DORA the ignorer: Prescription-tracking system failing to monitor all high-risk addictive drugs

Diazepam, quetiapine and fluoxetine contributed to ex-Navy submariner's death, says coroner

A coroner has stressed the need for real-time script-tracking software to cover addictive schedule 4 drugs such as diazepam and quetiapine, not just opioids.

doctor consulting drug tracking software

The Tasmanian coroner made the comments after investigating the 2014 death of 44-year-old ex-Navy submariner Michael Allan Steer, who died from a toxic combination of prescription medication.

Toxicology analysis revealed the presence of diazepam, quetiapine, fluoxetine, paracetamol and codeine.

Since 2012, GPs in Tasmania have had access to DORA, a real-time prescription monitoring system, which was introduced to help prevent prescription drug misuse.

The first of its kind in Australia, DORA tracks schedule 8 opioids and alprazolam when they are prescribed and dispensed, plus schedule 4 opioids such as codeine and tramadol when they are dispensed.

However, most of the drugs linked to Mr Steer’s death are not covered by DORA or the Federal Government’s promised national system.

Dr Andrew Nolan, Mr Steer’s GP for the 18 months before his death, arranged with Tasmania’s Pharmaceutical Services Branch (PSB) to send a memo to local pharmacies asking them not to dispense scripts for his patient from other GPs.

But in findings published last week, coroner Olivia McTaggart said without real-time tracking of diazepam or quetiapine, this was not effective.

“Although the intention of Dr Nolan (with assistance of the PSB) was that he would be the only prescriber, this could not be monitored effectively and it relied upon the pharmacies reading and retaining the PSB circulars and complying with the request not to fill prescriptions other than those written by Dr Nolan,” she said.

Ms McTaggart recommended that the Tasmanian Government extend DORA to cover these schedule 4 drugs “of a high abuse potential”, as well as potentially pregabalin, which had previously come under scrutiny because of its abuse potential.

“On the evidence, there is a very good case for implementing greater regulation in prescribing drugs regularly contributing to toxicity and death,” Ms McTaggart said.

Analysis of data from the Tasmanian Register of Overdose Deaths showed that quetiapine was present in 98% of cases between 2007 and 2016, she added.

In recommending an expansion to DORA, Ms McTaggart pointed to the Victorian Government’s decision to roll out the broader, real-time script-tracking program SafeScript.

The first trial of SafeScript began on Monday in western Victoria, ahead of a full rollout in 2019.

Unlike DORA, Safe Script will be compulsory for all doctors and pharmacists to use, starting in 2020.


More information: Coroner's findings