Newsletter: November 2018

As oral health practitioners, being able to prescribe drugs as part of our clinical practice is a privilege.

To preserve this right practitioners must ensure they adhere to the relevant legislative requirements and meet all ethical principles, professional and practice standards that apply.

Council has considered several cases where prescribing has given rise to concern – these cases are a useful reminder about potential issues and provide an opportunity for practitioners to check their own practice in this area.

Lost or repeat prescriptions

The practice of dentistry often requires using medication such as antibiotics, pain relief and sedation for our patients. A prescription is the request from the dentist to the pharmacist to dispense the required drugs, and is often given directly to the patient to take to their preferred pharmacist. However it is not always convenient or possible to give the patient their prescription, so an alternative is required. 

Recently Dental Council received a notification from the Pharmacy Council, relating to concerns about a dental practitioner emailing a prescription to their patient. This notification from the Pharmacy Council arose from a Professional Conduct Committee of the Pharmacy Council investigating 37 pharmacists who dispensed allegedly fraudulent prescriptions to a particular patient of this practitioner over a four month period.

The patient involved presented to the practitioner in pain as an emergency. The cause of the pain was identified and options for treatment given. The patient consented to root canal treatment and in the interim, antibiotics and tramadol were prescribed because the patient said paracetamol was not working.

Ten days later, while the practitioner was away, the patient rang and explained that they had lost the prescription. The practice manager rang and spoke to the practitioner and it was agreed that a prescription would be emailed to the patient. The prescription was not signed. The patient presented copies of a single prescription, for Flagyl and 10X100mg Tramadol slow-release tablets at several pharmacies. 53 of the 60 prescriptions presented were unsigned.

According to the Pharmacy Council this raises concern regarding the practitioner’s professional practice, specifically with respect to therapeutic oversight and the unlawful provision of a prescription to the patient.

When a patient needs to repeat their prescription, or has lost a prescription form, they often prefer to make their request by phone or email rather than pick up the prescription from your practice or arrange a follow up visit.

In these situations, it is preferable for you to contact the patient’s chosen pharmacist and submit the prescription form by email or fax to the pharmacist directly. When this process is followed you must then supply the signed original prescription to the pharmacist within seven days.

Codeine

Concerns have been raised throughout various sectors in New Zealand recently about the availability of codeine and misuse of analgesics containing codeine, particularly as it can be converted into heroin using a process known as “home baking”.

Dental Council received a notification from a pharmacist about the amount of codeine prescribed by a practitioner in the pain management strategy for a specific patient.

According to the practitioner, the patient had stated that paracetamol and ibuprofen were not effective for their pain and insisted that codeine and tramadol were more successful. In this case, an analysis of the records indicated that the prescriptions matched the treatment provided. Once treatment was completed the prescriptions ceased.

The first line of treatment for most dental and dento-alveolar surgery pain is usually paracetamol and/or a non-steroidal anti-inflammatory drug (NSAID). The addition of codeine or an opiate (either alone or in combination with NSAID) appears to offer no benefit.

Exceptions do arise and drugs, such as codeine and tramadol, may be required on occasion. Where patients insist on alternatives, or where it is apparent first choice pain relief is not adequate, consider, or reconsider, the following:

• What is the diagnosis or cause of the pain?
• Are further local measures possible? 
• Could the patient have any drug dependency or other drug related issues?
• Should the patient’s medical practitioner be consulted?
• Would it be wise to share the case with (specialist) colleagues?

Also of note is Medsafe's recent alert following a review on the safety of codeine. The review concluded that codeine poses an unacceptable risk of harm for children and has recommended changes to the age restrictions for its use.
In particular, Medsafe recommends codeine should not be used in:

• Children aged less than 12 years.
• Adolescents aged less than 18 years to control pain following surgery to remove tonsils or adenoids, for symptomatic relief of cough, or in those whose respiratory function might be compromised.
• Women who are breastfeeding.

The changes to the approved use of codeine in New Zealand are in line with changes in other countries, including Australia, the United States, Europe and Canada.
Medsafe is working with sponsors of codeine-containing products to update the data sheets and package labelling to include the revised age restrictions.

Prescribing for legitimate purposes

A pharmacist notified Council of concerns about the prescribing pattern of a practitioner.

A practitioner, with repetitive strain injury was prescribed codeine by his medical practitioner. Based on the long term and chronic nature of the pain, the practitioner requested further prescriptions for codeine from a family member (a medical practitioner) and a number of colleagues. The practitioner then presented prescriptions for codeine to various pharmacies to ensure “a supply to provide to patients when required for pain management”.

It was not possible to reconcile the amount of codeine prescribed by Medical Practitioners Supply Order (MPSO) with the clinical records. In this case it was also not possible to reconcile the amount of nitrous oxide purchased with the number of cases receiving inhalation sedation at the practice.

Prescribing drugs should be for legitimate patients only. It is not appropriate to prescribe for colleagues, friends or family members unless they are your legitimate patients. In this case the practitioner had developed a drug dependence.

Controlled drugs register and storing drugs

If you do hold or dispense controlled drugs, you are required to keep a controlled drugs register in accordance with the requirements of regulation 37 and as laid out in Schedule 1 of the Misuse of Drugs Regulations 1977, regulation 40. It is good medical practice to keep a drugs register even if you do not prescribe or dispense controlled drugs – particularly where the drug cabinet is jointly accessed by members of a group practice.

Controlled drug prescription pads and forms must also be kept secure. Where a controlled drug prescription is posted, you must ensure that it is done in a secure manner, and you must maintain a record of all controlled drug prescriptions you send by post.

Council received a notification from a pharmacist regarding the amount of Midazolam required by a group practice.

During the inquiry process Council identified a number of concerns about compliance with requirements for practitioners treating patients under sedation, and securely storing drugs with limited access available for appropriate staff.

Some important requirements to remember

A register must be kept and should include details of:

• Drugs purchased and placed in storage
• Any drugs used, allocated to a particular clinician
• Patient details with respect to the drugs used – in addition to requirements in the patient records 
• A note of a regular audit of the register
• Amount of nitrous oxide purchases and details of patients provided with inhalation sedation and an estimate of length of time of administration.

If you have any questions or comments about this article, please contact us.