With the agreement of the respondent the Tribunal finds as follows:

Inappropriate Prescribing and/or Medical Treatment

1. Dr Andrew John Griffiths has, in contravention of the Medical Practice Act 1994 (Vic) (MPA), engaged in unprofessional conduct as defined in s 3(1)(a) and / or (b) and / or (c) of the definition of unprofessional conduct contained in s 3 of the MPA which is of a serious nature in respect of allegations 1, 9, and 18.
2. Dr Griffiths has, in contravention of the Health Professions Registration Act 2005 (Vic), (HPRA) engaged in unprofessional conduct within the meaning of s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the HPRA in respect of allegation 1A.
3. Dr Griffiths has, in contravention of the HPRA, engaged in professional misconduct within the meaning of s 3(1)(a) and / or (b) of the definition of professional misconduct contained in s 3 of the HPRA in respect of allegations 10, 19 and 35.
4. Dr Griffiths has, in contravention of the Health Practitioner Regulation National Law (Victoria) Act 2009 (Vic), (National Law) engaged in professional misconduct within the meaning of s 5(a) and / or (b) of the definition of professional misconduct contained in s 5 of the National Law in respect of allegations 2, 11, and 20.

Inappropriate treatment of a person with whom shared a close personal or family relationship.

1. Dr Griffiths has, in contravention of the MPA, engaged in unprofessional conduct within the meaning of s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the MPA which is of a serious nature in respect of allegations 3, 12, and 24.
2. Dr Griffiths has, in contravention of the HPRA, engaged in unprofessional conduct as defined in s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the HPRA in respect of allegations 4, 13, and 25.
3. Dr Griffiths has, in contravention of the National Law, engaged in unprofessional conduct within the meaning of s 5(a) and / or (b) of the definition of unprofessional conduct contained in s 5 of the National Law in respect of allegations 5, 14 and 26.

1. Dr Griffiths has, in contravention of the MPA, engaged in unprofessional conduct within the meaning of s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the MPA in respect of allegations 15 and 21.
2. Dr Griffiths has, in contravention of the HPRA, engaged in unprofessional conduct within the meaning of s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the HPRA in respect of allegations 6, 16 and 22.
3. Dr Griffiths has, in contravention of the National Law, engaged in unprofessional conduct within the meaning of s 5(a) and / or (b) of the definition of unprofessional conduct contained in s 5 of the National Law in respect of allegations 7, 17, and 23.

Prescribing a drug of dependence in circumstances where knew or ought to have known that the patient was a drug-dependent person

1. Dr Griffiths has in contravention of the National Law, engaged in professional misconduct within the meaning of s 5(a) and / or (b) of the definition of professional misconduct contained in s 5 of the National Law in respect of allegation 8.

Breach of permit obligations; prescribing Schedule 8 poisons without a permit, after the expiry of the permit, in excess of maximum specified dosages

1. Dr Griffiths has, in contravention of the HPRA, engaged in unprofessional conduct within the meaning of s 3(1)(a) and / or (b) of the definition of unprofessional conduct contained in s 3 of the HPRA in respect of allegations 29, 33 and 36.
2. Dr Griffiths has, in contravention of the HPRA, engaged in professional misconduct within the meaning of s 3(1)(a) and / or (b) of the definition of professional misconduct contained in s 3 of the HPRA in respect of allegation 27.
3. Dr Griffiths has, in contravention of the National Law, engaged in unprofessional conduct within the meaning of s 5(a) and / or (b) of the definition of unprofessional conduct contained in s 5 of the National Law in respect of allegations 30, and 34.
4. Dr Griffiths has, in contravention of the National Law, engaged in professional misconduct within the meaning of s 5(a) and / or (b) of the definition of professional misconduct contained in s 5 of the National Law in respect of allegations 32 and 37.

Note: Allegations 28 and 31 were withdrawn. References to allegations are to the Amended Notice of Allegations dated 11 November 2016.

Pursuant to section 196(2) of the Health Practitioner Regulation National Law (Victoria) Act 2009 (Vic), the Tribunal orders:

1. Dr Griffiths is reprimanded.
2. Dr Griffiths' registration is suspended for the period of three (3) months commencing 1 May 2017.
3. The following conditions are imposed on Dr Griffiths' registration on and from 1 June 2017:

3.1 Dr Griffiths must undertake and successfully complete a program of education or one-to-one education, approved by the Medical Board of Australia (Board) that includes a reflective practice report in relation to pharmacotherapy and prescribing of medication in accordance with Drugs and Poisons Legislation and training in relation to the code of conduct for doctors in Australia, specifically working with patients and managing personal relations (the education).

3.2 Within one (1) month of the imposition of these conditions, Dr Griffiths must, on the approved form (HPN24), nominate for approval by the Board an education course or one-to-one education, assessment or program addressing the topics required. Dr Griffiths must ensure:

• 3.2.1 The nomination includes a copy of the curriculum of the education;

• 3.2.2 The education consists of a minimum of twenty-four (24) hours;

• 3.2.3 If nominating one-to one education, to nominate a person(s) to be approved by the Board to act as the educator and provide an acknowledgement that AHPRA will obtain a report from the approved educator at the conclusion of the education: and

• 3.2.4 If nominating one-to one education, that the nomination of an educator is accompanied by acknowledgment on the approved form (HPNA11), from the nominated educator and by an education plan outlining the form the education will take and how the topics will be addressed.

3.3 Dr Griffiths must complete the education within nine (9) months of the notice of the Board's approval of the education.

3.4 Within six (6) months of completing the education, Dr Griffiths is to provide to AHPRA:

• 3.4.1 Evidence of successful completion of the education; and
• 3.4.2 A report demonstrating, to the satisfaction of the Board, that Dr Griffiths has reflected on the issues that gave rise to this condition requiring he undertake education and how Dr Griffiths has incorporated the lessons learnt in the education into Dr Griffiths' practice.

3.5 At the completion of the education, Dr Griffiths must submit to three (3) audits of his practice (the audits), including any supporting records, by permitting an auditor approved by the Board (auditor) to attend any and all places of practice (public and private) for the purpose of the audit and by permitting the auditor to provide reports in relation to the findings of the audits. The audits and the audit reports are to focus on record keeping, Dr Griffiths' prescribing practices including his use of Schedule 4 and 8 poisons and whether Dr Griffiths is complying with Drugs and Poisons Legislation, and must include, at a minimum, an audit of Dr Griffiths' patient records.

