A 38-year-old woman with a history of suicide attempts and an Ativan prescription from her psychiatrist, dies of an overdose after being prescribed Oxycodone by a sleep specialist.

Key Lessons

  • Patients with complex histories and needs benefit from ongoing coordination among caregivers.
  • Selection of opioids for treatment requires patient-specific clinical scrutiny.
  • When prescribing opioids, assessing the risks of all medications the patient may be taking, and close monitoring, is critical to patient safety.
  • Clinicians who keep in touch with patients via email have to consider the clinical risks and time frames for a prescription renewal and expectations for a return office visit.

Clinical Sequence

A 38-year-old woman continued to receive psychiatric care for depression subsequent to two suicide attempts years earlier; she was taking Ativan and Celexa. Her psychiatrist referred the patient to an internal medicine sleep specialist for restless leg syndrome (RLS) and other sleep related issues. The specialist noted her history of depression, however no self-harm assessment was noted.

A sleep study noted sleep apnea. The internist recommended BiPAP, and prescribed Mirapax for her RLS. The internist and patient communicated weekly via email to assess the effectiveness of her treatment. Two months after her initial visit, the patient was again seen by the internist. Since the Mirapax was not helping the patient’s RLS, the internist prescribed low dose Oxycontin, ordering 60 (5 mg) tablets. Six weeks later, the internist prescribed another 200 (5 mg) Oxycontin tablets. There was no documentation other than the prescriptions noted in the patients record.

Three weeks later, the patient was found dead in her apartment. Autopsy indicated suicide by Oxycontin overdose.


The patient’s family brought suit against the psychiatrist and internist, alleging a failure to consider the patient’s suicide risk when prescribing medications.


The case was settled in the high range.


Risk: Communication and care coordination between the psychiatrist and the sleep specialist appears to have ended after the initial referral. Pertinent information regarding patient complexity and medications was not coordinated between clinicians.

Recommendation: Care coordination is essential in all opioid prescribing, with even more vigilance when multiple providers and/or mental health conditions are involved. Provider-provider communication to coordinate care is necessary at the start of any new treatment plan. Use of a prescription monitoring program is required.

Risk: The decision to prescribe and renew a narcotic was made despite the patient’s history of suicide attempts, ongoing depression, and other prescriptions.

Recommendation: When considering long-term opioid therapy, the clinician needs to evaluate for known risk factors, including pertinent mental health history (e.g., depression, anxiety). In some states (e.g., Massachusetts), the clinician core competency recommendations for preventing prescription drug misuse include the use of evidenced-based assessment methodologies for substance use disorders risk assessment tools such as SOAPP or ORT, prior to prescribing long-term narcotics.

Risk: The potential interaction of oxycodone with Ativan was not raised by the pharmacy when filling the oxycodone prescription.

Recommendation: Prescribers need to be alert to the potential lethal combination of opioids and benzodiazepines. The Massachusetts Board of Registration of Pharmacy applies a standard that includes the interdisciplinary consultation and collaboration, particularly when reconciling the patient drug/drug interactions.

Risk: The practice of emailing the patient for updates and treatment effectiveness—in lieu of direct contact—limits the ability to assess clinically meaningful improvements in pain and function.

Recommendation: Conduct a complete assessment of the patient prior to increasing opioid dosing, for example, using the PEG Scale (PEG: Pain average, interference with Enjoyment of life and interference with General activity.) For ongoing opioid treatment of more than 60 days establish guidelines for face-to-face reevaluation encounters to be at least every 90 days (as recommended Massachusetts Medical Society).

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