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Inaccurately Assigned Opioid Overdose on Hospital Admission – An Attorney’s Dream

/ Jeffrey Fudin / 33 Comments on Inaccurately Assigned Opioid Overdose on Hospital Admission – An Attorney’s Dream
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Over many years I have seen several cases where upon hospital admission, the house staff and emergency clinicians mistakenly assign blame to opioids, the diagnosis of which is in their minds indubitably an opioid overdose.  Imagine the outcome when a family member makes a B-line to the nearest attorney with intent to sue the prescribing clinician.

It seems that much like the untrained journalist, it is easiest to lay blame on opioids without a proper differential diagnosis.  Far be it from me to make or second guess a diagnosis upon hospital admission because as a doctor of pharmacy that is outside my scope of practice – or is it?  When blame is specifically misplaced because of a drug overdose, the lines between who is qualified to ascertain causation become less clear.

Below is a typical example which is based on a real case.  Names, dates, and specifics have been changed to protect the guilty.

Ms. Smith is a 62 year old Caucasian female who was seen in the hospital for purposes of continuity of care, and per notification from the in house clinical pharmacist and house staff.  She was seen at bedside by the Pharmacy Pain Team.

OUTPATIENT pain and pain-related related medications included many as listed below:

  1. AMITRIPTYLINE HCL 10MG TAB PO AT BEDTIME
  2. BACLOFEN 20MG TAB TAKE ONE TABLET PO TID PRN FOR MUSCLE RIGIDITY
  3. BUPROPION HCL 150MG 12HR SA TAB PO BID FOR DEPRESSION
  4. DULOXETINE HCL 60MG EC CAP TAKE ONE CAPSULE BY MOUTH EVERY MORNING FOR PAIN/DEPRESSION
  5. ETODOLAC 300MG CAP PO TID PRN FOR ARTHRITIC STUMP PAIN
  6. PREGABALIN 150MG ORAL CAP PO TID FOR PAIN
  7. ZOLPIDEM TARTRATE 10MG TAB PO AT BEDTIME AS NEEDED
  8. FENTANYL MATRIX 25MCG/HR PATCH APPLY 1 PATCH TO SKIN EVERY 48 HOURS FOR PAIN
  9. LEVORPHANOL TARTRATE 4MG TAB PO QID FOR PAIN

The patient was followed by our service for severe diabetic neuropathy and phantom limb pain.  She was admitted through our neighboring hospital with a diagnosis of “opioid overdose”.

ALLERGIES: CEFAZOLIN (RASH)

Active inpatient medications included:

  1. AMITRIPTYLINE TAB, Give:  10MG PO QHS                                 
  2. ASPIRIN E.C. TAB,EC, Give:  81MG PO DAILY                               
  3. BACLOFEN TAB, Give:  20MG PO TID PRN                             
  4. DOCUSATE/SENNOSIDES TAB, Give:  2 TABLETS PO TID                            
  5. DULOXETINE CAP,EC, Give:  60MG PO QAM                                 
  6. ETODOLAC CAP,ORAL, Give: 300MG CAPSULES PO TID                            
  7. HEPARIN SODIUM INJ,SOLN, Give:  5000UNIT/1ML SC BID                         
  8. LISINOPRIL TAB, Give:  40MG PO DAILY                               
  9. MULTIVITAMIN CAP/TAB, Give:  1 TABLET PO DAILY                           
  10. OMEPRAZOLE CAP,EC, Give:  20MG PO QAM                               
  11. PREGABALIN CAP,ORAL, Give:  150MG PO TID                                 
  12. TROSPIUM TAB, Give:  20MG PO BID                               
  13. BUPROPION 12HR TAB,SA, Give:  150MG PO BID                           
  14. OXYCODONE TAB, Give:  10MG PO Q4H PRN severe pain
  15. OXYCODONE TAB, Give:  5MG PO Q4H PRN moderate pain
  16. DOCUSATE/SENNOSIDES TAB, Give:  2 TABLETS PO TID PRN constipation

The patient had quite a long medical problem lest including:

  1. PMH of DM2
  2. Neuropathy and foot ulcer
  3. HTN
  4. GERD
  5. HepC
  6. Depressive Disorder
  7. PTSD
  8. Hip Joint replacement Status (Prosthetic or Artificial Device)
  9. Phantom limb pain
  10. Peripheral vascular disease
  11. Below knee amputation
  12. Other: Iron Deficiency Anemia, Nicotine Dependence, Lymphadenopathy

Ms. Smith was admitted with a reported pain level of 5 out of 10, with 10 being the most severe and 0 being no pain.  She was admitted for presumed opioid overdose.  On day of event, patient states that she was in her kitchen when she “lost balance” with her prosthesis and fell on her back, and was aided by her husband after the fall.  He moved her to the bedroom to lay her down, and her husband called for help.

This patient has always been a delight to work with and an excellent medication complier. Upon admission she denied taking any extra doses of her pain medications while at home as she uses a “pill box/organizer”.  She denied any episodes of loss of consciousness from home to being admitted through our Emergency Room. She confirmed last applying a fentanyl patch on 3 days earlier and self-removed it following the incident d/t feeling “scared” of what was happening.  She acknowledged storing her medications in a safe area away from others.

