A recent inquest highlights the risks of opioid-addicted patients doctor shopping to obtain medication. Mr William House was just 30 years old when he accidentally overdosed on a combination of OxyContin and fentanyl patches (opioid prescription medications used to alleviate symptoms of chronic pain). He was found near death by his sister on 28 August 2018, and was unable to be revived. The cause of death was found to be acute fentanyl poisoning, and his case was one of just four examined by Coroner James McDougall in his findings delivered on 21 May 2018.1
Like the other individuals whose deaths were examined in the inquest, Mr House’s use of the opioids had begun following a severe injury several years prior, from which he suffered chronic back and ankle pain along with debilitating headaches. He was initially prescribed opioid medications in order to manage his pain. Unfortunately, like many others, Mr House became addicted to the medications prescribed to help him, and began seeking higher and higher doses. Over the years he attended many different GPs and hospitals and was also under the care of a pain specialist.
Towards the end of 2011, a number of his regular doctors became suspicious of his frequent requests for prescriptions, and refused to provide him with further means to access these. Mr House then began seeing a wide range of other doctors, more than 20 in the months preceding his death, to obtain prescriptions for OxyContin and fentanyl. Despite the fact that the regulator in charge at the time (the Drugs of Dependency Unit or DDU) had access to this information through Queensland’s drug monitoring system, the Monitoring of Drugs of Dependency System (MODDS), the only action taken to warn doctors about Mr House’s troubling pattern of use was to send a letter to a single GP. There was no follow up and no communication with the host of other medical professionals sought out by Mr House.
Coroner McDougall’s findings highlighted systemic communication issues between treating doctors and hospitals, and recommended a multidisciplinary case management approach to pain management and the prescription of high risk medications. A major part of those recommendations included yet another call for the introduction of a real time monitoring system (for dispensation of Schedule 8 and some Schedule 4 drugs) accessible by doctors and pharmacists alike. This system would enable medical professionals presented with difficult cases to check a patient’s prescription history and make more informed decisions about whether prescription is the best method of treatment for an individual.
What’s the current approach across the States?
In Queensland (where Coroner McDougall’s inquest was based), the MODDS system used was first implemented in the 1980’s. Up until 1 October 2017, pharmacists were only required to report to the DUU about the dispensation of Schedule 8 drugs (and some Schedule 4 drugs) at the end of a month.2 Medical practitioners would only become aware of a patient’s attendance at another health provider to obtain certain drugs if the DDU contacted them directly to advise that an individual was exhibiting suspicious and possibly drug seeking behaviour. As highlighted with Mr House’s case, the problem with this approach is that DDU resources are spread too thin, meaning notifications are often unreliable and come too late. The legislation has now been updated so that reporting is required each week, however the onus still lies with the DDU to notify practitioners about potential cases of abuse or misuse.
There are a number of problems with the current approach, particularly that medical practitioners are not equipped with the information necessary to deal with these difficult cases in real time. What is needed, and has been repeatedly recommended by a number of inquests across the nation, is a system that allows medical practitioners access to a patient’s prescription history for particular drugs of dependency during a consult – i.e. so that a GP faced with a new patient has the tools to make an informed decision about whether or not to prescribe in that initial consultation, or whether some other form of treatment or intervention would be more appropriate.
Both Tasmania and the Northern Territory have had these “real time” monitoring systems for controlled drugs in place for several years, with noticeable results.3 The federal government has also been trying to push through a national model for real time monitoring.
Victoria’s Safescript, is an improvement on any of the existing monitoring systems in place, using cloud capability to create, transmit and store prescriptions. It is capable of integrating into existing software systems to provide easily accessible information to medical practitioners. This is particularly important given reports of poor uptake by doctors in relation to using the Tasmanian system, which is hosted on an external platform that requires practitioners to make additional logins. This can make using the system both time consuming and disruptive to use.4
The Fifth Community Pharmacy Agreement (Fifth Agreement) between the Australian Government and The Pharmacy Guild of Australia commenced on 1 July 2010. It saw the Federal government put forward its support for a nationalised, real time recording system, the Electronic Recording and Reporting of Controlled Drugs (ERRCD), with Commonwealth funding. However, under the proposal each State was ultimately responsible for implementing the system in its own jurisdiction. So while the system has been available for implementation in each State for some time, none have opted to use it.
It wasn’t until April this year that Ministers at the Council of Australian Governments (COAG) Health meetings agreed that different State systems could be used, so long as they remained interoperable with a national system (the importance of a national model being to combat border hopping as a means of thwarting isolated state systems). This development has come about partly as a result of Victoria commissioning the production and implementation of its new “SafeScript” system, independently of the Commonwealth’s proposed ERRCD system.
Despite concerns about privacy and data collection (particularly in the context of My Health Record), Safescript is a good example of how collected data can work for us. By improving the availability and quality of information provided to the prescriber and dispenser in real time (and making this information easy to access), we increase the prospects of identifying and intervening in escalating drug seeking or dependant behaviour before it gets too late. Doctors will be able to access information on high risk medications at the time of prescription, in order to make considered decisions which will help to reduce adverse medical events. Pharmacists will likewise be able to manage prescriptions to monitor and intervene in the case of suspicious drug seeking behaviours, meaning that, rather than responsibility for this difficult task resting on a single department, it is shared amongst the medical profession as well.
Queensland’s way forward?
In the published decision of Coroner McDougall, comments by the head of the DDU (the body within Queensland’s Department of Health responsible for the regulation of Schedule 8 drugs) and Queensland’s Chief Health Officer show that Queensland:5
- Is currently undertaking a review of the Commonwealth ERRCD system to determine its compatibility with the existing MODDS framework and overall suitability.
- Has provided in-principle support for the implementation of the ERRCD system in Queensland, and will seek appropriate funding for a real-time monitoring system from the Treasury for the 2018 - 2019 financial year.
- In the event that the ERRCD system is deemed not suitable, will work on developing the existing MODDS system into a real-time monitoring and reporting system, or look at the possibility of creating a MODDS and ERRCD hybrid to achieve the same effect.
Given the cost of Victoria’s system, and the expressed intention of sticking with the foundation technology already in place, it seems very unlikely that Safescript will be coming to Queensland any time soon. On current predictions, it will not be until 2022 or later that any real-time system becomes operational in Queensland.
While this might sound disheartening given the progress down south, the information gathering process currently underway (in order to determine the suitability of the ERRCD system) will put Queensland in a strong position to learn from what’s already out there and to create something that’s both easy to use for practitioners and effective.
Watch this space.
2It is important to note, that this monitoring is not targeted at people suffering from legitimate ailments or to stop doctors from prescribing essential medications. This clinical tool has been designed to track specific medications Oxycodone , morphine , alprazolam, methylphenidate and dexamphetamine and some Schedule 4 medicines including all benzodiazepines such as diazepam, ‘Z-drugs’ such as zolpidem, quetiapine and codeine.
5https://www.courts.qld.gov.au/__data/assets/pdf_file/0010/566920/cif-house-white-smith-milne-20180521.pdf - paragraph 285 - 292.