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Pressure to prescribe: investigated doctor tackles town problem

15 April 2019 | Hannah Shiel, LLB, Solicitor, Avant Law, NSW

Pressure from patients is a many and varied challenge doctors can face on a daily basis. A patient has googled their symptoms, for example, and requests a specific referral that you aren’t convinced is clinically necessary or they may request a particular medication to treat their self-diagnosed ailment.

When it comes to prescribing Schedule 8 medications, the pressure can be acute. From the patient who complains about travelling out of town to see a pain specialist, to the one who has chronic non-malignant pain, it is understandably confronting for doctors.

With Schedule 8 and opiate drug prescribing reaching a crisis point, health departments and policymakers are becoming increasingly interested in doctors’ Schedule 8 prescribing practices. Regulators are primed to act against practitioners who aren’t complying with their obligations.

The following case study details how one general practitioner (GP) member, who experienced acute pressure to prescribe, used the 11-month complaints process experience to take on their town’s drugs-of-addiction problem.

A knock at the door

It was an ordinary weekday for the GP in their small regional practice when Pharmaceutical Regulatory Unit investigators came knocking.

The investigators had attended the local pharmacy and conducted a review of the dispensing records, which consequently led them to pay the GP a visit.

They were concerned the GP had been prescribing high-strength opioids to patients without the required permits. Namely, the investigators wanted to learn about the GP’s prescriptions of:

  • multiple, concomitant, high-strength opioids to patients who may be drug dependent without the required authority
  • methadone for a period exceeding two months without the required authority
  • drugs of addiction in large quantities and/or frequency for chronic non-malignant pain, not in line with the recognised therapeutic standards
  • Lyrica at a quantity and/or frequency above that recommended within manufacturer product information.

Based on this visit, the Pharmaceutical Regulatory Unit provided a report to the relevant complaints body who asked the GP to submit a written response and, ultimately attend an interview. The GP was taken aback by this and contacted us for assistance.

Leading the charge to turn around town drug problem

A solicitor and medical advisor assigned to the case explained the investigation process and assisted the member with their written submission to the complaints body. They helped them set out a response to each of the patients involved, including listing steps taken since the Pharmaceutical Regulatory Unit attended the practice.

They talked through the legislative requirements to make sure the practice was meeting those guidelines and also provided the GP with resources to refresh their knowledge of Schedule 4 and Schedule 8 medication.

The response noted the GP was working to increase their knowledge around prescribing drugs of addiction. This was later helpful at the interview because the GP was able to highlight their understanding of the legal requirements.

A champion for change

Since that first interview with the Pharmaceutical Regulatory Unit, the GP obtained the required state authority and was actively taking steps to improve their practice.

They not only made significant changes to their own practice, but also rallied other medical professionals in town to establish a collective approach to tackling local problem use of Schedule 8 medications.

Their practice had a close affiliation with other local practices and the nearby hospital. They supervised registrars and overseas-trained doctors and attended antenatal clinics. They used these platforms for education and change implementation to reduce the risk of any further non-compliance with prescribing obligations across the spectrum of their clinical work and of colleagues.

Some specific steps the GP took

  • They set up regular case conferences with other medical practitioners in town to discuss safe Schedule 8 prescription management and highlighted potential drug-seeking patients.
  • They invited the local pharmacist to these case conferences, as well as set up specific dispensing agreements with the pharmacy, such as:
    • Fentanyl patches being dispensed one at a time (when a new patch is dispensed the old patch is collected by the pharmacist for safe disposal)
    • opioids for patients who require them for more than two months being dispensed by the pharmacist in a Webster pack and only on a weekly basis.
     
  • The GP arranged for all patients on opioids long term to see a pain specialist. They previously found this difficult because patients complained about the four-hour round trip to the closest one. Understanding how important this is, they stopped prescribing to patients who didn’t attend.
  • They started noting during hospital rounds who is on the opioid treatment program in the town and were using the ‘Doctor Shopper’ information line more regularly.

Complaints body buoyed by efforts

Eleven months after the Pharmaceutical Regulatory Unit knocked at the door, the GP attended an interview with the complaints body.

The complaints body decided the GP had taken on board the concerns raised, had made changes to their prescribing practices and had brought their education up-to-date using the Avant materials. In delivering the decision, the complaints body noted they had addressed the issues and made an effort to turn things around in their own prescribing practice but also within the community.

As such, the GP avoided the matter being taken further because, as the complaints body put it, “We are confident that in the future [they] will be much more aware of [their] prescribing obligations”.

Safeguards in practice

Emma Gibson, BN, GradCert ICU, MHM, Risk Advisor, Risk Advisory Service, NSW

Interestingly, one of the most common medico-legal risks Avant’s Risk Advisory Service advised on in the last year was appropriately prescribing medications.

Our risk advisors work with members to identify and manage medico-legal risk, with the ultimate goal of reducing the risk of complaints and investigations.

In this case, the risk advisor helped brainstorm strategies to implement in the practice and it was through this that the GP enhanced their practice’s clinical governance, systems and policies.

This included:

  • installing signs in the waiting room to advertise the practice protocol on prescribing drugs of addiction – the GP’s practice policy was ‘no drugs of addiction will be provided on a first appointment’
  • having patients with complex pain management needs requiring drugs of dependence sign a patient agreement for drugs of dependence stating their goals of treatment and expected behaviours
  • applying a common approach among practitioners such as:
  • having a policy for managing patients exhibiting drug-seeking behaviour
  • nominating one doctor to manage the patient with complex pain needs
  • scheduling follow-up appointments with this doctor only
  • establishing sound handover policies within the practice
  • imposing a universal practice policy to not prescribe opioids or benzodiazepines, unless there is communication from the patient’s regular general practitioner, for out-of-area patients or patients who report a lost script for drugs of dependence.

And remember, it is okay to review and possibly end a therapeutic relationship if a patient doesn’t comply with your practice’s requirements.

Performing under pressure: tips for doctors

Prof Greg Whelan, AM, MBBS, MD, MSc, FRACP, FAFPHM, FAChAM, Senior Medical Advisor & Case Manager, Medical Defence Services, VIC

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.

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.

Avant’s Medico-legal Advisory Service and Risk Advisory Service can assist members with advice and resources, if you are concerned about prescribing to a patient or current practices – ensure the prescription of a drug of dependence is clinically indicated before considering medico-legal issues.

Useful resources

News articles

Prescription drug related deaths: Coroner calls for mandatory education

Doctor’s lapse of judgment leads to disciplinary action

Factsheet

Prescribing drugs of dependence

eLearning course

Prescribing: principles and practices

Other resources

Access the NPS Medicine Wise self-audit tool

RACGP template policies: Prescribing drugs of dependence in general practice

This article was originally published in Connect Issue 11.

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