 whose suicide was entirely unforeseen. Slone had been placed on "an astronomically high dose" of opioids by other clinicians when he was at a nursing facility recovering from surgery. His pain physicians then lowered his dose to i that he had previously been on. And when he misused that prescription, burning through it too fast, they had no choice but to deny a refill until his engagement. This was standard of care.
"This is a setup for a drug overdose," Stephen Kyle Young, i of two physicians named in the suit, said about the possibility of authorizing more pills.
The ii assertions illuminate a thorny, essential question that has been bubbling into greater awareness: How should doctors safely care for patients who have been on high-dose opioids for years? There'due south a push to lower opioid levels amid the country's addiction crisis, just advocates and experts agree that mismanaged dose reductions — whether too aggressive or besides broadly implemented — introduce new, serious harms. Not only can they lead to resurgent pain or withdrawal, advocates say, but they tin drive people to seek out illicit opioids or to have their ain lives.
Cases like Slone's are complex, experts told STAT, involving vulnerable patients and high doses of potentially unsafe drugs. But too often, they warned, people who rely on these medications are seeing them taken abroad under the guise that information technology will brand them safer, when instead information technology can endanger them.
At the trial, the jury agreed. The panel found the physicians and hurting dispensary at error and awarded the family virtually $7 million, with $3 million allocated for Slone's daughter, who was 12 when her father died.
Researchers stress that attributing suicide to a single cause is difficult. In these situations, patients often have multiple risk factors — including opioid apply itself, chronic pain, and accompanying mental health issues.
Still, Slone's case is notable considering information technology appears to be the commencement fourth dimension a jury sided with a patient whose opioid medication was, in their eyes, improperly withheld. It is a sign of the growing recognition that after a reckoning over the harm wrought by prescription opioids, the pendulum swung too far back in certain cases and left another grouping of people with chronic hurting at chance. The message is starting to come from the highest levels, with federal wellness regime upping their warnings in recent years virtually the harms of unsafe dose reductions and stoppages.
"This is the first example that I've seen that took that on and said, this is problematic, that endangering people's health like this is problematic," said Kate Nicholson, president of the National Hurting Advocacy Center.
For CaSonya Richardson-Slone, Brent'south wife, hearing the judge read the jury's verdict was a moment of relief, one that validated her decision to pursue the case.
"I felt similar I had been in fight way," she said. "I did it for him, and for my daughter, for everything we've gone through, for everything she'due south gone through. Nosotros had already suffered a lot, through his motorcar accident, but we had adjusted to that new normal. We still had family traditions that were important to usa. We still went to dinner and to the movies, and played guitar and did karaoke. We celebrated her birthday, nosotros went to Red Lobster. We nevertheless did normal things that families do."
B efore her husband'due south death and the subsequent trial, earlier the machine accident that meant her husband would be in hurting for the remainder of his life, a teenaged CaSonya was a cashier at Winn-Dixie. Brent would go through her checkout line and then he could flirt with her, with a boldness that both charmed her and took her ashamed. They eventually married and had their daughter, settled in Louisville, and spent much of their gratuitous time outdoors — hiking, swimming, camping.
Then, in 2011, came the crash. Slone sustained a broken pelvis, a compressed spinal cord, and other injuries that acquired chronic pain and put him in a wheelchair. He developed depression. To atmosphere his pain, Slone relied on opioid and not-opioid medications, and in 2014, became a patient at Commonwealth Pain and Spine, which has a network of clinics in Kentucky and Indiana.
Doctors measure opioid dosages in units chosen morphine milligram equivalents, or MMEs. Federal guidelines now caution against doses above ninety MME a mean solar day for chronic pain, or say such doses demand to be justified (pain direction specialists generally accept more breadth). Simply some patients have been on college levels for years. Slone'due south dose hovered effectually 240 MME a day, varying depending on his hurting levels and procedures.
Slone's handling coincided with campaigns to rectify opioid prescribing. To claw back from years of lax dispensing that flooded communities with pills, clinicians started offering smaller doses for shorter periods of fourth dimension to new patients. As a outcome, U.Due south. opioid prescribing has plummeted in the past decade, fifty-fifty equally the overdose crunch has reached record heights due to an explosion of illicit fentanyl.
Some experts take as well called for clinicians to "taper" the doses of legacy patients to safer levels, to essentially find the everyman dose that tin can control their hurting. Information technology's non just that the drugs carry some run a risk of addiction and overdose, but are associated with other risks and side effects also, including mental health issues. There'southward disagreement most whether long-term opioids are fifty-fifty treating pain in many people or they just go physically dependent on the drugs; some evidence indicates that lasting opioid utilise tin worsen pain.