All too often, patients similar to this are labeled (diagnosed) as an “opioid overdose”.  Even at the point of death, I have seen medical examiners label the cause of death as “opioid overdose” without checking the medical records to ascertain whether or not a patient was opioid naïve or tolerant.

In this case, the patient’s fentanyl and levorphanol were discontinued upon admission and prior to transfer.  Of note, 2mg of levorphanol is equivalent to 15mg of oral morphine (or 10mg oral oxycodone) and 25mcg/hour of transdermal fentanyl is equivalent to 90mg of oral morphine (or 60mg oral oxycodone).  The patient was placed on oxycodone IR 5-10mg PRN and left on pregabalin 150mg TID, duloxetine 60mg daily, amitriptyline 10mg QHS, etodolac 300mg TID PRN, baclofen 20mg TID PRN.  Since being admitted three days earlier, the patient stated that she received “rapid detox/Narcan”, and has been in “more pain”, acknowledged having “sweats” and abdominal cramps while off of her levorphanol and fentanyl likely consistent with opioid withdrawal symptoms.

For educational purposes, it’s worth noting that most traditional opioids carry a higher risk of gastrointestinal bleed when combined with certain SNRIs, especially duloxetine.  Since the patient is on heparin, that too elevates this risk.  But, etodolac is actually more COX-2 specific than even celecoxib as seen HERE.

In the previous 12 hours, the patient had received 45mg of oxycodone (67.5mg MEQ) which is subtherapeutic in comparison to her outpatient regimen. She denied any lightheadedness, dizziness, drowsiness, excessive sedation, peripheral edema, nausea, vomiting, or headache.  Her most recent labs indicated normal renal and hepatic function.  A urine drug screen performed on admission in ER was appropriately positive for opiates and negative for other screened substances while on fentanyl and levorphanol prior.  This is consistent and expected.

To clarify, we do agree that neuromodulators would be the first choice line medications here, but the patient failed to respond adequately to several trials with various combinations.

A state prescription drug monitoring program (PDMP) report was performed on upon admission and no DEA Controlled Schedule II-IV prescription medications were found.  The patient reported no new allergies to any medications.  She denied any OTC analgesics, herbal products, or dietary supplements.

There is more to the history, but for the sake of this discussion, it was relatively inconsequential. 

No doubt that all sedating drugs could enhance lethargy from opioids.  These included at minimum, amitriptyline, pregabalin, and zolpidem.  But it is not appropriate for a chart to reflect an opioid overdose as a definitive diagnosis at the previous hospital or the one to which the patient was transferred.  In fact, statements such as…

“Especially in light of her recent narcotic overdose, it is important to focus on pain management without long-acting opioids.  The adverse effects of polypharmacy are a concern in this individual.”   

Reality Check #1: While I do agree with the statement regarding polypharmacy, that is not synonymous with “narcotic overdose”.  The recommendation was for “…may give oxycodone 5mg qid PRN and only short supply (a week at a time)”.  Note also, that had the dose been appropriate, IR formulations provide higher serum peaks that could prove even more problematic in terms of side effects and lethargy.

Reality Check #2: I DO NOT believe that opioids were the PRIMARY cause of this “overdose”, nor that it was an overdose. I do acknowledge that opioids could be additive in sedating effect to other underlying medical cause(s) considering the multiple co-morbid conditions and polypharmacy. THIS SHOULD BE NOTED IN THE MEDICAL RECORD BY A PHARMACIST OR A MEDICAL PROVIDER THAT UNDERSTANDS!

Six months earlier, the patient came to us on fentanyl transdermal 50mcg/hour changed Q48HOURS (200mg PO morphine equivalent – MEQ) plus methadone 15mg PO TID (110 MEQ), for a total daily PO MEQ of 310mg.  At the time the patient presented to the ER, presumably found “to be obtunded from opioids”, the pharmacy pain clinic, in collaboration with Primary Care Provider had her on fentanyl 25mcg/hour (100mg MEQ) + levorphanol  4mg PO QID (120mg MEQ), for a total daily MEQ of 220mg. 

Compared to the 310mg she was on at the time she was originally seen in six months ago, she is now actually on MEQ 310mg – 220mg = 90mg of morphine equivalent LESS than the patient was taking previously.  While I acknowledge that the notes from our sister institution stated that the patient responded to Narcan, I submit that any patient that is sedated for physiological or medication reasons other than opioids, who remains on long term high dose opioids and are injected with Narcan, will in fact have ADRENERGIC OVERSTIMULATION, which could “jolt” someone into an awakened state even if the overall cause is not narcotization.  So in this case, reversal alone cannot be confirmatory especially without considering that the patient was also noted to be orientated to time and place just minutes before.

The plan was to send this patient home with only oxycodone 5mg qid PRN. 

Reality Check #3: This is 90% less opioid equivalent than this patient had been receiving over the last several weeks and would undoubtedly result in discomfort from withdrawal and tremendously increased pain. I anticipated overt withdrawal to begin within the next 24-30 hours based on the half-life of transdermal fentanyl (following patch removal) and the 16 hour half-life of levorphanol.  This would have been additional patient suffering and possibly a readmission.