3.6.1 The first audit must take place within three (3) months of Dr Griffiths' return to practice;

3.6.2The second audit must take place within six (6) months of the first audit; and

3.6.3 The third audit must take place within twelve (12) months of the second audit.

3.7 Within one (1) month of the imposition of these conditions, Dr Griffiths must:

3.7.1 Make contact with a Board approved auditor and establish an audit plan outlining the form the audits will take and how the areas of concern for the Board will be addressed. The audits will take the form determined by the auditor;

3.7.2 Provide the Board approved auditor with a copy of the conditions on his registration;

3.7.3 Provide to AHPRA, on the approved form (HP8), acknowledgement that AHPRA will seek reports from the auditor; and

3.7.4 Provide to AHPRA a copy of the audit plan, together with written acknowledgement from the auditor on the approved form (HPNA8).

For the purposes of this condition, 'mentoring' is defined as a relationship in which a skilled registered practitioner (the mentor) helps to guide the professional development of another practitioner.

3.8 Dr Griffiths must undertake a twelve (12) month period of mentoring by another registered health practitioner in relation to pharmacotherapy and prescribing of medication in accordance with Drugs and Poisons Legislation; appropriate prescription of drugs of dependency; appropriate medical management and/or referral of drug-dependent patients; compliance with the code of conduct for doctors in Australia, including working with patients and managing personal relations, and maintenance of the practitioner's own health and well-being.

• 3.8.1 The mentoring must comprise a minimum of twelve (12) monthly sessions occurring over a twelve (12) month period with each session being of at least one (1) hour duration.

• 3.8.2 Within one (1) month of the imposition of these conditions, Dr Griffiths must, on the approved form (HPN16) nominate a person(s) to be approved by the Board to act as mentor. Dr Griffiths must ensure that the nomination is accompanied by acknowledgement, on the approved form (HPNA16), from the nominated person(s).

• 3.8.3 Within one (1) month of the imposition of these conditions, Dr Griffiths must provide to AHPRA, on the approved form (HP16), acknowledgement that AHPRA may seek reports from the approved mentor on any or all of the following occasions:

  • 3.8.3.1 every three (3) months;
  • 3.8.3.2 at the conclusion of the mentoring relationship in order to confirm the outcomes of the mentoring;
  • 3.8.3.3 whenever the mentor has a concern or becomes aware of a concern regard Dr Griffith's conduct or professional performance, and
  • 3.8.3.4 when otherwise directed by AHPRA or the Board.

• 3.8.4 In the event an approved mentor is no longer willing or able to provide the mentoring required Dr Griffiths is to provide a new nomination in the same terms as previous nominations. Such nomination must be made by Dr Griffiths within twenty-one (21) days of becoming aware of the termination of the mentoring relationship.

• 3.8.5 Within six (6) months of the conclusion of the mentoring Dr Griffiths must provide a report demonstrating, to the satisfaction of the Board, that he has reflected on the issues that gave rise to the condition requiring he attend for mentoring and outlining how he has incorporated the lessons learnt in the mentoring into his practice.

3.9 All costs associated with compliance with the conditions on his registration are at Dr Griffiths' own expense.

4. The review period for the above conditions is twenty four (24) months from the date of Dr Griffiths' return to practice.

Note: The above determinations are imposed with the agreement of both parties.

SUPPRESSION ORDERS AND FILE ACCESS RESTRICTIONS IN FORCE**

Under s 146 of the Victorian Civil and Administrative Tribunal Act 1998 (Vic): no person other than a party to the proceeding or their legal representatives may inspect the Tribunal file.

Under s 17 of the Open Courts Act 2013 (Vic):

• Any information that might enable the patients and notifiers the subject of these proceedings to be identified must not be published. That information includes information regarding the locality in which the patients and notifiers live or the patients lived while they were patients of the respondent medical practitioner;
• This order applies throughout Australia;
• This order operates until further order or the death of the patients or notifiers.

1. Dr Andrew John Griffiths has been a registered medical practitioner since 1980. For the last 35 years he has worked as a general practitioner in Cobden, Victoria.
2. Dr Griffiths is in sole practice. Although he is not the only doctor in Cobden, he is the only on-call after hours doctor for the town, including its 60-bed nursing home, and the surrounding rural community. He works weekdays and weekends, regularly seeing over 200 patients a week. His high workload reflects the difficulties many rural communities have in attracting and maintaining enough doctors to meet their needs. But such a high workload also carries risks for the medical practitioner.
3. This case is about his professional conduct in relation to nine patients at various times between 1999 and 2013. These are the first and only disciplinary proceedings that have been brought against him in his medical career.
4. The conduct includes inappropriate prescription and/or medical treatment; inappropriately treating persons with whom he shared a close personal or family relationship and inadequate notes or records in relation to those persons; prescribing a drug of dependence in circumstances where he knew or ought to have known that the person was a drug-dependent person; and breaches of permit obligations to do with the prescription of Schedule 8 poisons. The drugs prescribed included opioids and benzodiazepines.
5. In late 2015, the Medical Board of Australia (the Board) referred allegations against him to the Tribunal. By a process of discussion and agreement, and with Dr Griffiths' cooperation, the allegations were amended to 36[1] allegations, and the parties provided to us:
   • a statement of agreed facts;
   • joint agreed submissions on findings in relation to the conduct; and
   • joint agreed submissions on determinations [orders by way of penalty.

It was clear that there had in this case been 'a carefully and extensively negotiated outcome'.[2]

1. Dr Griffiths agrees that in respect of the nine patients he has breached his obligations as a medical practitioner. The findings we have made with his agreement reflect the fact that his conduct in some instances represented a substantial departure from accepted standards, and in others a departure, but to a lesser degree, from those standards.
2. The determinations the parties jointly proposed to us at the hearing were a reprimand, further education, an audit of his practice and a period of suspension from practice of three months. It was said that any longer than three months would mean that Dr Griffiths would have to close his practice.
3. Unusually in such matters, we were given strong letters of support by community leaders on behalf of the whole community, which concerned not only Dr Griffiths' commitment and dedication to the town and district for over 30 years, but also the direct impact on the community of removing him from practice.
4. While it is always for the Tribunal to determine the level of conduct and the appropriate determinations, an outcome jointly proposed by the regulator and the practitioner will have considerable weight.
5. Nevertheless, panel members were concerned that the proposed period of suspension, three months, did not adequately reflect the nature and seriousness of the conduct and sufficiently address general deterrence. We invited the parties to address us further on these matters.
6. At a further hearing, written and oral submissions were made. A further condition - for a period of mentoring - was proposed on his behalf as an alternative to a longer period of suspension, together with an increase in the hours of further education. Importantly, three of Dr Griffiths' character witnesses attended in person and gave additional evidence in chief about Dr Griffiths' importance to the town and the impact on the community were he to close his practice. Their evidence was impressive and compelling.
7. Although removing a clearly unsafe practitioner from practice will take priority over the impact on the community of losing a doctor, Dr Griffiths is not in that category, and it was relevant in this case to consider the impact of any period of suspension and the need to limit any period to no more than is necessary to achieve the objectives of determinations. The orders by way of determinations we have made reflect the jointly proposed determinations with an increase in the education hours, and a period of mentoring for twelve months.
8. This case highlights the hazards of high workloads for general practitioners in sole rural practices, and the pressures they can come under in the course of their practice, including to treat persons with whom they have a close personal or family connection.
9. Ultimately, practitioners themselves must ensure that they are able to maintain the standards the profession and the public expect of them.
10. But rural communities that depend heavily on the commitment and dedication of their doctors will also need to do all in their power to ensure those doctors do not break under the strain.

