By Andrew Joseph | Nov. 22, 2021

CaSonya Richardson-Slone poses near her home in Odessa, Fla. Richardson-Slone's husband died by suicide in 2017 after being denied pain medication. EVE EDELHEIT FOR STAT

For six years, Brent Slone had relied on opioid medication to tame his agonizing pain — and then he ran out. He raced to resolve the hang-up over his prescription. He tracked down old medical records, he called his pain clinic repeatedly, he even showed up at the door. But the final word came down: no refills until an appointment almost a week away.

“they denied script im done love you,” Slone, 40, texted his wife on the afternoon of Sept. 12, 2017. He killed himself shortly after.

In an unusual step, his wife then sued the clinic and its physicians — a rare legal challenge to doctors over their decisions to reduce patients’ opioid doses.

Her lawyer argued that Slone was neglected by his doctors and his care mishandled by the pain clinic. Since a car crash paralyzed him from the waist down, Slone had been prescribed high-dose opioids and taken them as instructed. But through his providers’ carelessness, the lawyer contended, his dose was rashly cut by 55%. When he couldn’t get any more medication, he feared days of no relief.

“This is a patient safety, a patient abandonment case,” said the lawyer, Hans Poppe, at the trial, held this August in Louisville, Ky.

The clinic argued Slone’s pain doctors were trying to responsibly treat a patient who was at a precarious moment, one whose suicide was entirely unforeseen. Slone had been placed on “an astronomically high dose” of opioids by other clinicians when he was at a nursing facility recovering from surgery. His pain physicians then lowered his dose to one that he had previously been on. And when he misused that prescription, burning through it too fast, they had no choice but to deny a refill until his appointment. This was standard of care.

“This is a setup for a drug overdose,” Stephen Kyle Young, one of two physicians named in the suit, said about the possibility of authorizing more pills.

The two assertions illuminate a thorny, essential question that has been bubbling into greater awareness: How should doctors safely care for patients who have been on high-dose opioids for years? There’s a push to lower opioid levels amid the country’s addiction crisis, but advocates and experts agree that mismanaged dose reductions — whether too aggressive or too broadly implemented — introduce new, serious harms. Not only can they lead to resurgent pain or withdrawal, advocates say, but they can drive people to seek out illicit opioids or to take their own lives.

Cases like Slone’s are complex, experts told STAT, involving vulnerable patients and high doses of potentially dangerous drugs. But too often, they warned, people who rely on these medications are seeing them taken away under the guise that it will make them safer, when instead it can endanger them.

At the trial, the jury agreed. The panel found the physicians and pain clinic at fault and awarded the family nearly $7 million, with $3 million allocated for Slone’s daughter, who was 12 when her father died.

Researchers stress that attributing suicide to a single cause is difficult. In these situations, patients often have multiple risk factors — including opioid use itself, chronic pain, and accompanying mental health issues.

Still, Slone’s case is notable because it appears to be the first time a jury sided with a patient whose opioid medication was, in their eyes, improperly withheld. It is a sign of the growing recognition that after a reckoning over the damage wrought by prescription opioids, the pendulum swung too far back in certain cases and left another group of people with chronic pain at risk. The message is starting to come from the highest levels, with federal health authorities upping their warnings in recent years about the harms of unsafe dose reductions and stoppages.

“This is the first case that I’ve seen that took that on and said, this is problematic, that endangering people’s health like this is problematic,” said Kate Nicholson, president of the National Pain Advocacy Center.

For CaSonya Richardson-Slone, Brent’s wife, hearing the judge read the jury’s verdict was a moment of relief, one that validated her decision to pursue the case.

“I felt like I had been in fight mode,” she said. “I did it for him, and for my daughter, for everything we’ve gone through, for everything she’s gone through. We had already suffered a lot, through his car accident, but we had adjusted to that new normal. We still had family traditions that were important to us. We still went to dinner and to the movies, and played guitar and did karaoke. We celebrated her birthday, we went to Red Lobster. We still did normal things that families do.”