In the end, we made recommendations as outlined below.  The patient was thoroughly counseled on fall risk medications with advanced age, instability with prosthesis, and rationale behind discontinuation of her sedating medications.  The patient was provided with education on being a possible candidate for a naloxone kit/EVZIO. 

MEDICATION RECOMMENDATIONS, for remainder of inpatient admission and continued after discharge…

  1. Discontinue fentanyl 25mcg/hr transdermal patch, oxycodone PRN, zolpidem, amitriptyline, and baclofen.
  2. Increase pregabalin to 200mg PO TID for phantom limb pain (max dose).
  3. Continue therapy with levorphanol 4mg PO QID for BLE neuropathic pain.
  4. Continue therapy with duloxetine 60mg PO QD for pain/depression.
  5. Continue therapy with etodolac 300mg PO TID PRN for arthritic shoulder/stump pain.
  6. Obtained signed consent for Long-Term Opioid Therapy (DONE).
  7. Discussed and provided a handout for “Taking Opioids responsibly” education as well as naloxone kit/EVZIO (naloxone HCl auto-injector) education, with a printed copy of the former being provided to the patient.
  8. PCP to order naloxone kit/EVZIO (naloxone hcl auto-injector) if available; will provide re-education to patient and husband to demonstrate competency. THIS SHOULD BE COMPLETED PRIOR TO DISCHARGE!00_HC_shutterstock_94048387_steth_gavel_659px

So there you have it – one of the longest blogs here ever.  But, I hope this encourages my medical and pharmacy colleagues to work together as a team and to clarify whenever possible the morphine equivalent doses in similar situations and note [IN THE MEDICAL RECORD] the chronic prescribed opioid history.   To have notes that state the cause as an “opiate overdose” without any indicators or clarification to the contrary opens the door to liability.  Unfortunately I’ve seen it and as my attorney says, “people can sue for anything – the paper won’t reject the ink”.  In this case, ambulatory care clinicians must rely on savvy hospitalists and clinical pharmacists to document the reality and to mitigate against liability for their community counterparts.

As always, we invite you to share your comments.

33 thoughts on “Inaccurately Assigned Opioid Overdose on Hospital Admission – An Attorney’s Dream”

  1. Thank you for taking the time to write this blog. Ive searched far and wide on the internet for information that addresses this topic and have had little to no luck at all. All Ive come across are accolades for the drug Narcan and stories about those who have had positive experiences with it. Please dont get me wrong…I dont want to be misunderstood on this…I do not oppose Narcan, or the prescription of it to addicts and to the public to carry in case they encounter someone who has overdosed on opiates.

    Twice I have been given Narcan by EMS paramedics during heroin overdose and it saved my life both times and im grateful for the drug and those that admistered it when I needed it. Both times it was administered through an IV and when I woke up I began violently vomiting and shaking, and was in the worst pain Ive ever experienced….but they had saved my life and even in the midst of that hellish experience I was grateful to be alive and had no ill will toward the people who were saving my life or toward the drug narcan or the results of being administered the drug qqqqqqqqq+++q+to save my life while I was overdosing.

    However, a recent experience with narcan has me feeling like I would be justified in suing the hospital and the doctor that administered it. I was living in my vehicle and had only slept several hours over the course of several days due to the inability to find a quiet and safe place to park overnight…as a result of this lack of sleep, and of being on methadone maintenance and having done some heroin I fell asleep at the wheel and ran into a shopping cart holder in the parking lot of A Wal-Mart. When the paramedics showed up they had me come into the ambulance and spent about ten minutes asking me questions and making sure that I was ok and wouldnt require further medical attention. They paramedics cleared me and said I didnt need to go to the hospital. When I stepped out of the ambulance I was immediately arrested by the officer at the scene for a dollar bill they found in my car that they said tested positive for cocaine. When we arrived at the jail I sat in the processing
    Area for 20-30 minutes waiting to see the nurse so she could clear me to be processed into the jail. Upon seeing me the nurse told the arresting officer that she would not admit me into the jail because I looked high, and told him to take me to the closest hospital to have them medically clear me. I was then put back in the police car, transported to the hospital and admitted into the ER…all the while completely coherent, walking on my own with no assistance or falls. We explained to the ER nurse what had happened, and she informed me that she was starting an iv in my hand to get some blood. After that she left the room for several minutes. Having had little to no sleep over the past several days, and it being 4AM I dozed off while she was gone. (Keep in mind that at this point it had been several hours since the incident in the parking lot, that I had been medically cleared and deemed ok by the medical proffesionals in the ambulance several hours before, and I had been awake and moving about the entire time since the arrest.)

