the mere finding of abusable drugs at autopsy doesn’t necessarily mean that the drugs caused the death

Sudden, Unexpected Death in Chronic Pain Patients

Severe pain, independent of medical therapy, may cause sudden, unexpected death. Cardiac arrest is the cause, and practitioners need to know how to spot a high-risk patient.

Sudden, unexpected death may occur in a severe, chronic pain patient, and the terminal event may be unrelated to medical therapeutics. Fortunately, sudden death is not as commonly observed in pain patients as in past years most likely due to better access to at least some treatment. Sudden death still occurs, however, and practitioners need to know how to spot an “at-risk” patient.

Unexpected, sudden death due to severe pain is poorly appreciated, since many observers still view severe pain as a harmless nuisance rather than a potential physiologic calamity. In many cases, just prior to death, the patient informs their family that they feel more ill than usual and seek relief in their bed or on their couch. Unfortunately, some of these patients don’t awaken. Other patients die, without warning, in their sleep or are found collapsed on the floor. Modern medicine’s aggressive toxicology and forensic procedures after death have contributed to the poor understanding of pain’s death threat. In some cases, a pain patient that was being treated appropriately with an opioid or other agent with overdose or abuse potential has suddenly and unexpectedly died. Drugs were found in body fluids after death, and in my opinion a coroner wrongly declared the death to be an “accidental overdose” or “toxic reaction” to drugs rather than implicate the real culprit, which may have been an “out-of-control” pain flare.

This article is partially intended to call attention to the fact that the mere finding of abusable drugs at autopsy doesn’t necessarily mean that the drugs caused the death. In fact, the drugs may have postponed death. Some physicians have been falsely accused of causing deaths due to drug overtreatment when, in fact, undertreatment of pain may have caused the death. Additionally, opioid blood levels assessed at autopsy of a patient who died suddenly are all too often wrongfully considered accidental overdoses because the pathologist is unaware that chronic pain patients on a stable dose of opioids can be fully functional with serum levels of their prescribed opioids that far exceed lethal levels in opioid-naïve patients.1

Given here are the mechanisms of sudden, unexpected death in pain patients and some protective measures that practitioners must take to keep from being falsely accused of causing a sudden, unexpected death. More importantly, given here are some clinical tips to help identify the chronic pain patient who is at high risk of sudden, unexpected death so that more aggressive pain treatment can be rendered.

A Brief Anecdotal History
As a senior medical student at Kansas University in the early 1960s, I was required to take a rural preceptorship with a country doctor. In making our rounds one day to the county’s nursing home, I heard a farmer’s wife declare, “pain killed my mother last night.” Since then, I’ve repeatedly heard that pain killed a loved one. Folklore frequently mentions that people die “from,” as well as “in” pain. There is, however, little written detail of these events.

In the early years of my pain practice, which I began in 1975, I had several patients die suddenly and unexpectedly. This rarely happens to me today as I’ve learned to “expect the unexpected” and to identify which patients are at high risk of sudden death. In recent years, I’ve reviewed a number of litigation and malpractice cases of sudden, unexpected death in chronic pain patients. In some of these cases, physicians were accused of over- or misprescribing and causing a sudden, unexpected death, even though the patient had taken stabilized dosages of opioids and other drugs for extended periods. Also, the autopsy showed no evidence of pulmonary edema (a defining sign for overdose and respiratory depression). In cases where the physician was falsely accused, the post-death finding of abusable drugs in body fluids caused a family member, regulatory agency, or public attorney to falsely bring charges against a physician.

Setting and Cause
Unexpected deaths in chronic pain patients usually occur at home. Sometimes the death is in a hospital or detoxification center. The history of these patients is rather typical. Most are too ill to leave home and spend a lot of time in bed or on a couch. Death often occurs during sleep or when the patient gets up to go to the toilet. In some cases, the family reports the patient spent an extraordinary amount of time on the toilet just prior to collapse and death. Sudden and unexpected death, however, can occur anywhere at any time, as pain patients who have died unexpectedly and suddenly have been found at work or in a car.

