While the legalities of prescribing drugs of dependence can seem complex, this recent case reminds doctors of the key requirements to prescribe these medications safely for patients.
The GP was investigated by the Pharmaceutical Regulatory Unit (PRU). It was found she had prescribed drugs of dependence without the authority required and which were prohibited under the Poisons and Therapeutic Goods Act 1966 (NSW).
The Medical Council of NSW conducted a hearing into the doctor’s conduct and suspended her registration. This led the Health Care Complaints Commission (HCCC) to investigate the complaint on disciplinary grounds. The allegations centred on her prescribing of oxycodone, alprazolam, fentanyl patches and flunitrazepam to eight patients.
It was found the doctor knew, or should have known, the patients were drug dependent and she prescribed the Schedule 8 drugs for a continuous period of more than two months without obtaining the proper authority. Expert medical evidence was strongly critical of her prescribing practices. Some of the concerns included:
- providing prescriptions without assessing the patient, for example in response to email requests and requests from a patient’s family member
- prescribing oxycodone in excessive quantities, and especially to patients being treated for opioid dependence
- continuing to prescribe drugs of dependence for patients identified as prescription shoppers
- continuing to prescribe for patients who failed to follow the practitioner’s recommendations to engage with specialist services
- failing to obtain past medical history from patients about diagnoses prior to prescribing drugs of dependence
- ignoring red flags and drug-seeking patient behaviour and continuing to prescribe for those patients.
The tribunal agreed with the expert’s findings for all patients.
Breach of patient confidentiality
The tribunal also found she breached patient confidentiality while treating two patients, a married couple who had recently separated. Patient A told the doctor about an extramarital affair, which she disclosed to Patient B without Patient A’s consent or any therapeutic justification, and no legal or public interest reason to explain the disclosure. When told of the affair, Patient B disclosed incidences of self-harm and threats to the person with whom Patient A had been having the affair.
The tribunal highlighted the Medical Board of Australia’s Code of Conduct which states patients have the right to expect their information will be held in confidence by doctors or practice staff, unless it is legally required or permitted to be released.
The doctor gave evidence she “was not even thinking about confidentiality during this consult” and disclosed the information because she thought it would reduce Patient B’s risk of self-harming or harming others. The tribunal found this represented a “total lack of understanding” of the obligation of patient confidentiality.
The doctors’ failure to respond to and act on Patient B’s threats was also a concern. She was found not to have properly assessed Patient B or made any referral for specialist treatment, or developed a management plan.
Lack of documentation
The doctor’s lack of documentation during the consultations was also strongly criticised. This centred on her failure to document any information or advice given to the patients about the purpose, importance, benefits or risk of the medication prescribed. The tribunal found this was below the standard for record keeping under the RACGP’s Standards for General Practitioners.
The tribunal also noted an absence of record keeping for Patients A and B. There was no record of counselling sessions and ongoing assistance to Patient B and no documentation of a mental health care plan, assessment, or further clinical review.
Ultimately, the doctor was found guilty of professional misconduct and unsatisfactory professional conduct. The disciplinary actions are pending.
Drugs of dependence present unique challenges for doctors and patients. Doctors must be satisfied the medication they prescribe is clinically indicated. Additionally, there are strict legal requirements around prescribing drugs of dependence. These vary across states and territories, and according to whether the patient is considered drug dependent or not.
To determine if your patient is drug-dependent before prescribing, take a comprehensive medical history and assessment, and if necessary, confirm the information from other sources if the patient is unknown to you. It’s also important to check the real-time prescription monitoring system if it is mandatory in your state or territory.
Legislation in most jurisdictions includes a definition of a ‘drug-dependent person’. The definition varies between the states and territories, however generally it is a patient who:
- exhibits impaired control or drug-seeking behaviour
- is likely to experience withdrawal symptoms of a mental and/or physical nature as a result of cessation of the medication
- has consumed prescribed medications contrary to, or in excess of, prescribed instructions.
If prescribing for a drug dependent patient, a doctor must obtain a permit or authority from the relevant state or territory pharmaceutical services unit.
For non-drug dependent patients, a drug of dependence cannot be prescribed for more than two months (this time frame includes prescribing by previous doctors) without approval in most states and territories. This applies to drugs listed on Schedule 8 of the Poisons Standard by the Therapeutic Goods Administration.
- Obtain all relevant authorities and consider any concerning drug-seeking patient behaviours before prescribing Schedule 8 drugs.
- Document all treatment and prescribing decisions in the patient’s records. This includes any information or advice given to the patient about the purpose, importance, benefits or risk of the medication prescribed.
- Always comply with your professional obligations around patient confidentiality.
This article was first published as: R Brell Professionalism, prescribing and privacy: HCCC v Sriskanda (2021) 29(5&6) HLB 85.