    I was jolted awake and immediated knew upon waking up that I’d been given narcan. The nurse was standing next to the bed and I asked her, panicking, if she’d given me narcan while I was sleeping and not paying attention. She replied that “she had per the doctors orders” and as the effects of being thrown into precipitated withdrawal from being on 140mg of methdone a day began to commence the nurse left room. The pain, and sickness that began to experience can not be described with words. I began vomitting violently and once my stomach had been emptied of its contents I continued to violently dry heave…in the midst of all this I realized that my hand was cuffed to the metal bar on the side of the hospital bed. About five minutes into this hell, I started to feel like I was about to lose control of my bowels any minute. I pled withthe officer that was in the room to take the handcuffs off so I could use the toilet but he completely ignored me. Panic stricken, I yelled for the nurse and repeatedly begged for someone to give me a bedpan or to take my cuffs off and that I was going to shi*all over myself any minute. No one acknowledged me, and I lost control and messed myself there on the ER hospital bed I was handcuffed to. As I laid there in precipitated withdrawal covered in my own mess, the nurse finally came back in and told me she’d been busy and instructed the officer to remove the cuffs so I could walk to the bathroom. After telling me that I would be tased if I did anything other than to walk to the bathroom the officer released me and I was able to go to the bathroom and clean myself up. I was terrified and appalled at this point for evwrything that had taken place since being admitted to the ER. To my knowledge, narcan is to be used on people who are displaying signs of opiod overdose, not someone who had been coherent and awake since being
    medically cleared by medical proffesionals hours ago. When i dozed off on the hospital bed noone tried to wake me by saying anything at all, and certainly no sternum rub or anything of that sort was done prior to injecting me with narcan. I would have definately woken up if I was even gently shaken or touched on the shoulder. Being given narcan when you have substantial amounts of opiates in your system is a very, very difficult thing to experience and the experience itself can be traumatizing to say the least. It should be used to save lives…not to speed up the process of sobering up from an opiate high because youre under arrest and need to be in fit shape to be processes into jail….or for any other reason. I would like to know if I can sue them for medical malpractice.

    Reply

      1. Currently there is no case….Im not really sure what you speak of when you say you would need t0 review the case files. Please advise.

        Reply

  2. This has happened to me and I found this site looking to see If i could sue because of it. I did not take my pain medications all day my last dose being at approximately 4am of 15mg oxycodone. I also wear a patch of 75mcg/hr. I have been on much higher doses for the past 20 years. But because of the war against pain doctors my recent doses have been cut by 75 percent. Leaving me in pain and unable to do much at a time. I always plan my day and space out physical activity. This one day though my washer broke and water is coming out everywhere, causing me to do much physical activity to clean up the water and to get the clothes out. Being so busy I also didn’t drink or eat that day. I had to drive almost 2 hours as well and I forgot to bring my water with me as I usually do . I had planned to stop at a hotel after the 2 hours as that is about my limit of what I can handle. I ended up going into a store prior to going to the hotel and I fainted in the store. The store called the paramedics and the cop came as well. He immediately accused me of overdose even though He is a cop, not a dr and I told him that was impossible. I said possibly I am dehydrated and exhausted. Even the paramedics did not treat me for an overdose as they gave No narcan, I was up talking the whole time though some of the answers did not come to mind fast enough because I was distracted by what the cop was saying to me. Mostly afraid because my child was with me and THe cop was threatening to take him. Upon admission,, they just kept asking me WHy I was taking pain medicaiton. While I kept telling the PA my diagnosis, SHe was not satisfied. SO even while I am talking to her she administered Narcan to me and I began to dry vomit. I said, What did you give me? she said a small dose of Narcan I said WHY? she said because you are not answering me fast enough. SO I started yelling her the answers to her questions I was so angry that she did this to me. She also administered Zofran to stop me from the dry vomiting I was doing. . I have been taught if the person can talk then they are in fact breathing!. So this PA diagnosed me with overdose based on the fact I take prescribed pain medication without any evidence of an overdose aside from her saying I didn’t answer her questions fast enough. Well I was afraid of what else they would do to me and my child so I did whatever they asked to get me discharged out of there. They did not take my urine though I got a discharge paperwork that listed all the drugs they supposedly tested me for. They did not take blood work but they listed that they did in order to get a level of one of my other medications.
    I did not consent to this treatment/mistreatment. I didn’t even know that some ER’s were doing this to people. I am shocked. SHe was not interested in finding out the true cause of my fainting. THe fluids that the Paramedics gave me was the only thing that made me feel better and I was released after 1 1/2 hours of them babysitting me to see if I would need more narcan. Of course I didn’t even need it in the first place. They even said they would leave my patch on.
    How can they get away with this type of mistreatment? The doctor finally comes in at the end just to give me two boxes of Narcan … in case this happens again someone can administer it to me. Really? If I faint after NOT taking any medications for over 14 hours I should administer Narcan? I don’t think so.
    To add insult to injury when I got my purse back and my medications back, My purse was ransacked through and keys to my truck removed. My money was also ransacked and put into a different place of my purse of where I had it. Plus my pain medications; more than 3/4 of my pain medication was stolen. They left a perfect count of 40 pills. I know for a fact I didnt have a perfect count as I have some that would be cut in 1/2 and since I had recently filled the bottle I calculated that approximately 90 pills were removed from my prescription bottle. I completely suspect the cop did this. He would not give me my pocketbook while I was in the ambulance nor would he even give me my phone so I could call someone. The nurse returned my purse AFTER the cop left. I then got the medication that was in my purse returned upon discharge (minus the oxycodone pills they removed)
    The taking of my pain pills is not an isolated event as this happened to me almost 10 years ago as well when riding in the ambulance. They returned only 2 tablets to the hospital out of a bottle of 180 ER Morphine. My attorney back then assured me he knew that police lie but there was nothing I could do about that since back then that cop had accused me of a crime in order to steal my meds. It took 2 years to get that case dropped. I am fortunate he did not falsely accuse me of any crime this time but he still did call dcf and LIE to them to say I was not sober and had my child with me at the hospital. Thankfully the hospital and cop released him into the care of my relative who lives with me.

