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Inquest into the Death of Mark Leslie SACH

Deceased

Mark Leslie SACH

Demographics

27y, male

Date of death

2016-03-01

Finding date

2018-12-06

Cause of death

combined drug toxicity (U-47700 and etizolam)

AI-generated summary

Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet purchase. He had chronic spinal pain following a 2012 motor vehicle accident and was managed by pain specialists and his GP with medications including pregabalin, tapentadol, clonazepam, and codeine. Dissatisfied with prescribed treatment and concerned about functional impairment, Mr Sach self-medicated with unlicensed substances without disclosing this to medical practitioners. A psychologist had warned him of the dangers in October 2015, but this information was not followed up before his death. The case highlights challenges in chronic pain management, including long wait times, appointment spacing of 6-9 months, lack of care continuity, and patient dissatisfaction with conservative opioid prescribing policies. Clinicians should maintain a high index of suspicion for undisclosed self-medication in frustrated chronic pain patients, improve communication about evidence-based opioid restrictions, and ensure timely follow-up of disclosures about non-prescribed substance use.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

pain medicinegeneral practiceemergency medicinepsychiatrypsychologypathology

Error types

communicationdelaysystem

Drugs involved

u-47700etizolampregabalintapentadolclonazepamcodeineparacetamoloxycodonetramadoldiazepam

Clinical conditions

chronic spinal painpost-traumatic myofascial painspinal fracturesmuscle spasmsdepressionanxietyopioid toxicitysynthetic opioid toxicitybenzodiazepine toxicity

Procedures

trigger point injectionscardiopulmonary resuscitation

Contributing factors

  • self-medication with unlicensed synthetic opioids and benzodiazepines sourced from internet
  • dissatisfaction with prescribed pain management
  • long gaps between pain clinic appointments (6-9 months)
  • lack of continuity of care at pain clinic
  • patient felt prescribed medications were ineffective
  • functional impairment affecting ability to work and family interaction
  • synergistic central nervous system effects of combined substances
  • lack of disclosure to treating practitioners about self-medication
  • inadequate follow-up of psychologist's warning about non-prescribed substance use

Coroner's recommendations

  1. Improve awareness among pain clinic staff that importation of substances from overseas may involve dangerous new psychoactive substances, not just supplements, and staff should obtain details of exactly what substances patients are taking
  2. Encourage pain clinic staff to have patients bring in their medications to verify what is being taken
  3. Increase awareness about the dangers and growing prevalence of new psychoactive substances (NPS) including U-47700 and etizolam
  4. Educate the public about the grave risks of purchasing drugs over the internet that have not undergone rigorous approval processes
  5. Improve systems to ensure timely follow-up when patients disclose self-medication or concerning substance use to any member of the treating team
  6. Enhance communication within pain management teams to ensure continuity of care when lead specialists are on leave
  7. Address resource constraints in public pain clinics that limit appointment frequency and contribute to long waiting times
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