1. In this case, it is not possible to go into the usual detail about the facts and findings without identifying a number of the patients. The following is a necessarily abbreviated summary which omits some matters which would better indicate the seriousness of the conduct but which could also identify patients.
2. In making findings, the Tribunal had the benefit of an expert report by Dr Angela Sungaila, who is a forensic physician at the Victorian Institute of Forensic Medicine and is also an adjunct lecturer in forensic medicine at Monash University. Dr Sungaila holds appropriate qualifications to provide an expert opinion in this case.
3. In her report, Dr Sungaila provided background information to the drugs prescribed by Dr Griffiths and their actions, evidence about the use of opioids for chronic pain, evidence about appropriate practice for the prescription of benzodiazepine and other matters, and her observations about the appropriateness of various prescribing and treatment decisions Dr Griffiths made.
4. Dr Sungaila's report was accepted by Dr Griffiths in relation to the matters the subject of the allegations.

Evidence about the drugs prescribed and their actions

1. To provide context for the agreed facts and findings, the following information is from Dr Sungaila's report.

Tramadol is a synthetic opioid preparation used to treat moderate pain. It can create dependence and tolerance. It has in the past been suggested as an opioid substitute however it has of its own accord the potential for abuse and dependence.[3] It is contraindicated for use in opiate withdrawal. In patients who have a tendency for drug abuse or dependence it should be used for short periods. Cases of dependence and abuse of tramadol have been reported rarely.[4] There are no clinical studies measuring the safety of using tramadol beyond 6 months.[5]

Paracetamol 500mg/Codeine 30mg - Panadeine Forte, Codalgin Forte

Morphine (S8 schedule) is a potent drug derived from opium. It is used for severe pain in oral or injectable form. It can cause rapid dependence and withdrawal symptoms if ceased suddenly.

Oxycodone (S8 schedule) is a semisynthetic opioid derived from opium. In its oral form it is somewhat more potent than morphine.[6] There is a plethora of literature acknowledging the danger of using this class of drugs without adherence to strict principles.

Paracetamol 500mg/codeine 30mg is a less potent opioid preparation however can but is less likely to cause dependence similarly to others in the class. Codeine is metabolised in the liver to morphine and norcodeine. It should be used with caution in patients with drug abuse or dependence.[7]

Fentanyl (S8 schedule) is a potent opioid analgesic. Used in a transdermal preparation it delivers a dose of the drug through the skin. It is indicated for the use of chronic pain when opioid analgesia has been considered necessary. The restricted benefit indicated is for 'chronic severe disabling pain not responding to non-narcotic analgesics.' It can be abused and dependency states can arise.[8]

Dr Michael McDonough, specialist in addiction medicine and toxicology at the Western Hospital states 'The evidence for harm associated with long-term opioid use is mounting while there is little evidence to support long term efficiency. In many cases, reducing and eventually stopping opioid therapy may be the best course of action.'[9] Dr McDonough also recommends the preparation of an opioid treatment plan and regular objective monitoring of function rather than relying on the patient's subjective analysis of their pain.[10]

MIMS 2014 advises in the treatment of non-malignant chronic pain:

'An initial comprehensive assessment should be conducted using a biopsychosocial approach to identify a cause for the pain, the appropriateness of opioid therapy, and to identify psychosocial factors that may exacerbate pain or magnify overall distress (e.g. depression, anxiety, post-traumatic stress disorder, borderline personality disorder, marked family stressors, history of sexual abuse). In the absence of a clear indication for a strong opioid analgesic, drug seeking behaviour must be suspected and resisted, particularly in individuals with a history of, or propensity for, drug abuse. Factors that may put the patient at increased risk of opioid abuse/addiction include a personal/family history of substance, prescription medication and alcohol abuse, and major psychosocial issues (e.g. psychological/psychiatric disorder). The use of opioids to treat predominant[ly] emotional distress should be avoided.

Generally, opioid analgesics are not initiated prior to a full initial clinical assessment and before consideration of other treatment options such as physiotherapy/exercise/rehabilitation approaches, psychosocial interventions such as CBT (cognitive behavioural therapy), self management approaches, involvement of a psychologist or psychiatrist to address psychological comorbidities which may be impacting on pain coping and trials of other non-opioid pharmacotherapeutic or interventional strategies.'

With respect to the use of Oxycontin, MIMS recommends:

Use of Oxycontin in 'chronic, non-malignant pain should be restricted to situations where all other conservative methods have been tried and have failed; the pain is having a significant impact on the patient's quality of life; there is no psychological contraindication, drug seeking behaviors or history of drug misuse... Should be integrated into a comprehensive approach...'[11]

There is an acknowledged non-medical use of opioids. For this reason, authors recommend universal precautions should be applied when prescribing these drugs rather than necessarily restricting prescribing policies. The precautions should include regular review, consideration of effectiveness, other non-opioid treatments, multidisciplinary referrals, close monitoring and restrictions on the amounts dispensed.[12] The Australian Medicines Handbook recommends that if an opioid such as oxycodone is used for chronic non-cancer pain, a specialist pain team should be involved.

