Doctor shopping, or the practice by patients of seeking prescriptions from multiple prescribers and presenting them at multiple pharmacies, has long been an area where pharmacists have needed to be extremely vigilant.

It has come to the notice of the Pharmacy Council of NSW that some doctor shoppers are becoming more strategic and establishing themselves in a local area, with a local address, and a local GP practice then presenting prescriptions for fentanyl 100mcg patches to the local pharmacy. Often the address is non-existent but uses a local street name with a number that does not exist. 

These individuals are effectively setting up an apparently legitimate presence with both the doctors and the pharmacists and are often meticulous in their knowledge of the legislation (for example not coming in before the repeat interval has elapsed) so as not to raise suspicion. This modus operandi differs from previously encountered means whereby the doctor, the patient’s address and the pharmacy were all remote from each other, so that one of the red flags to alert suspicion is thus removed.

Pharmacists are reminded that they must be constantly vigilant and alert to the fact that many prescriptions for fentanyl (particularly the higher strength patches) and other highly addictive Schedule 8 medications are subject to diversion/misuse.

We particularly draw your attention to the issues surrounding the prescribing and use of fentanyl.  

In July 2020, the Pharmaceutical Regulatory Unit issued a warning about the misuse of fentanyl patches. Excerpts from this are reprinted below, but in summary, if you receive a prescription for fentanyl patches, you should take steps to ensure that the prescription is valid, and that the quantity and purpose are in accordance with recognised therapeutic standards.

The following points are relevant:

• the use of fentanyl 100 mcg patches is rare as each patch delivers the equivalent of 300mg of morphine daily (oMEDD calculator available here)
• the Pain Management Network recommends an oMEDD of less than 40mg for chronic non-cancer pain, and less than 300mg for cancer pain
• fentanyl patches are designed to be applied once every three days. You should be suspicious of dosage regimens where a new patch is to be applied daily or every second day.
   

                        WARNING – MISUSE OF FENTANYL PATCHES

Key messages

• Fentanyl is a highly potent synthetic opioid

• one fentanyl 100mcg / hour patch applied every 3 days is the equivalent of 300mg of morphine orally daily
• Fentanyl can be extracted from patches and misused
• the risk of drug dependence on fentanyl patches is high
• Fentanyl misuse is an emerging problem
• Pharmacists should check the validity of fentanyl prescriptions, especially if on private prescriptions or for multiple packs.

Use of fentanyl patches carries a number of risks of overdose, with a small margin between an appropriate therapeutic dose and a toxic dose. Use of fentanyl patches requires care when commencing treatment and is only appropriate in patients in whom opioid analgesic treatment is well established. Use in opioid naïve patients is rarely if ever/never justified. It is recommended that a patient’s drug and alcohol history is assessed before any opioid is prescribed.

When fentanyl transdermal patches are used appropriately, plasma levels may take around 24 hours to reach a steady state. Fentanyl patches are designed to provide a steady release of fentanyl over 72 hours. There is no advantage in prescribing fentanyl patches to be applied daily or every two days.

Misuse of fentanyl patches

A number of deaths have been associated with the misuse of fentanyl patches, including multiple patches applied for an intoxicating effect and the injection of fentanyl extracted from fentanyl patches.

Fentanyl patches have a high illicit value and are subject to trafficking. In Australia the main source of fentanyl patches used illicitly is from those obtained on prescription.

Careful scrutiny of prescriptions for fentanyl patches required

It is important to check the validity of any prescriptions presented for dispensing, especially for multiple packs and as private prescriptions. Any concerns about the appropriateness of prescriptions for fentanyl patches, including the directions for use, should be addressed with the prescriber in the first instance. If still concerned about patient safety or diversion risk, pharmacists can refuse to dispense and should report their concerns to NSW Health’s Pharmaceutical Regulatory Unit.

NSW Health Contact Details:

More information is available on the NSW Ministry of Health Pharmaceutical Services website
Telephone: (02) 9391 9944