    Reply

  3. Just recently after going through my hospital records, I found I was administered 5 doses of .4 mg between 3 days in the hospital after my gallbladder was removed. Best part? I was 17, my senior year of high school and almost didn’t graduate. They told me and my dad my liver was enlarged and he had a hard time finding my gallbladder in the surgery. I found test results from an ER visit XR on (8/09/16) saying my gallbladder is collapsed. Is that suspicious?

    all my “pain”was due to a “bile leak” but I remember the first day I was admitted 4 days after the gallbladder removal I was in constant pain and the XR and CT say there were surgical clips and “suspicious for biliary leak. I’m now 19 (this was in Jan 2017) but the hospital missed my gallbladder attacks in 3 diff hospital visits (8/9/16, 12/30/16,12/31/16, and 1/6/17 but the surgeon was too busy it’s a small hospital they don’t even have a pediatric unit so I had to keep going to the adult ER (they diagnosed me with unspecified chest pain (12/30) and gastritis and unspecified chest pain (12/31). They realized what it was (1/6) after a visit with my PCP (1/5). On 1/6 at my er visit they suggested I go to a pediatric hospital to have the surgery but then reassured me saying I could get it there and they’d set me up with one of their surgeons. Keep in mind, I was still 17. Surgery couldn’t be scheduled until (1/20/17) because the hospital couldn’t do a nuclear medicine test they were too booked, I had to go to the main campus of Cleveland Clinic which took weeks to get an appointment. Ok anyways, after surgery I immediately was in pain post op and couldn’t walk. They still sent me home and i came back 4 days later (1/24) but they removed those records from being accessible to me because they diagnosed me with CONSTIPATION and sent me home. I sat home and couldn’t move, breathe or go to the bathroom. I had my parents buy me 3 heating pads for the pain- one for my abdomen- 2 for my shoulders/back because the pain radiated through my body and it hurt too bad to walk I did not go back to the hospital until (1/29) right before they admitted me (1/29/17?? —- they marked all my ER stays as “telephone calls” to the original surgeon who did my surgery)

    all it says in my MyChart is “hospital stay” (2/1-2/2) and procedure (1/20) then telephone call (1/24) telephone call (1/25) and the ER visits

    On (1/29/17)
    after (6-8mg) of morphine overnight on (1/31) (they edited the times and dates out of order so this is the part I cant figure out) It says 2mg (18:30 and 23:57) then it also says 4mg given once at (20:05)

    and aparently gave me 5 doses of narcan between 1/31-2/2/17.

    – they told me at this point all of my pain is from a bile leak

    I had an ERCP to place a stent on (1/31/17) and then was released on (2/2/17) and came back for the stent removal (4/10/17) I’m confused and super upset I dont know where to begin. I still have pain from the gallbladder attacks constantly it’s just a dull pain, it helps if i smoke cannabis but i’d never rely on opioids or anything else for pain relief. Is this a medical malpractice or am I overreacting? Any advice would be appreciated!

    Reply

    1. You need an attorney for your case. But, the hospital needs to be reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the State Board of Medicine Office of Misconduct.

      Reply

  4. My mom was in the hospital getting a colostomy bag due to her cancer. While in tg he hospital, they gave her morohine for pain not realizing that her liver could not handle it due to her cancer. They evidently gave her too much morphine and her bidy could not take it. They realized that they had overdosed her on morphine and admistered narcan. This caused her a great deal of pain. She then went into a coma abd passed away the next day. What should i do? I am considering filing a lawsuit but do not know where to begin.

    Reply

  5. I just read your blog with great interest, as I was trying to research why I was given Narcan in the middle of the night, day 3 of a hospital stay, post esophageal hiatal hernia surgery with fundoplication.
    I have a complicated med history: Mitochondrial Disease, Mast Cell Activation Syndrome, Chiari Malformation Type 1 with pressure headaches (cerebral spinal fluid leaks out my ears & nose), RSD, post ulnar nerve transposition, GERD, IBS, depression.
    I told my caregivers on the second day that my breathing was getting harder. I felt like I was filling with fluid. (I got pneumonia after gallbladder surgery. Felt the same as then.) They started heparin shots, and for the next 2 nights, I was sent for 3am CT scans with contrast, each time looking for PE’s.
    I kept saying I could barely breathe. When the oxygen mask slipped, my SATs dropped to 40%.
    I was scared, I felt like I was breathing with top inch of my lungs. I told the nurses and the doctor, “I know my body. Something is terribly wrong. My chest pain is awful and I can’t breathe!”
    The hospitalist suggested activan. I refused it, saying, “I am anxious because I feel like I have to work at breathing! I am afraid to fall asleep!’
    The next thing I hear is that I am getting Narcan. I didn’t know why.
    It was awful. Pain skyrocketed and I was.nauseated. I just watched the clock, focusing on breathing.
    Later, someone from the lab came to draw blood for blood gasses. I had pneumonia. I feel angry. No one even listened to my chest before that.

