Junee pharmacist to be suspended over professional misconduct

Junee Discount Pharmacy proprietor and its sole chemist Michael Ezzat Helal Azzer, 34, will be officially suspended from July 5 after a decision was handed down by the NSW Civil and Administrative Tribunal this week.

An NCAT panel ruled on Wednesday that Azzer was guilty of unsatisfactory professional conduct on the basis of four separate complaints relating to a number of patients he administered drugs to between 2017 and 2018.

NCAT also found Azzer guilty of professional misconduct for a further complaint.

One complaint involving nine patients involved multiple instances where Azzer excessively dispensed a range of opioids including oxycodone, fentanyl, morphine, alprazolam and benzodiazepines between July 2017 and December 2018.

The tribunal heard these drugs have the potential to lead to physical and psychological dependence and can also be diverted into the community for illicit use.

The Health Care Complaints Commission (commission), who brought the complaint to NCAT against Azzer, argued that many of the "dispensing instances were vastly excessive, to the point where they could have caused death or serious harm if they had actually been consumed".

In particular, the commission said over an 88-day period in 2017, pharmacists at the Central Coast pharmacy where Azzer was working dispensed 50 prescriptions for oxycodone to just one patient - totalling 1392 tablets in various strengths weighing 83,280 milligrams.

The tribunal heard this equates to a daily dosage of 1419 milligrams - over 35 times the recommended amount for non-cancer pain and almost eight times the amount actually prescribed to the patient in question.

The tribunal heard Azzer dispensed 30 of the 50 prescriptions during this period - totalling 832 tablets, despite having access to the patient's dispensing history.

At the same time, 24 prescriptions for three different types of benzodiazepines were dispensed to the same patient, 15 of which (600 tablets) were provided by Azzer - despite the prescription for each benzodiazepine being for just one tablet per day.

An expert report by former compliance pharmacist for Medicare Australia Alexandra Torrens noted oxycodone is by nature an addiction-producing drug and said an authorised practitioner or pharmacist must not supply any drug of addiction in a quantity or for a purpose other than that recognised by the appropriate therapeutic standard.

The commission heard the oxycodone drugs were supplied to the patient in very short interval - including at one time just four days after a pack expected to last 28 days was supplied.

Ms Torrens noted Azzer was not the pharmacist involved in all of the instances where the drugs were supplied, but said when he accessed the patient record he would have still been able to see the relevant dispensing history and make a professional judgement about what was appropriate to do.

She concluded that Azzer's conduct in supplying those medications was "significantly below the standard required".

The commission argued the conduct in this complaint fell significantly below the standard reasonably expected of a practitioner such as Azzer and that it amounted to unsatisfactory professional conduct.

Azzer admitted he exceeded the recognised therapeutic standard regarding the amount of drugs he was supposed to dispense but defended his actions.

Azzer said he "maintained strong lines of communication with prescribing doctors" and when he had concerns about dispensing, he would only do so if he was "reassured by the prescribing doctor" that there was a need for the dose prescribed.

NCAT found Azzer was required to make an independent judgement about whether it was suitable to dispense the amount in question for patients - including having regard for their history and taking steps to ensure the patients are not put at risk by the conduct of practitioners.

Azzer, as a chemist, also had an obligation to notify the AHPRA if he had reason to believe a practitioner was endangering the public by significantly departing from accepted professional standards.

But Azzer said at the time he was unaware he could challenge the prescribing doctor about the drugs dispensed and considered contacting the doctor in question was all he had to do to fulfil his duty of care to the public.

The Commission however said it was concerning Azzer felt this way, especially given he had only recently completed his intern training and exams and said he knew what the law was.

NCAT found Azzer ought to have known better and should not have simply taken the word of a prescribing doctor at face value.

The tribunal found Azzer did not apply any independent judgement about whether the drugs, being prescribed in "vast quantities" as frequently as every two days, could be misused.

In a separate complaint, a patient - who was also a doctor - was given 50 tablets of Alprazolam and 50 tablets of diazepam on the same date in May 2018 by Azzer.

Both drugs are benzodiazepines and were prescribed by two prescribers.

While not admitting to the actions, Azzer also did not admit that the concurrent dispensing of the drug had put the patient at risk.

Explaining why he believed this, Azzer said given the patient was a doctor working at an adjoining medical centre - he knew the patient and believed he understood the risks of medications given his medical training.

He said he would not have dispensed two supplies of the drugs unless the prescribing doctor had confirmed there was a good reason for doing so.

A complaint of professional misconduct was also brought forward by the commission, which argued Azzer had repeatedly and over an extended period of time dispensed large quantities of dangerous drugs to numerous patients.

The commission said these drugs were known the trigger dependence and were prone to misuse and abuse by patients themselves - or illicit redirection into the community.

The commission argued some of the quantities supplied to patients were extraordinary - being several times the highest recommended dose for serious cancer pain in some instances.

The tribunal heard it should have been evident to even the most junior of practitioners at the time that the amount dispensed was manifestly excessive and liable to cause serious harm either to patients or the community at large.

Azzer argued there were mitigating factors that he had a lack of experience at the time and that he had received poor guidance at the critical stage of his career - and that this meant he had not engaged in professional misconduct.

However, the tribunal disagreed, finding he had committed professional misconduct and that it was serious enough to warrant a suspension or cancellation of Azzer's registration.

The tribunal heard Azzer has now reformed his ways significantly, and has since 2022 owned and been the sole pharmacist at the Junee Discount Pharmacy.

The tribunal heard that since the conduct from the complaints brought forward, Azzer has practised without complaint at his pharmacy and has taken the appropriate steps to address shortcomings in his practice.

Azzer argued against a suspension, saying the residents of Junee would be put at a great disadvantage if they lost "a pharmacist of his calibre and commitment".

The tribunal accepted Azzer has fundamentally changed his ways and appears to be complaint these days, however they found a suspension was necessary, and ruled that it last for a period of three months.

However, given the circumstances, where Junee has only one other operating chemist - the Junee Capital Chemist - the tribunal ruled that the suspension will not take effect until July 5 in order to give Azzer time to find a replacement while he is unable to practise.

Azzer was also ordered to pay the costs of the commission.