You are concerned that one of your patients is beginning to become dependent on prescription medication. She is a single parent and you worry her children might be put at risk when she is under the influence. What are your professional obligations and how can you ensure the safety of your patient and her children?
A doctor takes full responsibility for prescriptions issued to their patients and is obliged to prescribe responsibly and safely, particularly in cases involving drugs with potentially serious side effects. GMC guidance makes it clear that, whether prescribing with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, so as to minimise the risk of your patient becoming dependent on prescription drugs in the first place.
In this scenario, it is not clear how your patient has become dependent on prescription drugs but a common risk factor is repeat prescribing systems. MDDUS has received many calls regarding repeat prescription system failures that have resulted in patient harm. Such incidents can often be avoided by ensuring robust procedures are in place to monitor the patient's condition and regularly reviewing the appropriateness of continuing the prescription.
Prevention is key; before adding a repeat prescription to your system, you must be satisfied that it is safe and appropriate to do so. GMC guidance states that doctors must have procedures in place to ensure the patient is issued with the correct prescription at the correct dose. The doctor signing a repeat prescription takes responsibility for it and should ensure that each prescription is still necessary and that items no longer required are discontinued.
Repeat prescribing systems should allow regular medication reviews and, where appropriate, the patient should be invited to book an appointment for further assessment and discussion of the need for continuing treatment.
If you suspect your patient has become dependent then it is important to carefully discuss the issue with them and consider the next steps. Never make rash decisions, such as abruptly ending a patient's prescription without warning, or discussion.
If you are concerned for your patient, then invite them to the surgery to discuss the matter with a view to gradually reducing the medication dose or frequency where appropriate.
In this case, you have the added consideration of the children's safety. Again, you should discuss your concerns with the patient in the hope of reaching agreement over the most appropriate way forward. The best outcome would be for you and your patient to work together towards gradually eliminating her dependency, thereby reducing the risk to her children. In more serious cases, it may be necessary to involve relevant outside organisations (such as social work or another support group) but again this would ideally be done in partnership with the patient and with her consent.
If the patient denies she has a problem, then you should endeavour to reach an agreement with her over the best course of treatment. Clearly explain your concerns to her, offer support and discuss the issue in an open and honest way as this is a sensitive subject. Try to maintain a positive relationship with her so that she doesn't become defensive or feel threatened.
Throughout this process you should keep clear, comprehensive and accurate records of what has been discussed/agreed with the patient, including all medicines prescribed. This will be important if there should be a concern raised about the care of the children, or indeed in the event of a patient complaint about you reducing/stopping her medication.
If the patient still refuses to accept she has a problem, then seek advice from an experienced colleague or from your medical defence organisation.
In serious cases, if you have good reason to be concerned over the children's welfare then it may be appropriate to breach patient confidentiality to seek help from outside agencies.
GMC guidance Confidentiality states that ‘personal information may be disclosed in the public interest, without the patient's consent, and in exceptional cases where patients have withheld consent, if the benefits to an individual or to society of the disclosure outweigh both the public and the patient's interest in keeping the information confidential'.
Dr Mary Peddie is medical adviser with the UK-wide medical defence organisation MDDUS