Coronary spasm and/or cardiac arrhythmia leading to cardiac arrest or asystole is the apparent cause of death in the majority of these cases, since no consistent gross pathology has been found at autopsy.2-5 Instant cardiac arrest appears to account for sudden collapse or death during sleep. Perhaps constipation and straining to pass stool may be cardiac strain factors as some pain patients die during defecation. Acute sepsis due to adrenal failure and immune suppression may account for some sudden deaths.

Two Mechanisms of Cardiac Death
Severe pain is a horrific stress.6,7 Severe pain flares, acute or chronic, cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenalin and noradrenalin) in an effort to biologically contain the stress.8,9 Catecholamines have a direct, potent stimulation effect on the cardiovascular system and severe tachycardia and hypertension result.10 Pulse rates may commonly rise to more than 100 beats per minute and even rise to more than 130 beats per minute. Blood pressure may reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to adrenal catecholamine release, pain flares cause overactivity of the autonomic, sympathetic nervous system, which add additional stimulation to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic, sympathetic overactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, vasoconstriction with cold extremities, hyperreflexia, hyperthermia, nausea, diarrhea, and vomiting.

CVS/Caremark Complaints State of Florida Employee Plan 2015-2016

CVS/Caremark Complaints State of Florida Employee Plan 2015-2016

Thanks to tax watch dog liberal public records laws in Florida, PUTT was able to obtain through the public records request process from the Department of Management Services the complaints from the state of Florida employees regarding their PBM – CVS/Caremark.  The request was specific for: 1 number of complaints and 2 nature of the complaints.

What was received were the “escalated” complaints with specific notes from the CSR (customer services representatives) who field the 800 number for CVS/Caremark.

The volume of requests (for 2015 and 2016) were overwhelming to say the least, so we’ve attempted to compile and condense the complaints in a document that will be forthcoming to our members, members of the media, plan sponsors, pharmacy association executives, pharmacy school professors and legislators.  If you are interested in the compilation, send us an email to

2015 January CVS Complaint to Customer Care Escalation

2015 February CVS Complaint to Customer Care Escalation

2015 March CVS Complaint to Customer Care Escalation

2015 April CVS Complaint to Customer Care Escalation

2015 May CVS Complaint to Customer Care Escalation

2015 June CVS Complaint to Customer Care Escalation

2015 July CVS Complaint to Customer Care Escalation

2015 August CVS Complaint to Customer Care Escalation

2015 September CVS Complaint to Customer Care Escalation

2015 October CVS Complaint to Customer Care Escalation

2015 October CVS Complaint to Customer Care Escalation

2015 November CVS Complaint to Customer Care Escalation

2015 December CVS Complaint to Customer Care Escalation

2016 January CVS Complaint to Customer Care Escalation

2016 February CVS Complaint to Customer Care Escalation

2016 March CVS Complaint to Customer Care Escalation

2016 April CVS Complaint to Customer Care Escalation

2016 May CVS Complaint to Customer Care Escalation

2016 June CVS Complaint to Customer Care Escalation

2016 July CVS Complaint to Customer Care Escalation

2016 August CVS Complaint to Customer Care Escalation

2016 September CVS Complaint to Customer Care Escalation

2016 October CVS Complaint to Customer Care Escalation

2016 November CVS Complaint to Customer Care Escalation

2016 December CVS Complaint to Customer Care Escalation

How broad is the definition of “medical error” and “adverse effects” ?

