The Verdict is In
Archive | Q1 2020

Wrongful Death Suit: A case to highlight best practices and minimize exposure in opioid cases.

We are presenting an emergency medicine (EM) case from 2010 that highlights how practice changes and resources available in 2020 enhance patient safety and can reduce risk for providers.

In 2010, a 33-year-old presents to the same ER six times in 2.5 weeks. He is well known to the ER for his history of chronic pain, lumbar disk disease and surgery, anxiety, methadone and Dilaudid use. Upon later discovery, it was found the patient was simultaneously visiting another ER (5 additional visits) with similar complaints.

Visit 1:

Presents for reported "seizure". Patient claims he had run out of his valium 2 days prior before this reported seizure. He also complains of abd pain and diarrhea. Had CT abd and head. Admitted for systemic inflammatory response from c. diff colitis, chronic pain and opioid use disorder. It was felt he likely did not have a seizure. The patient signed out AMA because he did not get his methadone and received an Rx for Flagyl and Levaquin.

Visit 2: (2 days later)

Presents to ER with cc of "difficulty getting medication filled". Discharge summary was not yet available. The patient reports he was given an Rx for antibiotics, benzodiazepines and methadone when he left the hospital. He states he tried to get his medications filled but was only able to get the benzodiazepines, not the antibiotics or methadone. He said CVS pharmacy was "out of methadone". He was given a dose of Dilaudid and Phenergan for opioid withdrawal, a dose of Flagyl, and 1 dose of methadone 40mg PO. He requested an Rx for methadone numerous times, but it was explained he would need to see his primary care doctor for a methadone Rx.

Visit 3: (6 days later)

Presents complaining of painful abrasions between his toes from wearing new flip-flops. There was mild redness and swelling. He was discharged on doxycycline for early cellulitis and gabapentin for pain. He requested methadone and benzodiazepines several times but was told he needed to follow-up with his regular clinic for that. He was given an Rx for Norco.

Visit 4: (3 days later)

Patient presents with the cc of abdominal pain and diarrhea. He states he is withdrawing from methadone. Nursing note reports his current medications are Valium 10mg, methadone 40mg, Flagyl and doxycycline. He was agitated, confrontational, and yelling obscenities. He demanded repeat doses of medications for pain and withdrawals. He states he has been taking methadone chronically for 2 years, 80mg per day, but has now been out for 2 days because he could not refill his prescription. States his diarrhea initially got better with Flagyl and Cipro but has returned. Labs and CT were performed for the abdominal pain, methadone 80mg with Levaquin/Flagyl were given in the ER because of the return of diarrhea.

Visit 5: (1 day later)

Presents with cc of "I need my methadone". He states he ran out a couple days ago. He had been taking 80mg twice daily but has been out of his methadone for the last couple of days. He also states he takes Dilaudid 8mg tid and Valium 10mg qid. He was belligerent and appeared under the influence of likely prescribed drugs. He complained of diarrhea, 10/10 pain, and was eating as he was triaged. He contracts for safety and has a benign, non-surgical abdominal exam. ER physician reviewed yesterday's records and saw he had unremarkable labs and abdominal CT. He was dx with chronic pain and opioid dependence. The emergency physician provided a prescription for methadone 80mg PO bid #6 and recommend follow-up with a pain specialist.

Visit 6: (2 days later)

Returns for nausea, vomiting and anxiety. He reports he was taking Paxil, but abruptly stopped it on his own out of concern for sexual side effects, and he is also out of his Valium. He says after stopping his Paxil a few days ago the n/v and anxiety symptoms got worse. He says the abdominal pain from the last visit resolved, he is just anxious with n/v. He denies SI and HI. Vitals were normal and there was no evidence of dehydration. He was given IM Phenergan for nausea, a refill of Valium for anxiety, and was instructed to restart low-dose Paxil of 20mg per day.


The patient was found dead in his apartment 6 days later. Per the medical examiner, he had expired 1-2 days prior to being found. Autopsy revealed decedent died of methadone toxicity. Patient’s father sued for wrongful death due to the methadone dosing.

Survey Questions

1. Who was the defendant?

  1. The last physician who saw the patient on visit 6.
  2. The physician who saw the patient on visit 5 and prescribed the methadone.
  3. All the physicians involved throughout these 6 visits.

2. Plaintiff, patient's father, alleged the ER physician that prescribed the methadone killed his son by doubling the methadone dosage. Can you guess the outcome of the claim?

  1. Case was thrown out as it was clear the patient had drug dependence and manipulative behavior.
  2. Case went to trial and the defendant won.
  3. Case went to trial with a verdict for the plaintiff.
  4. The case ended with a confidential settlement within policy limits. Plaintiff's experts were critical of the care from the ED physician on visit 5 who relied on the decedent's representations as opposed to carefully reviewing records despite the decedent demonstrating manipulative behavior with known polysubstance abuse. The patient was prescribed 80mg of methadone twice per day which was double his normal dose.

3. Practice has evolved in how we manage pain and addiction since this case in 2010. Considering the risks surrounding opioids in general (not specifically methadone as described in this case) how can you minimize your risk surrounding opioid addiction with resources available in 2020?

  1. Commit to using your state’s Prescription Drug Monitoring Program (PDMP). Nearly every state (except Missouri) has a PDMP that tracks prescriptions. Research suggests "doctor shopping' has decreased in states that require doctors to check their patient's previous prescriptions. These monitoring systems are great for patient safety and risk reduction IF doctors commit to use the systems.
  2. Have a high index of suspicion for patients with a history of substance abuse, inconsistent histories and out of state addresses. Prescribe with caution.
  3. Stay informed on the medication you presccribe, including dosages and contra-indications
  4. Read BUPE a "Buprenorphine use in the Emergency Department Tool" by ACEP
  5. Naloxone. Naloxone distribution programs and overdose education have been shown to decrease overdose deaths, and not increase opioid use. The emergency department (ED) is an ideal setting for opioid overdose death prevention through the distribution of (or prescribing of) overdose naloxone rescue kits, overdose prevention and response education.
  6. Read "Vituity Combats the Opioid crisis with MAT in the ED" and "Approaches to Acute and Chronic Pain and Opioid Use" which are whitepapers available on Vituity's Community
  7. All the above

The winner of the raffle for the previous The Verdict is In was John Hipskind, MD. Dr. Hipskind practices at Kaweah Delta Health Care District in Visalia, CA. Dr. Hipskind received a Visa gift card worth $150; his site also received a Visa gift card worth $150, which can be used for any worthy cause.