self prescribing???

[marchiafava]

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Beyond the ethical issues of self prescribing, as an intern are you able to write a prescription for yourself??? of course not narcotics, just antibiotics and the such....

 

[streetdoc]

wow, that's a weird thought. I hate going to doctors, but never REALLY realized that I could one day just write myself an antibiotic. I guess my friends and family will be knocking my door down too. So is it legal?
streetdoc

 

[Apollyon]

It is legal and ethical. However, if it is something like a narcotic, you WILL get caught if you do it even twice, and, also, you may (as dumb as it sounds) have to keep a record on yourself (a written paper with your vital signs, your hx/ROS, and your examination of...yourself) depending on what state you're in.

I've written myself for antibiotics 3 times in NY and once in NC (all as a resident).

 

[Sebastian.]

It is legal and ethical. However, if it is something like a narcotic, you WILL get caught if you do it even twice,

Are you saying it's perfectly safe to do just once? 😕

 

[jamie]

residents also write scripts for each other all of the time (not necessarily for narcotics, though).

Beyond the ethical issues of self prescribing, as an intern are you able to write a prescription for yourself??? of course not narcotics, just antibiotics and the such....

 

[BKN]

residents also write scripts for each other all of the time (not necessarily for narcotics, though).

If your institution is self-insured, you will probably not be covered if you write a scrip for someone who is not registered for a visit in the system. Be sure you truly trust whoever asks you to write a script. Best to set a rule-everybody registers, everybody gets an exam, everybody gets a chart.

And never, ever write a narcotic for another doc as a "curbside" or for their patient that you haven't seen. Usually in this situation the Doc is addicted and trying to manipulate you.

Oh, if I'd known then what I know now.

 

[DrNick2006]

bignami

 

[BKN]

bignami

Come again?

 

[Solideliquid]

This is something I am def going to bring up during orientation week.

Lets have a simple example. If my wife is having an episode of GERD, and a zantac is not helping much, can I prescribe her a PPI course?

 

[mackie]

This is something I am def going to bring up during orientation week.

Lets have a simple example. If my wife is having an episode of GERD, and a zantac is not helping much, can I prescribe her a PPI course?

It's not illegal to do it, but we were advised during orientation to not get in the habit of writing prescriptions for family and friends. I really don't think there is anything wrong with it for simple problems, with a limited timecourse, and on few occasions. I wouldn't do narcotics, and I wouldn't write for anything that will require multiple refills. Folks really should be followed by their own doctor for such.

 

[BKN]

This is something I am def going to bring up during orientation week.

Lets have a simple example. If my wife is having an episode of GERD, and a zantac is not helping much, can I prescribe her a PPI course?

Sure, but depending on the plan's preferred drugsand whether they require her seeing her PCP first, you may end up paying for the scrip.

No controlled drugs nor psychopharmaceuticals for family members.

 

[EctopicFetus]

BKN,

When are we allowed to write scripts? Is it once we start residency? (I know for Narcs it is different) I am talking about simple things like Antibiotics or something else low profile.

 

[DropkickMurphy]

No controlled drugs nor psychopharmaceuticals for family members.

I can understand the controlled drugs, but why wouldn't you be able to write your wife a script for Zoloft (or a similar med)?

 

[EctopicFetus]

because she needs to be followed by someone who knows what they are doing..

 

[Hurricane]

because she needs to be followed by someone who knows what they are doing..

And IIRC the APA recommends against treating one's own family members, so even if you do "know what you are doing" you shouldn't be treating your spouse anyway.

Pesky ethics.

 

[BKN]

BKN,

When are we allowed to write scripts? Is it once we start residency? (I know for Narcs it is different) I am talking about simple things like Antibiotics or something else low profile.

when you begin residency you are given a "institutional" license allowing you to prescribe only as part of your training. This includes the ability to write controlled substances using the institutional DEA number. Once you get your own license,you must also get a DEA number and cannot use the institutional numbers thereafter.

 

[BKN]

I can understand the controlled drugs, but why wouldn't you be able to write your wife a script for Zoloft (or a similar med)?

What EF and Hurricane said. More importantly, if a spuse needs zoloft he/she also needs therapy by a unbiased therapist, which hubby/wife cannot be. In fact, in that case Dr. Hubby/wife is almost surely part of the problem.

 

[DropkickMurphy]

For the love of God some states let Psy.D's and clinical psych PhD's prescribe those meds...it can't be that hard to manage a simple antidepressant.

