Finding into death of Amanda Jane Harris

Contributing factors

• Intimate partner violence
• Untreated psychosis likely tramadol-induced or withdrawal-related
• High-dose tramadol prescribing without specialist oversight
• Lack of substance abuse assessment despite documented polysubstance dependence history
• Drug interaction between tramadol and newly commenced desvenlafaxine
• Recent cessation of heavy alcohol and cannabis use
• Inadequate mental health support and follow-up
• No documented monitoring for tramadol abuse or dependence

Coroner's recommendations

1. Referrals to specialist clinicians such as pain management specialists and/or psychiatrists should be considered reasonable inclusions in the treatment plan when patients are prescribed long-term tramadol
2. Regular substance abuse assessments should be conducted when prescribing medications with abuse potential, especially over prolonged periods and in high doses, not predicated solely on current evidence of misuse
3. Careful and regular monitoring should be carried out when tramadol is required long-term to establish whether and to what extent ongoing treatment is necessary
4. Formal assessment of substance abuse history should be documented at initiation of prescribing medications with abuse potential, particularly in patients with known history of polysubstance dependence
5. Referral to alcohol and other drug (AOD) services should be considered for complex cases involving chronic pain, long-term analgesic use, past addiction history, and recent substance use
6. Referral to psychiatry should be considered for patients with long-standing musculoskeletal pain requiring long-term analgesic treatment and associated mental health or social problems