Feature

Doctor shopping and what it means for GPs


Neelima Choahan


23/08/2018 3:24:43 PM

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.
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



Kelly-Anne Forrester   6/01/2019 11:41:24 AM

I, myself have now been put on this list, for two reason:
1. My doctor who originally prescribed my medication, and dealt with my prolapsed disc, had left his practice in my hometown to go else where, and in the meantime of finding another doctor, I had to get scripts from several doctors, and present my self to the ED, until I found a new doctor.
2. I found a bulk billing GP, and explained to him after receiving a script for Targin off him, that I needed a stronger dose as the one I was on wasn't working, to which he replied that, "it was because I was becoming used to the dose". So therefore had to go back to my ED several times to obtain a script for pain killers, which got me on the list.
I never asked for my pain, and at this very moment have had no pain medication other than some muscle relaxant, that had on made me sleep, and I have 4 children to look after, and when I sleep all day that is no good for parenting. I am suffering a great deal because of my back, and the fact I am an asthmatic has left a lot of medicine of the table because of side affects.
I would give anything to go back to before my injury, which was spontaneous I might add, and live a for filling life, even though my asthma gives me a heck of a lot of trouble, all the time. I have constant pain if I don't have pain medication that is appropriate for my pain. I am losing faith in doctors and all the medical society because of this misconception of me being a "doctor shopper", I was absolutely devastated when the doctor at the ED informed me of this because all I want is relief from my pain. But then again, to the standards of this website, I will probably be seen as just trying to "tell a story of misery to make it hard for doctors to say no".
Writing this makes me so upset that I feel I will never receive the right help ever again.
#faithlesspatient


Richard Kelly   12/02/2019 7:18:18 AM

I am being prescribed Targin pain killers ( Targin 40/20s and Targin 20/10s twice a day) down from you 80/40s, then 60/30s over a period of 6 years, for 2 disk protrusions, associated nerve pain, and l am also riddled with ostio arthritis. My doctor retired, and then the government stepped in to make it harder for doctors to prescribe it, by warning them that they could loose their right to prescribe S8 dangerous drugs of dependance. In fact one doctor did just that, at the same practice l go to, but that was because he was seeing patients from a doctor that was on holidays for 6 weeks, as well as his own, resulting in way too many prescriptions for this class of drugs. So it wasnt because of the actual prescribing, it was the quantitiy of patients, that brought him down. He had actually boasted to me, that he had over 520 patients a week to see. So this was just greed, and consequently, he got the appropriate punishment in my opinion. He now has to be supervised in his room, and cannot prescribe at all, any strong pain medication. This has frightened off all the other 10 doctors, who are now actively trying to get patients off these drugs. But my question is, what about the patients who genuinly need these medications for their injuries, and who are leading a less a quality of life because of the reductions that we now have to go through to lower doses, then eventually off the medication totally. I have been told that the next monthly visit, l will be reduced to 20/10s, and 10/5s, even though l am still suffering fõr the last 3 months from the last reduction. The government might be trying to get, the way too many patients off opioid medications, using this method of frighting doctors future, but it does nothing to solve the genuine patients. I do not get any uforia, or high on these drugs, just a reduction in pain, so l dont feel addicted. I actually volunteered to go from oxycodiene to targins, as they are less addictive, and do not block you up like the oxys do. Im pissed off that l am a victim of the governments drive to get people off these drugs, and am caught in a system, ,that does not think of the patient anymore. We are now all tainted with the brush of addiction, and therefore must be making up our pain, according to most GPs who are just suspicious of you now. I even volunteered to go to a pain management place, in the mean time, but now l cant get out much, due to the reduction of the meds. I also need a triple arthridesis on my R ankle, that gives me additional pain. I have mountains of CT scan results, and reports telling the story, and still l "need to be reduced off targins completely" is the aim of my current doctor. I have been going to the same surgery for over 10 years now, and so they all know me well, and know that l am not putting on an act. I am caught in a cycle, and just want my meds restored to their proper levels. I live now in the Bundamba area, and was wondering if any sympathetically minded GPs or anyone who sells on the black market could help me to get Targin 40/20s x56 (1 months supply) for cronic pain, not responding to other medications. This government is cruel on the middle, and late aged patients, l am 57 years old. Is thjs happening tk other patients throughout australia, Thankyou for reading my story. Richard


Sam   27/02/2019 1:27:07 PM

I am not being prescribed anything for my chronic pain after my authorised GP had to go on immediate personal leave for over a month. I presented to emergency and although it was the same department seeing me different drs writing prescriptions after a physical examination that warrented pain relief needed got me flagged me as a "shopper". How utterly mortifying. I have no help. My gp has not offered any solutions and went as far to call her insurance provider. The suffers are not those who abuse the drug, but the ones benifiting from the theapy. Doctors, proffessors, i woner if one day you suffer from chronic pain caused by disease or an accident and have YOURSELVES labled as addicts for needing pain medications only to have them taken away with no care to you emotional, social or physical wellbeing.


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