The class of drugs known as benzodiazepines include diazepam, which has multiple trade names, but in relation to this matter specifically Valium. Adverse effects resulting from the use of benzodiazepines in general have been well documented over a number of years. They are known to be capable of abuse and physical dependence.[13] The phenomenon of tolerance and dependence is moderated by the drugs' effect on particular receptors in the brain.[14] A clinician prescribing any psychoactive medication needs to be mindful of the potential for misuse and set a clear endpoint to the use of the drug. Facilitation of a potentially serious problem can result from a clinician not denying drugs to persons with dependency problems.[15] Prescriptions for hypnotics should be limited to a few days and if used as anxiolytics should be in conjunction with other treatments such as counselling and anti-depressant medication. The length of time of use should be no longer than 2 - 4 weeks. Short courses at low doses may prevent the development of dependence.[16]

Alprazolam is a benzodiazepine, which has been associated with widespread illicit use. In particular alprazolam has been shown to be over represented in benzodiazepine events in Australia.[17] In cases of deliberate overdose by one form of benzodiazepine, alprazolam was found to be relatively more toxic than other benzodiazepines.[18] Its widespread use and misuse deserves special mention. Data collected by the Victorian Institute of Forensic Medicine at the time of the examination of individuals arrested by police for the year 2009 indicate the self-reporting of the use of alprazolam in 26% of persons arrested on suspicion of assault.

The Victorian Coroners Prevention Unit has collected data on deaths due to drugs and has found benzodiazepines feature in 50.3% of drug related deaths. This is exceeded only by opioid analgesics at 51.4%.[19]

An audit of overdose presentations was done in an inner Melbourne emergency department. It was found that alprazolam and diazepam were over-represented in the data relative to the rate of prescriptions in the population. In this study the most common source of the medication was prescription by the patients' usual doctor.[20]

The problems associated with the use of alprazolam were recognised and as consequence the scheduling was changed for S4 classification to S8 on 1 February 2014.

RACGP Guidelines for the use of benzodiazepines

The guidelines are currently under review however the following applied to the period prior to 2014. These guidelines include as point 2) 'Dependence is neither a reason to continue prescribing nor a reason to refuse to prescribe. A short term response would be to prescribe a small quantity of benzodiazepine and seek specialist advice.'[21]

The RACGP's guide: Prescribing Drugs of Dependence will be released in the near future.

This is an antipsychotic medication indicated for the use in schizophrenia and bipolar disorder. In the last few years, reports have been emerging regarding the illicit use of Seroquel.

This is an antidepressant medication used for the treatment of major depression.

Aropax is an SSRI antidepressant Indicated for major depression, obsessive compulsive disorder, panic disorder, social anxiety, social phobia, generalised anxiety disorder, post traumatic stress disorder.

Aropax is associated with increased suicidality in children and adolescents with major depressive disorder. Long term safety data in children and adolescents concerning growth, maturation and cognitive and behavioural development are lacking.[22]

This is a sleeping medication. The indications are insomnia in adults. In general it is well tolerated but in recent years it has been associated with adverse effects including tolerance, dependence, psychiatric paradoxical reactions including hallucinations, nightmare, anger, abnormal behaviour, somnambulism and others.[23] The finding on 10 December 2014 by Coroner, Peter White into the death of Phoebe Handsjuk on 2 December 2010 included the statement '...there is a need for the Australian Therapeutic Goods Administration to review the conditions under which Stilnox is permitted to be prescribed and sold in Australia.'[24]

This is a SSRI anti-depressant medication. Indications for its use are major depression, social anxiety and generalised anxiety disorder.

This is a SNRI anti-depressant medication. It is indicated for major depression, generalised anxiety disorder, diabetic peripheral neuropathy pain, fibromyalgia and chronic musculoske[le]tal pain. It should not be used when there is liver disease also present.[25]

This is a SNRI antidepressant medication indicated for use in major depression and generalised anxiety.

Addiction has a physical basis and is an extremely prolonged illness, perhaps even life-long. The adaptation of the brain to the drug of addiction promotes the compulsive character of drug seeking in addicts.[26] In that drug abuse physically alters a neural pathway causing uncontrolled cravings; it should be viewed as a brain disease. Relapse following cessation can occur by a single drug dose.[27]

1. Agreed facts included that Dr Griffiths:
   • Between 1999 and 2001 prescribed Aropax without recording a clinical reason for the prescription in the notes and without referring the patient for appropriate specialist management despite continuing to prescribe
   • Between 2007 and 2011 prescribed paracetamol/codeine in the form of Codalgin Forte and Panadeine Forte without documenting a clinical reason to do so; and in combination over an extended period of time and in excessive amounts
   • In 2008 prescribed Endone, an addictive medication, with minimal clinical notes
   • In 2010 and 2011, prescribed Valium where there was no medical rationale for the prescription recorded and where in 2011, the prescription of Valium followed a prescription of Xanax, thereby failing to limit the use of hypnotic drugs, and prescribed benzodiazepines without also referring the patient for other forms of treatment such as counselling or antidepressant medication or for specialist assessment or referral
   • Prescribed Oxynorm in 2011 with no or limited clinical notes documenting a rationale to support use of the medication and the dosage and frequency of the medication
   • Prescribed morphine ampoules in 2011 when there was no apparent record of the consultation having occurred
   • Prescribed Xanax Tri-Score in 2010 and 2011 without documenting a medical rationale for the medication, dosage and frequency of the medication
   • Although he ought to have known that the patient was a drug dependent person, did not notify the Department of Human Services that the patient was a drug dependent person, contrary to s 33(3)(b) of the Drugs, Poisons and Controlled Substances Act 1981 (DPCS Act) at any time.
2. Agreed findings included:
   • Inappropriate prescription and/or medical management:
     • unprofessional conduct of a serious nature under the MPA, unprofessional conduct under the HPRA and professional misconduct under the National Law
   • Inadequate records:
     • unprofessional conduct under the HPRA and unprofessional conduct under the National Law
   • Prescribing drugs of dependence in circumstances where practitioner knew or ought to have known that the patient was a drug dependent person:
     • Professional misconduct under the National Law.

1. Agreed facts included that Dr Griffiths:
   • During the period 1999-2013 (intermittently) prescribed:
     • Aropax
     • Xanax, including in 2013 after becoming aware that the patient was on methadone and had a drug dependency
     • Stillnox
     • Codalgin Forte and Panadeine Forte
     • Temazapam
     • Murelax
     • Alprazolam
     • Oxynorm
     • Pristiq
     • Valium.
   • Did not refer the patient for specialist assessment and treatment during the period he treated the patient in circumstances where he was prescribing drugs of addiction, and without preparing a mental health plan for the patient until 2012
   • Did not maintain adequate clinical records explaining the diagnoses and medical rationale for the prescribing and for the quantities and repeats.
2. Agreed findings included:
   • Inappropriate prescription and/or medical management:
     • unprofessional conduct of a serious nature under the MPA, professional misconduct under the HPRA, professional misconduct under the National Law
   • Inadequate records:
     • unprofessional conduct under the MPA, unprofessional conduct under the HPRA, and unprofessional conduct under the National Law.