And IIRC the APA recommends against treating one's own family members, so even if you do "know what you are doing" you shouldn't be treating your spouse anyway.

Pesky ethics.

So it's really just a recommendation then? It's not like a "Do this and kiss your license goodbye" type of deal? My ethics are flexible if it saves me the cost of a psychiatrist for something I will be able to handle myself.

 

[DropkickMurphy]

What EF and Hurricane said. More importantly, if a spuse needs zoloft he/she also needs therapy by a unbiased therapist, which hubby/wife cannot be. In fact, in that case Dr. Hubby/wife is almost surely part of the problem.

Point well taken.....but for example my fiancee who has had long standing intractable depression stemming from her parents that is only alleviated by Zoloft (the therapy doesn't do much for her), it just seems rather odd that you have to refer someone out for that....but I do see where you are coming from in most cases....Thanks BKN. As always your input is appreciated.

 

[glorytaker]

OK, so psych meds are not OK but what about birth control pills/patches/rings? Those are long-term but aren't too harmful.

 

[BKN]

For the love of God some states let Psy.D's and clinical psych PhD's prescribe those meds...it can't be that hard to manage a simple antidepressant.

Simple antidepressants are some of the most dangerous drugs in the formulary handed to the patients most likely to overdose. People without pharmacology training, an MD and some psychiatric training absolutely should not be handing them out. Read the preceding to mean a FP who received good psychiatry training or a psychiatrist.

So it's really just a recommendation then? It's not like a "Do this and kiss your license goodbye" type of deal? My ethics are flexible if it saves me the cost of a psychiatrist for something I will be able to handle myself.

Again, you cannot treat your loved ones' emotional problems. It will turn into a disaster. You cannot handle it yourself. I can not handle it myself after 30 years in the business.

 

[BKN]

OK, so psych meds are not OK but what about birth control pills/patches/rings? Those are long-term but aren't too harmful.

Maybe, if you're an OBG or a FP. Others should pass.

I limit myself to acute problems, within my expertise. Example, the wife gets bitten over a joint by a cat, needs antibiotics right now to avoid septic joint. I've got no problem writing her some augmentin.

Of course, she's a vet so she just goes to her cabinet and pulls out doggy augmentin and takes it, but you know what I mean.

 

[DropkickMurphy]

Thanks BKN. Your advice is appreciated...I apologize for being so thickheaded.

 

[Poety]

Thanks BKN. Your advice is appreciated...I apologize for being so thickheaded.

prae I sent you a pm -

 

[Poety]

Maybe, if you're an OBG or a FP. Others should pass.

I limit myself to acute problems, within my expertise. Example, the wife gets bitten over a joint by a cat, needs antibiotics right now to avoid septic joint. I've got no problem writing her some augmentin.

Of course, she's a vet so she just goes to her cabinet and pulls out doggy augmentin and takes it, but you know what I mean.

Personally, I like to order my antibiotics, anxiolytics and antidepressants from vetmd.com, I keep them on standby in the medicine cabinet for me, my dogs, my cats, my birds, or my husband as needed. I find it useful and cheap this way. Plus, its so easy to prescribe, it says "one tablet for every 10 lbs" none of those annoying dose calculations to work out 😛

 

[BKN]

Thanks BKN. Your advice is appreciated...I apologize for being so thickheaded.

fugedaboutit.

 

[DropkickMurphy]

Don't laugh...one of the local ambulance services got in trouble with the state for buying it's lidocaine from a veterinary pharmacy.

DOCTOR: "The good news is that your husband survived the cardiac arrest ma'am"
WIFE: "What's the bad news doctor?"
DOCTOR: "We can't get him to stop dragging his ass on the carpet in the ICU nurses station."

 

[Apollyon]

Are you saying it's perfectly safe to do just once? 😕

I don't know if you are trying to be funny or are just a dim bulb, and moreover with your black and white concrete-thinking "perfectly safe" comment I will explicate.

In virtually every state, auditors for various state agencies (either medical boards or departments of health, but whomever oversees doctors and/or pharmacies) will pick up two or more prescriptions for controlled substances that are written to and signed by the same person, because that is what is called a "pattern", and, since narcotics are prone to abuse, the red flag goes up, and the prescriber will be investigated for "diversion" for illegal use.

In some states, just one self-prescribed narcotic prescription may trigger an investigation.

