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prescribing

prescribing medications in Australia

introduction

  • prescribing medications in Australia is controlled by Federal laws including:
    • Drugs, Poisons and Controlled Substances Act 1981
  • medical boards investigating doctors' inappropriate or dangerous prescribing including failure to comply with regulations, have usually been a result of either:
    • ignorance
    • naivete
    • inability to refuse a patient's request for medication
    • failure to adequate check for allergies
  • verbal instructions to nurses to administer should be confirmed in writing as soon as possible
  • nurses are not permitted to give verbal instructions to pharmacists to supply medications - this can only be given by medical practitioners in an emergency, and then confirmed in writing ASAP.
  • pharmacists are legally obliged to confirm with the prescriber if they have concerns about a prescription and it is expected the prescriber will respond to the request. The pharmcist is legally obliged to refuse to supply a medication if they are sufficiently concerned.
  • faxed prescriptions to pharmacies are generally NOT permitted for Schedule 4 and 8 poisons - originals must be provided.

ordering and precribing medications in a hospital

  • there are 3 DIFFERENT PROCESSES:
    • the medication and IV charts:
      • these are NOT precriptions but ORDERS FOR ADMINISTRATION
      • they are thus NOT under the same legal requirements as prescriptions
      • they are ONLY for administration of medications to patients and are NOT for prescribing and dispensing of medications for the patient to take home
    • discharge prescriptions:
      • these are prescriptions which are dispensed by a pharmacist
      • the general PBS hospital script pad is in triplicate
      • the last page is retained in the hospital medical records if the patient will be presenting the script to an external pharmacy
    • non-pharmacist dispensed discharged prescriptions:
      • these are generally prescribed within an Emergency Department and dispensed from the ED “After-Hours” or drugs of dependency cupboard and given to the patient to take home
      • these are subject to the same legal requirements as for all prescriptions
      • just documenting the order on a medication chart does NOT fulfill these requirements
      • some hospitals mandate a full PBS triplicate script is completed
      • some hospitals allow for alternate mechanisms

TGA schedules

  • Unscheduled:
    • these items are not classified and you can purchase them without restriction (for example, at a supermarket)
  • over-the-counter (OTC):
    • Schedule 2 (S2): You can only purchase these medications at a pharmacy
    • Schedule 3 (S3): You can only purchase these medications from a pharmacy, where a pharmacist must personally hand you the medicine and give you an opportunity to seek advice on the medicine
  • prescription only:
    • Schedule 4 (S4): You can only purchase these medications with a prescription, this includes most items on the PBS
    • Schedule 8 (S8): These medicines are classified as drugs of dependence or addiction
  • they must be written in indelible form (i.e., ink or ball-point pen) in the prescriber's own handwriting either on the standard PBS prescription, or on paper approximately 18 cm x 12 cm, or they can be generated by computer on a form approved by the Department of Human Services. For patient safety reasons, both the original and the duplicate must be legible
  • contain full details of the prescriber including name, practice address and telephone number
  • contain the patient's name and address
  • identify the medication unambiguously
  • show the item, dose, form, strength, quantity and instructions for use, and number of repeats (in words and figures if Schedule 8 poison)
  • be signed by the prescriber, preferably in a manner that prevents the patient from adding an additional item above the prescriber's signature.
  • must not be forward or back dated
  • maximum of 3 items per script (one only if Authority script)
  • contain precise directions for administration, except if directions are too complex and are provided separately in writing, or if administration is to be carried out by a doctor or a nurse.

prescriber responsibilities

medical practitioners must only administer, prescribe, sell or supply Schedule 4 and 8 poisons:

  • for the medical treatment of a person under their care
  • after taking reasonable steps to ascertain the identity of the person
  • after taking all reasonable steps to ensure a therapeutic need exists for that drug or poison

it is NOT acceptable to prescribe

  • a Schedule 4 or 8 poison to yourself - or self-administer it unless in accordance with prescription by another doctor (in Victoria)
  • anabolic steroids for body building purposes or for enhancing sporting performance
  • stimulants merely to enhance or prolong wakefulness in long distance drivers
  • additional opiates and opioids for patients receiving opioid substitution treatment from another practitioner
  • for people who are not under the doctor's care, such as a resident in another country, or people who have not personally consulted the doctor, including internet-based prescriptions.

before prescribing a drug of dependence

  • doctors must make their own assessment about whether to prescribe it on the basis of their clinical judgement - NOT just because it has been precribed previously.
  • regularly review whether ongoing treatment with drugs of dependence is necessary.
  • consider whether there are alternatives
  • ask what other prescribed and over-the-counter (OTC) medications the patient is taking - particularly, codeine products
  • inform the patient of the potentially addictive nature of the drug
  • inform the patient of the potential side effects, consequences of drug interactions and risk of overdose
  • consider whether the patient is at risk and whether strategies such as limiting amounts prescribed or arranging for small quantities to be obtained from a nominated pharmacy is indicated.
  • inform the patient that this is intended to be a short-term measure
  • refer the patient to a relevant specialist or unit for advice and management early if this is indicated.
    • eg. patients with chronic pain may benefit from review by a pain management specialist
  • document in the medical record what is prescribed, the indications for prescribing and any discussions with the patient about side effects, warnings, etc.
  • be aware that prescribing for friends or family may constitute “unprofessional practice” liability

Schedule 8 permit system

  • a PBS authority prescription for a Schedule 8 poison ONLY indicates that the Commonwealth will subsidise the cost of the medication. It DOES NOT give you permission to prescribe it - you may need a DPRG permit to do that.
  • DPRG permit applications are made on Form DP1 (pdf)
doctors need a DPRG permit if
  • treating a person with a Schedule 8 poison when they have reason to believe that the patient is a drug-dependent person
  • prescribing dexamphetamine, methylphenidate or methadone to ANY person, though some new exceptions are listed below.
  • treating a person who is not drug dependent with any Schedule 8 poison for a period greater than 8 weeks unless specifically exempt.
    • this 8 week period includes any preceding period of treatment by other medical practitioners.
    • if wishing to prescribe to a patient who is already being treated with such medications from another practitioner, the doctor must submit a permit application immediately, and in genuine cases, the doctor may prescribe a minimal quantity whilst the permit is being processed.

exceptions to the 8 week rule

  • certain conditions such as cancer pain and child attention deficit disorder although written notice must be given to DPRG by completing section 3 of the permit application form.
  • prisoners, in-patients and residential aged care
    • a permit is not required as the patient is not personally managing their medications in this scenarios
  • multi-practitioner clinics
    • only one valid permit per patient is necessary in a multi-practitioner clinic, and precribing by all practitioners providing care for the same patient is consistent with and does not exceed any limits of the permit.
  • exceptions related to methadone, dexamphetamine and methylphenidate
    • the additional permit requirement to obtain a permit before prescribing methadone DOES NOT apply when a medical practitioner is treating a person who is:
      • an in-patient of a hospital
      • a patient of an oncology clinic
      • a patient under the care of a palliative care service or a patient of a pain clinic at a hospital
    • the additional permit requirement to obtain a permit before prescribing dexamphetamine or methylphenidate DOES NOT apply when a medical practitioner is a paedaitrician or psychiatrist who is treating a person with attention deficit disorder.
  • HOWEVER, a permit to prescribe these 3 medications is still required to treat a drug-dependent person, or to provide treatment of more than 8 weeks, unless another exception applies.

references and other resources

prescribing.txt · Last modified: 2016/10/25 15:27 (external edit)