Feature
Doctor shopping and what it means for GPs
For the sixth in a series on legal matters in general practice, newsGP spoke with two experts regarding what GPs need to know about doctor shopping.
The legislative requirements for doctors to prescribe Schedule 8 drugs are different for drug-dependent and non-drug-dependent patients.
A GP’s aim is to heal, but what happens if their prescription could harm?
Prescription drug deaths in Australia is a growing problem. In fact, Australian deaths related to prescription drugs now outpace deaths from illicit drugs, with the majority attributed to opioids and other prescription medications at high risk of misuse.
Addiction to drugs of dependence can often lead patients to ‘doctor shopping’ to gain access to extra prescriptions for drugs.
Stuart Le Grand, Le Grand Margalit Lawyers
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Personal injury lawyer Stuart Le Grand says doctor shopping has different meanings in medical and legal contexts.
According to Mr Le Grand, the term ‘doctor shopping’ has different meanings in medicine and law.
‘In medicine, doctor shopping is a phenomenon where patients consult a number of different doctors to obtain a prescription for a drug of choice, often a drug of dependence such as an addictive pain medication,’ he told newsGP.
‘A patient consults multiple doctors on the knowledge that the prescribing doctor is not aware that another doctor has prescribed the same or similar drug, such as if the prescribing doctor did know he or she would refuse to prescribe it on the basis that it would be detrimental to the patient’s health and wellbeing.’
Mr Le Grand said this phenomenon has a high prevalence across Australia.
‘In some jurisdictions, such as Victoria, legislation has been passed which will give prescribing doctors the ability to check a real-time register of the patient’s prescribed medication history before dispensing the medication,’ he said.
In legal terms, however, Mr Le Grand said doctor shopping refers to a situation in which a party to a proceeding deliberately consults multiple doctors of the same or similar discipline so as to obtain a favourable opinion that will advance their case.
‘Put simply, if the party – injured person, insurance company or the lawyer –
did not like the opinion that was expressed by Doctor A, they will attend Doctor B and Doctor C until such time that they secure an opinion which does advance their case,’ he said.
‘Experienced lawyers and barristers are able to identify doctor shopping and commonly request a decision-maker, such as a judge or jury, to draw inference that the reason why the party has consulted multiple doctors was to secure an opinion to advance their case.’
Mr Le Grand said if there is evidence or a suggestion of this type of legal doctor shopping, it can be a method of attacking the credit of the party.
‘If a patient – plaintiff – is proven to be consulting multiple doctors of the same discipline, without valid reason, a defendant will ask the court to draw a conclusion that the plaintiff is doctor shopping. This could negatively affect the plaintiff’s prospects of success in a case,’ he said.
‘If a solicitor has directed their client to attend multiple medical appointments (of the same discipline) without valid reason, that could be held to be an abuse of process, which may lead to disciplinary action against the solicitor. That is because solicitors are required to conduct their cases to prevent unnecessary costs and delay.’
Dr Sara Bird, Manager, Medico-legal and Advisory Services, MDA National
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Dr Sara Bird says the most common reason people are doctor shopping is to obtain drugs of dependence.
Dr Bird said the most common reason people are doctor shopping is to obtain drugs of dependence.
‘When you are using that term “doctor shopper” it is generally referring to patients who are seeing multiple doctors to obtain drugs of dependence, either to feed their own dependency or for use on the black market to sell them,’ she told newsGP.
The legislative requirements for prescribing Schedule 8 drugs are different for drug-dependent and non-drug-dependent patients.
Drug-dependent patients
Dr Bird said the legal definition of a drug-dependent person varies in each state and territory.
‘In general terms, a drug-dependent person is someone who, as a result of the repeated consumption of a drug of addiction/dependence, acquires an overpowering desire for the continued consumption of such a drug, and is likely to suffer mental or physical distress upon ceasing the drug,’ she said.
In all states and territories, Dr Bird said, it is a mandatory requirement for GPs to seek an authority/permit/approval from the appropriate health department unit in order to prescribe a Schedule 8 drug to a drug-dependent person. These health department units include:
- Pharmaceutical Services (ACT, NSW, WA and Tasmania)
- Drugs of Dependence Unit (SA)
- Medicines and Poisons Control (NT)
- Medicines Regulation and Quality (Queensland)
- Drugs and Poisons Regulation (Victoria)
The Pharmaceutical Services branches in
Tasmania and
WA also require GPs to provide consultant support with an application for the proposed treatment of a drug-dependent person with Schedule 8 drugs.
Non-drug-dependent patients
‘If the patient is not drug-dependent, there are strict limits on the length of time that drugs of dependence can be prescribed before an authority/permit/approval is required,’ Dr Bird said.
‘In general terms, GPs prescribing Schedule 8 drugs and other restricted drugs of dependence for more than two months will need to obtain approval from the relevant health department unit. In most states and territories, the two-month period includes prior treatment by other prescribers.’
Dr Bird said in NSW an authority is required for only a very limited list of Schedule 8 drugs, including alprazolam, but not for commonly prescribed oral opiates such as oxycodone.
