DIY methadone dispenser lands former pharmacist in strife

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A former pharmacist has been disqualified from re-registering for 18 months after crafting his own methadone dispenser

The Dubbo man had been the Pharmacist in Charge at a pharmacy in the Orana region of NSW between January 2013 and 2016.

The pharmacy dispensed methadone to patients under the opioid substitution program.

The Health Care Complaints Commission (HCCC) alleged that he not only failed to do accurate stock checks and maintain proper records, but also constructed a modified methadone dispensing unit for the storage and dispensing of Biodone.

Towards the end of 2015, the pharmacist resigned from his job and another pharmacist took over as Pharmacist in Charge.

Before long she had called the Pharmaceutical Regulatory Unit (PRU) to express her concerns about the way the pharmacy was storing methadone.

“Her concerns related to a unit modified by [the pharmacist] which meant that the methadone was transferred from the manufacturer’s bottles into a large plastic container similar to that used to store pool chlorine,” the NSW Civil and Administrative Tribunal noted.

“The plastic container was stored in a safe. The methadone pump was affixed to the countertop and plastic tubing extended from the pump into the container via a hole drilled through the top of a safe.”

The second pharmacist then contacted the PRU, sending it photographs of the contraption, and advised that the police had attended and disposed of the contents of the container in the safe. This resulted in a shortfall of 2,418ml of methadone solution.

The Tribunal noted that the modified methadone dispensing unit comprised a 15L blue plastic container into which the pharmacist poured bottles of Biodone.

He estimated that a month’s supply of Biodone was poured into the blue plastic container each month. The container was in turn stored in a safe.

The pharmacist then drilled a hole into the safe, breaching its integrity, from which a tube connecting to the blue plastic container holding the Biodone was fed.

He also created a stop valve inside the safe, which would be switched off at the end of each day to ensure that no Biodone could be accessed through the top of the safe. He attached the tubing out of the safe to a Socorex dispensing device and placed a bolt with a padlock above the Socorex dispensing device to prevent more than a few millilitres from being accessed through the top of the safe when locked.

“The Biodone was stored and dispensed directly from this container to methadone patients at the pharmacy.”

The second pharmacist soon had cause to contact the PRU again, after she was approached by a patient, identified as Patient A, seeking medication without a prescription, and telling her that the first pharmacist had in the past provided it without one.

The pharmacist who had constructed a modified methadone dispensing unit surrendered his registration on 1 June 2016.

He maintained that his methadone dispenser was an “appropriate device” and that its efficiency provided a “positive outcome” for the health and safety of patients in the opioid replacement program.

The Tribunal did not agree.

As well as finding the pharmacist had failed to keep appropriate records in the controlled drugs register for Schedule 8 medications, it found that his home-made methadone dispenser did not comply with legislative requirements.

The Tribunal further found that he had dispensed sildenafil to Patient A without a script on at least 40 occasions over a period of 18 months.

He was also found to have dispensed dexamphetamine to himself at the pharmacy on multiple occasions, on prescriptions which were not valid as they did not include the necessary prescriber authorisation number.

Altogether the former pharmacist was found to have engaged in both unsatisfactory professional conduct and professional misconduct.

He stated that he wishes to return to work as a pharmacist despite “serious breach” of the required standards.

The HCCC had sought a disqualification of two to three years, but the Tribunal felt this was more serious a consequence than necessary, and disqualified him from practising for 18 months.

“Accordingly if [he] were still registered we would have cancelled his registration and disqualified him from being registered as a pharmacist for a period of 18 months,” it noted.

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    • chris

      On one hand a very bad boy but on the other hand such innovation has to be applauded. Maybe self consumption of the Dex gave him insight and clarity beyond the realm of a mere undosed human being. A little bit of Brett Whitely channeling, or Lennon and Mccartney per chance?

  1. Philip Smith

    So you can illegally supply a S4 on 40 occasions, not keep S8 records and dispense your own S8s from a script without all legal requirements and Macgyver up a Methadone pump and your punishment is for 18 months you can not be a pharmacist.

    Another question where were the owners during all of this since it is imperative that a pharmacist owns a pharmacy to maintain its integrity???

    • Notachemist

      This report only covers the HCCC decision. I expect that there would be separate criminal charges as well which have not yet been to court – this is a separate matter.

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