Mr M was a 48-year-old married man with 3 children. He had been seeing his primary care physician (PCP) regularly since 2005 for chronic, debilitating cervical pain. The patient had been diagnosed with multi-level degenerative disc disease and cervical radiculopathy stemming from injuries he sustained in a car accident in his 20’s. The patient was prescribed opioid medications for pain management by his previous PCP, starting in 2005.

Mr M took his medication as prescribed and showed up for his medical appointments. By 2017, the patient was on a combination of medications to manage his pain including morphine sulfate (60 mg 3 times a day), oxycodone/paracetamol (5/324 mg every 4 hours, as needed), and zolpidem (10 mg/d),  

In late February 2017, Mr M was told that his PCP was retiring in a few weeks and he should find a new primary care provider. He set up an appointment to establish care at another clinic but his first appointment was not until May. In early April, Mr M filled his final prescription from his PCP. By early May, the patient had run out of medication but was unable to get an earlier PCP appointment.

In severe intractable pain, Mr M went to his local emergency department (ED) in mid-May, the day before his new PCP appointment. He told the ED providers that his morphine sulfate prescription had lapsed the previous day. He explained that his physician had retired and he was unable to get an appointment with a new primary care provider until the next day.

Mr M was given 1 dose of morphine sulfate in the ED and was then sent home with instructions to follow up with his primary care provider. The next morning, he went to his appointment at the new clinic. There he was assigned to a physician associate (PA). The PA examined the patient but did not refill Mr M’s opioid prescriptions. Because the PA did not take thorough notes, there was no mention in the patient’s record of why he refused to refill the prescriptions, or whether he consulted with any of the 4 supervising physicians at the practice.

What is known is that the PA did not renew the existing prescriptions and sent the patient home without pain medication. Mr M experienced severe withdrawal from the morphine, and, feeling hopeless, died by suicide the following day. He was survived by a wife and 3 children.

Legal Background

The patient’s widow hired an attorney who sued the PA and all 4 of the supervising physicians at the clinic. Discovery began, and the plaintiff’s attorney retained an expert physician to go over Mr M’s medical records.

The expert physician concluded that there was evidence of medical negligence in the treatment of Mr M. Specifically, the expert noted that the care provided by the PA and his supervisors fell below the appropriate standard of care required in such a case. The expert’s report alleged that the PA and his supervisors had:

• Failed to properly evaluate, diagnose, and/or treat Mr M who had been dependent on opioids for pain management for well over a decade.
• Improperly refused to renew Mr M’s pain medication prescriptions.
• Failed to prescribe adequate medication to manage the patient’s evident and well-documented pain.
• Failed to provide a taper or bridge medication to help transition off pain medication and to lessen withdrawal symptoms.
• Failed to appreciate the physical and mental dangers of acute opioid withdrawal.
• Failed to take adequate steps to prevent or minimize the severe effects of withdrawal from long-term opioid dependence.
• Failed to refer the patient to a pain specialist or detoxification center after declining to renew his prescriptions.

The expert’s list of the clinicians’ failures was extensive and blamed the supervising physicians as well for failing the patient.

The case was settled out of court for an unpublished amount. It is unclear why the family did not sue the original PCP who retired and left his long-time patient without any direction.

Protecting Yourself

We cannot tell from the facts in this case why the PA declined to renew Mr M’s prescriptions. The doses of opioids may have been higher than the PA was used to seeing in a primary care practice.

There were many mistakes in this case. The retiring PCP left his patient without clear instructions or referral to a pain specialist. He should have helped Mr M find a new provider who would continue the opioids, or he should have helped the patient to taper off his medications before he left his practice. Instead, the PCP retired and left his patient with no continuity of care.

It is not clear whether the PA had access to Mr M’s previous medical records at the time of their meeting. However, not treating a patient who is opioid-dependent is negligent. Mr M was not offered anything to help with his pain or offered medical management of his opioid withdrawal, a short prescription for pain relief, or a referral to a pain specialist. He was sent home in physical pain with no recourse.

We are all aware of the opioid “epidemic” in this country and the hazards that these medications can bring, but that should never be an excuse to deprive a patient of desperately needed help. 

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.