1. Agreed facts included:
   • Despite being aware that the patient was trying to get off heroin, Dr Griffiths did not acknowledge signs of drug dependency in the patient and continued to prescribe the patient with Panadeine Forte, Codeine Phosphate, Codalgin Forte, Xanax, Valium and, on one occasion, methadone
   • Did not refer the patient for specialist assessment and treatment
   • Was aware that the patient was drug dependent, that he was prescribing drugs of addiction and that prescribing those drugs would have created or alternatively continued a dependency on those drugs.
   • Did not take, record and maintain clear, accurate and adequate clinical records of consultations including details of clinical history and/or assessments, the reasons for prescribing schedule 8 poisons and other medications, and the nature of the treatment plan for the patient
   • Prescribed methadone, on one occasion, without holding a schedule 8 permit
   • Did not recognise and manage the risks associated with treating the person including that the person may have had drug dependency issues and depression and did not act in the patient's best interests by making referrals and when providing or arranging treatment or care.
2. Agreed findings include:
   • Inappropriate prescription and/or medical management:
     • unprofessional conduct of a serious nature under the MPA, professional misconduct under the HPRA, and professional misconduct under the National Law
   • Inadequate notes:
     • unprofessional conduct under the MPA, unprofessional conduct under the HPRA, unprofessional conduct under the National Law
   • Prescribing a schedule 8 poison without a permit:
     • professional misconduct under the HPRA.

1. Agreed facts include:
   • Dr Griffiths held permits to prescribe the schedule 8 poison Oxycodone to the patient at different times between 2008 and 2015
   • After a permit had expired in February 2010 and before a new permit was obtained in December 2011 Dr Griffiths prescribed Oxynorm from July 2010 until 19 September 2011.
2. Agreed findings include:
   • Prescribing schedule 8 poisons without a permit:
     • unprofessional conduct under the HPRA and unprofessional conduct under the National Law.

1. Agreed facts include:
   • Dr Griffiths held permits to prescribe the schedule 8 poison Oxycodone to the patient at different times between 2010 and 2015
   • Prescribed Oxycodone and OxyContin on multiple occasions between 2010 and 2013 when he did not hold a permit, and on multiple occasions prescribed in excess of the maximum dose prescribed on the permit.
2. Agreed findings:
   • Prescribing schedule 8 poisons without a permit and/or in excess of prescribed maximum doses:
     • professional misconduct under the National Law.

1. Agreed facts include:
   • Between April 2010 and September 2010, Dr Griffiths prescribed Oxycodone to the patient being a continuous period of in excess of 8 weeks without a permit for supply, administration or prescription
   • Dr Griffiths later held permits to prescribe Oxycodone to the patient between September 2010 and April 2014 but on a number of occasions in 2012 prescribed Oxycodone when his permit had expired and on two occasions in 2011, prescribed Oxycodone when he did not hold the permit and in excess of the previously or subsequently permitted dosage, and on two occasions in 2012 prescribed OxyContin when his permit had lapsed.
2. Agreed findings:
   • Prescribing schedule 8 poisons without a permit or when permit had lapsed and in excess of the permitted dosages:
     • unprofessional conduct under the HPRA and unprofessional conduct under the National Law.

1. Agreed facts include:
   • Dr Griffiths treated the patient for a period of two years for neuropathic pain, continuously prescribing Tramadol/Tramal
   • Dr Griffiths:
     • continued to prescribe Tramal
     • also prescribed Valium and Codalgin Forte
     • did not refer the patient for specialist management or drug rehabilitation during his treatment of the patient and
     • did not take steps to reduce and cease the patient's drug dependence after the patient had expressed a desire to seek pain management treatment

• Dr Griffiths had discussed with the patient the need to reduce medication levels including the level of consumption and the overuse of benzodiazepines and analgesics
• Dr Griffiths had advised the patient that the patient was taking more than a safe amount of Tramal
• Dr Griffiths became aware that Tramal was not assisting the patient's recovery and
• the patient had expressed a desire to be referred for depression and a drug problem,

1. Agreed findings:
   • Inappropriate prescription and/or medical management:
     • professional misconduct under the HPRA.

1. Agreed facts include:
   • Dr Griffiths treated the patient from 2004 to 2013
   • Dr Griffiths held permits to prescribe oxycodone to the patient for periods in 2008 and 2009 but prescribed OxyContin to the patient for five months in 2008 without holding a permit, and on two occasions in 2009 without holding a permit
   • Dr Griffiths gave directions to the patient for OxyContin tablets in excess of the permit maximum per day on a number of occasions between October 2008 and January 2009.
2. Agreed findings:
   • Prescribing schedule 8 poisons without a permit and/or when permit lapsed and/or in excess of maximum permitted dosages:
     • unprofessional conduct under the HPRA.

1. Agreed facts include:
   • Dr Griffiths consulted with the patient between 2008 and 2012
   • The patient presented to Dr Griffiths in 2008 seeking assistance to stay off heroin and in circumstances where the patient was a drug -dependent person
   • Dr Griffiths prescribed MS Contin to the patient for a period in excess of eight weeks without a permit over three months in 2008.
2. Agreed findings:
   • Prescribing schedule 8 poisons in excess of permit and/or without a permit:
   • professional misconduct under the HPRA.

1. Because the conduct came under the MPA, the HPRA and the National Law, the findings represent the requirements of and the definitions in each of those Acts. The definitions of 'professional misconduct' and 'unprofessional conduct' under the HPRA and the National Law, and the distinction between 'unprofessional conduct of a serious nature' and 'unprofessional conduct not of a serious nature' under the MPA have been discussed in numerous cases.[28] The Board provided detailed written submissions about the definitions and the relevant cases, which we accept.
2. Having considered the evidence, including Dr Sungaila's expert opinion, and the agreed facts, we considered that the agreed findings were appropriate in each case and made findings accordingly at the hearing. We then heard submissions on determination.