Richardson-Slone holds a photo of her late husband holding their daughter shortly after she was born.EVE EDELHEIT FOR STAT

Before her husband’s death and the subsequent trial, before the car accident that meant her husband would be in pain for the rest of his life, a teenaged CaSonya was a cashier at Winn-Dixie. Brent would go through her checkout line so he could flirt with her, with a boldness that both charmed her and took her aback. They eventually married and had their daughter, settled in Louisville, and spent much of their free time outdoors — hiking, swimming, camping.

Then, in 2011, came the crash. Slone sustained a broken pelvis, a compressed spinal cord, and other injuries that caused chronic pain and put him in a wheelchair. He developed depression. To temper his pain, Slone relied on opioid and non-opioid medications, and in 2014, became a patient at Commonwealth Pain and Spine, which has a network of clinics in Kentucky and Indiana.

Doctors measure opioid dosages in units called morphine milligram equivalents, or MMEs. Federal guidelines now caution against doses above 90 MME a day for chronic pain, or say such doses need to be justified (pain management specialists generally have more latitude). But some patients have been on higher levels for years. Slone’s dose hovered around 240 MME a day, varying depending on his pain levels and procedures.

Slone’s treatment coincided with campaigns to rectify opioid prescribing. To claw back from years of lax dispensing that flooded communities with pills, clinicians started offering smaller doses for shorter periods of time to new patients. As a result, U.S. opioid prescribing has plummeted in the past decade, even as the overdose crisis has reached record heights due to an explosion of illicit fentanyl.

Some experts have also called for clinicians to “taper” the doses of legacy patients to safer levels, to essentially find the lowest dose that can control their pain. It’s not just that the drugs carry some chance of addiction and overdose, but are associated with other risks and side effects as well, including mental health issues. There’s disagreement about whether long-term opioids are even treating pain in many people or they just become physically dependent on the drugs; some evidence indicates that lasting opioid use can worsen pain.

But other experts have pleaded for a more cautious approach for the millions of people living with pain who take opioids — even if they agree that some should never have been placed on such high doses. Many patients are in delicate situations, with disabilities or mental health problems, but seem to have found stability with their medication. Unwise tapering can upend their lives and exacerbate their pain, advocates say. In some cases, physicians, insurers, or pharmacies have suddenly cut patients off. Tapering works for many patients, they say, but it can’t be forced.

It’s a fraught debate, draped by the legacy of profligate prescribing. But despite the divide over how widely to pursue tapering, experts and governmental guidelines agree that — with few exceptions — dose reductions need to go slowly, with patient buy-in. 

In 2016, Slone started traveling to California for advanced wound care. His wheelchair caused pressure sores that resulted in bone infections.

He went again in the summer of 2017 for surgeries, including skin grafts, and then recovered for weeks at a nursing facility in La Jolla. His daily opioid intake increased from 240 MME to above 400 MME, occasionally reaching 540 MME. On Aug. 11, he was discharged from the nursing facility at that highest dose for a visit to Kentucky.

Slone’s medical team in California contacted Commonwealth and said that he had enough medication to last through Aug. 16, court records and testimony indicate. Young, the pain management doctor, wrote Slone a “bridge” prescription at that 540 MME level to last until his Aug. 22 appointment at Commonwealth, even as he worried about Slone being on such a massive dose.

Brent and his support dogCOURTESY

It was at that appointment that Slone’s dose was dropped by more than half, to 240 MME.

Why such a reduction occurred was disputed at the trial. Poppe pointed to testimony indicating that a nurse inadvertently slashed Slone’s dose to his prior one — perhaps because she copied over information from his chart from months earlier — and that the doctors didn’t catch the error. Poppe argued such a mistake amounted to an unsafe taper, citing guidelines that recommend starting with a roughly 10% dose reduction, and that it demonstrated a failure in patient care.

