A NSW doctor has been found guilty and reprimanded for unsatisfactory professional conduct for prescribing addictive opioids and other pharmaceuticals to 13 patients.
But he was allowed to keep practising under supervision because of his previous "unblemished record" and his inexperience dealing with difficult patients who were drug dependent and doctor shopping.
In a decision released this week, Dr Angelo Manuel Arreza was found to have prescribed drugs in dosages that were too high and too frequent. There were five cases where he prescribed inappropriate combinations of drugs and 10 patients to whom he prescribed drugs not recommended for their conditions.
He had "seriously threatened the future safety of the patients", the NSW Civil and Administrative Tribunal ruled. It decided against suspending or cancelling his registration because he was unlikely to ever be guilty of professional misconduct again, given his extensive research and reading about prescribing addictive drugs and other therapy for pain sufferers since the complaints were made more than two years ago.
Opioid prescribing in Australia increased 15-fold between 1992 and 2012, contributing to a rise in accidental overdoses where prescription drugs accounted for 70 per cent of deaths. Opioids are not recommended for non cancer chronic pain such as in the knees or backs. These drugs had been shown to be ineffective pain relief and to carry high risks of addiction.
Dr Arreza's culpability was "less than one might expect of someone with his years of experience", found the Tribunal. He was licensed as a doctor in the Philippines in 1999.
Until he began working at NSW's Nabiac Village Medical Practice in 2013, Dr Arreza's experience of prescribing had been exclusively in hospitals where opioids are frequently provided for severe acute pain after childbirth, cancer, a car accident or surgery.
It was also the first time that Dr Arreza had worked in general practice.
Dr Simon Holliday, a rural GP and a physician specialising in addiction, said the system was designed to make "opiate provision almost reflexive".
"Our current health systems contributes to many doctors, and not just this doctor, putting patients at risk of harm. We are providing morphine-like drugs to too many patients, often long term, at high doses for indications where their use lacks scientific evidence," he said.
Making its decision, the Tribunal took into account Dr Arreza's attempts to educate himself since the complaints and his "genuine commitment to his career as a medical practitioner".
He had undertaken 17 courses including webinars on "prescribing perils", managing difficult patients, recognising doctor shoppers, the law and addictions, and the challenges of treating pain in the elderly.
The Tribunal noted there were few "doctor shoppers" in hospitals where he had worked before.
A senior doctor, John Olsen, told the Tribunal that Dr Arreza's "sympathetic compassion" made him vulnerable to patients who doctor shopped. And it took him several months to realise he was "being duped and manipulated," said Dr Olsen, who had recruited Dr Arreza from the Philippines for the local hospital system in Newcastle.
The Filipino doctor was not prepared for the type of patient who could "threaten a novice GP".
Prescription shopping by people dependent on pain medication has been growing, prompting the promise of a national alert system to stop doctor shopping. These patients are often desperate and may lie about their medical history.
The complaint by the Health Care Complaints Commission detailed professional misconduct in relation to 13 patients.
In the case of a drug dependent patient with right knee pain known only as Patient B, Dr Arreza was found to have inappropriately prescribed a combination of fentanyl, oxycodone and temazepam from April 2013 to March 2014.
He also failed to ask Patient B about his level of pain, whether the pain affected his sleep or daily activities, if the medication affected his mind or body, and failed to suggest any non-pharmaceutical remedies such as physical therapy.
He also failed to identify the patient's drug-seeking behaviour because he didn't examine Patient B's prior medical records until a year after the first consultation. It was a similar story with Patient C, a drug dependent patient who was given fentanyl and morphine in a dose greater than the therapeutic standard.
Dr Arreza told the Tribunal that the practice booked patients in blocks of 10 minutes.
When GPs are time poor, Dr Holliday said the system encouraged them to provide quick fixes for complex problems.
Dr Arreza told the Tribunal he was sorry. "I am deeply ashamed and embarrassed ... [that] I had a lack of understanding of the requirements surrounding the prescribing of drugs of addiction."
Prescribing opioids for persistent non cancer pain is not recommended by experts. Yet many doctors in their early careers found it was difficult to help patients stop opioids, a study by Dr Holliday found. These doctors tended to routinely renew scrips written by their colleagues for painkillers to treat chronic pain in the knee or sore backs.
"There is now indisputable evidence that long-term opioid painkillers place patients at risk of harm, including increased pain, depression, sleeping problems and overdose.
Yet these harms weren't confirmed to doctor shoppers. The majority of patients at risk had seen only one doctor and were taking low doses, Dr Holliday said.
The Tribunal banned Dr Arreza from administering, supplying or prescribing any drug of addiction (except in the case of palliative care) for one year and he was required to practice under the supervision of another doctor for a year.