“1,000 Preventable Medical Deaths a Day”: U.S. Senate Committee Investigating Epidemic of Medical Errors

On July 17th, Sen. Barrie Sanders (I – Vt.) opened a hearing of the U.S. Senate Subcommittee on Primary Health and Aging by reciting some harrowing statistics:

  • As many as 400,000 people die each year from preventable medical errors in U.S. hospitals;
  • Approximately 180,000 Medicare patients die every year from adverse and preventable medical errors in hospitals
  • One in twenty-five patients acquire an infection while in the hospital, which led to 700,000 people getting sick and 75,000 people dying in 2011.
  • Medical errors cost the U.S. health care system more than $17 billion in 2008. If you include indirect costs, medical errors may cost in excess of $1 trillion per year in the United States.
  • Preventable medical errors in hospitals are the third leading cause of death in the United States.

All of the foregoing statistics, shocking as they may be, are only estimates because hospitals and health care providers are not accurately compiling the data necessary to fully understand and address the scope of the problem. That was the focus of the hearing led by Sen. Sanders, entitled “More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.”

Six experts testified before the subcommittee, and all of them cited the need to improve the health care system as a whole to stem the tide of these avoidable deaths. Ashish Jha, MD, MPH, Professor of Health Policy and Management at the Harvard School of Public Health, told the panel that “medical errors are largely the result of bad systems of care delivery, not individual providers … The strategy for improvement has to focus on three main areas: metrics, accountability, and incentives.” Another expert, Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine, told the panel that”Our collective action in patient safety pales in comparison to the magnitude of the problem. We need to say that harm is preventable and not tolerable.”

Among the suggestions for addressing the problem was a proposal to establish a National Patient Safety Board — similar to the National Transportation Safety Board — to investigate patient harm. Jon James, a scientist and patient advocate who lost a son due to a medical error, also proposed a national patients’ bill of rights that would contain protections similar to those for workers and minority groups.

It is indeed inexcusable that so many Americans needlessly die every year due to medical errors that could and should be prevented. Any efforts to shed more light on the problem and come up with solutions to reduce the number of these deaths should be strongly supported.

Hovde Dassow + Deets: Indiana Medical Malpractice and Medical Error Attorneys

If you believe that you or a family member has suffered adverse effects as a result of a medical error, you are encouraged to contact the law firm of Hovde Dassow + Deets today at (317) 818-3100 or toll-free at (888) 404-6833 for a free, initial, and confidential consultation to discuss your case.

This article has been prepared by Hovde Dassow + Deets for informational purposes only and does not, and is not intended to, constitute legal advice. The information is not provided in the course of an attorney-client relationship and is not intended to substitute for legal advice from an attorney licensed in your jurisdiction.

If a prescriber reduces a pt’s opiate medication that has been stable and has been functioning fairly well and the reduction causes a reduced quality of life and function. Is that a “medical error” or just an intentional infliction of “adverse effects” ?

If a pt has been patronizing the same pharmacy for some time, getting the same pain management meds filled from the same prescriber and suddenly they refuse to fill the same legit/on time/medically necessary prescription(s)…  Is that a “medical error” or just an intentional infliction of “adverse effects” ?

Perhaps this is the first of  – hopefully – many law firms that are seeing the “personal injury” that has been INTENTIONALLY INFLICTED on hundreds of thousands or millions of chronic pain pts… and looking at trying to force the pendulum to move back to a more reasonable point.

Genocide at Veteran’s Administration Hospitals ?













Is this how our country repays their service to our country to protect our way of life ?

Opioid Drug Misuse: Emerging Trends and Alerts Webcast on Thursday, July 27th at 10a EDT
















The Indiana State Department of Health (ISDH), in collaboration with the U.S. Department of Justice Drug Enforcement Administration (DEA), will provide an overview of opioid drug epidemic trends.

To view ISDH webcasts, please test your access to view streaming videos several days prior to the event.  Please use the following link for the test and to view the webcast:

To test, simply “click” on any of the thumbnails.  The video should play, but your network may have restrictions that prevent you from watching streaming content.  If you experience problems with accessibility, please contact your system administrator. Also, please be aware that WiFi connectivity should be avoided given variable connection speeds and the risk of buffering problems.  At the appointed date and time, the webcast will be available via the Live Video options at the top and right side of the webpage.