But other experts have pleaded for a more cautious approach for the millions of people living with pain who have opioids — even if they concord that some should never have been placed on such high doses. Many patients are in delicate situations, with disabilities or mental health problems, but seem to accept found stability with their medication. Unwise tapering tin upend their lives and exacerbate their pain, advocates say. In some cases, physicians, insurers, or pharmacies have suddenly cut patients off. Tapering works for many patients, they say, but it can't exist forced.
It's a fraught debate, draped past the legacy of profligate prescribing. Merely despite the divide over how widely to pursue tapering, experts and governmental guidelines agree that — with few exceptions — dose reductions demand to go slowly, with patient buy-in.
I due north 2016, Slone started traveling to California for advanced wound care. His wheelchair caused pressure sores that resulted in os infections.
He went over again in the summer of 2017 for surgeries, including peel grafts, and and then recovered for weeks at a nursing facility in La Jolla. His daily opioid intake increased from 240 MME to to a higher place 400 MME, occasionally reaching 540 MME. On Aug. eleven, he was discharged from the nursing facility at that highest dose for a visit to Kentucky.
Slone's medical squad in California contacted Commonwealth and said that he had enough medication to last through Aug. 16, courtroom records and testimony signal. Young, the pain management doctor, wrote Slone a "bridge" prescription at that 540 MME level to last until his Aug. 22 appointment at Republic, fifty-fifty as he worried about Slone existence on such a massive dose.
It was at that appointment that Slone's dose was dropped by more than than one-half, to 240 MME.
Why such a reduction occurred was disputed at the trial. Poppe pointed to testimony indicating that a nurse inadvertently slashed Slone'south dose to his prior one — peradventure because she copied over information from his nautical chart from months before — and that the doctors didn't catch the error. Poppe argued such a mistake amounted to an dangerous taper, citing guidelines that recommend starting with a roughly ten% dose reduction, and that it demonstrated a failure in patient care.
The defense framed Slone'south reduction every bit intentional — and suggested the state of affairs was something other than a taper. The higher dose of 540 MME reflected what Slone was on for acute hurting following surgery, at a time when he was closely monitored at inpatient facilities. Such a dose would not exist safe for him out in the earth. They were just moving him dorsum to his chronic hurting baseline dose, and claimed he would not experience withdrawal because 240 MME was still supplying a sufficient opioid amount.
"This is not a taper case," said James Jackson, the other physician named in the lawsuit. "He was existence established back on his safe dose."
STAT reviewed the problems in the case with exterior experts. If the defense's portrayal of an intentional dose reduction was accurate, the experts still challenged the contention that someone whose prescription was lowered that much couldn't experience withdrawal — no matter how loftier the remaining dose was. Responses to opioids are highly variable, but some people go used to elevated doses in every bit little equally a week, they said. The body would wait a certain amount of opioid, and would notice if information technology wasn't there, so a return to a baseline dose should happen gradually. Such a rapid reduction could also have allowed Slone'southward postoperative pain to return, they said, though they cautioned they hadn't seen his total medical history.
"This is the problem that we see — there is this rush, almost a panic, to decrease doses rapidly under the guise of patient safety, but the irony is these rapid changes betrayal patients to greater hazard," said Beth Darnall, a psychologist and managing director of the Stanford Hurting Relief Innovations Lab, who is working on a report examining voluntary opioid tapering.
Whether you phone call what happened to Slone a taper or prefer another word for the reduction is semantics, they said.
"It was a dose change that people would non exist expected to tolerate," said Stefan Kertesz, a primary care and habit medicine physician at the University of Alabama at Birmingham's medical school, who is working on a report examining suicides that occur later dose reductions and stoppages.
On Sept. 11, a few weeks subsequently his dose was dropped, Slone chosen Commonwealth and reported he was running out of medication, though his prescription was supposed to last another calendar week. At the trial, Poppe best-selling that Slone misused the medication, taking some 300 to 400 MME per day instead of 240, but contended Slone did so because his dose was cut besides fast.
Slone chosen Commonwealth about a dozen times over the next 24 hours and fifty-fifty went to the clinic to inquire about his prescription, according to courtroom records. CaSonya said she chosen as well and told the staff that Slone was in hurting. From Sept. 10 to Sept. 12, Slone too went to emergency departments a number of times — including one time after dislocating his hip from falling from his wheelchair — and reported that he was out of medication and was in pain. He was given low levels of painkiller, but was told to speak to his hurting specialists to resolve the prescription issue.
"In that location is this rush, about a panic, to decrease doses rapidly under the guise of patient safety, but the irony is these rapid changes expose patients to greater take a chance."
Beth Darnall, Stanford Pain Relief Innovations Lab
But Young denied a refill or a bridge prescription ahead of the appointment scheduled for Sept. 18, saying that Slone had violated the narcotic agreement he had signed by taking his medication more often than prescribed.
At the trial, defense chaser Sean Ragland argued that Slone's suicide could non have been predictable and that he had not exhibited any signs of suicidal ideation. The greater risk at that moment was overdose, because when Slone went through his medication too quickly, his doctors couldn't know whether he had obtained an illicit supply or how much opioid he had in his arrangement, the defense force contended.
