Short time frames between dispensing, inadequate instructions and high-priced private scripts for controlled drugs were all problems at one western Sydney pharmacy
Part Two of a report into multiple failures at a Sydney pharmacy owned by the GP next door. Part One is available here.
A GP and pharmacist has had a number of complaints made and proven against him at a hearing conducted by the NSW Civil and Administrative Tribunal.
The practitioner was a registered GP who worked out of a general practice in western Sydney, adjacent to a pharmacy of which he was the sole proprietor.
Regarding dispensing practices at the store, the Tribunal said that said a report on them given as evidence by an investigating pharmacist should be “compulsory reading for every pharmacist”
While the practitioner said he did not work at his pharmacy next door to the medical practice, only having an administrative role, he was strongly criticised for his failure of oversight.
The Tribunal detailed a very long list of problems related to its dispensing of certain drugs of concern.
It included the supply of strong doses of fentanyl to opioid-naive patients where it was not an appropriate medicine to start treatment, with long gaps between dispensing, after which the patients should have been treated as new patients for the purposes of starting them on the medication, but were not.
Further problems included insufficient gaps between dispensing of medicines, expensive private scripts for controlled drugs and dispensing of drug combinations which should have caused intervention.
One opioid-naïve patient’s first dispensing at the pharmacy was for Durogesic (Fentanyl) 100 patches in April 2014.
“The next dispensing of Fentanyl 100 patches occurred over one year later on the 15th May 2015 and due to the long interval between scripts a pharmacist should have treated this dispensing as if for a new patient and a clinical intervention inserted to confirm that the patient had been continuing opioid treatment away from the pharmacy and therefore the prescription was appropriate.
“It is noted that between the 15th May 2015 and 24th November 2015, Fentanyl appears to have been prescribed by five different doctors and in three different strengths. The pharmacist should have considered that it is better for the patient to have only one doctor responsible for prescribing and monitoring a patient’s opioid use.”
On one occasion the interval of repeat was only four days, and on two, 10 and 11-day intervals.
“The pharmacist should have considered the possibility that the patient was struggling with pain control or possibly abusing the opioid,” the Tribunal noted.
On three occasions the directions for use were not provided except for apply as directed or simply as directed.
One patient was given 28 Oxycontine 80mg tablets in September 2011, then two days later, another 28 Oxycontin 80mg and 20 Tramal SR 200mg. Significantly early dispensing of Oxycontin 80mg occurred on three more occasions between December 2011 and March 2012, but no clinical interventions were provided.
Nor were interventions provided when the same patient was dispensed 40 Tramal SR 200mg in October 2011 for $45 on a private script – more than three times to cost of two lots of 20 Tramal SR 200mg on the PBS.
Another private script for this patient in October 2012 saw them charged $105 – 21 days after the previous dispensing for a 14-day supply.
In February 2012 this patient was dispensed five Fentanyl 50 patches, one day after Endone had been dispensed.
“Two days later a script was dispensed for 2 Norspan 20mcg patches, another opioid analgesic, and four days later 5 Fentanyl 100 patches were dispensed.
“Between 23rd February 2012 and 11th November 2015, Five Fentanyl patches, equal to fifteen days supply, were dispensed many times but with many anomalies,” – including scripts being dispensed well before the due date, with long gaps in the dispensing history of Fentanyl patches, and on four occasions, privately charged.
On around 20 occasions Fentanyl scripts were dispensed without adequate directions for use.
In May and August 2013 this patient was given Antenex 5mg prescribed by another doctor, and the pharmacy also regularly dispensed them Aurorix 300mg whilst the patient was taking Fentanyl patches.
“A pharmacist should have known that this combination is contraindicated due to the possibility of causing Serotonin toxicity,” the Tribunal observed.
Another patient was dispensed 50 Diazepam 5mg with a dose of 2 twice daily when needed and 25 Oxazepam 30mg with a dose of 1 daily; this patient had also been dispensed mirtazapine less than two weeks earlier.
“A pharmacist should have had strong reservations about dispensing these three medications at the same time so the prescribing doctor should have been contacted to clarify the prescriptions,” noted the Tribunal.
Subsequent Diazepam and Oxazepam scripts were dispensed nine days later by the same doctor, four days after that from another doctor (not known if from the same practice) and again seven days after that by the first doctor.
Six months later this patient was dispensed Norspan 10mcg/hr patches and 13 days later, Oxazepam and Diazepam scripts.
A couple of weeks later, this patient was dispensed fentanyl; from 3rd April 2015 until 2nd September 2015 there was continued dispensing of the two benzodiazepines and the Fentanyl, with short intervals of supply.
The histories of nine of these patients was outlined and it was found that the practitioner’s lack of oversight of his pharmacy meant his conduct fell significantly below the expected standards.
The Tribunal also heard about three forged prescriptions for fentanyl which were dispensed in December 2014.
As for the delay in surrendering his drug authority, the practitioner said he had an “honest belief” that he did not need to do so, because he had already surrendered the authority he had held as a medical practitioner to prescribe S8s and S4D drugs in 2016, as a result of the proceedings against him as a GP.
The Tribunal noted that ignorance does not necessarily excuse non-compliance.
“At all times the respondent was aware that he was first registered to practice as a pharmacist, and later as a medical practitioner,” it said.
“We conclude that he must have known and been aware of the need for separate registration. We further conclude that the respondent must have been aware that medical practitioners and pharmacists have different functions in connection with the supply of drugs of addiction to patients.
“Medical practitioners issue prescriptions which are then dispensed by pharmacists. In the circumstances, ignorance of the fact that he possessed two separate authorities does not constitute an excuse for having failed to surrender the authority issued to him as a pharmacist.”
The pharmacist was found guilty of professional misconduct and unsatisfactory professional conduct, and disqualified from being registered as a pharmacist for three years.
The Tribunal noted that it would have cancelled the pharmacist’s registration if he had currently been registered.
The full list of the pharmacist’s drug dispensing can be accessed via the Australasian Legal Information Institute here.