Coroner's Finding: Barnes, Deearne Joan

Contributing factors

• Failure to comply with mandatory prescribing conditions for methadone
• Inadequate risk assessment despite documented substance abuse and prior overdoses
• Inappropriate continuation of polypharmacy with multiple CNS depressants
• Failure to involve addiction medicine and pain management specialists
• Loss of methadone tolerance not addressed during reintroduction
• Permitting unsupervised self-management of medications despite documented misuse
• Significant coronary artery atherosclerosis
• Inadequate monitoring and review of medication regime

Coroner's recommendations

1. Government and medical professional bodies ensure prescribers understand current scientific evidence on opioid risks, limited effectiveness for chronic non-cancer pain, tolerance development, different pain mechanisms, risks of chemical coping and abuse, comorbidity complications, and require risk-benefit assessment before prescribing
2. Primary prescribers be provided with support including: coordinated and integrated pain management systems, multidisciplinary support options, appropriate time recognition in Medicare costing for CNCP consultations, funding models for multidisciplinary support, and professional development in managing demanding and chemical coping patients
3. Prescribers and patients be informed that opioid pharmacotherapy cannot be the core component of chronic non-cancer pain management
4. In implementing White Paper recommendations, early determination be made of required qualifications, experience and competence for 'specialist medical practitioner with sub-speciality training in pain management'
5. Any coordinated pain management model ensure Alcohol and Drug Services is structured to provide clinical guidance and assistance on addiction issues to hospitals, persistent pain services, primary prescribers, and the Pharmaceutical Services Branch
6. Continuation of funding for employment of pain management and addiction medicine specialists, with consideration given to suitably qualified nurse practitioners to fill current and projected needs
7. Government assist medical professional bodies in educating the general community on current scientific knowledge regarding limited role and benefits of opioid medication for chronic non-cancer pain and concurrent risks, highlighting benefits of multidisciplinary approach
8. Medical professional bodies highlight to members the dangers of polypharmacy and ensure medication is prescribed appropriately in context of total medication exposure, with regular review of medication regimes to ensure safety
9. Pharmaceutical Services Branch Protocol for Opioid Prescribing (2009) be revised to reflect current state of scientific knowledge concerning opioid prescribing
10. To address continued inappropriate opioid prescribing for chronic non-cancer pain: limit prescribing to patients engaged with multidisciplinary pain management programs; limit prescribing to those with access to and using DORA; remove prescribing rights from practitioners not conforming to safe practice; provide additional Pharmaceutical Services Branch resources; and develop protocol for assessment and intervention of inappropriate prescribing
11. Government work with appropriate medical and allied health specialists to implement recommendations from the National Drug and Alcohol Research Centre (2012) Review of Opioid Prescribing in Tasmania: A Blueprint for the Future
12. Future coronial investigations relating to combined drug toxicity should assess: whether prescribing was appropriate and safe; whether consideration was given to adverse effects of individual drugs, cumulative effects, and drug interactions; and whether fatal outcome was likely and avoidable
13. Government and medical professional bodies objectively assess efficacy of quetiapine when used off-label, and consider making it reportable under section 59E for drug-dependent patients given limited evidence and increased involvement in fatal overdoses
14. Complete and introduce revised application for authority to prescribe opioid medication without delay, with necessary resources provided to support implementation
15. Consider standardization of terminology and definitions used in reporting misuse of prescribed medication, including terms such as addiction, substance abuse, dependence, and drug seeking, to improve consistency among health professionals and research