Prescribing drugs of dependence in general practice

Part A - Clinical Governance Framework - Chapter 5

Patient focus

Last revised: 01 Nov 2019

Introduction

Patients have the right to respectful care that promotes their dignity, privacy and safety. Maintaining a patient focus for all patients ensures that care – including the prescribing or non-prescribing of drugs of dependence – is provided in partnership with patients, their families and carers, respecting their diverse needs, preferences and choices, and in coordination with other organisations whose services impact on patient wellbeing.21

This means balancing patient-centred care, evidence-based practice, legislative requirements and partnerships with other healthcare providers to patients across the spectrum of users of drugs of dependence. Further considerations include such things as driver’s licence requirements and potential risks to others (eg children and others in the patient’s care).

Clinical discipline is required as there can be elements of manipulation behind patient requests for drugs of dependence. Patient-centred care does not mean professional boundaries can be crossed, laws ignored or therapy continued if it is considered detrimental to the patient’s health.

It also does not mean that practices and practitioners are obliged to take full responsibility for care in higher risk situations. These situations include those:

  • where staff safety may be impacted
  • where care is outside the expertise of practitioners
  • where long-term health prospects of patients are being compromised by lack of access to state or territory facilities.

Medication and illicit drug misusers have the same entitlement as other patients to respectful care. Treatment should seek to maximise treatment outcomes across a range of domains including drug and alcohol misuse, health, crime and social functioning.

Recommendation
General practices and GPs should provide patients with information (at the appropriate level and manner) about the purpose, realistic expectations, options, and benefits and risks of any treatments
Reference to the Standards
(Extrapolated from Criterion 1.2.2)

Recommendation
GPs may wish to consider using patient information resources to help patients understand their options and consequences of their decisions

Grade: Consensus-based recommendation

Recommendation
GPs should develop respectful, non-judgemental and clear responses to requests for drugs of dependence that are inappropriate

Patient information and informed consent

Shared decision making is vital to patient-centred care. For patients to be an active partner in their care, they need to be well informed. Information provided should allow realistic expectations about the likely or potential outcomes of their treatment. Shared decision making has been shown to build trust, prevent harm and reduce surprise and distress if complications or adverse events occur.69

Shared decision making respects a patient’s autonomy. A patient with the capacity to consent to treatment also has the right to refuse medical treatment, even when the medical practitioner deems the treatment appropriate.

Consent is a basic legal principle that reflects autonomy. In a healthcare context, it means a person’s agreement to something being performed on them or a sample being taken from them, as well as their agreement to undertake a medical investigation or treatment. Informed consent, in a legal sense, reflects that a patient has received information that enables the making of an informed decision on whether to undertake this treatment or investigation.

If a patient refuses the advice of a GP, they should be advised about the implications of deciding not to receive the healthcare offered. The patient should be given sufficient time to consider and clarify any information in order to make an informed decision, taking into account the context of the clinical situation.

There is a general paucity of evidence regarding long-term use of drugs of dependence. When starting a drug of dependence for long-term use, informed consent should be obtained and a contractual approach to prescribing is advised.

Patients need to be informed about the purpose, importance, benefits and risks of their medicines. GPs may consider using a written management plan to document patient and doctor responsibilities, goals and expectations, and desired outcomes in behavioural terms. This may assist in patient education.

An example of a benzodiazepine patient information sheet is available at Appendix D.12 of the PDF version.

An example of an opioid patient information sheet is available at Appendix D.13 of the PDF version.

Clinical responsibility in shared decision making

Whilst most patient involvement with drugs of dependence is clinically driven, there can also be elements of manipulation (and rarely criminal intent) behind patient requests for drugs of dependence.

The important caveat when prescribing drugs of dependence relates to healthcare benefits. Some patients with chronic non-management pain or drug dependence may request higher opioid analgesic doses on the basis that they have a ‘right to analgesic drugs for pain’ and are making a choice as an informed patient.

Patients have a right to good healthcare, and not a right to drugs of dependence. Patients need to be informed of this at the beginning of any trial using drugs of dependence. If the clinician feels that further therapy is detrimental to a patient’s health, then clinical withdrawal of medication should begin.

Doctors typically have a strong desire to alleviate patient distress and suffering. The psychological phenomenon of transference in addiction, pain and mental illness can result in doctors having difficulty in these clinical areas. There are a number of GPs who find it difficult to set boundaries for patients and are at risk of being pressured to prescribe inappropriately. Others have difficulties in saying ‘no’ or hold the belief that they are ‘helping’ or using a harm minimisation approach by giving patients who are seeking drugs what they ask for.

All practitioners express difficulty responding to manipulative behaviour or techniques posed by some patients (eg ‘I will suicide if I do not get my medication’). GPs should educate themselves about appropriate responses to common manipulative techniques and behaviours posed by some patients to access drugs of dependence. To aid GP negotiation skills, scripted replies have been developed to help with appropriate responses in difficult situations.

For examples of GP responses to patient requests for benzodiazepines, refer to Appendix E in the RACGP’s Prescribing drugs of dependence in general practice, Part B – Benzodiazepines (available May 2015).

Setting patient behaviour standards

Prescribers have a responsibility to make patients aware of behaviour standards they expect when prescribing drugs of dependence or when changing a prescription in order to manage documented risk. This process is best untaken where there is a good therapeutic alliance with the patient and in an empathetic, non-judgemental manner. Practice policies will help this process.

Behaviour standards may include:

  • only obtaining scripts from one doctor and one pharmacy
  • staged supply through pharmacy
  • supervised dose to patient only at pharmacy
  • attending appointments regularly
  • engaging with other supports
  • engaging with psychological supports
  • agreement when a therapeutic trial of treatment will cease
  • the consequences of inappropriate patient behaviour (eg formal review, possible referral or cessation of clinical relationship).

Any coercion or threat (physical or verbal) to prescribe is an immediate red flag and a breach of the therapeutic alliance. Where boundaries have been crossed and the GP no longer considers it appropriate to treat a patient who has behaved in a violent or threatening manner, the GP has the right to discontinue the care of that patient.20 The GP may choose to end the therapeutic relationship during a consultation or, depending on the circumstances, by letter or telephone.20 Safety should dictate the method chosen. It is advisable for the practice to document a process to be followed by practice staff if the patient makes any subsequent contact.20

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