The defense framed Slone’s reduction as intentional — and suggested the situation was something other than a taper. The higher dose of 540 MME reflected what Slone was on for acute pain following surgery, at a time when he was closely monitored at inpatient facilities. Such a dose would not be safe for him out in the world. They were simply moving him back to his chronic pain baseline dose, and claimed he would not experience withdrawal because 240 MME was still supplying a sufficient opioid amount.

“This is not a taper case,” said James Jackson, the other physician named in the lawsuit. “He was being established back on his safe dose.”

STAT reviewed the issues in the case with outside experts. If the defense’s portrayal of an intentional dose reduction was accurate, the experts still challenged the contention that someone whose prescription was lowered that much couldn’t experience withdrawal — no matter how high the remaining dose was. Responses to opioids are highly variable, but some people get used to elevated doses in as little as a week, they said. The body would expect a certain amount of opioid, and would notice if it wasn’t there, so a return to a baseline dose should happen gradually. Such a rapid reduction could also have allowed Slone’s postoperative pain to return, they said, though they cautioned they hadn’t seen his full medical history.

“This is the problem that we see — there is this rush, almost a panic, to decrease doses rapidly under the guise of patient safety, but the irony is these rapid changes expose patients to greater risk,” said Beth Darnall, a psychologist and director of the Stanford Pain Relief Innovations Lab, who is working on a study examining voluntary opioid tapering.

Whether you call what happened to Slone a taper or prefer another word for the reduction is semantics, they said.

“It was a dose change that people would not be expected to tolerate,” said Stefan Kertesz, a primary care and addiction medicine physician at the University of Alabama at Birmingham’s medical school, who is working on a study examining suicides that occur after dose reductions and stoppages.

On Sept. 11, a few weeks after his dose was dropped, Slone called Commonwealth and reported he was running out of medication, though his prescription was supposed to last another week. At the trial, Poppe acknowledged that Slone misused the medication, taking some 300 to 400 MME per day instead of 240, but contended Slone did so because his dose was cut too fast.

Slone called Commonwealth about a dozen times over the next 24 hours and even went to the clinic to ask about his prescription, according to court records. CaSonya said she called as well and told the staff that Slone was in pain. From Sept. 10 to Sept. 12, Slone also went to emergency departments a number of times — including once after dislocating his hip from falling from his wheelchair — and reported that he was out of medication and was in pain. He was given low levels of painkiller, but was told to speak to his pain specialists to resolve the prescription issue.

“There is this rush, almost a panic, to decrease doses rapidly under the guise of patient safety, but the irony is these rapid changes expose patients to greater risk.”

BETH DARNALL, STANFORD PAIN RELIEF INNOVATIONS LAB

But Young denied a refill or a bridge prescription ahead of the appointment scheduled for Sept. 18, saying that Slone had violated the narcotic agreement he had signed by taking his medication more often than prescribed.

At the trial, defense attorney Sean Ragland argued that Slone’s suicide could not have been anticipated and that he had not exhibited any signs of suicidal ideation. The greater risk at that moment was overdose, because when Slone went through his medication too quickly, his doctors couldn’t know whether he had obtained an illicit supply or how much opioid he had in his system, the defense contended.

Doctors at Commonwealth “embrace an idea of the conservative approach to opioid use that takes into account each patient’s needs with respect to their pain and also takes into account the risks that opioids present,” Ragland said. (Following the verdict, the defense requested that the case be retried, but a judge has yet to rule on the motion.)

The experts STAT consulted said situations when a patient goes through a prescription too quickly are challenging — but not uncommon. Pain clinics shouldn’t dole out more pills whenever that happens, especially when someone is on as high of a dose as Slone was, but each case needs to be considered individually, they said. Slone had had a major dose reduction, and he had until then generally complied with his prescription instructions. Given Slone’s tolerance to high doses, the experts also questioned how much of an overdose risk he presented.

