Could real time prescription monitoring have helped?

legal medical tribunal doctor overprescribing

A NSW doctor has been reprimanded for prescribing addictive drugs including fentanyl, oxycodone and morphine to drug-dependent patients without the proper authority

A specialist doctor, based in Taree in northern NSW, recently fronted the NSW Civil and Administrative Tribunal over 11 complaints brought by the Health Care Complaints Commission (HCCC) regarding his treatment of 10 patients.

These complaints included that the practitioner had prescribed oxycodone, hydromorphone, morphine, fentanyl, buprenorphine, tramadol and naloxone in various combinations to patients:

  • When failing to conduct an appropriate assessment of the patient before prescribing;
  • When he should have known the patient was a drug-dependent person;
  • Without the proper authority of the Secretary of the Ministry of Health.

In one case, the doctor prescribed fentanyl and oxycodone to a patient in circumstances where the patient presented wearing two fentanyl 100mg patches.

On another occasion, the practitioner prescribed fentanyl to a patient who admitted he had been wearing, for about one month, 75 µg per hour fentanyl patches given to him by a friend.

He also prescribed oxycodone, naloxone and buprenorphine in an inappropriate combination to a patient who had told the practitioner she had developed a dependence on morphine and wanted to get off the drug.

In 2014 the practitioner prescribed one patient fentanyl 12 mcg/hr patches with tramadol 100mg capsules twice daily and Tramal 50mg capsules up to three daily, without an appropriate therapeutic purpose.

Could real time monitoring fill the gap?

As part of the HCCC’s investigation, the records of a number of pharmacies in the area of Tuncurry-Forster, Nabiac and Taree were examined.

The report concluded that the practitioner appeared to have issued prescriptions for a drug of addiction within close proximity to the same or similar prescriptions having been issued by certain patients’ regular prescribers.

An expert witness to the Tribunal noted that due to a lack of communication between the practitioner and other GPs, there would have been times when the referring GP would have had no knowledge of the fact that the prescriptions might have been written for narcotics for the patient and might have unwittingly written additional prescriptions for the patients.

A real-time prescription monitoring system, which is currently being discussed in NSW but has reportedly been delayed, would be expected to fill this gap.

At the time of the conduct, the doctor was generally dealing with patients who were seeing him for acute and chronic back pain.

It was acknowledged by the Tribunal that in the doctor’s local area of practice, the availability of a pain management specialist is limited and general practitioners relied on him for referral for difficult patient cases in pain management.

Despite extensive training, having completed a medical degree in 1989, postgraduate training in rehabilitation medicine, and a Fellowship in rehabilitation medicine – as well as having been medical director of a large rehabilitation unit in France for several years – the doctor admitted to the Tribunal that he did not consider himself to be a pain specialist.

‘Lack of insight’

The practitioner denied that he was guilty of professional misconduct, although he admitted most of the particulars to the complaints.

Three references spoke highly of the capabilities and practices of the practitioner.

Meanwhile the NSW Civil and Administrative Tribunal found that the doctor had failed in his practice by taking a “more biomechanical rather than biomedical” approach to his patients.

“The Tribunal considers that the most significant failing of the practitioner lies in his lack of insight for the need to consider and to treat each patient in a holistic manner,” it said in its recent decision.

 “There seems to be no recognition or appreciation by the practitioner of the need for fundamental change: that is, there is a lack of insight by the practitioner into the importance and relevance of a patient’s whole medical and social history.

“With respect to psychosocial aspects, the practitioner did not consider it useful, stating that he could not see the purpose of it and that there was no need to ask about such matters,” said the Tribunal.

It found him guilty of unsatisfactory professional conduct in respect of each complaint, although not of professional misconduct.

The Tribunal reprimanded the practitioner “in view of the shortcomings and failures identified during the evidence” and ordered that he undertake several educational courses on opioid treatment and prescribing practices.

The practitioner is unable to possess, supply, administer or prescribe any Schedule 8 drug until he completes all the education courses required by previous condition.

After being granted new authority in the future, he must submit to audits of his medical practice.

The practitioner was also ordered to pay for the HCCC’s costs.

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