Electronic prescribing not legislated yet
PharmaCare and third-party insurance companies routinely audit the prescriptions for which they pay. If a pharmacy has accepted prescriptions that are invalid, they are required to pay back all of the costs of those prescriptions (drug costs as well as the dispensing fees). This is a significant financial penalty, and should make it clear why pharmacies sometimes have to contact physicians to ensure that a prescription is valid. In a recent audit, 10% of the recoveries sought from pharmacies by insurers were the result of physicians not having provided dispensing directions, dates or signatures.
Registrants are reminded that the details required of a “valid” prescription are:
- the name and address of the patient
- the name of the drug or ingredients and strength if applicable
- the quantity of the drug
- the dosage instructions, including the frequency, interval or maximum daily dose
- refill authorization if applicable, including the number of refills and interval between refills
- the name, identification and signature of the practitioner for written prescriptions
Electronic medical records (EMRs) make the issuing of prescriptions easier and safer; however, electronic transmission of those prescriptions except by physical fax is not yet permitted by regulation in this province (per section 27(6) of the Pharmaceutical Services Act). E-prescribing is the future, but it will only be permitted through PharmaNet. PharmaCare is currently conducting a pilot project and the College remains optimistic that broader implementation will occur sometime this year.
For this reason, the College continues to remind registrants that prescriptions must include a handwritten or “wet” signature. It is not acceptable to use a signature stamp. If prescriptions are generated from an EMR, they must be printed, authenticated with a handwritten signature, and faxed to the pharmacy.
Print, sign, fax
The College has received complaints that some physicians have told pharmacies that they will send their (invalid) prescriptions to another pharmacy that agrees to accept them. This is at best probably futile, in that once the other pharmacy has been audited and fined, they will also refuse to collaborate. However, this College would consider such action to be unprofessional behaviour towards our pharmacist colleagues.
Lack of medical evidence to support long term use of “Z” drugs
The Prescription Review Committee has observed that there continues to be extremely large volumes of sedative/hypnotic medication prescribed in the community. The committee recently requested review of the prescribing of one of the most common medications prescribed for insomnia in British Columbia –zopiclone. College staff reviewed the prescribed quantities for a three-month period (September to November 2013). The findings showed that each of the top 20 prescribers of zopiclone prescribed between 9,500 to 16,500 doses to their patients during that period. The committee will be reviewing the prescribing practices of these 20 physicians in more detail at its next meeting in March.
There is a lack of robust medical evidence supporting benefit from long-term use of “Z” drugs on sleep architecture, sleep quality, or overall patient health.¹
Zopiclone and other “Z” drugs are recommended for short-term use only (as are other sedative drugs). The zopiclone product monograph² highlights that its pharmacological profile is similar to that of benzodiazepines. As with benzodiazepines, the concomitant intake of “Z” drugs with alcohol or other CNS depressants (such as narcotics, psychotropic medications, and antidepressants) increases the risk of additive respiratory and CNS depressant effects. A small study from 2009 of patients 55 years or older with chronic insomnia showed that 41% of those treated with daily zopiclone for more than one year fulfilled the criteria for sleep apnea.³ All “Z” drugs can cause adverse effects such as anterograde amnesia and somnambulance. The risk of physical and psychological dependence or abuse is increased with the dose and duration of treatment. The argument for careful and considered prescribing is made more compelling given the evidence linking traffic collisions to daytime drowsiness caused by prescription sedatives.⁴
The zopiclone monograph advises that treatment should not exceed seven to 10 consecutive days, that prescriptions should not be prescribed in quantities exceeding a one-month supply, and dosages should not exceed 7.5 mg HS. Abrupt discontinuation of long-term “Z” drugs causes a withdrawal phenomenon similar to that of benzodiazepines, barbiturates and alcohol. Therefore gradual dosage tapering is required for any patient taking them for more than a few weeks.
Meta-analyses have concluded that most patients with insomnia will benefit from non-pharmacologic interventions such as cognitive behavioural therapy. This, in combination with reframing of age-appropriate sleep expectations, sleep hygiene, and regular exercise, are more likely to lead to meaningful improvements in sleep over the long term.
- Nutt DJ, Stahl SM. Searching for perfect sleep: the continuing evolution of GABAA receptor modulators as hypnotics. J Psychopharmacol. 2010 Nov;24(11):1601-12.
- Sanofi-aventis Canada. Produce monograph – Imovane (zipiclone) Tablets, 5.0 mg and 7.5 mg: Hypnotic and sedative. Laval: Sanofi-aventis Canada. 2011. 33p. Available from: http://products.sanofi.ca/en/imovane.pdf
- Sivertsen B, Omvik S, Pallesen S, Nordhus IH, Bjorvatn B. Sleep and sleep disorders in chronic users of zopiclone and drug-free insomniacs. J Clin Sleep Med. 2009 Aug 15;5(4):349-54.
- Gustavsen I, Bramness JG, Skurtveit S, Engeland A, Neutel I, Morland J. Road traffic accident risk related to prescriptions of the hypnotics zopiclone, zolpidem, flunitrazepam and nitrazepam. Sleep Med 2008;9:818-22.