Nearly seven times the recommended dose: pharmacist suspended

tribunal hearing legal case

A pharmacist who supplied excessive quantities of injectable testosterone to a patient has been suspended for three months

The Victorian pharmacist was found to have engaged in professional misconduct at a Victorian Civil and Administrative Tribunal hearing, the Pharmacy Board says.

In December 2014, the Department of Health and Human Services conducted a routine prescription monitoring inspection, and concerns were then raised about the pharmacist having supplied excessive quantities of testosterone (Primoteston and Sustanon) to a single patient.

The patient had been prescribed the same drug at different times by two medical practitioners between January 2012 and November 2014.

The pharmacist dispensed a total of 472 testosterone injections on 48 occasions to the single patient.

This equated to an average of 13 injections per month: in significant excess of the recommended dose, which the Board submitted to the Tribunal is at most, 250mg every two to three weeks.

The amounts dispensed equated to nearly seven times the recommended dose.

AHPRA then received a notification from the DHHS regarding the supply of testosterone injections by the pharmacist in October 2016; this was followed by a swift response from the Immediate Action Committee of the Board, which accepted an undertaking by the pharmacist restricting her from practicing as a sole practitioner, and restricting her access to steroids.

In April 2017, she was convicted in the Magistrates Court of Victoria for three criminal offences.

These included failing to report the dispensing of excessive quantities of a drug of dependence and failing to notify the different prescribing doctors that they were supplying the same drug of dependence.

The Court imposed a combined sentence of a $5,000 fine and payment of $6,820 in costs.

Next, the Board referred the matter to VCAT, where the pharmacist explained that in January 2012, the patient had presented a private script for testosterone from the first GP.

The Board noted that a private script does not restrict a doctor when it comes to the quantity of a medicine prescribed.

The pharmacist told the Tribunal that she had indeed queried the large dosage with the patient, who showed her a letter from a doctor. While she did not keep a copy of the letter, she did take notes including having sighted it.

She also said at the hearing that after the patient had given her a prescription for an increased dosage of testosterone in late 2014, she called one of the patients’ general practitioners who confirmed that the prescribed direction was for injections two or three times per week.

This GP agreed that he received a telephone call from a pharmacist to discuss the amount of testosterone prescribed.

The Tribunal noted both that the pharmacist had not been able to show it a copy of the doctor’s letter which she said the patient showed her in 2012, and also that even after contacting the GP, she continued to dispense testosterone medicines at the same excessive rate in 2013 and 2014.

The Board noted that its Guidelines for dispensing medicines state that the supply of multiple quantities of a particular medicine may not be in accordance with the prescriber’s intention.

It also states that in dispensing a prescription, a pharmacist should exercise independent judgement to ensure the medicine is safe and appropriate for the patient.

In its submission to the Tribunal, it pointed out the potential for serious risk to a patient from being administered testosterone in these quantities, including cardiovascular, neuroendocrine, neuropsychiatric, renal and hepatic effects.

Pharmacists are at the front line in terms of protecting the community from abuse of drugs of dependence, and drugs known to be abused, such as testosterone,” the Board said.

“The implications of [the pharmacist’s] conduct are that the protection the public needs and expects from persons who hold the respected position of pharmacists in the community, was not provided in this instance. 

The Tribunal also noted that in this case, it was “left to speculate” about what the patient actually did with the excessive doses of testosterone.

It found that the pharmacist had engaged in professional misconduct for supplying excessive quantities of anabolic steroids to one patient over approximately a three-year period.

The Tribunal noted that she had failed to raise concerns over the excessive rate of testosterone injections, failed to notify the relevant medical practitioners of concurrent prescribing and chose not to seek approval from the prescribers to supply multiple repeats in the same day.

It reprimanded the pharmacist and suspended her registration for three months.

The Tribunal also placed a condition on her registration which requires her to complete a program of education, approved by the Board and AHPRA, in relation to legal and ethical decision making and the harmful effects of steroid misuse.

This educational program is a minimum of 12 hours and includes a reflective practice support to demonstrate that the pharmacist has reflected on the matter.

Previous Run on masks, pharmacists to be on Coronavirus alert
Next Double dispensing would increase access, says CHF

NOTICE: It can sometimes take awhile for comment submissions to go through, please be patient.


  1. Anthony Zehetner

    What could possibly be the clinical indication cited for such high prescription numbers of testosterone? Presumably the drug was being sold and not all just used by the individual (likely to be hypertensive and had an infarct), not to mention testosterone insufficiency if the large dose was suddenly ceased (the patient would have virtually no GnRH, LH, etc), so I guess this is why it was termed a “drug of addiction” in the article, rather than ‘Controlled Substance’ which may be more physiologically accurate. So what happens to these opioid abusers who are on high doses and their doctor-pharmacist supplier get caught and they go into acute withdrawal? (Obviously not condoning illicit practices but what happens to the individual affected — do they get help for their opioid addiction/hormonal suppression?)

    • Philip Smith

      Clearly being used for body building. Your opioid abuser hopefully can enter the suboxone program.
      I refused a testosterone script by a nurse practitioner in QLD dispensing in NSW for excessive quarantines. Had all the letters from endocrine specialist on him. He was the size of a small building. NSW health got a copy of it all.

Leave a reply