1. Catherine A. Marco, MD, FACEP

2. Goals & Objectives Describe the proper physician-patient relationship Describe clinical decision making regarding medication prescriptions Delineate the basic components of a written prescription

3. The Physician-Patient Relationship Patient identification Establish diagnosis Treatment plan, options, counseling Follow-up care Online or telephone evaluations are not adequate A pharmacy may not fill a controlled substance prescription in the absence of a proper physician-patient relationship

4. Prescription A prescription order is written for diagnosis, prevention or treatment of a specific patient's disease Is written by a licensed practitioner Is written as part of a proper physician-patient relationship Is a legal document, "prima facie" evidence in a court of law.

5. Over-The-Counter -OTC Patient can use drug safely by reading the labeling instructions. Examples analgesics like aspirin and ibuprofen topical antibiotics Cough and cold remedies Some vitamins

6. Rx Only Drugs Can only be dispensed on a prescription order Synonyms: Legend (or dangerous) Physician training required to use safely Examples Most systemic antibiotics Cardiovascular drugs Most drugs that have dependence liability

7. Controlled Substances Drugs with abuse potential Classification CI, CII, CIII, CIV, CV Schedule III,IV, V are obtained on a regular prescription Must include date Must include prescriber DEA# Schedule II drugs require an “official” Rx form (formerly used a “triplicate Rx”) Schedule I, some drugs (chemicals) may not be available by any legal means Heroin LSD

8. Schedule I The drug or other substance has a high potential for abuse. The drug or other substance has no currently accepted medical use in treatment in the United States. There is a lack of accepted safety for use of the drug or other substance under medical supervision. Some Schedule I substances are heroin, LSD, marijuana, and methaqualone.

9. Schedule II The drug or other substance has a high potential for abuse. The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. Abuse of the drug or other substance may lead to severe psychological or physical dependence. Schedule II substances include morphine, PCP, cocaine, methadone, and methamphetamine.

10. Schedule III The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence. Anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates are Schedule III substances.

11. Schedule IV The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III. Included in Schedule IV are Darvon, Talwin, Equanil, Valium and Xanax.

12. Schedule V The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule IV. The drug or other substance has a currently accepted medical use in treatment in the United States. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV. Over-the-counter cough medicines with codeine are classified in Schedule V.

13. Parts of the Prescription Rx (an abbreviation for "recipe," the Latin for "take thou.“) Superscription (Patient Information) Inscription Subscription Signa Date Signature lines, signature, degree, brand name indication Prescriber information DEA# if required Refills Warnings

14. Patient Information Name Address Age (Required on triplicate or “official”) (30y/o) Weight (optional, but useful) Time-(inpatient medication orders)

15. Inscription What is the pharmacist to take off the shelf? Drug Name Dose = Quantity of drug per dose form Dose Form = The physical entity needed, i.e. tablet, suspension, capsule Simple vs Compound Prescriptions Manufactured vs compounded prescriptions Clarity of number forms 0.2, 20| not 2.0 (Zeros lead but do not follow!)

16. Subscription What is the pharmacist to do with the ingredients? Quantity to be dispensed (determines amount in bottle) Dispense # 24 For controlled substances write in numbers and letters (like a bank check) #24(twenty four) Any special compounding instructions

17. Signa, Signatura or Transcription Instructions for the patient Route of administration: Oral, nasally, rectally, etc Take by mouth.., Give, Chew, Swallow whole, etc. Number of dosage units per dose (Take one tablet, Give two teaspoonfuls, etc). Frequency of dosing (every six hours, once a day, etc.) Patient lifestyle, inpatient schedules (compliance) Duration of dosing (...for seven days,... until gone,...if needed for pain). Purpose of medication for pain, for asthma, for headache, etc. Avoid “As directed” Special instructions (shake well, refrigerate etc.) Warnings

18. Refills and Date Prescribed Indicate either no refills or the number of refills you want (don’t leave it blank) Date the prescription All prescriptions expire after one year Schedule II drugs can only be dispensed within 6 months of date on RX

19. Signature of the Prescriber This makes the prescription a legal document Include your degree One signature line You must write “brand necessary” or “brand medically necessary” to get non-generic agent. Electronic Rx’s coming!

20. D.E.A. Registration Number Drug Enforcement Agency (DEA)-US Government Also enforced by Texas Dept. Public Safety (DPS) DEA# is needed on any controlled substance (CII-CV)

21. Communicate Before You Medicate! Tell patient the name of the drug and what it is for. Tell your patient exactly how to use the medication Warn them of possible problems What to do if dose is missed Cost (source?) and storage Review Rx for possible for errors

22. Common Abbreviations qd or od = every day qod = every other day bid = twice daily tid = thrice daily qid = four times/day ac = before meals pc = after meals hs or qhs = at bedtime disp = dispense prn = as needed po = by mouth (orally) IV = intravenous IV push or bolus = at one time IV infusion = infuse over time IM = intramuscular stat = immediately sq or sc = subcutaneous sig = signa or signetur = directions for use

24. Qod and qid can get mixed up; qod and qd can get mixed up. One solution is to write out “once a day” or “once every other day” or “four times daily.” This brings up the confusion between q6h and qid. Does this medication require a strict 6-hour dosing interval? Or, can it be given four times daily, for example, in a 6:30 AM to 11:00 PM day?

25. Telephone Orders Telephone orders may be placed for drugs in Schedules III, IV, and V. A written prescription is required for ordering drugs in Schedule II. In an emergency, a prescription for Schedule II drugs may be telephoned to a pharmacy. If the pharmacy is willing to accept the telephone order, only enough drug to cover the emergency may be prescribed. The physician is then required to supply a written prescription to the pharmacy within 72 hours. The pharmacist is required to call the "Feds" if he doesn't receive the prescription within 72 hours. "Emergency" means that the immediate administration of the drug is necessary to proper treatment, that no alternative treatment is available, and that it is not possible for the physician to provide a written prescription order for the drug at that time.

33. Risk Management Strategies for Prescribers B E P ROFESSIONAL AND C OURTEOUS K EEP G OOD R ECORDS P ROVIDE A DEQUATE AND I NFORMED C ONSENT T ELL AND ALLOW P ATIENTS TO CALL WHEN NECESSARY P ROVIDE THE P ATIENT WITH A R EALISTIC A SSESSMENT OF O UTCOME, B ENEFIT, AND A DVERSE R EACTIONS D O NOT SUPPORT F ALSE E XPECTATIONS

34. Let’s Write the Prescription!

35. John Smith 4/12/10 NKDA 25 Motrin 600 mg tablet onepoThree times dailyPRN Pain 50 tabs 1 Catherine Marco, MD Ankle sprain

36. Questions?