Overdose victim’s file: ‘Dr shopper, please do not prescribe anything’

pharmacy deregulation: shopping trolley full of pills

A Victorian coroner has said she hopes Real Time Prescription Monitoring will help prevent cases such as that of Milica “Mary” Minchev, who died from combined drug toxicity involving oxycodone, benzodiazapines and other drugs.

Minchev, 48, obtained a “staggering” amount of the medicines in the 12 months leading up to her death, said coroner Audrey Jamieson.

A note in one of Minchev’s patient files read: “Dr Shopper, please do not prescribe anything to her esp alprazolam/oxy, see notes April 2012”.

The reference to “April 2012” appeared to relate to a note by one of Minchev’s doctors about a pharmacist who reported Minchev was doctor shopping.

Minchev was taking medications including amitriptyline, lamotrigine, gabapentin, alprazolam, oxycodone and Targin (containing oxycodone and naloxone), and had also on occasion been prescribed Mersyndol Forte.

She died in February 2013 and was found by family members at home; her medical history included epilepsy, depression, anxiety, some self-harm and abuse of benzodiazepines and opioid narcotic analgesics. She had recently suffered a mild stroke and leg swelling.

Diazepam, nordiazepam and temazepam were also found present in Minchev’s toxicology results.

“Between February 2012 and 2013 Ms Minchev was prescribed a staggering amount of pharmaceutical medication from at least 30 different prescribers from 12 different medical practices,” the coroner noted.

“The majority of her medication was prescribed by two clinics: Epping Plaza and Epping Healthcare.

“Ms Minchev’s prescription history included repeated examples of consecutive daily prescribing from doctors at the same practice.”

It was likely that the Coroners Prevention Unit were unable to get a completely accurate picture of Minchev’s medication history because of the possibility she had also obtained private scripts.

In the 12 months before her death, Minchev was given:

  • 58 prescriptions for alprazolam (of differing doses) from 12 different prescribers at four different practices;
  • 10 scripts for amitriptyline from two different practices;
  • prescriptions for oxycodone on 64 occasions from the Epping Plaza doctors, sometimes on the same day or within one day of the last prescription; prescriptions for oxycodone on 21 occasions from Epping Healthcare; 16 prescriptions for oxycodone from Dr Steven Qingwu Lu at the Reservoir Medical Centre, who had also “frequently” prescribed oxycodone while at the Epping Healthcare location; prescriptions for oxycodone on six occasions from the Northern Hospital; and oxycodone from five more health services;
  • Mersyndol Forte and morphine;
  • two prescriptions for diazepam, both in March 2012; the coroner said that “the review noted it was possible that she was able to obtain a private script for this medication in the days closer to her death, from a clinic whose medical records the CPU did not request because there was no PBS evidence to suggest they should be sought”.

Coroner Jamieson said that the review of the circumstances of Minchev’s death “highlighted a number of interrelated issues with her clinical management”.

The evidence clearly indicated that Minchev was prescription shopping, she said; highlighting Minchev’s poor coordination of care, she said that while Minchev “undoubtedly” misled at least some doctors, “there was evidence in the coronial material to suggest that doctors at Epping Healthcare, Epping Plaza and Reservoir Medical Centre knew or suspected she was attending other clinics”.

This included:

  • the note about the April 2012 report by the pharmacist;
  • the fact that Dr Stephen Qingwu Liu saw Minchev at both the Reservoir Medical Centre and Epping Healthcare;
  • a 2007 notification in the Epping Plaza medical records from the Medicare Australia Prescription Shopping Program that Minchev was identified to be prescription shopping for diazepam and oxycodone, among other drugs; and
  • a 2005 letter from a Lalor Plaza Medical Centre doctor advising a Northpark Hospital doctor that Minchev was drug-dependent and doctor shopping for both oxycodone and benzodiazepines.

“The review found no evidence that the doctors at Epping Healthcare, Epping Plaza or Reservoir Medical Centre made any efforts to identify other prescribers and coordinate care with them,” the coroner noted.

“The only doctor for which there was any clear evidence of an attempt to coordinate care was Associate Professor Doherty”.

A/Prof Doherty had treated Minchev at The Melbourne Clinic from early 2008; he reported that he “considered her an over-user of prescription medication, and for some years he progressively reduced her prescribed psychotropic medication and attempted to contain her benzodiazepine use”.

He refused to prescribe narcotic analgesia for Minchev, who he said would often complain and told him she would find another doctor. He also wrote to a doctor at Epping Plaza stating she was drug dependent and had been notified to the DHS.

The coroner noted that “practically all of the oxycodone prescribing to Ms Minchev in the 12 months leading up to her death was done inconsistently with the Schedule 8 permit requirements”.

On at least two occasions, doctors at Epping Plaza were refused Schedule 8 permits; the letters of refusal stated that another practitioner had applied for a Schedule 8 permit for Minchev, and further prescribing of Schedule 8 drugs without a permit would be an offence.

“The evidence suggested that doctors at Epping Plaza continued to prescribe – despite these warnings – through to Ms Minchev’s death.

“There was evidence identified in consultation notes that the doctors who prescribed oxycodone to Ms Minchev often raised concerns about the lack of permits or the need to stop prescribing the medication.

“The review noted that some doctors even went as far as discharging her from their care, advising that they would not continue prescribing opioids.

“In any case, it did not prevent her from accessing the medication even where she simply attended a different doctor in the same clinic.”

The coroner said it could not be established from the consultation notes whether any of the practices which simultaneously prescribed oxycodone and alprazolam to Minchev had made any plan to offset the potential for harm associated with combining opioids and benzodiazepines.

She said that Minchev’s death underlines the need for real-time prescription monitoring in Victoria.

The proposed system “may limit the type of prescribing that occurred in the case of Ms Minchev, if its operation covers the use of all pharmaceutical drugs”.

She said that she is also optimistic that real-time monitoring could rectify issues around failing to obtain Schedule 8 permits and make appropriate notifications about drug dependence.

Coroner Jamieson had called for real time monitoring earlier this year following her findings regarding the death of Frank Frood, who also doctor shopped to obtain large amounts of diazepam, codeine, tramadol and oxycodone.

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