Controlled drug supply debate

RE: Controlled drug supply debate

Stephen Courtney — Wed, 26 Jun 2019 18:20:59 GMT

If a client wants to off themselves by taking their dog's epiphen, then as was commented above, surely the amount dispensed is the danger, rather than the length of time. three months of phenoleptil for a tiny vs 28 days of epephen for a large breed dog...

We are not responsible for what a client might choose to do and while would not like to defend giving a ridiculous supply of something, I don't think 3 months worth of epilepsy medication to a well known client with a stable animal is an issue.

Hopefully I won't get a nasty surprise, but surely its just as likely to happen with a 28 day supply as a 3 month one... and what do you do for the client who has mislaid their meds/ left them at a relatives etc....

RE: Controlled drug supply debate

Gillian Mostyn — Wed, 26 Jun 2019 17:25:35 GMT

[quote user="Stephen Courtney"]It is NOT illegal to prescribe 3 months worth of epiphen![/quote]

As I did agree to above.

[quote user="Stephen Courtney"]It is advised to prescribe 4 weeks at a time but it is perfectly OK to act against this recommendation and prescribe 3 months worth if you feel comfortable / confident that the client can be trusted.[/quote]

Absolutely - you are entitled to do so. Not sure how you can ever know a client or their personal circumstances that well, but that is your choice.

I still reiterate that we should follow the 28 days supply guidelines unless there is a very good reason. The guidelines are there for good reason.

RE: Controlled drug supply debate

Stephen Courtney — Wed, 26 Jun 2019 15:02:44 GMT

[quote user="Gillian Mostyn"]

We're obviously reading it differently. I've only ever dispensed one month and will continue to do so. (I don't demand a consultation any more often.)

I have had a prescription returned to the practice from an internet pharmacy because a colleague had put 3 months of epiphen on it ... At the clients request. Rightly, and admirably, the pharmacy refused to supply it.

An option would be for the client to check the pharmacy's rules. They might find the wouldn't dispense that much anyway.

[/quote]

It is NOT illegal to prescribe 3 months worth of epiphen!

It is advised to prescribe 4 weeks at a time but it is perfectly OK to act against this recommendation and prescribe 3 months worth if you feel comfortable / confident that the client can be trusted. We do have a new practice rule not to do this, and I comply with new cases, but someone who has always had the 3 month supply will continue to get it.

If there was a particular reason as a one off, eg someone was going on holiday and wanted a 60 day supply, it seems very jobsworthy to deny that request

I have several clients that I give 3 months worth to, both by dispensing and by written prescription. I have never had a script queried by the online supplier, and would be irate if they did.

RE: Controlled drug supply debate

Thomas Johnson — Wed, 19 Jun 2019 12:40:49 GMT

[quote user="Michael Woodhouse"]I agree to a point. If on the liquid then I would generally dispense the smallest bottle size that would last as close to 1 month as possible. There has to be a policy somewhere. I guess the flip side is how does this look when the teenage son takes the dogs pills and dies, when it becomes apparat they had large quantities of drug in the house to last the dog for many months, going against the principals of CD prescribing? [/quote]

Epiphen Solution only comes in one size, a 30ml bottle of 40mg/ml solution. I would also like to point out that I am not advocating routinely dispensing large quantities of controlled drugs, my default is to dispense enough for one month, but if I client requests more I will consider whether that is appropriate as the rules allow us to do this.

RE: Controlled drug supply debate

Gillian Mostyn — Wed, 19 Jun 2019 11:35:52 GMT

[quote user="Thomas Johnson"] For example I'm treating a Labrador which is on 150mg of phenobarb twice a day so a month's supply is 9,000mg, and a Chihuaua on 22.5mg in the morning and 15mg in the evening so a month's supply is only 1125mg. If they put a limit on the total amount of drug rather than the time period it lasted for it would make more sense.[/quote]

No it wouldn't. The rules make perfect sense...we are being asked to use our own judgement. Putting a limit on the total amount would be making life difficult for all the reasons you describe.

