Organised crime targeting GPs for potent fentanyl patches

Anastasia Tsirtsakis

19/05/2021 2:31:22 PM

NSW Health has issued a warning for doctors to be on high alert amid reports of patients seeking opioids as part of organised criminal activity.

A fentanyl patch.
A single 100 microgram/ hour fentanyl patch has an illicit value of up to $200. (Image: AAP)

A joint investigation by NSW Health’s Pharmaceutical Regulatory Unit and the state police force has revealed a sophisticated plot among organised criminal elements to deceive GPs into prescribing highly potent fentanyl patches, oxycodone tablets, other opioids, and benzodiazepines.
The medications are later sold on the black market at inflated prices and are highly sought after, a NSW Health spokesperson told newsGP.
‘These are sophisticated operations, relying on fraudulent means, which may include fraudulent documentation and referral letters claimed to be from interstate and overseas specialists supporting the requested opioids and/or benzodiazepines,’ the spokesperson said.
‘The people presenting may use an alias and a fake address and date of birth.
‘These opioids are then subject to trafficking in the community. This abuse and misuse of opioids is dangerous, leading to overdoses and deaths.’
Dr Hester Wilson, Chair of RACGP Specific Interests Addiction Medicine, told newsGP she knows doctors who have had first-hand experience with these ‘patients’ and is trying to raise awareness among GPs.
‘It happened to one of my colleagues just recently,’ she said.
‘The man was in tears in the surgery, talking about how they had to come down [to Sydney] from Queensland because his wife’s mother had died, and they hadn’t been able to get down because of COVID. His wife is having twins and [had] just gone into hospital.
‘The phone rang, and he was talking to her on the phone – it was an extraordinarily believable story.’
Many of the opioids that are being sought can be incredibly lucrative; for example, a single 100 microgram/hour fentanyl patch is equivalent to 300 mg of oral morphine per day and has a street value of up to $200.
‘GPs are already aware of the risks, but I think sometimes they may not be totally aware of the risks of a patch; [they may think] that somehow a patch is safer because you put it on the skin and it’s long acting,’ Dr Wilson said.
‘But they are sold on and people extract the opioid out of it and then inject it. So it’s a huge issue in terms of risk for that vulnerable group of people who have opioid dependency.’
According to NSW Health, examples of common features of fraudulent presentations include:

  • the patient may claim to be travelling from overseas, interstate or from rural and regional areas of NSW, or departing for overseas or interstate
  • there will be no previous history of the patient at the first presentation
  • the patient may present claiming chronic pain, particularly back pain
  • if acceding to the patient request, the patient will seek to establish an ongoing relationship with the prescriber
  • the patient will claim to be unable to attend referrals for specialist review
  • the patient may claim to have prescriptions stolen or lost
  • the patient may claim not to have a Medicare card
  • the patient may claim to be on workers compensation
  • the patient may request private prescriptions and greater than PBS quantities, for example 10, 15 or more fentanyl patches, or 56, 112 or more oxycodone tablets
  • once a relationship with a prescriber is established, they may then present multiple fraudulent prescriptions to pharmacies utilising the name of the same prescriber
  • in a multi-doctor clinic, once prescribing is regularly established with one doctor, the patient may then present to other doctors in the same clinic
If a patient’s request raises a red flag, NSW Health recommends that the prescribing GP makes enquiries to substantiate the patient’s claimed circumstances.
‘If necessary, and if unable to substantiate the background and claimed presentation at the time of consultation, the GP may use their professional judgement to prescribe a minimal quantity of 1–2 days’ supply of the requested medication until the claimed presentation can be confirmed,’ the spokesperson said.
‘Consideration could also be given to prescribe intranasal naloxone.’
And should a GP elect to give the patient minimal doses, the advice is that they choose the most appropriate pharmacy to set up daily staged supply or supervised dosing.
‘The GP should call the pharmacist and let them know a small amount of high-risk medicine has been prescribed to a patient whose circumstances have not yet been fully verified,’ the NSW Health spokesperson said.
‘The prescription should be immediately faxed directly to the pharmacy and the original prescription promptly provided.’
However, Dr Wilson says it is also important that GPs aim to walk a line between taking what their patient has to say at face value and making a risk assessment.
‘That should be the same for any high-risk medication,’ she said.
‘But really, it’s a very tiny percentage of people who are actually doctor shoppers and are doing this for financial gain.
‘There is a larger group of people who have really serious health issues and opioid use disorder that drives the unsafe use, and I would hate to think that those people are just told to go away from a practice.’
Dr Wilson says this does not necessarily mean giving in to the patient’s request, but rather having a respectful conversation around risk and harm, and effective treatments.
‘And we do have highly effective treatments for opioid use disorder,’ she said.
‘Think about what kind of treatments you can offer as a GP, or where you can refer them; where are your local drug and alcohol services who are very good at helping people with this, and supporting people to access the care that they need to reduce their harms?’
For more information and assistance, GPs can contact the Duty Pharmaceutical Officer from NSW Health’s Pharmaceutical Regulatory Unit on (02) 9391 9944 during business hours.
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benzodiazepines fentanyl naloxone opioids oxycodone patches tablets

