Prescription drug-related deaths: coroner calls for mandatory education

20 June 2018 | Professor Greg Whelan, AM, MBBS, MD, MSc, FRACP, FAFPHM, FAChAM, Senior Medical Advisor and Claims Manager, VIC.

A recent inquest into the deaths of four patients from overdoses to prescription painkillers has elicited further calls for a real-time prescription monitoring system and mandatory education for GPs on prescribing S8 drugs.

In all four cases, the patients visited multiple GPs to obtain prescriptions, prompting the Queensland coroner to call for the implementation of a real-time prescription monitoring system over the next two years. The coroner also encouraged Queensland Health to provide further education on prescribing painkillers for GPs.

"It seems there is a lack of effective, independent and mandatory clinical education and support to GPs," the coroner said, in response to a number of the doctors explicitly stating during the inquest they weren’t educated on prescribing controlled drugs.

However, while the courts have highlighted the growing prevalence of prescription drug misuse and the need to introduce law reforms to address it, a national real-time prescription monitoring system is estimated to still be five years away.

Currently more people in Australia die from prescription drug use than illicit drug use. Between 2011 and 2015, 2,145 overdose deaths occurred from prescription opioids while 985 deaths were due to heroin according to Australia’s Annual Overdose Report 2017 by the Pennington Institute. Despite this, the uptake on real-time monitoring services by state governments has been slow, until recently. It is something Avant has been advocating on behalf of our members, calling for reforms to improve the way drugs of dependence are prescribed, monitored and regulated.

Implementation across the states

Tasmania: The first state to implement a real-time prescription monitoring system in 2011, known as DORA, to monitor the prescription of Schedule 8 medicines.

Victoria: Committed to implementing a real-time service, as a result of recommendations made across 21 coronial inquests since 2012. The system will make it mandatory for doctors to check prescription history through its portal, SafeScript, before being able to prescribe high-risk medicines and will be rolled out at the end of 2018.

South Australia: Premier Steven Marshall announced that SA would implement a real-time system as part of his election campaign last year. An implementation date is yet to be confirmed.

ACT: A nine-year inquest involving a prescription drug-related death in the ACT has led to some positive progress in this area, with a bill introduced in May 2018 to establish a voluntary real-time service.

NSW: During an inquest in May this year, NSW health authorities stated they have no timeline for implementing a real-time monitoring service despite the state government committing to do so.

Western Australia: The state is looking to roll out a real-time prescription monitoring system by the end of 2018.

Northern Territory: The Northern Territory has been utilising real-time information software retrieval systems since 2015.

In April 2018, the Health Council of the Council of Australian Governments confirmed that a national real-time system would be established. The federal system will collate data from all state systems to effectively monitor prescriptions across state lines.

Your legal obligations

The legal obligations of doctors differ slightly across states and territories, so familiarise yourself with the regulations where you practise. Generally though, you require approval from the relevant state or territory authority if you wish to prescribe a drug of dependence:

  • to a patient for more than two months (this timeframe includes prescriptions by previous doctors)
  • if the patient requiring the drug is considered “drug dependent”
  • before prescribing certain drugs, for example, amphetamines or methadone.

If in doubt, contact your local authority for further information, or Avant for advice.

Should you or shouldn’t you?

Drug-seeking behaviour by patients is often sophisticated, manipulative and demanding. Familiarising yourself with these behaviours can help you identify patients seeking drugs for the wrong reasons and decide whether you should prescribe them medication.

The Royal Australian College of General Practitioners outlines some of these behaviours in their clinical guidelines. These include:

  • aggressively complaining about needing medication
  • frequent unscheduled clinic visits for early refills
  • frequently calling the clinic
  • unwilling to consider other medications or non-pharmacologic treatments
  • pattern of lost prescriptions
  • claiming to be on a waiting list or unable to afford dental work and needing to manage pain.

If you suspect that a patient is seeking drugs for the wrong reasons, some strategies you could use to minimise the risk a patient may abuse or misuse the drugs include:

  • dispensing controlled or smaller quantities of the drug
  • setting up specific dispensing arrangements with their pharmacy (also noted on the prescription)
  • informing patients that call up the practice to get top ups or because they lost their script, to see the GP in person instead
  • referring the patient to a pain management specialist clinic, addiction medication specialist or for a psychiatric consultation, where appropriate, to provide a second opinion on prescriptions and advise on other treatment.

You may also be able to obtain a fuller picture of the patient’s habits and prescriptions outside your practice by calling Medicare's Prescription Shopping Information Service, which is available 24 hours a day, seven days a week on 1800 631 181. It’s important to note that patients will only be flagged as a doctor shopper if they have visited six or more doctors and received 25 prescriptions from these doctors in total. Therefore, only frequent drug-seeking behaviour is identified. The Service also doesn’t monitor private scripts or those from the Department of Veterans’ Affairs.

Key things to keep in mind

  • Be cautious when prescribing drugs of dependence.
  • Familiarise yourself with drug-seeking behaviour.
  • Make the most of services that can help you identify drug-seeking behaviour.
  • Employ strategies to minimise the risk of a patient misusing or abusing drugs.
  • Understand when a permit is required for prescribing drugs of dependence.
  • Refer the patient to a specialist for further treatment if appropriate.

Further information

For more information, download our factsheet Prescribing drugs of dependence or complete our eLearning course, Prescribing: principles and practices.

To speak with an expert for advice regarding prescribing drugs of dependence, call Avant’s Medico-legal Advisory Service (MLAS) on 1800 128 268, available 24/7 in emergencies. MLAS can also be contacted via email at nca@avant.org.au.

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