Healthcare Inspection—Unexpected Death of a Patient: Alleged Methadone Overdose, Grand Junction VA Health Care System, Grand Junction, CO

OIG conducted a healthcare inspection in response to an allegation received in 2016 that a patient died of an accidental methadone overdose 2 days after receiving a prescription for methadone from a primary care physician (PCP) at the Grand Junction VA Health Care System (System), Grand Junction, CO. We substantiated the allegation that the patient identified in the complaint died 2 days after receiving a prescription for methadone from a System PCP. We were unable to substantiate that methadone contributed to or was the cause of the patient’s death. Neither an autopsy or toxicology study was performed, so additional information was not available. The System lacked a process to ensure prescribers were aware of, or considered, current Veterans Health Administration (VHA) directives, policies, and guidance related to obtaining an electrocardiogram before prescribing methadone for the management of chronic pain. VHA’s “Consent for Long-Term Opioid Therapy for Pain” is an electronic document that is used to obtain consent for long-term opioid therapy. The template document may also be used as a patient education tool but does not include risk factors specific for methadone. System PCPs we interviewed were not aware of how to add methadone specific risk factors to the electronic consent form. After investigating the events surrounding the death of the patient identified in the complaint, System leaders did not confer with the Office of Chief Counsel to determine if an institutional disclosure was necessary. We made five recommendations.