    Kathryn Boling

    Reply

  6. I was admitted to the hospital threw the emergency room as a drug overdose but I really was having a severe MS attack. They kept me for a week in the hospital & gave me a blood transfusion. Please let me know how long & who to contact with the information.

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  7. I have recently been diagnosed with nocturnal epilepsy and now I have some new neurological issues in trying to cope with. Not only do I loose consciousness I’ve been suffering from extreme migraine headaches, I loose my motor skills and I can’t walk or talk, especially after a seizure. I used to be prescribed opiates for pain, for about 6 years, while I am not prescribed them anymore I have a couple bottles leftover that I will resort to taking ONLY if my migraine is extreme. I have naturally low blood pressure and twice now I have been administered Narcan at the ER when clearly I was not overdosed. I was there due to an extreme migraine, and both times I suffered multiple SEIZURES after going home from the ER after being unnecessarily narcaned. The Doctor kept giving me more and more Narcan because I wasn’t “responding” to the Narcan. I didn’t puke it simply made my body ache and forced my eyes to open for a minute. SEIZURES make people tired why wouldn’t they let me sleep? I had SEIZURES and they were convinced I overdosed! Stupid

    Reply

    1. I have similarly been treated by PIH in whittier. They dosed me with Narcan which I ‘ve never had before because I been battling bronchitis while living at a shelter, and being homeless which automatically translates to me being a drug attic. Not my COPD+Bronchitis+lack of sleep for several days+cold weather outside+ plus appropriate prescribed pain meds and muscle relaxers and severe chronic pain t7 to s1 due to undiagnosed bed sores that paralyzed me and ate away my vertebra, discs and spinal cord post 2 back surgeries plus 1 heart valve replacement due to same infection. Add 1 additional back surgery to try and mitigate some pain resolution year later with some minor improvement.
      Thanks to that od assumption I was 50/50 whether or not I req’d a 911/er trip. The er narcan’d me forcing me into icu for 2 weeks, intubation and false medical reporting on cures report. Error was admitted by pih that I cannot get removed nor will the hospital remove it or the doj help. Let alone give me a copy of my medical record that is wrong to fix it. Even though the hospital and pharmacy has admitted the error.
      Why????
      Can’t anyone help me after 3 and 1/2 years of hell, misery, pain, suffering and bad medicine?
      I thought this was America, best country in the world. But right now my issues would be fixed by most of the European countries, hell even S. Korea is better than America for my situation.

      Reply

  8. I’m a little late to the party so to speak, I just found this blog entry today.
    I’m a 40yo woman and I have had 5 back surgeries, starting at age 19. I have been in pain mgmt for nearly 10 years. I live with PTSD, anxiety and post concussion syndrome from an abusive relationshit™️ (I escaped from him nearly 3 years ago). I have also had repeated dizzy spells and sometimes passing out for about 20 years and no one has ever found a definitive cause despite a plethora of various tests. Many times during the syncope episode I’d fall hard enough to hit my head, but never once was I evaluated for a concussion. (During the domestic violence I ended up getting concussed at least 6 times in a 9 month period…. probably more but the abuser refused to allow me to go to a doctor)
    It usually gets blamed on the opiates even though I’ve experienced the syncope episode at times when I was not taking any opiates or any other medications. I’ve been to the ER after passing out and felt like I was being aggressively interrogated by the police – “just admit that you took pain pills” or “tell me what drug you’re on”. Being treated like human trash or a drug seeker.
    So Feb 2016 I was at a neighbors house, sitting down chatting with her and passed out cold (ended up breaking my fibula!?!). By the time the paramedics got there I was semi-cohearant, a bit foggy but I could answer what date it was, who the president is, what state I live in and list off all of my medications. In the ambulance, the second they heard I was on methadone for pain management (50mg/ day) the EMT declares me an opiate over dose and administers IV Narcan. Despite my protests that I did not take more than the prescribed dose of any of my meds. As soon as th Narcan was administered I remember him handing me a barf bag. I have zero memory of the next 7 hours. My mom said I kept vomiting, had severe, near constant diarrhea and got violent, thrashing about. I woke up with restraints on, triggering a ptsd panic attack which the doctor would not do anything for and didn’t take off the restraints until the panic subsided. I had withdrawals from hell! My back pain was a strong 9 on the pain scale, my broken leg was a strong 10. But they wouldn’t administer any pain meds because of my alleged “overdose”.
    I was admitted to the cardiac ward after my broken bone was set (omg is all i can say). I finally started getting pain meds of 2mg IV morphine. But having a high tolerance that didn’t even touch the pain, so I started IV dilauded every 2hours.
    They did every kind of test, MRI, CT, blood work. Echocardiogram, ultrasounds, etc. But never did find the cause of the syncope. My tox screen showed positive for methadone as expected and the forensic tox screen showed the amount of methadone did not exceed my prescribed dose, proving I did not lie and I did not try to overdose. Also verified with a pill count. However I was still treated as a pariah by the docs and nurses. I was in there for 3 days and constantly being accused, lectured, verbally abused. Being treated like a street drug junkie rather than a woman who lives with crippling pain and manages it faithfully with my pain mgmt doc.

