Queensland coroner calls for real-time doctor shopping system

A Queensland coroner has echoed counterparts in Victoria and South Australia in calling for a new system to enable real-time access to relevant prescription and doctor attendance history following the death of another person from an accidental overdose of prescription drugs.

Brisbane coroner Christine Clements yesterday released a report into the death of Katie Lee Howman in late 2013 from an overdose of the opioid fentanyl.

Ms Howman, a critical care nurse at Toowoomba Base Hospital, was known to the Australian Health Practitioner Regulation Authority (AHPRA) and was under supervision and restrictions regarding access to certain drugs after self-administering fentanyl at work in 2010.

While she was never prescribed fentanyl and appears to have sourced it from work, she did suffer from chronic pain, depression and anxiety and had been appropriately prescribed opioid painkillers such as tramadol and oxycodone by her regular GP.

However, between the 2010 episode and her death in 2013, she had visited 30 other doctors and numerous pharmacies in the Toowoomba area. This included 20 different doctors and 15 different pharmacies in the 13 months between October 2012 and November 2013.

“It was during these visits that she obtained 71 prescriptions providing her with 1705 doses of oxycodone,” the coroner reported. “In those last three months she had also obtained prescriptions for 340 doses of tramadol.”

Her long-standing GP was not aware of her behaviour and the coroner found that he had prescribed appropriately. However, she also found that only one of the 30 doctors Ms Howman visited had suspected she was doctor shopping and checked with Queensland Health's Medicines Regulation and Quality unit, which provides advice to doctors if they have detected a pattern of obtaining prescriptions which raises concerns about dependency.

The MRQ unit can also assist doctors with information on a patient's history for controlled drugs, whether the patient is consulting other doctors, whether they are on an opioid treatment plan, their drug dependence status and whether other GPs have raised questions about the same patient.

The coroner also pointed to Medicare's prescription shopping information service, which can identify in any given three-month period if a patient has consulted six or more doctors for PBS prescriptions or has obtained 25 or more PBS prescriptions for controlled drugs or drugs of dependence.

“The tragedy is that there was an undeniable record of [Ms Howman's] growing dependency and reckless behaviour in accessing prescriptions for opioids,” Ms Clements reported. “She was doctor shopping within the wider Toowoomba area and beyond, sourcing oxycodone as well as tramadol.”

However, Ms Clements said one deficiency in existing information systems is that they are reliant on a doctor or pharmacist forming a suspicion that then prompts a request for information, and the information is not available in real time.

She pointed to Tasmania and the NT, which she said were both using real time information software retrieval systems to inform decision making, and the New Zealand model, where information of concern was sent to the treating doctor rather than relying on the doctor to contact the information service.

“There is undoubtedly a huge human and fiscal cost in the way the Pharmaceutical Benefits Scheme is currently being misused to source and subsidise controlled drugs and drugs of dependence,” she said.

“There have been many previous inquests throughout Australia that have highlighted deaths due to overdose, usually inadvertent, of people who have developed a dependency on prescribed medication. Countless more deaths have been reported to coroners where findings have been made without a public inquest.

“And there have been repeated previous recommendations made by coroners to improve the real time accessibility of information for doctors and pharmacists about their patient’s prescription history.”

She strongly recommended that there be statutory change to enable real-time access to relevant prescription and doctor attendance history.

“No doubt there would be ways to accommodate privacy issues while still safeguarding patients from harm and the abuse of a publicly funded resource. These matters should be urgently investigated and considered by government.”

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