Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtaining prescriptions from multiple clinicians across different practices. In the three months before death, she obtained 460 tramadol tablets (789mg/day vs 400mg maximum), 538 oxazepam tablets (180mg/day), and 575 amitriptyline tablets (174mg/day). Multiple prescribers were aware of drug-seeking behaviour but continued dispensing. Critically, tramadol and amitriptyline are contraindicated in epilepsy as they lower seizure threshold. Prescribers lacked coordination and were unaware of overlapping prescriptions or her seizure disorder. Better prescriber communication, awareness of drug interactions in epilepsy, and real-time prescription monitoring could have prevented this death.
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Specialties
general practicepain medicinepsychiatryneurologyemergency medicineforensic medicine
Prescriber unawareness of overlapping prescriptions
Prescriber unawareness of patient's seizure disorder when prescribing seizure-lowering drugs
Excessive doses of tramadol (789mg/day vs 400mg maximum)
Excessive doses of oxazepam (180mg/day)
Excessive doses of amitriptyline (174mg/day)
Contraindicated drug combinations
Drug-seeking behaviour not consistently managed
Absence of antiepileptic medications in final toxicology
Coroner's recommendations
The Royal Australian College of General Practitioners should develop further training and education materials to highlight the harms and hazardous effects of tramadol, as well as the adverse interactions of tramadol with other contraindicated medications.
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