Medication used for non-medical purposes can originate from physician prescriptions. Large dispenses have been identified by public health and law enforcement authorities as a major source of diverted medications (mainly sedatives and opioids). Once dispensed, these medications are stored in a home presenting a public safety issue to an experimenting teen or visitor. Police report vulnerable patients (e.g. seniors) observed filling their prescriptions and then being robbed, or persuaded to sell medications with street currency.
Providing large dispenses makes it very hard to monitor individual patients’ use. It increases the risk of medication error by patients as they may be less mindful of the amount taken, or become more prone to overuse, when hundreds of tablets are in their possession. Such misuse can go unchecked for long periods of time if they do not have frequent follow-up appointments.
The self-reporting of drug use is often unreliable, and the detection of illicit drugs is important in the early intervention of addiction. Patients with current or past history of substance misuse will often experience increased loss of control if provided large dispenses. Physicians should consider medication and treatment agreements for all patients on long-term psychoactive medications, including provision for random urine drug screening, random pill counts and blister packaging as indicated. The agreement should also include provision for referral to addiction services or a pain specialist if required for continued safe prescribing.
Pharmacovigilance dictates that prescription sizes should be modest. The College recommends that dispenses should not exceed a three-month supply or 250 tablets, whichever is less. However, logic and prudence suggest that dispenses of psychoactive medications should be in modest amounts, usually 50 to 100 units, for anyone facing the risks noted above. There are options for writing prescriptions that allow flexibility and avoid large dispenses, such as more frequent dispenses of smaller quantities from the pharmacy.
Misuse and diversion of prescription medication is at epidemic proportions. Physicians have an obligation to play their part in addressing this through careful prescribing.