Page 1165 - Basic _ Clinical Pharmacology ( PDFDrive )

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