“The first thing you should ask is not, [is] this guy is taking advantage of me, but, what broke his consistency this time?” said Michael Barnett, an assistant professor of health policy and management at Harvard’s T.H. Chan School of Public Health, who studies opioid prescribing. (Barnett has served as a paid expert witness for plaintiffs in lawsuits against opioid manufacturers and distributors.)

Steven Stanos, a pain medicine specialist at Swedish health system in Seattle, said pain doctors used to have the instinct not to provide any more medication when patients ran out early. But they’ve realized that by halting the drugs, “you really don’t make the patient safer,” he said. Doctors now try to see patients when that happens, offer a bridge prescription for a low-dose opioid until an appointment can be made, or try buprenorphine, a medication that can ease withdrawal symptoms and address some pain.

“If someone runs out early, the question is, why?” said Stanos, who is on the board of the American Academy of Pain Medicine.

But on the afternoon of Sept. 12, Slone was told he wouldn’t be getting more medication until his appointment, six days away. He killed himself about two hours later.

Richardson-Slone and the legal team after the jury verdictCOURTESY

Health authorities are increasingly publicizing the risks of unsafe opioid reductions. In 2019, the Food and Drug Administration warned about the dangers of rapid discontinuation and mandated changes to prescribing information. In September, California’s public health department alerted providers that they should “continue opioid therapy for patients in transition” and “use caution when tapering opioid therapy” when taking on legacy patients.

The Centers for Disease Control and Prevention is also revising its 2016 prescribing guidelines, which were intended as recommendations for primary care physicians treating certain chronic pain patients, but have been used to justify hard caps on doses. Even the guidelines’ authors stress they’ve been misapplied. The updated version is expected next year.

“Some policies and practices citing the guidelines went beyond its recommendations and were inconsistent with its guidance,” the CDC’s Deborah Dowell said at a July meeting. “For example, the guideline does not support abrupt tapering or sudden discontinuation of opioids, but we heard many reports of it being inappropriately cited to justify suddenly cutting off opioids.”

Still, the concerns around opioid dose reductions are taking time to reach all clinicians, said Joanna Starrels, a primary care and addiction medicine physician at Albert Einstein College of Medicine and Montefiore Medical Center. Prescribers for the past decade have been thinking more about the risks and benefits of giving opioids, and now they’re having to consider the risks and benefits of reducing doses as well.

“There is increasing awareness among providers that there are risks of tapering opioids, and we’re beginning to understand those risks,” said Starrels, who focuses on chronic pain management. “Unfortunately, we’re pretty early in that process, both in terms of the research and the evidence to understand who’s at risk for bad outcomes with tapering and when and why … I do think if a provider is not an expert in this field, it’s hard to keep up.”

Brent Slone, and his situation, looks like other patients who have lost access to opioid therapy, experts said — namely that he was a person with disabilities who seemed to fall through the cracks when he transferred between medical teams. But there are important differences. Slone’s issue arose when he had an unusually high dose for acute pain on top of his already high dose for chronic pain. And Slone didn’t experience the abandonment that some patients do, when their physicians stop providing them medication permanently or when their pharmacy or insurer cuts them off.

For CaSonya, who now lives in Florida with her daughter, her hope is that the lawsuit and the verdict help ensure chronic pain patients get the proper care.

She and Brent were separated when he died, but remained close and were figuring out their next steps. What still nags at her about what happened is that they did everything they were supposed to do. They got Commonwealth the medical records from the California facility that the clinic asked for. Brent sought help at the emergency department. When the emergency departments told him he needed to sort this out with his pain physicians, they called Commonwealth repeatedly. It wasn’t enough.

“It was unthinkable that he wouldn’t be seen in their office, or that he wouldn’t get a bridge prescription,” she said. “I never thought I’d lose him in that way.”

If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.