‘Urgency’ to implement real-time script monitoring: coroner

An inquest into four deaths related to opioid prescribing and doctor shopping has highlighted the urgent need for real-time monitoring

A joint inquest into four recent deaths was recently held in the Coroners Court of Queensland with the aim to consider the issues associated with misuse of opioid prescription medication in Queensland and, more broadly, Australia.

Coroner James McDougall explored the circumstances surrounding the deaths of William House, 30 years old at the time of his death; Jodie Anne Smith, 41 years old at the time of her death; Vanessa Joan White, 38 years old at the time of her death; and Daniel Keith Milne, 40 years old at the time of his death.

Each of the patients had participated in doctor shopping in the lead up to their deaths, and in several instances had been able to gain access to large amounts of OxyContin and fentanyl from various doctors at different medical practices, sometimes on the same day or within days of the last prescription.

This was in addition to sometimes being supplied opioids after presenting at hospital emergency departments.

Mr House alone had attended upon 20 different GPs in the space of eight months, with only a single action taken by the Queensland regulator to send correspondence of one general practice, with no other proactive monitoring or follow up in relation to his escalating drug-seeking behaviour.

Ms Smith had been provided repeat scripts for OxyContin and Endone over the phone from a Sydney doctor whilst she resided in Queensland, telling him she was “unable to see a local doctor as she was housebound by her level of pain”.

This was in addition to her gaining OxyContin and Endone scripts from a local doctor.

Ms White in one case had been provided 60 OxyContin 80mg tablets in one go, despite having been provided scripts for tablets just a few days before.

Mr Milne had been provided with scripts for fentanyl patches 100mcg/hour by his GP for a work injury, despite having no supporting documentation to verify his alleged injuries.

After a pattern of doctor shopping and drug seeking, each of the patients was found to have died of a drug overdose, the Coroner found.

Many of the practitioners involved in the management of the patients before their deaths expressed some levels of regret to the inquiry, in relation to the clinical decisions they had made.

A clear call for real-time monitoring

Coroner McDougall said there have been more than 20 coronial inquests held in Australia that have considered deaths associated with prescription opioid abuse.

Following these inquests, coroners along with the majority of Australia’s peak medicine, pharmacy and consumer bodies have called for the introduction of a real-time monitoring system to enable effective management of the prescribing and supply of drugs of dependence.

Computerised monitoring (MODDS) was introduced in Queensland in 1983 to assist in identifying inappropriate prescribing and use of S8 medicines.

On a monthly basis, electronic records of all S8 prescriptions dispensed at community pharmacies in Queensland are uploaded by dispensers and entered into the MODDs database by the Medicines Regulation and Quality (MRQ) authority.

However Coroner McDougall found the system does not allow ‘real-time’ monitoring.

According to MRQ, 50% of dispensing data is visible in MODDs within two to three weeks of the dispensing event, although some data does not appear until as many as six weeks after the dispensing of S8 medications.

MRQ data confirms there has been a “pronounced growth” in the number of S8 prescriptions provided by Queensland GPs, rising from 754,200 in 2006 to 1.59 million in 2012.

Furthermore, since 2000 there has been an 846% increase in the base supply of oxycodone.

While there is a recognised need for the Electronic Recording and Reporting of Controlled Drugs (EERCD) platform to be rolled out in Queensland, concerns have been raised by the Queensland Department of Health as to the suitability and adaptability of the EERCD system to the state’s prescription landscape, which has led to a delay in its implementation.

Meanwhile both Tasmania and Northern Territory have been using real-time information software for years, while Victoria and Western Australia have expressed their intent to transition to a new system by 2018.

NSW pharmacy leaders have expressed their disappointment over reports that no strategy has yet been pinned for real-time prescription monitoring in the state, despite a commitment from the government.

The coroner along with expert witnesses noted that a real-time prescription monitoring system could have alerted prescribers and dispensers to the drug-seeking behaviours of Mr House, Ms Smith, Ms White and Mr Milne.

Expert witnesses concur

Forensic Medical Officer Dr Don Buchanan “vehemently supported” the need for “urgent” introduction of a real-time prescription monitoring system, preferably in a nationally consistent manner.

He told the inquest that collection of all dispensing data by a pharmacist in real time would provide an adequate solution to doctor shopping behaviour.

Pain specialist Dr David Gronow, director of the Sydney Pain Management Centre, agreed with Dr Buchanan, adding that episodes of attempts to obtain prescriptions for controlled medication also need to be recorded, with the monitoring available to the pharmacy to prevent the prescription being dispensed.

He also noted that there was inappropriate prescribing of opiates to Mr House, including increasing quantities and early repeat scripts, while Ms White’s case highlighted the willingness of some general practitioners to prescribe opiate medication to patients.

Pharmacist witness Dr Esther Lau, from the Queensland University of Technology, highlighted the fragmentation of information in relation to the dispensing of S8 in the cases of Mr House, Ms Smith, Ms White and Mr Milne.

She noted that the current system, as it is designed, “is intended for one patient, who requires drugs of dependence medicines, to be managed by one prescriber, and ideally to have their medication dispensed from one pharmacy.

“However, the system in its present state is unable to detect, in a timely manner, the prescribing of drugs of dependence by a number of different general practitioners, often at concurrent times,” said Dr Lau.

Dr Lau also suggested introduction of real-time prescription monitoring in Queensland.

Coroner’s findings

“The tragic circumstances of Mr House, Ms Smith, Ms White and Mr Milne’s deaths highlight the broad systemic issues present in relation to the prescribing, dispensing and monitoring of Schedule 8 medicines in Queensland,” said Coroner McDougall in his findings delivered on 21 May.

“Each of these deaths highlight the need for prescribers and dispensers to be alterted to potential misuse of Schedule 8 medicines by a patient in real-time, so that preventative and clinically meaningful measures can be taken to immediately reduce the risk to the patient and community.

“It is evident from the circumstances of each of these deaths … that the present regulatory monitoring in Queensland is … retrospective rather than proactive.

“As such, patients are able to obtain excessive scripts from multiple practitioners before any meaningful intervention can take place, as largely occurred in each of the cases considered during the inquest.”

He called on the Queensland Department of Health to “urgently consider and determine” how a real time monitoring system could be implemented in the state “at the earliest opportunity, but certainly within the next two years”.

Coroner McDougall also called on the RACGP to urgently consider what further measures and programs can be introduced to improve education and standards of care for GPs in relation to the prescribing of S8 medicines and chronic pain management.

He added that the RACGP should liaise with the Pharmacy Guild and PSA “with a view to promoting the use of staged supply and other means to reduce the risk of the misuse of prescription medication”.

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