Multiple drugs implicated in death of doctor-shopping patient

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The Chief Pharmacist of Tasmania says doctors are failing to recognise the risks of psychoactive drugs, and calls for pharmacists to be better utilised

The death of a 44-year-old Tasmanian man from mixed drug toxicity has prompted a coroner to call for a review of legislation and real-time monitoring in the state.

Michael Allan Steer, from Launceston, died in August 2014 after ingesting a combination of quetiapine, codeine, diazepam, and fluoxetine.

The death was ruled to be accidental, as a result of ingesting excess medication.

For more than a decade before his death, Mr Steer was reported to have manifested continuous doctor-shopping and drug seeking behaviours.

He had consistently attempted to obtain medication in excess of that prescribed, according to the coroner’s report.

One of his treating GPs stated Mr Steer made continual requests to alter or increase his doses of certain medications, and would consult other doctors to attempt to obtain more medication.

This GP, who treated Mr Steer from February 2011 until February 2013, said she had implemented a system in conjunction with a local pharmacist, whereby Mr Steer’s medications were dispensed to him in blister packs with weekly pickups.

It was further arranged that his medications were never to be collected early or reissued, and that medication changes would be sent directly to the pharmacist by the GP.

The pharmacist said Mr Steer would often come into the pharmacy claiming his medications had been stolen or locked in a box that he didn’t have access to.

However from March 2013 until his death, Mr Steer was treated by another GP.

This GP had agreed to trial Mr Steer in handling his own medications, as the patient had expressed a wish to have “more control over his life”.

The same pharmacist who had implemented the weekly pickup system, in conjunction with the first GP, agreed that it had become “untenable” due to Mr Steer’s outstanding scripts and refusal or inability to attend the GP regularly.

Mr Steer had made a habit of consistently requesting for prescriptions from the pharmacist after the medication had been supplied, using this system to avoid face-to-face consultations.

A circular had been sent out by the Pharmaceutical Services Branch in the month before his death, requesting all pharmacies in Northern Tasmania to restrict the supply of Mr Steer’s medication to only that prescribed by his treating GP.

However it was shortly after Mr Steer took charge of his own medication pickup, and was no longer on the weekly dispensing schedule, that he died after ingesting excess medication.

An autopsy pathologist and a forensic pathologist concurred that Mr Steer had died as a result of mixed drug toxicity.

A blood sample revealed quetiapine in the toxic range, as well as codeine, diazepam, fluoxetine and paracetamol.

Tasmania’s Chief Pharmacist Peter Boyles reported to the Coroner’s investigation that while the second treating doctor’s management of Mr Steer’s medication was in the realm of a reasonable GP, there were suggestions he would have made.

This includes the GP having Mr Steer reviewed by the Alcohol and Drug Services, and considering daily pick up from the pharmacy (or even supervised dosing of these medications in the pharmacy).

Mr Boyles stated that there are often common factors in potentially preventable accidental overdose deaths.

These include failure by doctors to recognise to risks associated with prescription of psychoactive drugs including opioids, benzodiazepines, quetiapine, tricyclic antidepressants and gaba analogues.

He also said that there is “overconfidence in the therapeutic usefulness of psychoactive agents through a failure to apply evidence-based best practice guidelines and recommendations to these low-value, high-risk medications.”

The Chief Pharmacist added that there is a failure to protect high-risk patients through routinely implementing:

  • unannounced, supervised urine drug screens;
  • checks for past and current injection sites;
  • restrictions of quantities supplied by pharmacy of high-risk medications; and
  • supervision by pharmacists of doses of these medications.

Coroner Olivia McTaggart found another issue is that some substances that are not Schedule 8, for example diazepam, quetiapine or codeine, do not require an authority to be prescribed and therefore cannot be monitored effectively.

In addition, only 60% of medical practices and pharmacies are currently accessing DORA – Tasmania’s real-time prescription monitoring system.

Coroner McTaggart recommended that legislation be amended so that prescription of drugs such as benzodiapines, z-drugs, pregabaline and quetiapine require authorisation where the patient has been reported as drug dependent or drug seeking.

“On the evidence, there is a very good case for implementing greater regulation in prescribing drugs regularly contributing to toxicity and death,” said the Coroner.

She also recommended that real-time monitoring in Tasmania be reviewed to include a requirement for dispensing pharmacists to record dispensing of S4 drugs of high abuse potential on the system at the time of dispensing.

Recent data indicates that pharmaceutical drugs contribute to approximately 90% of Tasmanian overdose deaths each year.

Between 2007 and 2016, diazepam and codeine were respectively the first and third most frequent contributing drugs in deaths from multiple drug toxicity.

Quetiapine was present in 97.5% of deaths in this category.

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