(Sorry for the terse tone - I can't sleep.)

 

[marchiafava]

thanks for all the responses. very helpful. another question: What script do you use to write yourself a medication?? I have a few scripts from my hospital but is that what I would use????

 

[BKN]

thanks for all the responses. very helpful. another question: What script do you use to write yourself a medication?? I have a few scripts from my hospital but is that what I would use????

You will be given personalized scripts when you start residency, unless your system is entirely elctronic (most aren't). I usually just call it in and they fill in a blank. If I'm in the pharmacy and didn't have my own with me, I'd fill in theirs.

 

[EctopicFetus]

You will be given personalized scripts when you start residency, unless your system is entirely elctronic (most aren't). I usually just call it in and they fill in a blank. If I'm in the pharmacy and didn't have my own with me, I'd fill in theirs.

BKN in the EDs I have been in they arent personalized is it different at your program? Of course like you mentioned you can just call the pharmacy!

 

[Smurfette]

BKN in the EDs I have been in they arent personalized is it different at your program? Of course like you mentioned you can just call the pharmacy!

It's program-specific. We don't have personalized scripts where I'm at, we just have generic scripts with the hospital name and address on the top.

 

[BKN]

It's program-specific. We don't have personalized scripts where I'm at, we just have generic scripts with the hospital name and address on the top.

Your prescriptions may not meet the legal requirements for name of physcian, location of practice etc. Do you always sign legibly so the pharmacists in town can read it? Or are they typing Dr. General Hospital, since they have no idea who wrote the script. Do you have different scrips for the clinics if they are off site form the hospital?

 

[sdn1977]

I'll chime in here as a pharmacist. There are actually two specific issues you are considering. The legal (which is clear cut and state specific - unless you are in a VA system) and the ethical. Legally, in CA, a prescriber cannot prescribe for a patient who is not a "patient of record" which means you have seen him/her professionally. So, when my husband prescribes Amoxicillin for me for a dental infection - it is legal because I am his patient (I have an ongoing chart in his office). Now...the other legal issue in CA, as a prescriber, you can only prescribe "within your scope of practice". So...no - my husband as a DDS cannot legally prescribe contraceptives for me or anyone else. This applies to the psychiatrist prescribing Tazorac cream - really outside the scope of practice. The absolute is that you legally cannot self prescribe for yourself (you cannot be a patient of record for yourself). Now...what actually happens in practice? Well, I fill Rxs written or phoned in for prescribers if it is reasonable (yeah - you do have to bend to my judgement here - if it hits the fan I suffer A LOT!). I'll do this for antibiotics, ibuprofen (Rx strength), contraceptives,etc but I will NEVER do it for controlled substances. The reason is very simple - everything that is CII or CIII automatically goes to the Justice Department in real time as its processed. It is tracked by your DEA# & my DEA#. Yes - they really do follow patterns - I get DEA agents all the time inquiring about a specific pt or prescriber. So - thats the legal part. The ethical part is when you are asking for something which is for an acute illness (ie antibiotic) or chronic (depression). For an actue illness, I don't have an issue with you prescribing for your wife, children, auntie, no matter what specialty you are in. But, for a chronic illness (unless out of town mother-in-law comes without medication), you can address the medical ethics of treating your own family. If its within your scope of practice, I'd go ahead and fill it. Now, if you don't have a DEA#, whatever you prescribe can't be processed by an insurance company (that is how they identify you uniquely as a prescriber), however, this will be changing. They are moving to a unique prescriber # that you'll have to memorize (in addition to your license # & DEA #). Hope this helps to clarify from my point of view.

 

[Samoa]

The absolute is that you legally cannot self prescribe for yourself (you cannot be a patient of record for yourself).

Also, there is a difference between what prescriptions the medical board will allow a physician to write, and what the pharmacy board will allow the pharmacist to fill. As a pharmacist in the states where I have a current license, I can legally fill any self-prescribed drug whatsoever for a physician, or anything written for a family member. What kind of records the physician keeps is not something I can reasonably be expected to know. So I choose to draw the line at controlled substances, because I believe it's prudent for all concerned for those to be written by a second physician who is not a family member. If it's for a legitimate use, there shouldn't be any difficulty finding someone to write it. This is actually the community standard of practice where I went to pharmacy school, I find it very reasonable.

