High-quantity Rxs for controlled substances: Suggested guidelines for prescribers, pharmacies, and patients

September 10, 2014

A few simple precautions could decrease opioid abuse significantly.

Most pharmacists are well aware of the newly enacted laws regarding the reclassification of hydrocodone products to Schedule II. The reality is that two players are the major providers of controlled substances to reach the street. They are the prescribers and the pharmacist.

Teachable moment

I had a phenomenal mentor when I became a pharmacist. One day he asked me to fill a prescription for the drug Seconal, a very addictive medication for sleep. I pulled the drug off the shelf and compared it to the prescription. It looked fine.

He asked me, “What's wrong with this prescription?”

I double- and triple-checked. “ I don’t see anything wrong,” I said.

He asked me who the doctor was. I read off the name, and again my mentor asked, “What is wrong with this prescription?”

I was baffled.

My mentor said, “You just made the classic error of most pharmacists. What is the doctor’s specialty?”

 “He’s a podiatrist,” I replied.

“Why would a podiatrist write for 30 Seconal, unless he wants the person's feet to fall asleep? This prescription is not legitimate. Remember, only fill prescriptions written within the expertise of the prescriber.”

 

Baby steps

Would you fill a prescription for 90 Vicodin from a dentist, 120 Percocet from a pediatrician, or 90 OxyContin from a dermatologist? This is what is happening today.

If you look at the areas of medicine, only 5% have the need to write for large quantities.

In my opinion, rather than clamping down on prescribers and pharmacies, the DEA is taking baby steps. Currently the DEA wants to make these drugs Schedule Two, allowing the prescriber to write for large quantities, with no refills allowed. This does not really solve the problem.

The prescriber’s responsibility

My suggestion to the DEA is this.

Any prescriber who wants to write for large amounts of a controlled substance should obtain a special provider number, assigned only to providers who want to prescribe large quantities of a controlled substance, such as oncologists and surgeons.

When I was doing research on addiction, for example, I needed to get an additional license to obtain cocaine and heroin, which were classified as Schedule One drugs. I am suggesting a similar special license.

Then, when the prescription is written, a prior authorization will be required before the prescriber can write for a larger amount.

There may be a problem with prescribers who claim that their specialty is pain management. To get around this, they should be required to prove their expertise by being board-certified.

 

Spell it out

In addition, when prescribers are writing Rxs, any required quantity should be spelled out - written in letters and not in numerals. For example, 10 should be written ten, 12 should be twelve, 20 should be twenty, and so on. This totally eliminates the possibility that an Rx could be altered.

Addicts will add a 0 to the 10 or 12, giving them 10 times the amount ordered. Or they will put a 1 in front of the 20 and get the same results.

Really, the quantities for all control substances should be written out.

The pharmacist’s responsibility

When the prescription is presented to the pharmacy, it will be the responsibility of the pharmacy to verify the authorization.

In the case of an emergency, the pharmacist should contact the prescriber; any prescriber can write for a three-day supply.

The patient’s responsibility

It is the responsibility of the patient to keep tabs on the supply and contact the prescriber when necessary.

Don’t abuse the privilege

To be able to prescribe is a privilege that is not to be abused. Some physicians still have the attitude that because they have a license, they can write for anything, even though they have no expertise in the field of pain management.

Will this be inconvenient for prescribers and patients? I really doubt it.

Will it help keep these drugs off the street? Absolutely.  And it will save lives.

Robert Katz has been a working pharmacist for 43 years and is still passionate about the profession. You can e-mail him atPharmrobert@gmail.com