By Forest Tennant, MD, DrPH
Sudden and unexpected death may occur in a patient with severe chronic pain, and the terminal event may not be related to medical treatment. Fortunately, sudden death is not as common in pain patients as in recent years, probably because of better access to at least some treatments. However, sudden death persists and professionals need to know how to identify a “risky” patient. Unexpected sudden death due to intense pain is barely perceived, as many observers still regard intense pain as a harmless nuisance rather than a potential physiological calamity. In many cases, shortly before death, the patient informs the family that he is feeling sicker than usual and is seeking relief from the bed or couch. Unfortunately, some of these patients do not wake up. Other patients die without warning while they sleep or collapse on the floor. The aggressive toxicology of modern medicine and post-mortem forensic procedures has contributed to a misunderstanding of the threat of death by pain. In some cases, Part of the purpose of this article is to draw attention to the fact that the mere discovery of drugs that are susceptible to abuse at autopsy does not necessarily mean that these drugs caused the death. In fact, the drug could have delayed death. Some doctors have been falsely accused of causing deaths due to excessive drug treatment when, in reality, insufficient treatment of pain could have led to death. In addition, blood levels of opioids assessed at the autopsy of a patient who died suddenly are mistakenly considered to be accidental overdoses because the pathologist is unaware that patients with chronic pain associated with a stable dose of opioids may be fully functional with prescribed serum opioid levels exceeding so far. 1 We present here the mechanisms of sudden and unexpected death in patients with pain and some protective measures that practitioners must take to avoid being falsely accused of causing sudden and unexpected death. More importantly, here are some clinical tips to help identify the patient with chronic pain who is at high risk of unexpected sudden death so that the most aggressive pain treatment can be treated. A brief anecdotal story As a medical student at the University of Kansas in the early 1960s, I had to follow a rural precept with a hinterland doctor. While we were going to the county retreat house one day, I heard a farmer’s wife say, “The pain killed my mother last night.” Since then, I have heard many times that the pain has killed a loved one. Folklore often mentions that people are dying “of” or “in” pain. However, there are few written details about these events. In the early years of my pain practice, which began in 1975, many of my patients died suddenly and unexpectedly. This has rarely happened to me today as I learned to “wait for the unexpected” and identify patients at high risk of sudden death. In recent years, I have analyzed several cases of litigation and neglect regarding sudden and unexpected death in patients with chronic pain. In some of these cases, the doctors were accused of overwriting or improperly prescribing and causing sudden and unexpected death, even if the patient had taken stabilized doses of opioids and other drugs for long periods of time. . In addition, the autopsy showed no pulmonary edema (signal defining overdose and respiratory depression). In cases where the doctor has been falsely accused,
Scenario and cause Unexpected deaths in patients with chronic pain usually occur at home. Sometimes death is in a hospital or rehab center. The story of these patients is pretty typical. Most are too sick to leave home and spend a lot of time in bed or on the couch. Death usually occurs during sleep or when the patient gets up to go to the bathroom. In some cases, the family reports that the patient spent a lot of time in the bathroom just before the collapse and death. Sudden and unexpected death, however, can occur anywhere, at any time, such as pain patients who have died unexpectedly and are suddenly found at work or in a car. Coronary spasms and / or cardiac arrhythmias leading to cardiac arrest or asystole are the apparent cause of death in most cases, as no macroscopic pathology compatible with autopsy has been observed. 2-5 Instant cardiac arrest seems to be responsible for sudden collapse or death during sleep. Perhaps constipation and the effort to pass through the stool can be factors of heart tension because some patients with pain die during defecation. Acute sepsis due to adrenal insufficiency and immunosuppression may be responsible for some sudden death.
Two mechanisms of cardiac death Intense pain is a horrible stress. 6.7 Acute acute or chronic pain attacks cause the hypothalamic-pituitary-adrenal axis to produce glucocorticoids (cortisol, pregnenolone) and catecholamines (adrenaline and norepinephrine) for the purpose of biologically reducing stress. 8,9 Catecholamines exert a direct and powerful stimulating effect on the cardiovascular system and lead to severe tachycardia and hypertension. 10 Often, heartbeats can reach more than 100 beats per minute and reach more than 130 beats per minute. The blood pressure can reach more than 200 mmHg systolic and more than 120 mmHg diastolic. In addition to the release of adrenal catecholamines, exacerbations of pain cause hyperactivity of the autonomic and sympathetic nervous system, which adds an additional stimulus to catecholamine-induced tachycardia and hypertension. Physical signs of autonomic and sympathetic hyperactivity, in addition to tachycardia and hypertension, may include mydriasis (dilated pupils), sweating, cold-end vasoconstriction, hyperreflexia, hyperthermia, nausea, diarrhea and vomiting.