‘Gross, dangerous and reckless overprescribing.’

A GP is set to be disciplined over reckless prescribing of opioids, and inappropriately disclosing a patient’s extramarital affair

A NSW tribunal has found a Central Coast GP guilty of professional misconduct following an investigation by the Pharmaceutical Regulatory Unit.

The GP, who has been suspended from practice since January 2019, was discovered to have inappropriately prescribed Schedule 8 drugs of addiction to nine patients who were exhibiting drug-seeking behaviour.

Her prescribing of oxycodone to Patient A “fell significantly below the standard reasonably expected” and was “grossly excessive”, an expert told the NSW Civil and Administrative Tribunal.

On one occasion the GP prescribed oxycodone to Patient A, who did not attend the appointment, and the prescriptions were provided to his daughter. On another occasion prescriptions were provided upon email request.

Amounts included 1,092 tablets of oxycodone 40mg prescribed between March 2017 and May 2018, and 1,036 tablets of oxycodone 80mg, an oral morphine equivalent daily dose (oMEDD) of 444.5mg whilst the patient was being treated for dependence on oxycodone on the NSW Opioid Treatment Program (OTP).

The GP prescribed Patient B, the daughter of Patient A, 532 tablets of oxycodone 40mg and 504 tablets of oxycodone 80mg between September 2017 and December 2017, with no clinically indication for these amounts and no documentation in the medical records of the presenting complain.

She prescribed Patient C 20 tablets of oxycodone 5mg, 816 tablets of oxycodone 20mg, 28 tablets of oxycodone 30mg, 308 tablets of oxycodone 40mg and 280 tablets of oxycodone 80mg while she was being treated for dependence to oxycodone on the NSW OTP.

Patient C had been exhibiting drug-seeking behaviour. For example, the patient sought opioids scripts on 24 March 2017, claiming that the scripts were not received in the pharmacy.

Despite the GP’s medical records noting she was notified these scripts were in fact received by the pharmacist, she inappropriately prescribed the medications three days after the previous script.

In November 2015, the GP identified through her own enquiries and recorded in the medical notes that Patient D was a prescription shopper with more than six prescribers in three months, and more than 12 scripts.

However on the next occasion when she consulted the patient she prescribed three opioids — fentanyl, oxycodone and OxyContin.

Two weeks later she repeated the fentanyl and OxyContin prescriptions and another two weeks later, on 1 April 2016, she prescribed Durogesic (fentanyl), OxyContin and Valium. She continued this kind of prescribing every 2-3 weeks up to at least 25 January 2019.

Her prescribing behaviour invited strong criticism from the Tribunal’s expert witness.

Similar inappropriate prescribing occurred for Patients E, F, G, H and I with regards to S8 and S4 medicines.

For example, Patient H was prescribed oxycodone and alprazolam in the absence of any valid clinical reasoning evident in the notes on which to base the prescribing, other than the recorded patient narrative of “bad anxiety”.

The GP did not seek any appropriate investigations or assessments, despite the fact the patient had reported the apparent use of alprazolam for 10 years, which is meant to be a short-term medication.

Between 12 March and 25 June 2018, the respondent prescribed the patient 550 tablets of alprazolam 2mg, equivalent to a daily dose of over 10mg of alprazolam and oxycodone at an oMEDD of 192mg in this period.

“Such prescription exceeded the safe OMEDD of 100-120mgs a day. It was not clinically indicated nor appropriate to issue such prescriptions,” said the expert witness.

Over a period of five months, the GP prescribed 30 tablets of alprazolam 1mg, 200 tablets of clonazepam 500mcg, 900 tablets of diazepam 5mg, 30 tablets of flunitrazepam 1mg, 25 tablets of nitrazepam 5mg, 325 tablets of oxazepam 30mg, 125 tablets of temazepam 10mg and 20 tablets of oxycodone 5mg to Patient I.

This occurred despite documented aberrant substance use presentations and advice from colleagues expressing concern about management of the patient’s addictions.

The GP was also brought before the Tribunal for a complaint that alleged unsatisfactory professional conduct over her treatment of Patient J and Patient K, who had recently separated as husband and wife.

In October 2018, Patient J attended a consultation with the practitioner, during which Patient J disclosed details of an extramarital affair.

Two days later, Patient K attended a consultation during which the practitioner disclosed Patient J’s extramarital affair to Patient K.

The Health Care Complaints Commission alleged the practitioner inappropriately disclosed to Patient K confidential information – namely that Patient J had engaged in an extramarital affair – without Patient J’s consent, in the absence of a proper therapeutic or clinical reason, and in the absence of a legal or public interest requirement.

The Tribunal found the breach of confidence constituted a breach of the Code.

Meanwhile the GP, being aware of disclosures that Patient K had been self-harming and had made a threat to the woman involved in the affair with her husband, failed to refer her for appropriate psychiatric support and to construct an appropriate ongoing management plan for her.

“The psychological needs of Patient K were acute, yet no plan was devised,” the expert found.

In its April decision, the Tribunal observed “the gross, dangerous and reckless overprescribing of opioid medications and the inappropriate prescribing of Schedule 8 and Schedule 4D drugs, and combinations of these drugs, including the inappropriate prescribing of Schedule 8 drugs to drug-dependent persons, which the respondent had no authority to prescribe.”

“On every occasion, there was a lack of the required due diligence to ascertain if the patient was drug-dependent, a lack of clinical assessment and a lack of a comprehensive management plan,” it continued.

“In certain instances, the prescription quantities were so high as to give rise to serious concern that the prescribed drugs could have put the patient at risk of significant harm and/or that these drugs were being illegally diverted to other persons.”

The Tribunal found that the conduct of the respondent as a whole constituted both unsatisfactory professional conduct and professional misconduct.

Proceedings have been adjourned to determine the appropriate disciplinary sanction to be imposed.

A finding of professional misconduct means the practitioner’s conduct is of a sufficiently serious nature to justify suspension or cancellation of their registration.

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