1. The objectives and principles in relation to determinations in disciplinary proceedings are well established.
2. The purpose of determinations is protective not punitive. The objective is primarily the protection of the public and the maintenance of professional standards in the eyes of the public.[29]
3. With that protective focus in mind, the Tribunal considers a range of factors including:
   • the nature and seriousness of the conduct;
   • whether the practitioner pleaded guilty or other evidence of contrition or remorse;
   • whether there is a need for specific deterrence (deterring the particular practitioner from further inappropriate conduct) or general deterrence (deterring other practitioners from engaging in similar conduct);
   • whether there have been other disciplinary findings before or since the conduct in question;
   • evidence of character;
   • evidence of rehabilitation;
   • any delay from the time the investigation started to the end of the Tribunal hearing;
   • other mitigating factors such as medical or psychological evidence, family or other personal circumstances.
4. Some of the above factors will overlap. Specific deterrence, for example, requires consideration of the likelihood of the practitioner re-offending,[30] whether because of:
   • a lack of insight into what occurred;
   • a lack of remorse about what occurred;
   • a history of offending conduct as opposed to a one-off explicable departure from otherwise high standards of conduct; or
   • other matters indicating either that a particular sanction is required to deter the practitioner from re-offending or, conversely, that rehabilitation has taken place.
5. As observed by the Tribunal in Medical Practitioners Board of Victoria v Grolaux [No. 2]:[31]

In context, this "insight" might be reflected in a variety of ways, such as an understanding of the nature of the conduct, an acceptance that the conduct was seriously wrong, an appreciation of why the practitioner engaged in that conduct, empathy with the consequences, and/or the willingness to take measures to identify risk factors and to avoid similar behaviour.

1. General deterrence requires consideration of whether there is a need to signal to other members of the profession that adverse consequences will follow such conduct, and thereby deter them from the same conduct, in the interests of maintaining professional standards and public confidence in the profession.[32]
2. The task of the Tribunal in disciplinary proceedings is described by Cosgrove J in Dickens v Law Society:[33]

There is high authority for the proposition that the powers given to the disciplinary committee to discipline a practitioner are entirely protective in character. No element of punishment is involved... But to say that is merely to say that the powers are to be exercised for the purpose of, and in a manner seen likely to achieve, the maintenance of that high standard of conduct within the profession which will continue its good reputation, and protect, not only the future of the profession, but also protect its clients from harm.

With this object in mind, the committee is required to look to the future. Even if the practitioner's misconduct be relatively slight, he may yet be struck off, if his capacities and attitude have been revealed to be such that his continuance in practice constitutes a threat to the profession. On the other hand, conduct which is itself more grave in nature, may not warrant striking off, if it is seen as a temporary and explicable departure from the practitioner's own high standards... The order which the committee is called upon to make is that order which, in its opinion, is necessary, and no more than is necessary, to maintain professional discipline and high standards of conduct.

1. Every case will be different. The nature of the offending conduct, the particular circumstances of the practitioner, the context of the offending and its duration, and the risk of repetition are all factors which will rarely be identical in any two cases.[34]
2. Penalties imposed in other cases involving similar or analogous conduct will be a useful guide to proportionality, and to ensuring that the penalty imposed in the particular case is not outside the range of penalties imposed in the relevant jurisdiction. However, principles of parity should not override the need to consider the unique facts and circumstances of the case at hand.[35]
3. In this case, for example, we were referred to Medical Board of Australia v Garland (Review and Regulation) [2015] VCAT 873 (Garland) and Medical Board of Australia v Fox (Review and Regulation) [2016] VCAT 408 (Fox) as potentially comparable.
4. Both concerned inappropriate prescribing of schedule 8 drugs and medical management of patients, in Garland for a relatively short period of time, in Fox for an extended period of time.
5. In both Fox and Garland the practitioner had been convicted of offences under the DPCS Act, which Dr Griffiths has not.
6. Dr Garland was reprimanded and conditions were imposed. Dr Fox was reprimanded, conditions were imposed and his registration was suspended for a period of 12 months, which was a joint proposed determination by the parties. We note that Dr Fox's conduct involved 18 patients, 115 allegations and 58 convictions for offences under the DPCS Act.
7. Those cases are useful as showing the range of determinations that may be imposed, depending on the particular circumstances in the case.
8. As submitted by Counsel for Dr Griffiths, however, it is important for the Tribunal not to be distracted by what determination was imposed in other cases, but instead to focus on the factual matrix in the case before it, what the relevant considerations are in the case and what is necessary to achieve the objectives of a determination.
9. As was observed by this Tribunal in Medical Board v Schulberg (Review and Regulation) [2013] VCAT 823, [22]:

We have not attempted a detailed analysis of all the cases put before us by Mr Grace because, notwithstanding this Tribunal's desire to strive for consistency of decision-making, there is no such thing as a tariff in these disciplinary matters and each hearing turns on its own particular facts.

The relevance of the joint proposed determinations

1. As the Board submitted, the imposition of penalty is, ultimately, a matter for the Tribunal but the agreement of the regulator and the practitioner about determinations is a significant matter and weight can and should be given to it by the Tribunal.
2. As submitted by Counsel on behalf of Dr Griffiths, in Secretary to the Department of Planning and Community Development v Muto [2011] VCAT 328, Ross J adopted the same approach as taken in proceedings in respect of civil penalties, namely that where a regulatory authority and a respondent have reached a negotiated settlement and the penalty is 'broadly speaking within the permissible range having regard to all the circumstances,' the Court [or in Muto's case, the Tribunal], should not depart from it.[36] In that case, His Honour was considering the appropriate penalty for alleged misconduct by a councillor under the Local Government Act 1989.
3. What is often omitted in references to Muto, however, is that Ross J stated at the commencement of the relevant section of the decision that:

Ultimately the question of the appropriate penalty in a particular case is a matter for the Tribunal, though the consent of the parties is clearly a significant consideration.[37]

1. With respect, we agree that it is ultimately a matter for the Tribunal what orders are made. Further, as submitted by Counsel on behalf of Dr Griffiths, it is the Tribunal's function to determine what the 'permissible range' is in any particular case. This requires in our view stepping back from the proposed determination and making an independent assessment of what might be appropriate determinations in the case, in order to determine 'the range'.
2. Nevertheless, an agreement of the parties obviously has weight in the Tribunal's consideration of the appropriate determinations; more so, in our view, where, as here, both the Board and the practitioner are represented by experienced legal practitioners. And there is a public interest in encouraging responsible parties to reach agreement. Agreed facts and findings save the need for witnesses to attend, considerably shorten hearings and significantly reduce costs for the parties and the Tribunal. Joint proposed determinations may be an integral part of the final agreement reached.
3. In reaching our view of the appropriate determinations, we have given weight to the jointly proposed determinations, as supplemented by the additional orders proposed at the further hearing.