RE: Controlled drug supply debate

Michael Woodhouse — Wed, 19 Jun 2019 10:15:43 GMT

I agree to a point. If on the liquid then I would generally dispense the smallest bottle size that would last as close to 1 month as possible. There has to be a policy somewhere. I guess the flip side is how does this look when the teenage son takes the dogs pills and dies, when it becomes apparat they had large quantities of drug in the house to last the dog for many months, going against the principals of CD prescribing?

In this case the owner is wanting more drug for cost and convenience reasons. That's not ok. That's not what sways my prescribing derisions. If you want a prescription for a CD you can pay for one monthly.

RE: Controlled drug supply debate

Thomas Johnson — Wed, 19 Jun 2019 09:02:05 GMT

[quote user="Michael Woodhouse"]I'm not comfortable with more than 28 days supply. However good the owner is. I will make an individual exemption for a specific reason - eg a holiday. I don't believe its responsible prescribing allowing larger quantities of these drugs be in people's possession. [/quote]

It's a very crude and ineffective way of limiting the amount of controlled drugs we prescribe. For example I'm treating a Labrador which is on 150mg of phenobarb twice a day so a month's supply is 9,000mg, and a Chihuaua on 22.5mg in the morning and 15mg in the evening so a month's supply is only 1125mg. If they put a limit on the total amount of drug rather than the time period it lasted for it would make more sense.

Also I have a couple of cats on Epiphen solution at a dose of 0.3ml twice a day, a bottle will last 2 months, should I split the bottle and only give them half at a time?

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 21:09:24 GMT

[quote user="Kate Richardson"]Am I being dim or are people reading too much into this? Surely the above paragraph makes it clear that you should consider only prescribing 28 days of a CD unless its a long term treatment eg phenobarbitone for treating epilepsy in which case it's fine to prescribe say a 3 month supply as long as you are comfortable with it?[/quote]

I think the weight in the interpretation should be the other way round. You should not prescribe more than one month's worth at one time, but you can consider prescribing more in exceptional circumstances. The default position is not to.

For a most larger dogs you'd be giving out 180 epiphen 60mg tablets or more IMO that really isn't a good idea, but, as you say, you can do so if you wish.

RE: Controlled drug supply debate

Michael Woodhouse — Tue, 18 Jun 2019 20:31:37 GMT

I'm not comfortable with more than 28 days supply. However good the owner is. I will make an individual exemption for a specific reason - eg a holiday. I don't believe its responsible prescribing allowing larger quantities of these drugs be in people's possession.

I'd hold firm. If they want written prescriptions then they are generally more hassle. They can go elsewhere if they want. I can make my policy whatever I want. Perfectly justifiable.

RE: Controlled drug supply debate

Kate Richardson — Tue, 18 Jun 2019 20:00:50 GMT

[quote user="bob lehner"]Quantity The VMD advise that for all CDs, you should consider prescribing only 28 days’ worth of treatment unless in situations of long term ongoing medication (e.g. when treating epilepsy in dogs). If you prescribe more than 28 days’ worth of treatment you must be sure the owner is competent to use the medicine safely.[/quote]

Am I being dim or are people reading too much into this? Surely the above paragraph makes it clear that you should consider only prescribing 28 days of a CD unless its a long term treatment eg phenobarbitone for treating epilepsy in which case it's fine to prescribe say a 3 month supply as long as you are comfortable with it?

RE: Controlled drug supply debate

Edward Jones — Tue, 18 Jun 2019 19:01:50 GMT

How is it less scrupulous, professional or fastidious to perfectly legally prescribe two or three month's supply of phenobarb?

The OP should refer the client to practice policy. Ask the people who set the policy for the justification to pass on to the client.

Criticising colleagues simply because they are flexible to prescribe within the law for longer periods to trusted clients is unprofessional.

RE: Controlled drug supply debate

bob lehner — Tue, 18 Jun 2019 15:20:59 GMT

[quote user="Gillian Mostyn"]

[quote user="bob lehner"]Seems a bit odd really as the end result appears to be the same?[/quote]

Not really. The owner will never have more than 30 tablets at any one time (assuming they are actually administering them- but that is another story! )

[/quote]

Yes - if the 'Repeats' were all dished out at the one time. The internet pharmacies I have dealt with tend to hold the prescription and dispense the 'Repeats' separately and over a period of time, as required by the client.

