This series highlights common medicolegal issues in general practice. Written by a team from medical defence organisation Avant, the series is based on actual cases, with details changed for privacy and some issues summarised for the sake of discussion. This scenario highlights an emerging trend of pregabalin misuse identified by coronial investigations into deaths involving mixed drug toxicity.
Since the analgesic and anticonvulsant pregabalin was listed on the PBS for the treatment of neuropathic pain in 2013, its use in Australia has increased dramatically. However, there is growing disquiet worldwide about the risk of pregabalin harms and misuse. Australian coroners, particularly in Victoria, have raised concerns about an increase in cases in which pregabalin is implicated in deaths due to multiple drug toxicity.
The following case scenario of a patient taking prescription pregabalin who died of mixed-drug toxicity illustrates some of the medicolegal issues for medical practitioners prescribing pregabalin. It also demonstrates the importance of real-time prescription monitoring systems for prescribers.
Dr Green, a GP in Melbourne, was contacted by the police after his patient Adam, aged 29 years, was found deceased at his home. Emergency services had been called, but Adam could not be revived. Multiple prescriptions were found in Adam’s name, prescribed by multiple doctors. An autopsy identified mixed-drug toxicity involving oxycodone, pregabalin and amitriptyline. Dr Green was required to give evidence at a coronial inquest.
Adam first presented to Dr Green at the age of 27 years with a history of a traumatic knee injury and chronic back pain from a motor vehicle accident five years earlier. At the time, he was being prescribed oxycodone. Over the years, he underwent multiple surgical procedures on the knee.
Adam reported to Dr Green that his pain levels were not being managed and, despite Dr Green’s efforts to reduce his oxycodone dose, this was not achieved. Dr Green began prescribing pregabalin, which he considered preferable to opioids. Specifically, he believed it could be taken on a long-term basis safely and without the risk profile and potential for misuse associated with opioids.