1. We have found that Dr Griffiths, over a period of time between 1999 and 2013, engaged in a range of conduct below accepted standards. Some of it has warranted findings of professional misconduct. The findings themselves indicate the range and seriousness of the conduct.
2. The context is that Dr Griffiths has been in practice since 1980, for over 30 years as a general practitioner in Cobden, and for most of those years in sole practice. He usually sees over 200 patients per week, and sees patients out of hours and on weekends. These proceedings concern nine of the patients seen over that period of time. This is not to minimise the seriousness of unacceptable conduct in relation to any of those patients but it is to put the incidence of the conduct in context.
3. It is clear that in relation to one category of conduct, that of inappropriate treatment of a person with whom he shared a close personal or family relationship, Dr Griffiths did not appreciate at the time but appreciates now that he lacked the objectivity required to treat the patients with whom he had a close relationship, and that though he came under some pressure to do so, should have resisted the pressure. He recognises now that he should have referred the patients earlier for specialist assessment and should not have tried to manage their various medical needs himself.
4. As submitted on behalf of Dr Griffiths, the Medical Board of Australia's Code of Conduct,[38] which came into operation in 2014, does not absolutely prohibit providing medical care to persons with whom the doctor has a close personal relationship.
5. The Code does, however, warn against providing medical care in such circumstances. The Code at s 3.14 states that:

Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because of the lack of objectivity, possible discontinuity of care, and risks to the doctor and patient. In some cases, providing care to those close to you is unavoidable. Whenever this is the case, good medical practice requires recognition and careful management of these issues.

1. As Dr Sungaila notes in her report, while there is no code or rule which absolutely prohibits prescribing to persons with whom a medical practitioner has a close personal relationship:

it is generally agreed that combining a therapeutic and personal relationship may be detrimental to the welfare of the patient.

Dr Julian Walter summarises the legislative requirements for self and family prescribing in Australia by saying 'prescribing for family members should be avoided as a matter of good medical practice.'[39]

American research has found that when family members become ill, physicians confront competing expectations especially when circumstances arise that are seen by the doctor to prevent adequate care for the particular family member. The authors also point out that physicians will always be family members and the value of their emotional attachments to relatives should not be dismissed.'[40]

1. Although the Code was not in force at the time of some of the conduct in this category, in our view it would be generally accepted that doctors should not seek to treat persons with whom they have a close relationship for anything requiring more than, for example, a one-off script for antibiotics where that is clearly warranted and it is important that treatment begin immediately.
2. What is or ought to be clear is that for anything more complex, the closeness of the personal relationship is likely to interfere with the therapeutic relationship, potentially cloud the practitioner's judgement, and introduce competing concerns to the detriment of the patient's welfare and best interests. This is obvious, in our view, where the proposed treatment includes opioids, benzodiazepines or other drugs of dependence or where there may be mental health concerns.
3. As we observed at the hearing, it is desirable, in our view, that clearer guidance be provided to doctors and specific examples be given of where the line should be drawn.
4. Dr Griffiths acknowledges that in the circumstances here it was not appropriate for him to treat the patients concerned, he accepts that his treatment may not have been in their best interests, and he no longer treats those persons.
5. An additional risk is that, particularly if the doctor sees the patient out of hours or on weekends or away from his or her medical practice, the records of the consultation may be inadequate, as they were in this case.
6. In relation to the findings about breaches of schedule 8 permit obligations, although there are a number of breaches, and they are of concern, Dr Griffiths has clearly tried to comply with the requirements. Dr Griffiths gives a strong impression of a practitioner who was mindful of permit obligations and tried to comply with the requirements. It is not a case of a practitioner entirely disregarding his or her permit obligations. On the other hand at the hearing he appeared to be unsure about some of the detail of his obligations, which was of concern to us. For this reason, apart from other considerations, some further education in the area is clearly desirable.
7. He stated that because of the number of patients he was seeing, he was finding it difficult to check his permits on each occasion. His process at the time was to attempt to check his permit obligations by searching the patient file, often a time-consuming and convoluted process.
8. He now has in place a system that more readily assists him to appreciate what his permit obligations are. The system involves writing the expiry date of the current permit on the open 'comments' box of his medical software; and it appears in red when he opens the patient's file for the purpose of the consultation. The same section will inform him whether or not he has applied for a permit for the patient, just in case the patient returns to him and the permit has not arrived. He says that his current system is working well.
9. This is also not a case where Dr Griffiths has become what might be described as a 'go to' doctor for drug dependent and drug seeking persons.
10. The references provided to us included one from Peter Clayton, recently retired Victoria Police member who had 30 years of service including the last 20 years policing in and around the Cobden, Camperdown and Colac areas. He stated that in the course of his duties he investigated numerous drug offences and offenders. As part of these investigations, he had contact with numerous informers and also spoke with numerous drug offenders during this time. Some of his investigation centred on the use and trafficking of prescription medications, including OxyContin and similar, which were usually sourced as a result of "doctor shopping" for attendance on sympathetic doctors.
11. Mr Clayton stated that during the course of his career, he has never heard Dr Griffiths being named in any way by either sources or offenders nor has he received any information that Dr Griffiths was open to being involved in the writing of prescriptions for OxyContin or similar under false pretences. Nor has he ever heard Dr Griffiths been named as a doctor who was approachable or a sympathetic doctor for obtaining OxyContin or similar. Over the course of his career, he did, from time to time, receive information about other doctors being sympathetic to persons wishing to obtain OxyContin, which he reported as a matter of course to the Health Department.
12. Mr Clayton also states that he has been a private patient of Dr Griffiths for approximately 20 years, and that if he had had any suspicions that he was a doctor who would write prescriptions for OxyContin or similar without a medical reason, would not have had him as his doctor.
13. As a long serving member of Victoria Police in the local area, Mr Clayton's character statement has weight and is consistent with the impression given that Dr Griffiths, unlike other practitioners who have come before the Tribunal, was neither amenable to doctor shopping or a 'soft touch' for drug seekers. If he were, it would have been more evident in the allegations made to the Tribunal, particularly as his patients include numbers of people who suffer from chronic pain as a result of work and other injuries and he works closely in conjunction with drug and alcohol rehabilitation service providers and pain management specialists.
14. It is also relevant that, unlike other practitioners who have come before the Tribunal, such as in Garland and Fox, Dr Griffiths was not charged with any offences under the DPCS Act.
15. In framing orders and determining their severity, credit must be given to Dr Griffiths for the cooperation he has shown and the admissions that he has made. It is also a strong indication of insight, which is directly relevant to an assessment of the risk of reoffending and in turn relevant to specific deterrence.
16. As observed by the Tribunal in Groleaux, referred to above, insight may be reflected in the number of ways, such as an understanding of the nature of the conduct, acceptance that it was seriously wrong, appreciation of why the practitioner engaged in conduct and willingness to take measures to identify risk factors and avoid similar conduct in the future.
17. By his cooperation in these proceedings, Dr Griffiths has demonstrated insight into and acceptance of responsibility for the conduct and has shown himself willing to take measures to avoid repetition of the conduct.
18. Dr Griffiths also gave evidence before us and submitted to cross examination, which is also to his credit.
19. There have been no other disciplinary findings, before or since, the conduct in question, the bulk of which occurred between 2008 and 2013. At no time since commencing its investigation, has the Board imposed any conditions on Dr Griffiths' registration (unlike in Fox) nor did the Board take any action to suspend his registration on an immediate action basis.
20. This is relevant in a number of ways. It indicates that Dr Griffiths was not considered to be a serious risk to the health or safety of the public. He has had almost four years in practice since the investigation started without incident. It is not a case where there are any reasonable concerns about his current fitness to practice.
21. As we understand it, the joint proposed determination of a three-month suspension of his registration is intended to address considerations of general deterrence. It will, in our view, achieve that.
22. In Honey v Medical Practitioners Board of Victoria (Occupational and Business Regulation) [2007] VCAT 526 at [41]-[61], the Tribunal discussed the difference between the determinations of suspension and cancellation and stated as follows:

The major difference between a suspension and cancellation is that once the doctor's registration is cancelled, he must reapply after the period specified. It is not guaranteed that he will be so re-registered. He must satisfy the Board that registration is appropriate and that he fulfils the qualifications for general registration...

Cancellation of registration sends a clear message of unsuitability to practice. Suspension may be thought to indicate confidence in the doctor's future ability to practise once the period of suspension is served.

There are some cases in which it is abundantly clear that deregistration is the only option available to protect the public from a miscreant doctor.

This is apparent in situations in which the practitioner does not accept the inappropriateness of his conduct or has been shown to be a serial offender.

1. In its submissions, the Board stated that the parties propose the determinations on the basis that Dr Griffiths' conduct was sufficiently flawed as to warrant a period of suspension in addition to a reprimand and the imposition of conditions on his registration. We agree.
2. In this case, we gave considerable weight to the joint proposed determinations. We expressed the concern that the period of suspension might not sufficiently address a number of relevant factors, but were ultimately persuaded that, with the addition of a further protective condition and additional hours of education, the proposed orders were appropriate in this case.

[1] Because there have been three Acts of Parliament regulating the conduct of medical practitioners over the period, separate allegations have to be made under each.

[2] Medical Board of Australia v Fox (Review and Regulation) [2016] VCAT 408.

[3] Duke A, Bigelow G, Lanier R, Strain E. Discriminative stimulus effects of tramadol in humans. J Pharmacol Exp Ther 2011 338(1) 255.

[9] McDonough M. Safe prescribing of opioids for persistent non-cancer pain. Australian Prescriber 2012 35(1).

[10] McDonough M. Safe prescribing of opioids for persistent non-cancer pain. Australian Prescriber 2012 35(1).

[12] Degenhardt L, Gilmour S, Shand F: Estimating the proportion of prescription opioids that is consumed by people who inject drugs in Australia. Drug and Alcohol Review 2013 (32) 468-474.

[13] Busto U, Sellers EM. Pharmacologic aspects of benzodiazepine tolerance and dependence. J Subst Abuse treat 1991 8(1-2) 29.

[14] Leonard, B. Commentary on the mode of action of benzodiazepines; J Psychiatr Res. 1993 27(1) 193.

[15] Finch J. Prescription drug abuse; Primary Care 1993 20(1) 231.

[16] Ashton H, Guidelines for the rational use of benzodiazepines. When and what to use. Drugs 1994 48(1) 25.

[17] Moylan S, Giorlando F, Nordfjaern T, Berk M 'The role of alprazolam for the treatment of panic disorder in Australia' Australian and New Zealand Journal of Psychiatry (2012) 46(3) 212-224.

[18] Isbister G, O'Regan L, Sibbritt D, Whyte I 'Alprazolam is relatively more toxic than other benzodiazepines in overdose' British Journal of Clinical Pharmacology 2004 58(1) 88-95.

[19] Jeremy Dwyer 'Coronial Insights into understanding and preventing drug-related harms' Pharmaceutical Society of Australia, Harm Minimisation Forum, 12 September 2012.

[20] Buykx P, Loxley W, Dietze P, Ritter A 'Medications used in overdose and how they are acquired - an investigation of cases attending an inner Melbourne emergency department' Australia and New Zealand Journal of Public Health 2010 34(4) 401.

[21] The Royal Australian College of general Practitioners. Guidelines: benzodiazepines.

[24] Inquest into the death of Phoebe Handsjuk 2014.

[25] Eli Lilley prescribing information 2014.

[26] Kalivas P, Volkow N. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry 2005 162(8) 1403.

[27] Clay S, Allen J, Parran T. A review of addiction. Postgrad Med 2008 120(2).

[28] See for example Medical Board of Australia v Jansz [2011] VCAT 1026, Medical Board of Australia v Fox [2016] VCAT 408 and Medical Board of Australia v Dr John Myers (Review and Regulation) [2013] VCAT 1315 [MPA and HPRA].

[29] Ha v Pharmacy Board of Victoria [2002] VSC 322 at paragraph [91] and [97] followed in Medical Practitioners Board of Victoria v Grolaux (No. 2) (Occupational and Business Regulation) [2009] VCAT 978; Health Care Complaints Commission v Lichfield [1997] NSWSC 297; (1997) 41 NSWLR 630 at 637; Medical Board of Australia v Janz [2011] VCAT 1026. Psychology Board of Australia v Mair [2010] VSC 628; Morris v Psychologists Registration Board (Unrep) Supreme Court of Victoria, 19 November 1997, per Harper J at 12.

[30] The risk of repetition of misconduct is an important factor for the Tribunal to consider: Ha v Pharmacy Board of Victoria at [101].

[31] [2009] VCAT 978 at [8].

[32] Per Ross J, in Brott v Legal Services Commissioner [2008] VCAT 2399 at [67]

[33] Unreported, Supreme Court of Tasmania. See also Chiropractic Board of Australia v Hooper [2013] VCAT 1346 at [22].

[34] Medical Board of Victoria v Myers [VCAT] 2013 1806 [17]-[18].

[35] Dental Practice Board of Victoria v Dr Hassed [2006] VSC 485 per Hargrave J.

[36] In Legal Services Commissioner v Zervas [2015] VCAT 356, Senior Member Smithers observed that it appeared that the approach taken by Ross J remained 'good law'.[25]

[38] Good Medical Practice: A Code of Conduct for Doctors in Australia (the Code).

[39] Dr Julian Walter, 'Prescribing for Self and Family' defence update September 18 2012.

[40] Frederick Chen, Chris Feudtner, Lorna Rhodes, 'Original Research: Role conflicts in physicians and their family members: rules but no rulebook', Western Journal of Medicine 2001: 175: 236-239.