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CHAPTER 65  Rational Prescribing & Prescription Writing        1151


                      their discharge medications because the hospital is not reim-  that can be safely self-administered by the layman for self-limiting
                      bursed for them by the insurer; others leave the hospital   conditions and for which appropriate labels can be written for lay
                      without having their prehospitalization medications resumed.   comprehension (see Chapter 63). Half of all drug doses consumed
                      In  many  cases, patients  cannot  afford  the  medications   by  the  American public  are  OTC drugs.  In 2014  in  the  USA,
                      prescribed.                                        $373.9 billion was spent on prescription drugs and $30.7 billion
                    2. The patient fails to take the medication as prescribed. Examples   was spent on OTC drugs, more than any other country.
                      include wrong dosage, wrong frequency of administration,   Physicians, dentists, podiatrists, and veterinarians—and, in
                      improper timing or sequencing of administration, wrong route   many states, specialized pharmacists, nurses, physician’s assistants,
                      or technique of administration, or taking medication for the   and optometrists—are granted authority to prescribe certain
                      wrong purpose. This usually results from inadequate communi-  drugs  (those bearing the federal legend statement, “Rx Only”)
                      cation between the patient, the prescriber, and the pharmacist.  on the basis of their training in diagnosis and treatment (see
                    3. The patient prematurely discontinues the medication. This can   Box:  Who May Prescribe?). Depending on the state, mid-level
                      occur, for instance, if the patient incorrectly assumes that the   practitioners may prescribe/furnish prescriptions. Pharmacists
                      medication is no longer needed because the bottle is empty or   are authorized to dispense prescriptions pursuant to a prescriber’s
                      symptomatic improvement has occurred.              order provided that the medication order is appropriate and
                    4. The patient (or another person) takes medication inappropri-  rational for the patient.  Nurses  are  authorized to administer
                                                                         medications to patients subject to a prescriber’s order.
                      ately. For example, the patient may share a medication with   Because of the multiplicity of third-party payers (health insurers)
                      others for any of several reasons.
                                                                         and Medicare and Medicaid claimants, the concept of electronic
                       Several factors encourage noncompliance. Some diseases cause   processing of prescriptions (“e-prescribing”) has become urgent.
                    no  symptoms  (eg,  hypertension);  patients  with  these  diseases   (Further information about e-prescribing may be found at http://
                    therefore have no symptoms to remind them to take their medica-  www.cms.gov/Medicare/E-Health/Eprescribing/.) To further stan-
                    tions. Patients with painful conditions such as arthritis may con-  dardize electronic prescription transmission and billing, the Centers
                    tinually change medications in the hope of finding a better one.   for Medicare and Medicaid (CMS) issued regulations effective in
                    Characteristics of the therapy itself can limit the degree of com-  2008 requiring all US health care providers to obtain a National
                    pliance; patients taking a drug once a day are much more likely   Provider Identification (NPI) number. This 10-digit identifier is
                    to be compliant than those taking a drug four times a day. Vari-  issued by the National Plan and Provider Enumeration System
                    ous patient factors also play a role in compliance. Patients living   (NPPES) at https://NPPES.cms.hhs.gov. The purpose of the NPI
                    alone are much less likely to be compliant than married patients   is to identify all health care transactions (and associated costs)
                    of the same age. Packaging may also be a deterrent to compli-  incurred by a particular practitioner with a single number.
                    ance—elderly arthritic patients often have difficulty opening their   In addition to a health care provider’s unique identification
                    medication containers. Lack of transportation as well as various   number,  some  states  require  that  prescriptions  for  controlled
                    cultural or personal beliefs about medications are likewise barriers   substances be written on tamper-resistant security prescription
                    to compliance. For example, some parents refuse to allow their   forms. The purpose of this legislation is to prevent forgeries and
                    children to be vaccinated because of a misguided fear of autism.  to tighten the control of prescription order forms.
                       Strategies for improving compliance include enhanced com-  The concept of a “secure” prescription form was expanded by the
                    munication between the patient and health care team members;   federal government in 2008 to all prescriptions written for Medicaid
                    assessment of personal, social, and economic conditions (often   patients. Any prescription for a Medicaid patient must be written
                    reflected in the patient’s lifestyle); development of a routine for   on a security form if the pharmacist is to be compensated for the
                    taking  medications (eg, at mealtimes  if the patient has regular   prescription service. In turn, the use of “triplicate” prescription forms
                    meals); provision of systems to assist taking medications (ie, con-  was eliminated and replaced with an online electronic transmission
                    tainers that separate drug doses by day of the week, or medication   system whereby orders for Schedule II, Schedule III, and Schedule IV
                    alarm clocks that remind patients to take their medications); and   prescriptions are transmitted to a company that acts as a repository
                    mailing of refill reminders by the pharmacist to patients taking   for these transactions. In California, it is called the CURES program
                    drugs chronically. The patient who is likely to discontinue a medi-  (Controlled Substances Utilization Review and Evaluation System).
                    cation because of a perceived drug-related problem should receive   Prescribers are provided with a record of who prescribed which con-
                    instruction about how to monitor and understand the effects of   trolled drug to which patient. Additional information about CURES
                    the medication. Compliance can often be improved by enlisting   may be found at http://oag.ca.gov/cures-pdmp.
                    the patient’s active participation in the treatment.   In the USA, prescription drugs are controlled by the US Food
                                                                         and Drug Administration (FDA) as described in Chapter 1. The
                                                                         federal legend statement as well as the package insert are part of
                    LEGAL FACTORS (USA)                                  the packaging requirements for all prescription drugs. The pack-
                                                                         age insert is the official brochure setting forth the indications,
                    The United States government recognizes two classes of drugs:   contraindications, warnings, and dosing for the drug.
                    (1) over-the-counter (OTC) drugs and (2) those that require a pre-  The prescriber, by writing and signing a prescription order,
                    scription from a licensed prescriber (Rx Only). OTC drugs are those   controls who may obtain prescription drugs. The pharmacist may
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