 

[scpod]

Now...what actually happens in practice? Well, I fill Rxs written or phoned in for prescribers if it is reasonable (yeah - you do have to bend to my judgement here - if it hits the fan I suffer A LOT!). I'll do this for antibiotics, ibuprofen (Rx strength), contraceptives,etc but I will NEVER do it for controlled substances.

Virginia makes it fairly easy because they spell it out in their laws under Standards of Professional Conduct


18VAC85-20-25. Treating and prescribing for self or family.
A. Treating or prescribing shall be based on a bona fide practitioner-patient relationship, and prescribing shall meet the criteria set forth in § 54.1-3303 of the Code of Virginia.
B. A practitioner shall not prescribe a controlled substance to himself or a family member, other than Schedule VI as defined in § 54.1-3455 of the Code of Virginia, unless the prescribing occurs in an emergency situation or in isolated settings where there is no other qualified practitioner available to the patient, or it is for a single episode of an acute illness through one prescribed course of medication.
C. When treating or prescribing for self or family, the practitioner shall maintain a patient record documenting compliance with statutory criteria for a bona fide practitioner-patient relationship.

 

[southerndoc]

It's program-specific. We don't have personalized scripts where I'm at, we just have generic scripts with the hospital name and address on the top.

My hospital is the same way. There is a spot at the bottom for our DEA number (if it's a controlled substance), signature, printed name, and department phone number.

Speaking of DEA numbers, I recently got a call from a pharmacy wanting to know my DEA number for a corticosteroid prescription. The reason? The insurance company wouldn't pay for it unless it is linked to a DEA number. WTF? Is this legal?

 

[Flopotomist]

Similar question - how does a physician acquire a reasonable supply of controlled substances to carry and use if for example the physician is going on an extended rigorous backpacking expedition and will be acting as the MD for a large group?

 

[DropkickMurphy]

Similar question, but only what if the physician wanted meds to carry for use while responding as an EMS physician?

 

[Samoa]

obtaining medications for uses like the ones in the last two posts varies by state. In one state where I'm licensed, the physician would write the prescription "for office use" and there would be no patient name attached to it. Controlled substances could be dispensed this way to the physician. In another state where I'm licensed, the physician is specifically prohibited from writing prescriptions for office use, so he or she would have to write a self-prescription, and explain the situation to the pharmacist, and it would be up to that pharmacist's judgment whether the purpose was legitimate or not. This would work for schedules III-V of controlled substances. In that state, a schedule II drug would have to be sold to the physician via a DEA222 form, rather than by a prescription.

 

[southerndoc]

Similar question, but only what if the physician wanted meds to carry for use while responding as an EMS physician?

This is done as with any ALS ambulance. The medical director's vehicle must be certified as an ALS first responder vehicle. Controlled substance regulations are followed by having the medical director "sign out" the controlled substances in a locked box. The physician must document any medicines given to a patient and have someone witness any wasted drugs.

 

[Loopo Henle]

I wish it was illegal to prescribe to family members. I am not even out of medical school yet and my family members are knocking down my door wanting free treatment. I tell them that when I get done I will be glad to treat them, but they are each going to get a full physical including a large bore digital rectal exam

 

[beary]

Wow, I was really ignorant that there are so many regulations about controlled substances. Or even just prescriptions in general!

 

[sdn1977]

My hospital is the same way. There is a spot at the bottom for our DEA number (if it's a controlled substance), signature, printed name, and department phone number.

Speaking of DEA numbers, I recently got a call from a pharmacy wanting to know my DEA number for a corticosteroid prescription. The reason? The insurance company wouldn't pay for it unless it is linked to a DEA number. WTF? Is this legal?