    The Narcan set back what progress I had made in managing the pain. Now doctors are terrified of prescribing opiates and are being pressured to cut down on prescriptions. I recently got a pain pump implanted in November. And even with that, the doctor is not willing to adjust the dose to anywhere near to recommended or average therapeutic dose. I’m at less than 20% of the therapeutic dose and my pain is averaging a 7 still.
    A year later, I’m still pissed at being narcanedfor no reason. Apparently it is now standard to give Narcan if you even mention that you’ve taken any kind of opiate no matter what. This opioid epidemic is terrorizing medical personnel, chronic pain patients and the general public.
    (So sorry for being long winded!) Thank you for your time.

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  9. This happened to me ,except I was fine until they gave me narcan ,I stopped breathing two times and had to be put on a vent ,then was kicked out of my pain clinic ,and all because I passed out and wanted to be checked out ,been on pain meds 3 years never a problem ,I don’t k ow what to do now

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    1. Do you know how much narcan they administered to you? Have you talked to an attorney n do u have any long term side effects cuz of this? Currently going through similar situation.

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    2. This happened to me in November of 2007 I was having a stroke at work but I did not know what was wrong finally one boss told the guard to call an ambulance which got there and I passed out trying to lay on but the one guy told my brother that I bacame unresponsive 3 different times and they gave me Narcan and in the ER I bacame unresponsive 2 more x and they gave me Narcan againthey said I woke up and said I took this one pill, I couldn’t talk and 2 days later when I did wake up they had a tube down my throat and they pulled it out and I still could not talk and the Dr asked me why I tried to kill myself and I wondered what she was talking about, but after being off of work for 2 weeks where I worked at called me in and they had a letter that this Dr sent them without me or any family members signing the hippa letter and the union and company said they had this letter from the Dr saying I either tried to kill myself or took a Drug OD and either I had to sign or get fired and I wanted to let my brother see it and they said I had to sign it right then or leave the factory without a job and I was still going to speech therapy and besides I just had a stroke 2 weeks before but they did not know that and a lot of my memory was gone,so I signed that they could drug test me anytime they wanted and of refused I would be fired. The following week later I woke up and could not see out of my left eye so my mother took me to the ER and seen a different Dr she looked into my eyes and said I had a stroke so when they done a scan of my brain it showed my first stroke who the Dr told my place of work it was a drug OD and when I did go back to work I had another Dr that wrote me out a letter saying that I had to separate strokes and no drug OD and asked my union if the company would accept this now and throw away the letter they made me sign and my union told me no. No one was supposed to know about the letter I signed and the so called drug OD on the work floor but the next day people were talking about me and they acted a lot different to me and after a week and half I could not take anymore of it the company was offering buyouts so I put in for one and with the buyout we could go back to school anywhere we wanted and be retrained but since I had the Strokes I couldn’t pass the test to go back to school so I never got retraining and now on disability making $1485 a month when I was making almost that much a week where I worked at. I have tried to get lawyers to take my case but all did not want to. But that was back in 2008 that Dr misdiagnosed me and ended up making me quit because people were talking about me in front of me and behind my back,when there was never any drug OD or tried to kill myself. But now after reading this I feel I would be better off dead I cannot support myself on only $1485 a month now I have diabetes and I have to pay out of pocket for my diabetic meds each month plus $60 for Dr Appts I want my payback now if anyone can help. I got all of my info from the hospital and there is no where that they even done a drug test on me. Also my left carotid artery is blocked 100% and no Dr will even try to unblock it plus my vision in my left eye is gone it never came back

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  10. Comment #2: When I was in practice I saw a number of patients who were clearly misdiagnosed because of the rush of ER staff to mislabel the pain patients as “drug seekers”. These missed diagnoses included insulin shock, viral myocarditis with serious arrythmias, encephalitis with permanent cognitive dysfunction, collapsed lung, kidney infection, and fractures from falls.

    One other adverse outcome of the mislabeling and mistreatment in the Emergency rooms is the impact on the patient’s willingness to even seek emergency care even when it is really needed. I have heard many patients say that they would rather suffer the new or increased symptoms rather than be confronted with the horrible name calling and disdain that they would suffer in the emergency room.

    Thank you Dr Fudin for raising an important and too often neglected issue.

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  11. Comment 1: Falls occur frequently in people with chronic pain. I have presented several poster abstracts about this correlation over the years, based on observations in my practice. Finally, Stubbs (http://www.archives-pmr.org/article/S0003-9993(13)00892-7/abstract) has presented rather conclusive evidence using meta analysis of published literature. This clinical fact is overlooked even more frequently that the mislabeling of pain patients as “overdose”. Certainly the knee jerk medical approach to falls is that it is caused by adverse effect of opioids and other medications. That explanation simply cannot work when addressing falls that occur in people with pain who are not taking any medication.

    I believe that these falls are caused by hyperactive reflexes that are caused by pain and I currently have an abstract under consideration. I do not have the space here to present a more detailed argument, but in the patient described above, the contribution of pain to the occurrence of the fall is totally missing but is at least a significant contributing factor.

