Rules and Regulations Governing How You Will Prescribe as an Intern: Outpatient Prescriptions

Question 1

DESCRIBE the eight critical parts of an outpatient Rx

Answer 1

1. Date prescribed
2. Patient name and ID information
3. Rx = “Recipe” (Superscription)
4. Name and precise formulation of drug (ex.
   capsules, type of release) (Inscription)
5. Disp: = Dispensing information (Subscription)
6. Label = “Signa” = “Mark thou” = Labeling information for patient (“take x tablets, times a day, +/- food”, for what, for how long)
7. Renewal information - if able to, and if feel like need to see them again before renewing
8. Prescriber and contact information (phone, address)
9. Sometimes include DEA number (controlled substance, other reasons??)

Question 2

EXPLAIN the context of the prescription in the office

Answer 2

• Often is the conclusion of the patient/doctor encounter
• “Whole doctor/patient interaction” reduced to one piece of paper: all six competencies involved
• Necessity of being clear and totally unambiguous
• Downside risk of communication errors = where some drugs look the same

Question 3

DEMONSTRATE the ability to write a clear, correct, complete, unambiguous prescription in the standard, accepted outpatient format preferred by pharmacists

Answer 3

1. Date prescribed
2. Patient name, ID
3. Rx
4. Name and precise formulation of drug
5. Disp: = Dispensing information
6. Labeling information for patient (“take x tablets, times a day, +/- food”, for what, for how long)
7. Renewal information
8. Prescriber and contact information
9. Sometimes include DEA number

Question 4

LIST common problems with inpatient orders seen at DHMC

Answer 4

Use of “prn” must be accompanied by frequency and indication (e.g. q 6 h prn abdominal pain)
Use generic names (brand names for special reasons)
Use of brand name OK for: combination product, or specific sustained release formulation
Do not abbreviate name of the drug itself (MSO4, MgSO4)
AVOID Qd, qod, qid (it is REALLY tempting!!)
Use metric units only
Misuse of the term “stat”
An order cannot be altered once it is written and signed (it can be cancelled and then modified)
Order liquid medications by dose and volume, not just volume
For continuous infusions, you need a lot of info (initial bolus if any, then infusion rate, then weight if appropriate, then titration parameters)
Micrograms or mcg, NOT ug
Units, NOT u or U
Write out “days” or “doses”, NOT d or D
Use leading zero (e.g. 0.2 mg), NOT trailing zero (2.0 mg)
Limitations on verbal orders only for emergencies

Question 5

DISCUSS pros/cons of generic and branded drugs

Answer 5

Cost: brand name only available
Cost: brand name plus one generic available
Cost: brand name plus multiple generics available
Could save up to 11% of the total costs of drug expenditures, compared to current practices (see Haas et al, 2005)
Extending period of exclusivity: how?
Paying generic companies NOT to produce

Question 6

EXPLAIN how the DEA defines five schedules of drugs

Answer 6

Dept of Justice&raquo_space; DEA
In general, federal laws take precedence, but whichever is stricter usually applies

Schedule I: Very high abuse potential, not currently accepted use in US, research only (e.g. heroin, MJ, LSD)

Schedule II: High potential for abuse, but DO have accepted medical uses (e.g. morphine, meperidine, oxycodone, codeine by itself, amphetamines, secobarbital)

Schedule III: Powerful, but less abuse potential (e.g. codeine in combination with acetaminophen)

Schedule IV: Lower abuse potential (e.g. diazepam, lorazepam, phenobarbital)

Schedule V: Minimal abuse potential (e.g. Lomotil, antitussives)

State regulations about prescribing for self and family members
Refills: up to 5 over 6 months for Schedules III-IV-V
No refills for Schedule II drugs! Need to be evaluated again before new Rx is written

Question 7

DESCRIBE the FDA drug approval process

Answer 7

Initial legislation 1906 about PURITY of product, accuracy of label and contents: no need to prove efficacy or safety
Legislation in 1938 to require DRUG SAFETY (elixir of sulfanilamide), and in 1962 to require DRUG EFFICACY (thalidomide tragedy)
New drugs require IND approval, then Phase I-II-III clinical testing
Tested in 200-2000 patient usually prior to NDA application
Generic drugs require only ANDA (abbreviated NDA), and are tested in about 20 healthy volunteers
Tradeoffs between more data and greater speed

Question 8

treatment of dog bite

Answer 8

1) wash area of bite with copious amts of soap & water

– pathogen: likely pasteurella, Bacteroides, Fusobacterium == GPC, GNR, anaerobes

Tx

1) amoxicillin 500mg-clavulanate 125mg oral TID
2) check rabies status of dog
3) check pt tetanus status == give Tda

complications of dog bites (5%) == cellulitis, skin and soft tissue infection, tenosynovitis (surgical emergency)

Question 9

can you prescribe for a family member?

Answer 9

yes - as long as it is not a controlled substance (antibiotic)

Question 10

Your brother comes to visit you during your internship. While out hiking, he lands a jump awkwardly and suffers a nasty and painful high ankle sprain. X-ray in ER reveals no fracture. He is sent home without Rx.
Back at your house, Aleve™ (naproxen generic) and acetaminophen are not adequate for his pain. He requests a prescription from you for something stronger. You don’t want to return to the ER (4-hour wait, expense, etc.) What would you do?

Answer 10

A controlled substance – depends on the state whether you are allowed to prescribe this.

Question 11

Opioid Case #2: 21 yo young man who injects heroin frequently
Comes into your office now for treatment of a localized skin abscess. Not febrile. No heart murmur. No other skin lesions. Your treatment plan includes?

Answer 11

Incision and drainage?
Antibiotic?
Opioid for pain?:
Oral methadone to prevent withdrawal (maintenance)?
Oral methadone taper (detox)?