PDL would like to remind pharmacists that ALL private prescriptions presented for potent opioids should be treated with high suspicion.
Prescriptions for high-dose fentanyl patches and oxycodone tablets make up more than 50% of forgeries reported. Despite ongoing warnings from the regulators and PDL, reports of pharmacists dispensing multiple supplies for these medicines continue to be received, which is of great concern.
A 2019 Australian Criminal Intelligence Commission report emphasised the high street value of fentanyl which supports the high incidence of fraudulent prescriptions for this drug.
On receipt of the script, PDL recommends firstly ascertaining that the script is legitimate. The following checklist can be used to assist in evaluating the prescription:
Consideration 1: Do you know this patient and/or the prescriber?
Red flags:
- Patient or prescriber unknown and/or not local
- Patient unwilling to provide Medicare details or identification
- Are there conditions on the prescriber’s registration? Check AHPRA register to confirm
Consideration 2: Prescription details
Red flags:
- Private/non-PBS prescription
- Quantities greater than standard PBS quantities, e.g. multiple boxes of fentanyl patches
- Some jurisdictions publish lists of lost or stolen prescription forms. Have you checked the list?
- Prescriber phone number is a mobile phone number rather than a landline
- Is this medication prescribed in accordance with the legislation? Details may be missing such as date of birth, interval for repeats, quantities in words and figures
Consideration 3: Presentation of prescription
Red flags:
- Patient presenting on the weekend, outside of usual GP business hours or just before pharmacy closing time
- Elaborate backstories, patient in a rush, aggressive or overly friendly and talkative
- Patient or “prescriber” calling ahead ensuring there is stock available
- Patient offering to organise for the prescriber to contact the pharmacy
Consideration 4: Is the purpose, strength and quantity of the medicine safe and appropriate?
Red flags:
- What is the condition being treated?
- Has a pain specialist been involved?
A fentanyl 100mcg patch provides an oral morphine equivalent dose (oMED) of 300mg daily. Guidelines indicate there are few conditions except palliative care where this dose is appropriate.
Should such a prescription be presented, due diligence is required to ensure the prescription is authentic, safe and appropriate. Criminal groups are often well resourced and may go to great lengths to obtain fentanyl patches. Despite contacting the “prescriber”, this may not be sufficient to ensure the prescription is legitimate as there have been reports of fake surgery websites and calls to landline numbers answered by associates of the patient. The Pharmacy Council of NSW recently released a Shopping for fentanyl alert that has information relevant for all pharmacists, with particular reference to the sophistication of recent criminal activity.
If presented with a prescription that triggers a red flag and you can’t immediately validate the prescription or have concerns as to the confirmation provided, you might consider the following:
- Checking the prescriber’s contact details using an internet search rather than relying on the phone number on the prescription.
- Providing a verification supply. Some jurisdictions in Australia allow pharmacists to provide a two-day verification supply until the prescription is verified. For fentanyl patches, this means providing one patch allowing a genuine patient some medicine until verification is achieved.
- Consider discretely taking a copy or image of the prescription if suspicious, so it may be reported if it’s confirmed to be a forgery. Save any footage of the patient if you have suspicions.
- Use Real Time Monitoring systems if available to you. This decision-making tool may not have all prescribing recorded but will have any dispensing done for that patient.
Valid prescriptions with concerns for pharmacists
Some prescriptions have been confirmed with prescribers as being valid, however, ongoing and frequent supply of these medicines may be considered as inappropriate and warranting pharmacist intervention.
Pharmacists need to satisfy themselves through discussion with patients and prescribers. Aspects include the indication for the medicine, any risk assessment by the prescriber such as a treatment plan, oversight or involvement of a specialist, referral for review to a specialist or a plan to taper a medicine are relevant. Pharmacists should be supportive of genuine patients and assist prescribers through professional discussion. In addition, pharmacists should offer to mitigate risk using staged supply options, agreements for supply at a single pharmacy, shared treatment plans and provision of naloxone for management of any overdose.
For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.
