Prescribing restricted medications without appropriate authorities sees GP’s registration cancelled

Under state legislation, restrictions apply to prescribing a range of medications with particular risk profiles, including drugs of dependence. Doctors must ensure they understand the requirements and obtain all necessary authorities before prescribing scheduled medications.

Dr J faced complaints of unsatisfactory professional conduct and professional misconduct over his prescribing for multiple patients over a period of seven years.

Regulatory requirements for prescribing restricted substances

Dr J was criticised for prescribing isotretinoin (Roaccutane) for oral use for two young female patients without authorisation.

Ms A was aged 16 and Ms F aged 15 when Dr J began prescribing, and treatment continued until they were 19 and 17 respectively.

The tribunal accepted that Roaccutane was clinically indicated for the patients’ cystic acne. However, it noted that Dr J did not have the proper authority to prescribe isotretinoin. In NSW, where this case took place, specialist dermatologists are authorised to prescribe the medication without applying for an authority, while other prescribers can only prescribe it after obtaining an authority from NSW Health.

The tribunal concluded Dr J should have referred each patient to a specialist dermatologist.

Responsibilities when prescribing restricted substances – examinations, assessments

The tribunal accepted expert opinion that Dr J needed to have assessed the suitability of the Roaccutane for the patients. That included considering any previous treatments tried, and relevant patient history such as depression or family history of high cholesterol or diabetes.

The Poisons Standard requires prescribers to exclude the possibility of pregnancy before prescribing, and to counsel patients against becoming pregnant while on the medication or for one month after ceasing use. In both cases Dr V had failed to assess the possibility of pregnancy or advise of side effects or risks of birth defects. He initially claimed he thought Ms F was too young to discuss contraception, but accepted that during the course of treatment he became aware she was sexually active and continued to prescribe.

He had also failed to make an ongoing assessment of the suitability of the medication, even after Ms F reported a suicide attempt.

The tribunal concluded Dr V’s conduct was significantly below the expected standard and constituted unsatisfactory professional conduct.

Regulatory requirements for prescribing drugs of dependence

Dr J was also criticised for prescribing drugs of dependence without appropriate authorities to five other patients.

For some of the patients, the tribunal accepted that Dr J’s initial assessment and decision to prescribe Endone was appropriate for the patient’s pain. However, the ongoing prescribing and escalating doses suggested the patient was exhibiting drug seeking behaviours.

The tribunal found that a doctor of Dr J’s experience ought reasonably to have suspected these patients were becoming drug-dependent and responded appropriately, including seeking authority to prescribe.

Further, even if Dr J did not suspect those patients had become drug-dependent, he prescribed opioids for more than two months continuously without seeking the necessary authority to prescribe.

Dr J admitted that his prescribing had been inappropriate and accepted that he had been ‘too soft’ in trying to keep patients happy.

The tribunal concluded Dr J’s wish to please patients had negatively impacted his clinical judgement and patient care. In all cases, his prescribing could have led to tragic consequences.

He had undertaken education on pain management and appropriate prescribing, however after the course he continued to prescribe drugs of dependence inappropriately.

In the circumstances the tribunal was not satisfied that conditions or suspension would be sufficient.

Dr J’s registration was cancelled for three years.

You must always exercise your clinical judgement when prescribing and satisfy yourself that the medications you prescribe are appropriate for the patient’s therapeutic need. This includes taking an appropriate history, and conducting any relevant examinations or tests.

A patient’s request for a prescription should only be complied with if you are satisfied the medication is appropriate. If a requested medication is inappropriate, ensure you have a clear discussion with your patient about the reasons why you are unable to provide the prescription.

Obtaining effective informed consent for medication includes discussing any risks and benefits of the treatment, including potential adverse effects, contra-indications for treatment and alternative treatments.

Ensure that you understand the requirements for prescribing drugs of dependence or restricted medications – including any authorities required and real time prescription monitoring obligations in your state or territory.

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