Doctors at Commonwealth "embrace an idea of the conservative approach to opioid use that takes into account each patient's needs with respect to their hurting and also takes into business relationship the risks that opioids present," Ragland said. (Post-obit the verdict, the defense requested that the instance be retried, merely a approximate has yet to rule on the motility.)
The experts STAT consulted said situations when a patient goes through a prescription too quickly are challenging — but non uncommon. Pain clinics shouldn't dole out more pills whenever that happens, especially when someone is on equally high of a dose as Slone was, but each case needs to be considered individually, they said. Slone had had a major dose reduction, and he had until so generally complied with his prescription instructions. Given Slone's tolerance to loftier doses, the experts also questioned how much of an overdose risk he presented.
"The commencement thing you should inquire is not, [is] this guy is taking advantage of me, but, what bankrupt his consistency this time?" said Michael Barnett, an assistant professor of health policy and management at Harvard's T.H. Chan School of Public Health, who studies opioid prescribing. (Barnett has served as a paid expert witness for plaintiffs in lawsuits against opioid manufacturers and distributors.)
Steven Stanos, a pain medicine specialist at Swedish health system in Seattle, said pain doctors used to have the instinct not to provide whatever more medication when patients ran out early. Simply they've realized that by halting the drugs, "you really don't make the patient safer," he said. Doctors now try to encounter patients when that happens, offer a bridge prescription for a low-dose opioid until an appointment can be made, or try buprenorphine, a medication that can ease withdrawal symptoms and accost some pain.
"If someone runs out early, the question is, why?" said Stanos, who is on the lath of the American Academy of Pain Medicine.
But on the afternoon of Sept. 12, Slone was told he wouldn't exist getting more medication until his appointment, six days away. He killed himself about 2 hours later.
H ealth authorities are increasingly publicizing the risks of dangerous opioid reductions. In 2019, the Nutrient and Drug Administration warned about the dangers of rapid discontinuation and mandated changes to prescribing information. In September, California's public wellness department alerted providers that they should "continue opioid therapy for patients in transition" and "utilise circumspection when tapering opioid therapy" when taking on legacy patients.
The Centers for Affliction Control and Prevention is also revising its 2016 prescribing guidelines, which were intended as recommendations for master care physicians treating certain chronic pain patients, but have been used to justify hard caps on doses. Even the guidelines' authors stress they've been misapplied. The updated version is expected adjacent twelvemonth.
"Some policies and practices citing the guidelines went beyond its recommendations and were inconsistent with its guidance," the CDC'south Deborah Dowell said at a July meeting. "For case, the guideline does not support precipitous tapering or sudden discontinuation of opioids, but we heard many reports of it being inappropriately cited to justify suddenly cutting off opioids."
Still, the concerns around opioid dose reductions are taking fourth dimension to reach all clinicians, said Joanna Starrels, a primary intendance and addiction medicine physician at Albert Einstein Higher of Medicine and Montefiore Medical Centre. Prescribers for the by decade take been thinking more most the risks and benefits of giving opioids, and now they're having to consider the risks and benefits of reducing doses as well.
"At that place is increasing awareness amongst providers that there are risks of tapering opioids, and nosotros're start to empathise those risks," said Starrels, who focuses on chronic pain direction. "Unfortunately, we're pretty early in that process, both in terms of the research and the evidence to understand who'southward at risk for bad outcomes with tapering and when and why … I do think if a provider is non an expert in this field, it's hard to proceed upwardly."
Brent Slone, and his situation, looks like other patients who have lost admission to opioid therapy, experts said — namely that he was a person with disabilities who seemed to fall through the cracks when he transferred betwixt medical teams. But in that location are of import differences. Slone's effect arose when he had an unusually high dose for acute pain on top of his already high dose for chronic pain. And Slone didn't experience the abandonment that some patients do, when their physicians stop providing them medication permanently or when their chemist's or insurer cuts them off.
For CaSonya, who now lives in Florida with her daughter, her hope is that the lawsuit and the verdict aid ensure chronic hurting patients get the proper care.
She and Brent were separated when he died, but remained close and were figuring out their next steps. What still nags at her almost what happened is that they did everything they were supposed to practise. They got Commonwealth the medical records from the California facility that the clinic asked for. Brent sought assist at the emergency department. When the emergency departments told him he needed to sort this out with his pain physicians, they chosen Republic repeatedly. It wasn't enough.
"It was unthinkable that he wouldn't be seen in their office, or that he wouldn't become a span prescription," she said. "I never thought I'd lose him in that mode."
If y'all or someone yous know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line past texting HOME to 741741.
Source: https://www.statnews.com/2021/11/22/her-husband-died-by-suicide-she-sued-his-pain-doctors-a-rare-challenge-over-an-opioid-dose-reduction/
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