Sudden and unexpected death in patients with chronic pain

Through the forest Tennant, MD, DrPH

Suddenly, unexpected death may occur in a patient with severe and chronic pain, and the terminal event may not be related to medical therapy. Fortunately, sudden death is not as commonly observed in patients with pain as in recent years, probably due to better access to at least some treatment. However, sudden death still occurs and professionals need to know how to detect a patient “at risk”.

Sudden and unexpected death due to severe pain is underappreciated, as many observers still see severe pain as a harmless nuisance rather than a possible physiological calamity. In many cases, just before death, the patient informs his family that he feels sicker than usual and seeks relief in his bed or on his couch. Unfortunately, some of these patients do not wake up. Other patients die, without warning, while they sleep or are collapsed on the floor. The aggressive toxicology of modern medicine and forensic procedures after death have contributed to the poor understanding of the threat of pain death. In some cases, a patient with pain who was being adequately treated with an opioid or another agent with an overdose or potential for abuse has died suddenly and unexpectedly. Drugs were found in bodily fluids after death and, in my opinion, a forensic doctor wrongly stated that the death was an “accidental overdose” or a “toxic reaction” to the drugs instead of implicating the real culprit, who can have been a “fact out of the ordinary”. control “flare pain.

This article is partially intended to draw attention to the fact that the mere discovery of drugs of abuse at autopsy does not necessarily mean that the drugs caused the death. In fact, drugs may have postponed death. Some doctors have been falsely accused of causing deaths due to excessive drug treatment when, in fact, the mistreatment of pain may have caused death. In addition, blood levels of opiates evaluated at autopsy in a patient who died suddenly are often mistakenly considered an accidental overdose because the pathologist does not know that patients with chronic pain with a stable dose of opioids can be fully functional with serum levels of opioids. his opioids prescribed so far.

Here we present the mechanisms of sudden and unexpected death in patients with pain and some protective measures that professionals must take to avoid being falsely accused of causing a sudden and unexpected death. More importantly, here are some clinical tips to help identify the patient with chronic pain who has a high risk of sudden and unexpected death so that more aggressive pain treatment can be performed.

A brief anecdotal history 
As a senior medical student at the University of Kansas in the early 1960s, I was required to take a rural preceptor with a rural doctor. One day, when we went to the county nursing home, I heard a farmer’s wife declare that “pain killed my mother last night.” Since then, I repeatedly heard that the pain killed a loved one. Folklore often mentions that people die “by” as well as “in” pain. There are, however, few written details of these events.

In the first years of my pain practice, which I started in 1975, several patients died suddenly and unexpectedly. This rarely happens to me nowadays, since I have learned to “expect the unexpected” and to identify which patients are at high risk of sudden death. In recent years, I have reviewed a series of cases of litigation and negligence of sudden and unexpected death in patients with chronic pain. In some of these cases, doctors were accused of over-prescribing or incorrectly prescribing and causing sudden and unexpected death, even though the patient had taken stabilized doses of opioids and other medications for prolonged periods. In addition, the autopsy showed no evidence of pulmonary edema (a defining sign of overdose and respiratory depression).

Scenario and cause 
Unexpected deaths in patients with chronic pain usually occur in the home. Sometimes death occurs in a hospital or detoxification center. The history of these patients is quite typical. Most are too sick 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 bathroom. In some cases, the family reports that the patient spent an extraordinary amount of time on the toilet just before the collapse and death. However, sudden and unexpected death can occur anywhere and at any time, as pain patients who died unexpectedly and suddenly found themselves 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 most of these cases, since no macroscopic pathology has been found at autopsy.2-5 Instantaneous cardiac arrest it seems to explain a sudden collapse or death during sleep. Perhaps the constipation and the effort to evacuate the feces can be factors of cardiac tension, since some patients with pain die during the defecation. Acute sepsis due to adrenal insufficiency and immune suppression may explain some sudden deaths.

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Two mechanisms of cardiac death
Severe pain is a horrible stress.6.7 Outbreaks of severe pain, acute or chronic, cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenaline and noradrenaline) in an effort to contain stress biologically . 8,9 Catecholamines have a direct and potent stimulation effect on the cardiovascular system and result in severe tachycardia and hypertension.10 Pulse rates can increase to more than 100 beats per minute and even increase to more than 130 beats per minute. Blood pressure can reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to the release of adrenal catecholamines, outbreaks of pain cause an excess of activity of the autonomic and sympathetic nervous system, which adds an additional stimulation to tachycardia and hypertension induced by catecholamine. The physical signs of sympathetic, autonomic hyperactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupil), sweating, vasoconstriction with cold extremities, hyperreflexia, hyperterflexia, nausea, diarrhea and vomiting.


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