Amisulpride overdose death raises questions about drug monitoring

 

A coroner has raised concerns about toxic levels of amisulpride prior to the death of Lianne Davenport. Liane sadly passed away on 4th December 2019. The coroner concluded that her death at home was most likely due to a combination of the high levels of amisulpride in her body and also coronary artery atherosclerosis. She also had left ventricular dysfunction.

 

The coroner has raised concerns about the monitoring requirements for such anti-psychotics medicines and has questioned whether monitoring requirements should be improved particularly in people who become elderly or frailer.

 

Liane had a 45-year history of schizophrenia and a 10-year history of lupus with associated arthritic problems. Over the last year of her life, she had had hospital admissions for sepsis due to pneumonia and endocarditis for which she received prolonged but successful treatment.

 

She had however become frailer and lost 10kg in weight during her final year of life.

 

She had been on long term treatment with high dose antipsychotic medicines. At her death, she was being prescribed amisulpride 800mg daily and quetiapine 800mg daily to control her mental state.

 

It was acknowledged at the inquest that the dose of amisulpride was above the dose of 300mg daily recommended by the BNF. However, at a review shortly before her death, the consultant felt that it was safe to continue based on the fact that Liane had no physical problems and that her blood chemistry and ECG were within normal limits.

 

There was no evidence to suggest that she had taken more than the prescribed dosage.

 

At post-mortem, toxicology results showed that her plain blood quetiapine level was 433ng/ml. This was within the quoted therapeutic range. However, her amisulpride level 10698ng/ml. The suggested upper therapeutic range for amisulpride is 400ng/ml.

 

An expert witness suggested that the large volume of distribution for amisulpride may have raised the level somewhat. The expert witness also stated that he could not find any quoted toxic or lethal ranges but did point to reported cases where a level of 9600ng/ml was survived with treatment whereas two fatal cases involved levels of over 40,000ng/ml.

 

As a result of this case and these findings, the coroner felt that there was a risk of future deaths if nothing was done. The coroner has asked if people on high dose powerful antipsychotic medicine regimes should have the medicine drug levels checked particularly as this patient group becomes older and frailer.

 

You can read the full coroner’s report here.

 

This coroner’s report is being shared under the Open Government Copyright licence.

 

 

What can pharmacists learn from this tragic propranolol overdose?

 

Emma was a 24-year-old pharmacy graduate. She had two degrees, was a high achiever and was making the most of her life.

 

Sadly Emma took an overdose of both propranolol and citalopram.

 

Emma called an ambulance, but her condition quickly worsened. Despite resuscitation efforts from both paramedics and medical staff in the hospital she was transferred to, Emma sadly died.

 

The purpose of this podcast was to highlight the findings of the report written as a result of the investigation undertaken by the Healthcare Safety Investigation Branch (HSIB). We were fortunate to be joined by Deinniol Owens a National Investigator at the HSIB. Deinniol and I had a chat about the aspects of the investigation that are pertinent to pharmacists.

 

The report makes a number of recommendations but also emphasises that there is a link between anxiety, depression and migraine and that more research is needed to understand the interactions between antidepressants and propranolol in overdose.

 

The safety recommendations focused on the following:

 

  • Updating clinical guidance (NICE) and the UK’s pharmaceutical reference source (the British National Formulary) on use of propranolol and highlighting the toxicity in overdose.
  • National organisations supporting their staff members to understand the risks when prescribing propranolol to certain patients.
  • Improving the clinical oversight in ambulance control rooms and the treatment/transfer guidance for ambulance staff for propranolol/beta-blocker overdose.

 

 

Deinniol Owens, National Investigator, Healthcare Safety Investigation Branch.

 

If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.

 

AnchoriTunesGoogle PodcastsSpotifyBreakerOvercastPocketCastsRadio PublicPodbeanStitcher

 

What can Scotland learn from British Columbia’s approach to overdose deaths?

 

Part of the answer to mounting drugs-related deaths in Scotland lies in grassroots charities, community groups and experts with lived experience taking a lead role, a Canadian substance use researcher says.

 

Professor Bernie Pauly of the Canadian Institute for Substance Use Research was in Scotland last week to speak at a Dundee harm reduction event organised by the Scottish Drugs Forum.

 

In Vancouver, the setting up of unsanctioned ‘pop up’ overdose prevention sites to save lives in the face of a rising tide of overdose deaths led to the provincial government backing these sites across the province, Professor Pauly, who is also a nurse at the University of Victoria School of Nursing, tells healthandcare.scot.

 

Her comments come amid an ongoing standoff over a safe consumption room in Glasgow. The Home Office refuses to allow such a facility, which campaigners, local politicians and the Scottish Government say has been proven to “save lives”.

 

British Columbia is home to just over five million people, compared to just under five and a half million for Scotland.

 

Like Scotland, it has also struggled with drugs. In 2015, overdoses became the highest cause of unnatural deaths, outstripping suicides and traffic accidents.

 

Fatalities have remained stubbornly high, with more than 1,500 people losing their lives in 2018 and, for the first time in recent history, life expectancy is falling.

 

In Scotland, 934 drug-related deaths were recorded in 2017.

 

Professor Pauly explains how, in light of long processes for federal approval of drug consumption rooms, activists and campaigners moved to provide an “essential health service” themselves.

 

“There were people, particularly in Vancouver, who started by setting up unsanctioned sites – often called pop-ups, because they were in tents. One of the ones in Vancouver was basically a tent in an alleyway where people could be observed and Naloxone administered immediately in the event of an overdose.

 

“People knew there were evidence based-interventions that would save lives – so why weren’t we doing that?”

 

Following the declaration of a public health emergency in 2016, the provincial government sanctioned overdose prevention sites – a move opposition politicians in Scotland have been calling for.

 

Overdose prevention sites are small-scale, “welcoming and friendly” spaces typically staffed by harm reduction workers, including staff with lived experience of drug use.

 

As well as expanding access to overdose prevention, they created “a space that was safe, where people felt like they wouldn’t be judged, with opportunities to develop trust and facilitate opportunities to access other services.”

 

In Canada, larger drug consumption spaces – of the kind proposed for Glasgow – have a broader range of staff, including nurses and counsellors. But while British Columbia is held up as an exemplar when it comes to harm reduction policy, Professor Pauly says a comprehensive response is critical.

 

Alongside overdose prevention sites, there was rapid scale-up of the provincial Take Home Naloxone Program and Opioid Substitution Therapy – but, she argues, more is needed. While no deaths occurred at supervised consumption or overdose prevention sites, British Columbia still saw 104 suspected overdose deaths in March.

 

Ultimately, these spaces are still “emergency measures,” Professor Pauly says. The ‘real prevention’ is ensuring a safe supply.

 

One idea being proposed in Canada’s western-most province is ‘compassion clubs’, in which members would be able to access a safe source of heroin.

 

It’s hoped this would undermine the illegal market, reduce poisonings and overdose deaths caused by impurities.

 

Asked what lessons Scotland could draw from the Canadian experience, Professor Pauly says:

 

“One is engaging people with experience right from the start because so many innovations are driven by them. The establishment of safe consumption sites…were really led by people with expertise and lived experience.”

 

Ultimately, she returns to the issue of supply, which is “something that should be addressed from the start.”

 

“You can scale up things like overdose prevention,” Professor Pauly says, “but you really have to address the fact there is an unsafe supply and really focus on changing policy to ensure a safe supply – that’s the real prevention.”

 

This story was supplied as part of our partnership with healthandcare.scot.