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Prof Max Kamien, AM   20/05/2021 8:31:19 AM

This has been going on for at least 4 decades and is the subject of scores of letters in the MJA and a greater number of coroners' reports. In many country towns, some pensioners supplement their pensions by selling 'oxy'. one or two tablets a week can make a big improvement in their standard of living. Picking up doctor shoppers (ds) requires about the same diagnostic acumen as picking up a classic case of appendicitis. And yet, some doctors are prepared to put their registration on the line because they are kindly souls who fall for the ds's spiel or else they are too lazy or' time-pressured to make the effort to check up. I always offer referral to the D & A . A small number have accepted it but not one has ever kept their appointment.
Many GPs have pointed out that if there were no Doctor Prescribers there would be no Doctor Shoppers. But thanks for the warning.

Dr Peter James Strickland   20/05/2021 11:13:02 AM

I agree with Max Kamien, as I experienced this Dr shopping for 4+ decades, and in the 1980s had 7 break-ins to my surgery as well in a 2 week period costing thousands of dollars in damage repair. Only give opiates on your own initiative to known patients --have that as an absolute rule on a notice (if necessary) in the waiting rooms. I am totally against the fact that there is a move to exclude GPs from commencing opioids, or prescribing them at all. Almost all the problems I had from opioid addiction came from specialist prescribing in hospitals or in their private practice, and NOT from GP prescribing them for genuine reasons, and especially in rural areas. Be tough, but fair, and informed, and have 000 at your fingertips!

A.Prof Christopher David Hogan   20/05/2021 5:06:35 PM

Gosh we doctors of a certain age seem to agree that this is a matter of history being reported as news.
As a one time Forensic Medical Officer p/t might I also quote a pharmacist who noticed her customers were being accosted outside the shop after they had a narcotic script.
They explained they were asked to "inform the doctor your pain is not controlled & the doc will double your dose. You keep half I take half & pay you $1 to $3 per mg."
Others were asked to sell their used patches rather than discard them.
There have also been some very sophisticated forgery syndicates.

Dr Nicholas Francis Carr   21/05/2021 3:53:49 PM

A certain age? Yes, Chris, I remember when we did our Masters of family medicine together back in the early 90s. Ouch.
Having taught GP registrars how to manage doctor shopping consults for over 25 years, it disappoints me to see an 'expert' (Dr Wislon) repeating hackneted advice that has been proven not to work. There is NO role for prescribing dangerous, addictive medications to patients we've never seen before at the very first consult. The risks of harm from this approach are minimal, the benefits huge. Not hard, really - doctors just have to believe this, then learn how to do it.