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  12. You pointed out a fear of all chronic pain patients- the withdrawal and the return of severe pain. I did see medications such as several antidepressants and several that could bleeding. I personally pray that the maximum amount of pain medication allowed is trashed because one dose does not work for all. Thank you for the great work up and for patient advocacy.

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  13. DR.Fudin,

    Yet another great blog, so great I sent it to my doctor. Its sad that there is a rush of judgement in a case such as this. As stated by a previous post above, I wonder if the numbers of overdoses that are reported are even close to being correct. Thanks again for all your hard work.

    Founder of / Opposition-to-Kentucky-HB-1-Reform-HB-217-aka-Pill-Mill-Bill/595049517218134

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  14. Dr. Fudin,

    Unbelievable how quickly it seems the entire world wants to blame opioid/opiate medications for ANY problem if the patient has a bad outcome, or in this case, just because. If opioids are available to be blamed, that’s certainly the easiest thing to do.

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  15. I log ago lost count of patients sent to me whose records contain knee-jerk “opiate overdose” diagnoses from E.R., Urgent Care or inpatient providers. Confusion, misdiagnosis and delay of care has happened when chronic stable opiate Rx users are given a shot-from-the-hip diagnosis of “drug-seeking”, “narcotic addiction” and/or “overdose”, when the real problem was something very different, including progressive respiratory failure due to COPD and bronchial infection, diabetic ketoacidosis, alcohol intoxication, mini-stroke, slip-and-fall, post-concussion syndrome, and even “absence” seizure.
    A most memorable case was a 5-times failed spine surgery victim who presented dramatically in E.R. with excruciating pain from intense multi-focal spasms, quickly labeled “drug-seeking” upon first word that he regularly took opiates for pain. Called out of bed by an irate ER doc to “take over” on “one of your addicts”, I quelled the pain crisis in 10-min with 2000-mg of I.V. magnesium sulfate. Labs I troubled to order revealed he had mild hypocalcemia causing spasms which, in turn, triggered a panic attack and hyperventilation, leading to worse hypocalcemia and a vicious cycle of pain>>spasm>>more anxiety>>more pain.
    Even more remarkable to me has been the number of times pain patients who are too sleepy or obtunded for a variety of reasons having nothing to do with opiates are presumptively labeled “overdose” despite no response at all to one or more injections of Narcan. This (incorrect) diagnosis then persists in the chart and becomes one of the discharge diagnoses after the real problem is finally identified and corrected . Once enshrined in the patient chart, the “addict” label forever colors later care-givers’ attitude and approach to caring for the patient, regardless of actual diagnosis.

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  16. Seems clinicians should leave the management of chronic pain to those that specialize in that department and stop the scrutiny of opioid overdoses. It seems so easy to just blame the opiates without further investigation.
    Next time people fall get back up and not make such a huge deal out of it unless it continues to happen.
    This was made in to a huge deal when it could have been taken care of much easier, with much less stress .The taking away of much needed medication and finger pointing is so unnecessary. I will give this lovely lady a few days and she will be back complaining of uncontrolled pain , then she will be seen as being dependent upon opiates. O what tangled mess that’s been weaved upon those that need some pain relief .

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  17. Too often, patients who require multiple medications are labeled noncompliant or as opioid overdose simply due to their personal characteristics. This is particularly true for females and the elderly. In addition to not being so hasty to apply the wrong label, we should be focused on providing evidence that the appropriate assessment has been made with evidence of this entered into the EHR. Then and only then can we begin to work with consumers on the basis of needs as opposed to filtering through our own shortcomings and biases. The syndrome of chronic pain by itself is associated with falls, with or without polypharmacy present. Without a doubt, the data is filled with error. Thank you for your efforts to focus on rational and logical approaches.

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  18. Hi Jeff,

    I enjoyed your blog.

    It made me question how accurate the current evidence is for the reported opioid overdose numbers.

    With the OEND program I wonder how many of those opioid overdose diagnoses are accurate. Might be something interesting to look at (retrospective and prospectively).

    Are there patients suing for having the wrong diagnosis of opioid overdose?
    I would, esp. if a rapid naloxone detox was done.

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    1. Christina, Thanks for the comment. Having seen this so many times, I too wonder how many overdoses are misdiagnosed. This example and post-op pain management exemplify that those suffering from chronic pain in the outpatient setting have a double whammy to deal with upon hospital admission and also perioperatively. In my mind the under education of clinicians in both settings is in a horrible state of affairs, as I have also been involved with cases as an expert where appropriate inpatient monitoring didn’t occur that ultimately resulted in overdose and harm. It goes both ways!

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  19. Was the patient upset with the initial plan (oxycodone 5mg QID PRN)?

    In terms of liability, could she have sued for poor pain management if the pharmacy pain team did not intervene?

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  20. The question is? What did she expire of? Right? Not opioid intoxication , but contributed to the bleeding. HEPARIN!/HTN/PVD/,,,,,,,,,,,,As a doc used to say in the ER, “This poor woman was SICK!!!!”……so it goes,,,,,,,Thanks Dr. Jeff,,,,,,,,,,,,,,,,herb “doc” neeland

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