Otherwise why would you not just make a single prescription for the whole lot and not bother with 'Repeats' (obviously i'm not talking about Sch 2 and 3 CDs here)?

RE: Controlled drug supply debate

Beats — Tue, 18 Jun 2019 14:54:29 GMT

Having personally had to deal with a call from the hospital in the past to confirm how many dog tablets and composition a comatose epilepsy-dog-owner may have taken in addition to her own prescription drugs, I would be very wary of supplying more than a month's worth at a time personally.

You are quite within your rights to supply the owner with 2-3months worth when this is requested if you wish and make an exception to your rule (assuming it is your rule and not your bosses rule), but don't be bullied into it - if you are happy to then fine.

Assuming you don't wish to, then you can politely advise that your policy is consistent with that of many vets and it is a blanket policy with no exceptions made on the grounds that the business cannot reasonably be expected to assess the risk of individuals to mental health issues etc, and breaking this blanket policy could make it hard to refuse prescription in cases where genuine concerns existed in the future regarding a different client.

... or you could say that an exception is only made on receipt of a doctors written endorsement that such prescription carries no risk to the client (as addicts look like rest of us and you cannot know what prescription drugs someone is receiving or health issues they may be facing), for liability issues.

...or you can just apologise for the inconvenience and re-state your policy.

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 14:31:47 GMT

[quote user="bob lehner"]Seems a bit odd really as the end result appears to be the same?[/quote]

Not really. The owner will never have more than 30 tablets at any one time (assuming they are actually administering them- but that is another story! )

RE: Controlled drug supply debate

bob lehner — Tue, 18 Jun 2019 14:29:30 GMT

Yes - as Gillian says above.

The RCVS Guidance on CDs more or less says the same:

''Validity and repeat prescriptions

CDs in Schedules 1 to 4 have a prescription validity of 28 days. Prescriptions for Schedule 5 CDs (and all other prescription medicines) have a validity of 6 months. You can only dispense a prescription for a CD in Schedule 2 or 3 once and only within the 28 days of the validity of the prescription. Single prescriptions with multiple dispenses (i.e. repeatable prescriptions) are not allowed for CDs in Schedules 2 and 3. Repeat prescriptions for Schedule 4 and 5 CDs are permitted. The repeats must be dispensed within the period of validity of the prescription (28 days or six months). If the prescription is not repeatable you should consider stating this on the prescription to avoid any misuse of the prescription. If the prescription has a section that states number of repeats you should consider crossing this out if the prescription is not to be repeated to avoid any misuse of the prescription.

Quantity The VMD advise that for all CDs, you should consider prescribing only 28 days’ worth of treatment unless in situations of long term ongoing medication (e.g. when treating epilepsy in dogs). If you prescribe more than 28 days’ worth of treatment you must be sure the owner is competent to use the medicine safely.

Instalment prescriptions The first instalment must be dispensed within the 28 day validity period. Further instalments do not need to be dispensed during the 28 day validity for Schedule 2, 3 and 4 CDs.''

So it seems to me that you can't write a prescription for say 30 tablets of a Sch 2 or 3 CD and say 'Repeat 3 times', but you could write a prescription for 90 tablets with instructions to the pharmacist to release 30 tablets every 28 days. Seems a bit odd really as the end result appears to be the same?

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 14:13:16 GMT

I've just been doing a bit of research (long lunchbreak!) OK... I still wouldn't be happy handing out more than one month of a controlled drug but it is legal under certain circumstances.

However, there is another option - instalments. I wasn't aware of it, but doctors can, and commonly do, prescribe by instalments. For example, a patient can have one prescription for methadone, but it to be released as a certain dose daily or weekly for x weeks. All the instalments do not have to fall within the 28 days - just the first one!

