GP ‘unaware’ that alprazolam was S8, failed to spot red flags

tribunal hearing legal case

A pharmacist was among those who raised the alarm about a NSW GP’s prescribing of drugs of addiction to drug-dependent patients

The NSW Health Care Complaints Commission has released a statement about Dr Gunedra Weerabaddana, who has been reprimanded and is no longer permitted to prescribe S8 drugs.

A Medical Professional Standards Committee heard that in January 2017, a Detective Senior Constable from Tamworth Police notified Ahpra of concerns about Dr Weerabaddana’s prescribing of drugs of addiction to drug dependent patients.

Prior to this, a medical practitioner in Tamworth and a pharmacist in Singleton had also raised concerns about Dr Weerabaddana.

Fourteen complaints were prosecuted before the Professional Standards Committee, each relating to a different patient.

Part of each complaint was an allegation that the doctor had failed to exercise appropriate care by inappropriately prescribing an S8 drug of addiction for continuous therapeutic use for a period exceeding two months, without proper authorisation, contrary to the Poisons and Therapeutic Goods legislation.

There was some variation between the 14 complaints, but each alleged that alprazolam was prescribed in this way.

It was also alleged that the doctor failed to undertake appropriate assessments, obtain information from previous treating practitioners, make specialist referrals and that he lacked an appropriate therapeutic purpose to continue prescribing alprazolam.

The Committee noted that Dr Weerabaddana had prescribed alprazolam for long periods of time, despite telling it that he understood it was a short-term treatment for anxiety.

The complaints indicate that one patient was treated for five years, and another for seven.

The Committee also noted that the doctor’s initial assessment of the patients was inadequate; several had said that they had already been prescribed alprazolam by a psychiatrist but could not remember that prescriber’s name.

Dr Weerabaddana also accepted at face value that patients had been assessed by a psychiatrist or a mental health team, without making any independent enquiries. For one patient Dr Weerabaddana did contact the treating psychiatrist, but 22 months after first seeing the patient.

“Dr Weerabaddana failed to identity red flags for drug seeking behaviour. Several patients travelled long distances… to consult him,” the Committee noted.

“Some patients travelled long distances even when they were diagnosed with agoraphobia, a debilitating form of social anxiety, which often restricts patients to their home.

“Dr Weerabaddana was not alert to other possible indicators of drug seeking behaviour, for example, some patients asked for Alprazolam by name, they could not recall the name of their original prescribing psychiatrist, for one there was evidence of past use of methadone and another stated his prescription had been stolen.”

As well as the alprazolam, one patient was prescribed fentanyl. On seven separate occasions in 2016, two people identified only as Patient E and Patient M consulted him on the same day and received the same script for alprazolam.

“On three occasions in 2016, three patients attended on the same day and on one occasion, 27 June 2016, four patients attended and were prescribed Alprazolam on the same day,” the Committee noted.

“When asked about this Dr Weerabaddana said that he had not noticed this occurring and that at the time he did not consider it unusual. Without further information it cannot be known whether these patients travelled together and attended Dr Weerabaddana’s practice together.”

The doctor said he now regarded these patients as drug-seeking patients, but at the time he did not consider this possibility.

He also admitted that he did not have a legal authority to prescribe alprazolam to the patients identified in the complaints, but he says he was unaware it was a S8 drug. Alprazolam became a Schedule 8 drug of addiction in February 2014.

He had been contacted by the Pharmaceutical Regulatory Unit in January 2017, and counselled about his prescribing in contravention of the Poisons and Therapeutic Goods Act, especially in relation to drug dependent patients.

The PRU also wrote to him regarding this advice, and after its Principal Pharmaceutical Officer Kim Dolan requested but did not receive confirmation Dr Weerabaddana had received this letter, faxed another copy to his surgery.

Subsequent inquiries by the PRU showed Dr Weerabaddana kept prescribing alprazolam for several patients despite this advice, and without seeking or receiving the appropriate authority.

In fact, all but three patients in question were prescribed alprazolam after Ms Dolan’s January phone call to Dr Weerabaddana.

The doctor said he thought Ms Dolan was wrong and that he believed only opiates were S8 drugs, and that his computer would prompt him in relation to the need for an authority.

Also part of each complaint was an allegation that the doctor failed to make adequate medical records.

Dr Weerabaddana admitted to most of the alleged conduct, though he did say that he did not know his patients were on the opioid treatment program.

The prescribing in question took place over several years, ending in early 2017.

The Committee noted that Dr Weerabaddana was not an inexperienced GP and had also had specific training and experience in addiction medicine.

It said it found it “difficult to accept” that he was unaware of the upscheduling of alprazolam.

The Committee also heard voluntarily provided information from Dr Weerabaddana about the death of a patient identified as “RM,” who was not the subject of a complaint, but for whom he had prescribed alprazolam a day before she died.

“RM died on 19 July 2016 from respiratory depression after loss of consciousness caused by mixed drug toxicity and possibly aspiration of vomit,” the Committee noted.

“The expert evidence provided to the Coroner was that the levels of alprazolam and methadone in RM’s blood were both in the toxic and potentially fatal range for each of those two drugs and that the combination of those substances could also be fatal.

“RM first consulted Dr Weerabaddana on 18 July 2016. She described a history of anxiety and panic attacks and told Dr Weerabaddana she was already on alprazolam.

“She identified her regular doctor’s practice but could not recall her doctor’s name.

“Dr Weerabaddana did not contact the practice. He prescribed Alprazolam 2mg twice a day and gave RM a prescription for 50 tablets with no repeats.

“The expert medical opinion expressed at the Coronial Inquiry was that Dr Weerabaddana’s prescribing of Alprazolam to RM was not in accordance with professional practice for a general practitioner.”

The Committee published its decision and found all of the alleged conduct proven and that Dr Weerabaddana was guilty of unsatisfactory professional conduct.

The Committee imposed a reprimand and placed conditions on Dr Weerabaddana’s registration so that he is subject to ongoing supervision, cannot prescribe Schedule 8 drugs and must submit to an audit of his medical records.

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