Case 26 Lost prescription: Benzodiazepine addiction

Samantha was 26. She arrived in reception at her GP surgery. She requested a prescription for diazepam tablets 5 mg, in a dose of two tablets three times a day, for a month. The same prescription had been issued 10 days earlier. The patient explained that she had just returned from a week’s holiday in Ibiza and had unfortunately left her tablets behind in her hotel room.

Dr Balla, the GP registrar who was on duty that day used the patient’s contact telephone number to speak to her. Samantha assured Dr Balla that her story was true and said she had previously had an epileptic fit when she had run out of tablets. Dr Balla issued the prescription.

A few days later Dr Balla was very upset to be contacted by the police. Samantha had been arrested for dealing in various drugs including diazepam. The police wanted to interview Dr Balla about the prescription. They said that under Section 29 of the Data Protection Act, she was entitled to release information without the parent’s consent.

Careful examination of the prescribing records indicated Samantha had ordered and been prescribed 15 monthly increments of her prescription in the last year, and had also obtained an additional issue from the Out of Hours service a few months previously by stating that she had arrived too late at the GP surgery to collect her prescription.

What options were open to the GP?

Samantha was plausible and Dr Balla was deceived. She had also felt pressured by the story of an epileptic fit.

At the time the request was made, Dr Balla could have reviewed the previous ordering pattern and would have discovered the over-ordering. However, she was not responsible for the continuing prescription, or the lack of previous medication review, or lack of response to the Out of Hours incident.

Should she speak to the police?

Expert comment

Benzodiazepine prescribing remains very common in general practice, despite the recommendation in the British National Formulary that all the drugs should only be given for short courses if being used to treat anxiety and insomnia. Over 12 million prescriptions for benzodiazepine are still dispensed annually in the UK.

Many benzodiazepines have a definite ‘street value’ and so diversion for criminal purposes is a significant risk.

Addiction and abuse of benzodiazepines also remains a significant problem and it remains one of the commonest causes of litigation against GPs, with patients alleging that they have suffered long term mental and physical health problems.

Warning signs include dose escalation; presenting too early for repeat prescriptions; abuse of other drugs; and stories of lost tablets, lost FP10s, and third parties stealing or throwing the tablets away.

Various strategies may be used. Diazepam can be prescribed using blue FP10 (instalment dispensing forms). Prescriptions may be issued weekly, with screen messages to prevent early ordering. Patients may be warned that stories of lost tablets will not be accepted.

Legal comment

A doctor owes his patients a duty of confidentiality in law and in ethics. Breach of that duty is a serious matter, which can lead to sanctions by the GMC. However, the duty is not absolute. For example, statute requires that doctors notify certain authorities of known or suspected cases of certain communicable diseases. This is just one example of how the wider public interest in disclosure can outweigh the advantages of maintaining confidentiality.

The GMC puts the principle like this:

Personal information may therefore 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 Balla needs to have this principle in mind when considering the police’s request for information about Samantha’s prescription. They have quoted the Data Protection Act to her in support of their request. But this Act is only concerned with whether or not data is processed fairly. It does not cover her legal and professional duties of confidentiality.

So Dr Balla has to do a balancing exercise between the interests of her patient and the public interest in the prevention and detection of crime. This is how the GMC puts it:

You must weigh the harms that are likely to arise from non-disclosure of information against the possible harm both to the patient and to the overall trust between doctors and patients arising from the release of that information.

The first step for Dr Balla to take is to ask for Samantha’s permission to disclose the records. If she says no, then the balancing exercise has to be done. In this case, Dr Balla may feel some embarrassment about having issued the prescriptions. That might affect her judgement. These balancing exercises are difficult enough in the best of circumstances. So she should definitely take advantage of the expertise available through her MDO. A medico-legal adviser will talk through the case and help Dr Balla reach an objective and considered decision.

She may conclude that she cannot see clearly enough who might be harmed if the information is not disclosed. If she declines to share the information with the police, then they will have the option of seeking a court order requiring the disclosure. At that point, Dr Balla will have no choice but to comply unless she has some grave concern about the consequences for her patient. In that case, she needs to get back in touch with her MDO.

If she decides the balance is in favour of making the disclosure to the police, then she needs to carefully record how she came to that decision. In principle, Samantha could either sue Dr Balla for breaching her confidence or report her to the GMC. But if Dr Balla can show that she took care to make a balanced judgement, then she will be able to defend herself successfully.

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