It describes it here:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/424680/VMGNote20.PDF

Might be an option that safeguards the liability of the practice and satisfies the client!

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 14:04:20 GMT

So I've just checked the human legislation, from the NICE website and it is understandably very similar.

The Department of Health and the Scottish Government have issued a strong recommendation that the maximum quantity of Schedule 2, 3 or 4 Controlled Drugs prescribed should not exceed 30 days; exceptionally, to cover a justifiable clinical need and after consideration of any risk, a prescription can be issued for a longer period, but the reasons for the decision should be recorded on the patient’s notes.

It may be the case then that the practice could make an exception for a holiday?

RE: Controlled drug supply debate

Rob Loxley — Tue, 18 Jun 2019 13:47:08 GMT

[quote user="Gillian Mostyn"]We're obviously reading it differently[/quote]

I read it the same as Thomas. I understand why we need to be careful about how much we are dispensing, that's why they are controlled drugs, and why such a practice policy might exist; if I was the OP would refer the client to someone higher up in the practice as it doesn't seem to be a decision they can make.

Anyone come across installment prescriptions in the veterinary sphere - the RCVS mention them but most of what I can find is about human methodone programmes?

Be aware that as gabapentin is now schedule 3 similar issues apply.

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 13:15:31 GMT

We're obviously reading it differently. I've only ever dispensed one month and will continue to do so. (I don't demand a consultation any more often.)

An option would be for the client to check the pharmacy's rules. They might find the wouldn't dispense that much anyway.

RE: Controlled drug supply debate

Bob Russell — Tue, 18 Jun 2019 13:02:11 GMT

It is clearly stated (BSAVA) that posting controlled drugs should be avoided as well.

We have exactly the same requirements for clients using prescriptions and those buying here.

RE: Controlled drug supply debate

Thomas Johnson — Tue, 18 Jun 2019 13:00:57 GMT

[quote user="Gillian Mostyn"]

Single prescriptions with multiple dispenses (i.e. repeatable
prescriptions) are not allowed for CDs in Schedules 2
and 3. Repeat prescriptions for Schedule 4 and 5 CDs
are permitted

The VMD advise that for all CDs, you should consider
prescribing only 28 days’ worth of treatment unless in
situations of long term ongoing medication (e.g. when
treating epilepsy in dogs). If you prescribe more than 28
days’ worth of treatment you must be sure the owner is
competent to use the medicine safely.

Last time I checked phenobarbitone is schedule 3.

[/quote]

I don't think we're talking about a single prescription with multiple dispenses, which you clearly can't do as it is schedule 3, we are talking about a single prescription for more than a month's supply of Epiphen, which the second paragraph says you can do, it makes no mention of which schedule the drug is.

RE: Controlled drug supply debate

Gillian Mostyn — Tue, 18 Jun 2019 12:56:17 GMT

Single prescriptions with multiple dispenses (i.e. repeatable
prescriptions) are not allowed for CDs in Schedules 2
and 3. Repeat prescriptions for Schedule 4 and 5 CDs
are permitted

Last time I checked phenobarbitone is schedule 3.

RE: Controlled drug supply debate

Sarah Channell — Tue, 18 Jun 2019 12:54:04 GMT

This is my problem......

RE: Controlled drug supply debate

Thomas Johnson — Tue, 18 Jun 2019 12:53:32 GMT

[quote user="Gillian Mostyn"]

[quote user="Thomas Johnson"]I would be tempted to tell the client that it was practice policy and if they weren't happy they should contact the senior partner/clinical director/practice manager.[/quote]

They'd need to go higher and take their argument to the VMD!

[/quote]

But the VMD say you can prescribe for more than a month, particularly with animals on long-term medication.

RE: Controlled drug supply debate

Sarah Channell — Tue, 18 Jun 2019 12:53:16 GMT

The guidance notes on page 10 say that if you authorise more than 28 days supply then all of that quantity had to be collected in the 28 days as the prescription is only valid for that long. The vmd says that although they advise all CDs only have 28 days supply of you use your discretion and say that the owner is competent to use the drug then you can prescribe more than 28 days supply......