This will be a great educational opportunity and allow you to ask questions.  Questions can be submitted to:



Study: Opioid Rx were down in Waynesboro in 2015. but still thrice national average

According to the CDC, the average amount of opioids prescribed nationally peaked in 2010 at 782 morphine milligram equivalents (MME) per person. That number had declined to 640 MME in 2015.

While the numbers for Waynesboro and Staunton show similar declines, figures for both years were still well above average. The CDC study indicates 1955.1 MME for Waynesboro in 2015, and 1592.8 MME for Staunton in 2015. 

In 2010, the figures for the two cities were 2232.7 MME per person in Waynesboro, and 1967.1 MME for Staunton.

Area police and health officials say coordination has improved in combating opioid abuse in Virginia, including a prescription monitoring program that allows physicians to look at a patient’s controlled substance prescription history. And one local police officer said an area drug task force he is a member of is now working with a physician to stem the tide of valid prescriptions being used to illegally sell opioid pain pills such as Percocet, Vicodin and Oxycontin.

While the study doesn’t touch on non-prescription opioid drugs such as heroin, which makes up a significant portion of the opioid epidemic, doctors and law enforcement say prescription drug abuse is nonetheless a big part of the problem. In many areas, in fact, it’s a far worse problem than heroin and other so-called “street” drugs.

The acting director of the CDC, Dr. Anne Schuchat, said “the amount of opioids prescribed in the U.S. is still too high, with too many opioid prescriptions for too many days at too high a dosage.”

Schuchat said healthcare providers “have an important role in offering safer and more effective pain management while reducing risks of opioid addiction and overdose.”

Dr. Laura Kornegay, health director of the Central Shenandoah Health District in Staunton, said there are some potential drawbacks and limitations of the CDC study, though she notes that those issues are acknowledged by the report’s authors. The drawbacks, Kornegay says, include the fact that the data was gathered from a third party warehouse and has not been validated. She also points out that the county-level analyses in the study are aggregated by the county where the opioid is dispensed, and not where the prescription is written or where the patient lives.

Nevertheless, Kornegay said “the issue with opiates is a significant public health emergency in our state and country as a whole,” and that any data that helps to shed light on the problem, and potential solutions, are welcome.

Last December, Virginia’s health commissioner declared opioid addiction a public health emergency in the commonwealth and issued a standing prescription for any resident to get the drug Naloxone, a drug used to treat overdoses, without a doctor’s specific OK.

Kornegay said there have been multiple actions taken by the Virginia Board of Medicine and medical societies, hospitals and clinics with the goal of ensuring the proper prescribing of opiates.

Recently updated guidelines from the Virginia Board of Medicine call for limiting the amount of medication prescribed, as well as continuing the close monitoring of patients for abuse potential, and also to know when the medication can be stopped. The guidelines also says doctors should avoid combinations of different kinds of controlled medicines, such as opioid painkillers and sedatives such as Valium or Ativan.

Police in the area are also working with medical professionals on opioid abuse. Capt. Mike Martin is the commander of the Waynesboro Police Department’s special operations division and a member of the Skyline Drug Task Force.

He said one area physician has reached out to the task force to identify people who are abusing and selling their prescriptions, including opioid prescriptions.

“For the first time we have created a direct line of communication between the prescribers and the enforcers,’’ said Martin. Now officers can let doctors know when one or more of their patients is selling their prescriptions — information the doctor can use to ensure that those patients either receive no more opioid prescriptions, or, if it’s absolutely needed, such as in the case of terminal cancer, that it is dispensed and monitored under strict guidelines. 

Previously, the CDC has provided guidelines for prescribing opioids for chronic pain. Those guidelines include using the drugs only when the benefits outweigh the risks, and starting with the lowest effective dose.