Perhaps I didn't explain clearly.....the DEA # is a unique identifier - there are NO prescribers (MD's, DDS's, DMD, mid-level, DO, DPM, anybody...) who has the same DEA # as you (the numbers are not random - they all add up in particular way and are tied to your the two letters preceding them). The insurance companies identify pt by ID (which is no longer a SSI #), DOB, dependent # and they identify you by DEA #, and me by DEA# - everybody and I mean EVERYBODY is identified by a #. If the insurance cannot identify YOU - they won't ok the Rx for payment. Sometimes we get around this by using "dummy" identifiers (these are the generic DEA #'s that institutions use for interns who do not have their own). Now...you might ask - why do they want this info....well....have you thought about who the reps are who come to see you & why those particular reps??? Not so much for steroids...but...perhaps you chose paroxetine (which is what I filled under your DEA#) - but they might ask...why not Lexapro (now, they make Lexapro...)???? So...you are put on the list for a visit to what - they push Lexapro or Celexa or whatever....they have eyes everywhere! Sorry - I can get carried away. But....seriously....they do actually need some identifier for a prescriber. The idea we are going toward is to get away from linking the DEA # - which we as pharmacists use to see what you can prescribe (CII, IIA, III, IV, V) and which has real value in seeing who is facilitating overuse of controlled substances - to a number which just identifies prescribers as that - prescribers only and leaves the pharmacist to decide if the prescriber really has the ability to prescribe that drug for that patient in that state. This is a monumental task....each prescribing group (MD's, DO's, dentists, mid-levels) each have their own licensing board in EVERY state. Each gives a # when licensed but it is not uniform...so every state (now...think about that) has to agree to a uniform licensing # then everyone who has gone before needs to be grandfathered the all that data needs to be loaded into the databases - really a big job!

 

[southerndoc]

How about using a medical practitioner ID number that is independent of the DEA number? I do not like my DEA number on every script.

 

[sdn1977]

Wow, I was really ignorant that there are so many regulations about controlled substances. Or even just prescriptions in general!

Oh my goodness...you don't even know the half of it...In CA we just got rid of triplicates for CII & CIIA's (Jan 2006) - we are slowly coming into meeting what the federal laws are. State laws always trump federal laws..so we have to know them all! But...talk to you pharmacist - usually there are ways to make what you want happen to happen - we just won't break any laws for you! We sometimes sound like awful people, but we don't mean to be!

 

[sdn1977]

Similar question - how does a physician acquire a reasonable supply of controlled substances to carry and use if for example the physician is going on an extended rigorous backpacking expedition and will be acting as the MD for a large group?

As you can see between Samoa & myself we have very different laws we operate under. My advice would be....talk to your pharmacist - not necessarily your hospital pharmacy - a community pharmacist. I have had this situation come up lots of times (I am in an urban area between 2 very well know medical schools in N.CA) and these folks have sebbaticals which allows them to travel just as your example pointed out. I have been able to help them out, however, they are restricted primarily to pain medications & medications for diarrhea - not for sleep or ADHD. They often opt out of the injectable narcotics for lots of reasons - difficulty in transporting a very sedated patient, risk of having the drug break (all are packaged in glass), cost, etc...I've usually dispensed oral narcotics and drugs for diarrhea (generic Lomotil). But...I can't speak for your state laws or what your pharmacist is comfortable doing...talk to him/her - if they don't help, find someone who will. As a last resort - find a compounding pharmacy - they are used to being a last resort for all sorts of folks.

 

[sdn1977]

How about using a medical practitioner ID number that is independent of the DEA number? I do not like my DEA number on every script.

Thats what we are going toward - a "practioner ID # - not medical because of all the other practioners (yes...medicine = medical, but professionally, there are lots of other folks who like to be called who they are - DDS, DMD, Podiatrists, NP, PA, etc...)...so yes..that is what is ahead. But...the reality is that it is an industry pushed idea (insurance companies, who many think are bad guys) trying to push multiple licensing groups in all 50 states - it has been going on for close to a decade and you can see they've not had a lot of good luck...It will happen, but it all takes time and right now we are pretty swamped by the mess called Medicare Part D! (oh - thats not even funny!). In the meantime, we (pharmacists) all know who you are by your DEA# - that's what we use for now and that's why the Rx you wrote for Medro Dosepak needed a DEA. Without insurace it was probably $55 - with it was about $5!

 

[Sebastian.]

I don't know if you are trying to be funny or are just a dim bulb, and moreover with your black and white concrete-thinking "perfectly safe" comment I will explicate.

In virtually every state, auditors for various state agencies (either medical boards or departments of health, but whomever oversees doctors and/or pharmacies) will pick up two or more prescriptions for controlled substances that are written to and signed by the same person, because that is what is called a "pattern", and, since narcotics are prone to abuse, the red flag goes up, and the prescriber will be investigated for "diversion" for illegal use.

In some states, just one self-prescribed narcotic prescription may trigger an investigation.

(Sorry for the terse tone - I can't sleep.)

Trying to be funny? Dim bulb? Neither. I just wondered why you specifically mentioned that it couldn't be done "twice". Thanks for explaining yourself. That wasn't at all obvious.

 

[Sebastian.]

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