Ms. P, age 49 years, was a nurse practitioner who specialized in pain management. Over her 20-year career, she had worked in various practice settings, but for the past three years she had been working as an independent practitioner in a pain management clinic. Ms. P’s patients were referrals from other practitioners, and Ms. P was well-regarded as a pain management specialist. 

One of Ms. P’s referrals was Mrs. L, a 37-year-old woman with a medical history that included chronic pain related to chronic sinusitis and multiple sinus surgeries. Her history also included anxiety, panic attacks, sleep difficulty, and depression. Mrs. L had originally been seeing a pain management physician, but after his retirement, her pain was managed by an ear, nose, and throat specialist and an infectious disease specialist, who both referred and turned over care of Mrs. L to Ms. P. 

The referring physicians had both received letters from the patient’s medical insurance provider warning them about the patient’s prescriptive habits and potential opioid and methadone abuse. However, neither of the referring physicians shared the letters with Ms. P nor alerted her to the fact that the patient had been obtaining duplicate pain medication prescriptions from multiple medical providers—a process commonly known as “doctor shopping.” Although Ms. P had requested the patient’s medical records from the referring physicians, they had not arrived by the date of the consultation.

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On the day of the consultation, Ms. P sat with the patient and obtained and documented a list of Mrs. L’s prescription use and past and current medical history. The patient was currently on methadone, and a urine analysis was performed to check the patient’s methadone level. 

Ms. P noted in her file that the results indicated a methadone level that was appropriate for 
Mrs. L’s height and weight. She also noted that the dose of methadone the patient reported taking was within the normal range. Ms. P also had, along with the referral, a copy of a drug screen performed on the patient three weeks prior to the consultation. 

Nothing about the consultation with Mrs. L—the previous drug screen results, the urine analysis performed in her office, or her discussion with the patient—raised any “red flags” or unusual concerns for Ms. P about the patient. 

Based on this information, Ms. P prescribed Mrs. L methadone for the next 28 days. She had the patient read and sign a regimen compliance agreement. The agreement clearly stated, and Ms. P reinforced verbally, that Mrs. L agreed to only use the pain medication prescribed by Ms. P and as prescribed by Ms. P. Mrs. L agreed to those statements, signed the form, thanked Ms. P, and left the office. 

Fifteen days later, Mrs. L was found dead in her home. An autopsy revealed the cause of death to be methadone toxicity. 

The patient’s husband retained an attorney who filed a wrongful death lawsuit against multiple defendants, including Ms. P, the referring physicians, and several local pharmacies.

Ms. P consulted with the attorney provided by her malpractice insurance. At their first meeting, Ms. P provided him with her notes. 

“Based on this,” he said, “I don’t see that you did anything wrong.”