I am seeing more and more evidence that the “powers to be” are using questionable data and ignoring other more solid data to come to a conclusion(s) that may be preconceived and/or feed an agenda.

Highlighted text in this article – IMO – clearly demonstrates this. I see – all to often – where people – on both sides of the issues – are jumping to conclusions after reading a HEADLINE and/or after reading certain words, sentences or paragraphs.

Federal officer or employee may NOT exercise any supervision or control over the practice of medicine  A 1935 federal law recently came to my attention – link above.  It appears that this federal statue would put into question the legality of a number of federal laws, regulations, guidelines that is attempting to compromise appropriate therapy for those with chronic health issues… especially those with subjective diseases.  There is an increasing number of various bureaucratic entities on the city, county, state, federal level that are determined to impose their will on those suffering from subjective diseases.  Getting a law declared unconstitutional, will cost several millions of dollars and will not have any monetary payback… it will only mean that the laws can no longer be enforced.  This means that unless those suffering from subjective diseases starts putting their dollars together and hire a law firm to take this on… Nothing will be reversed … will only continue to progress on the path which is currently on.




Careful what you ask for.. insurance will offer end of life meds in place of treatment

(BIVN) – An Oahu circuit judge on Friday dismissed a lawsuit asking the court to prevent existing Hawaii criminal laws from being applied to medical aid in dying practices.

In its decision, the court relied upon state legal precedent that prohibited it from issuing such relief, the state attorney general said in a media release. The attorney general opposed the suit, filing the successful motion to dismiss.

The lawsuit seemed to hinge on what the legislature would decide on the divisive matter this year. The House ended up killing the bill after it passed through the senate. From the AG’s office:

Legislation was introduced this year to legalize medical aid in dying in Hawaii and establish a regulatory process under which an adult resident of the state with a medically confirmed terminal disease may obtain a prescription for medication to be self-administered to end the patient’s life. The bill was deferred on March 23, 2017. Noting that the legislation generated 2,613 pages of testimony and comments, the court said “this underscores that the relief sought by the plaintiffs is political, not judicial, in nature and should be addressed by the political branches of government.”

Proponents of medical aid in dying have not given up. Last month during a community meeting held in Pahoa, Mountain View resident Ron Hart delivered a heart-wrenching account of the agonizing death of a friend (video above), and urged those gathered in the room to get involved with a new grassroots group.


Assisted suicide being ENCOURAGED by INSURANCE COMPANY rather than TREATMENT ?

I am being mistreated horribly by a pharmacy

I am being mistreated horrible by a pharmacy

Chronic pain treatment.

I have several severe illnesses.







Post concussion syndrome

I am a chronic pain patient.

I am being messed with to help deal with pain. What. Can be done. I’m in so much pain , can you help.

When the pt’s well being is not a healthcare professional’s top concern ?

My name is D. S. I’m 36 years old I have four children and I’m on social security. I’ve had six knee surgeries and I’m currently in a medical malpractice lawsuit with my knee surgeon. My surgeon caused me to have a chronic osteomyelitis in my left knee by leaving behind metal and lying about cultures! This has now caused me grand mal seizures.

The pain I get is intense . If I don’t sleep due to pain I can get a seizure!

I lost my driver license because my temperature gets to high from chronic infection.

I went to drop of my script at Ansr pharmacy in hollister CA. I absolutely love this pharmacy never had any issues. The pharmacy has wonderful people. As I dropped of my script which had my seizure meds, my pain meds they didn’t even look at my script and said we can’t help you!

I was in shock , confused, and literally on a break down of crying.

I’m at the mercy of Walgreens to help me. They stated that the DEA shut them down from dispensing too much narcotics. Today is sat July 15th. Come tomorrow I’m out of my pain meds , my seizure meds which nothing can be filled. There is something that needs to be done and I feel like each month being a Chronic pain patient I feel as though I’m getting treated worse. Do you have any where you would suggest I can file a complaint?

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