Prescriber shock: ‘My patient is lying to me’

As real-time prescription monitoring comes in around Australia, I’m having lots of conversations with GP colleagues and patients about this tool. Most GPs are positive, seeing it as great tool to support safe prescribing, while some GPs are worried.
 
And some patients are, quite frankly, terrified.
 
One thing is clear, real-time prescription monitoring is not going to fix everything as much as we wish it might.
 
It cannot treat poverty, trauma, or loneliness. Nor can it treat anxiety or chronic pain for that matter.
 
It can also result in harm if not supported by other initiatives, such as easy access to treatment with methadone and buprenorphine for the treatment of opioid dependency or opioid use disorder for those who need it, specialist support for the management of chronic pain and significant mental health issues, and awareness raising of overdose risk and access to naloxone for any one potentially at risk of this.
 
Real-time prescription monitoring is simply a tool. It doesn’t tell us what we can and can’t do, though it can feel that way.
 
This brings me to Frank* age 62. He suffered a workplace injury 10 years ago and was commenced on oxycodone by a pain clinic.
 
Over time his dose increased, and he ended up on 40 mg SR oxycodone BD. He obtained this medicine from one GP. He saw his GP monthly for prescriptions and was given this to take to his local pharmacy; always attending the same pharmacy.
 
Flagged by real-time prescription monitoring, his pharmacist told him that perhaps he should have a chat with his GP about his medication and when he raised this as suggested, his GP became worried about his medication and told him they could no longer prescribe. 
 
The GP gave him one more prescription for a month and told him to find someone else to prescribe.
 
Frank said, ‘It was like my GP was spooked, suddenly I’d become a doctor shopper. I couldn’t believe it. I felt so judged and so let down. I left the surgery in a daze.’
 
Think about how you might respond in this situation?
 
You might be saying to yourself, ‘Right decision, this medication is dangerous’, or ‘I’d never prescribe that dose’.
 
You may be worrying that you’ll get into trouble with the government, or you might be thinking, ‘What an overreaction’.
 
Whatever you’re thinking, I think it’s pretty likely that you’ll be like me, worrying about how you’re going to have this difficult conversation.
 
Wondering how you can avoid it, how your patient is going to respond, how you’re going to fit this into a busy surgery day with all the other demands on your time? I think all these responses are totally understandable and normal.
 
And to top it off, we have a broken system where we can’t get patients into pain clinics, or when we do they get sent back on higher doses or with impossible, unaffordable treatment plans. While some patients can afford and access talking therapies, physiotherapies, or other modalities that might be helpful, many can’t.
 
We as GPs are caught in the crosshairs, which is bad for us and terrible for our patients.
 

Dr Hester Wilson says it helps to remember that there are strong, evidence-based treatments for drug and alcohol addiction that work.

You may be thinking, ‘Okay Hester you’ve chosen an outlier; the guy who is only seeing one GP, one pharmacy, no other medications, no other morbidities that increase risk.
 
‘My patient isn’t like this. I trusted them, I thought I knew who they were and then I discover with real-time prescription monitoring that they’re seeing multiple doctors, picking up prescriptions at multiple pharmacies, using other medications that put them at increased risk and I feel worried and let down – they lied to me.’
 
I remember as a young doctor working in the ED (and I’m showing my age now as this was back in the days of IM pethidine), when patients came in writhing in pain with renal colic and I’d order a pethidine injection, and then go back to the bed to see how they were after the injection and find they’d gone.
 
I still remember this shame I felt as I was told with some glee by more experienced ED staff that ‘You got done!’
 
I also know that some of my colleagues have been threatened by desperate people requesting prescriptions and we’ve all heard and/or experienced the ‘doctor shopper’ who comes to our surgery with a sometimes complex and believable story that we don’t twig until after the person has gone.
 
These are experiences that shake us and our sense of ourselves and others.
 
I also suspect that while there is a very small number of people who have created a lucrative business from obtaining valuable medicines by deception, many patients who may appear to be doctor shopping are trying to manage complex chronic health issues, including addiction.
 
They may not have experienced safety as children. They may have chronic pain – both physical and psychological – that causes them great distress. They may have been let down by a system that was meant to keep them safe.
 
They are just struggling to remain ‘upright,’ to keep going. I don’t believe that anyone sets out with the plan to become dependent or addicted. It isn’t a childhood dream.
 
So how do we negotiate this space? It’s not easy. I don’t have a perfect easy answer, but I do think that making a risk assessment – ‘How risky is this situation for this patient and how can I mitigate this?’ – are important first steps.
 
Ask for support, talk to colleagues, ring your state or territory’s 24/7 drug and alcohol specialist advisory line and/or the support line associated with real-time prescription monitoring.
 
Look to options like staged supply or prescribing naloxone, and explain to your patient and their family what overdose looks like and what to do.
 
There are some patients (generally new) to whom I’ve said: ‘I am so sorry, I cannot prescribe for you, I am too worried about the risk of these medications.
 
‘I do want to help you but I can’t prescribe in the way you’re being prescribed now.’ 
 
While for others, it’s been: ‘Okay, we need to start reassessing this medication, this is risky and I don’t want you to come to harm. You and I are in this for the long haul and I’m here to support your best health and wellbeing.’
 
Above all, reflect on the difficult feelings this experience might create for you. Be gentle on yourself and be gentle on your patients. And know that this doesn’t mean prescribing high-risk medications in risky ways.
 
I often think to myself, curiosity, respect and boundaries are core to doing this work as best as you possibly can.
 
It can sometimes help to know there are no great solutions and this is not going to be fixed in one consultation – maybe never. But things can and do improve. As that dose of opioids cuts down, patients find they feel better, sharper and more in control of their lives and sometimes their pain actually improves.
 
And if they have developed opioid dependency – and I flag that this is not the case for everyone – it helps to remember we have strong, evidence-based effective treatments that work.
 
We, as GPs, can support our patients to access this treatment and even help manage this by prescribing buprenorphine and methadone with support from our local drug and alcohol teams and addiction specialists.
 
*Name has been changed.
 
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