‘In other states and territories, most Schedule 8 drugs are included and, in some states, benzodiazepines are also included in the restricted drugs for which an authority/permit/approval is required,’ Dr Bird said.
‘GPs should familiarise themselves with the specified drugs in their jurisdiction. Up-to-date information is available on the website of the relevant health department unit.’
Dr Bird said the RACGP’s
Prescribing drugs of dependence in general practice is also a good tool for GPs.
How can GPs avoid problems?
Dr Bird said GPs need to consider two issues:
- Are they prescribing in a clinically appropriate manner and using best practice prescribing for opioids?
- Have they complied with the legal and regulatory framework?
‘GPs really need to know and understand the legislation. It is absolutely vital,’ Dr Bird said.
‘Under the legislation, the first thing doctors have to do before they prescribe a drug of dependence is to take all reasonable steps to ensure that a therapeutic need exists.’
Tools for GPs to address doctor shopping
Dr Bird said there are a number of tools that are available to assist GPs to recognise patients who are doctor shopping.
One of them is the Department of Health’s
Prescription Shopping Program, a 24-hour information service designed to helps prescribers identify patients who may get more
Pharmaceutical Benefit Scheme (PBS) subsidises medicines than they medically need.
‘You can contact the service to see whether the patient does meet the criteria for being a doctor shopper,’ Dr Bird said.
‘It is quite a high bar, though, for being recognised as part of that prescription shopping information service.’
Dr Bird said a patient will only meet the criteria for that program if they have been supplied with:
- any PBS items prescribed by six or more different prescribers within any three-month period
- a total of 25 or more PBS target items
- a total of 50 or more items (this includes target and non-target PBS items).
‘The Government has also just introduced a new service as of 1 July 2018 called the Prescription Shopping Alert Service, where the Department of Health will actually be notifying doctors if they are concerned their patients are getting more PBS medicines than they medically need to,’ Dr Bird said
‘However, it is important to be aware that patients who might be obtaining drugs of dependence on private prescriptions will never show up and won’t meet the criteria for the prescription shopping program criteria.’
Loopholes
Dr Bird said doctors can write a private prescription that is not subsidised by the PBS, as well as a subsidised PBS prescription.
‘Under the PBS there are limits to the maximum number of tablets that can be prescribed on a standard PBS prescription,’ she said. ‘For example, a box of oxycodone comes in a pack of 20. So you are limited to writing that amount that is supplied under the PBS.
‘But under a private prescription, you can prescribe a larger quantity of drugs.’
Dr Bird said single doctor prescribers can also present a loophole for doctor shoppers.
‘If you are talking about the issue of misuse of drugs of dependence in the community, real-time prescribing is one of the tools to minimise doctor shopping and opioid misuse,’ she explained.
‘But this won’t deal with the problem of a single doctor prescriber of drugs of dependence, someone who is not complying with what’s considered to be clinically appropriate or best practice prescribing of opioids.
‘There are some doctors who, for a variety of reasons, aren’t aware of or complying with the legislation around drugs of dependence, maybe because they are new to general practice and are not aware that we have a structured regulatory and legal framework in relation to prescribing opioids and other drugs of dependence.’
What happens if you don’t prescribe according to the legislation?
‘A complaint may well be made against you to the Medical Board and/or the health department unit will contact you to say you are in breach of the legislative requirements,’ Dr Bird said.
‘Occasionally, breaches can be prosecuted criminally, depending upon the nature or the severity of prescribing.’
Most frequently, Dr Bird said, the health department unit will make a complaint about the GP’s conduct to the Medical Board.
‘The Medical Board can take disciplinary action, including conditions on a doctor’s registration, such as ongoing education to improve their knowledge about prescribing drugs of dependence,’ she said.
Recognising and managing inappropriate requests for drugs of dependence
Dr Bird said identifying drug-dependent patients is not always straightforward.
‘Dependency on Schedule 8 drugs can occur at any age and across all socioeconomic groups and professions,’ she said.
‘Some patients may exhibit drug-seeking behaviours, but this is not invariable.’
She said GPs will benefit from developing strategies to manage patients’ inappropriate requests for drugs of dependence.
‘Having some verbal scripts [for yourself] can be useful,’ Dr Bird said. ‘For example, “We don’t prescribe this medication. Let’s talk about how I can help you with your pain problems”, or “Under the state law, it is illegal for me to prescribe those medications to you”.’
But Dr Bird warns that it can be very difficult to say no to patients who are seeking drugs of dependence.
‘They are often very persuasive. They can present a story of enormous misery, distress and pain, and so dealing with this cohort of patients is really very challenging,’ she said.
‘There is a small group of patients who may well be doctor shopping to obtain the drugs to sell on the black market, but many of these patients are people who have genuine pain and suffering and misery.
‘It is not just a matter of saying to GPs, “Well, you shouldn’t be prescribing”, because the role of the doctor is to heal and to deal with pain and suffering.
‘It is a very complex issue and I think anyone who believes there is a simple solution to the whole problem of opioid misuse is very naïve.’
doctor shopping Drugs of Dependence medico-legal prescription monitoring
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