In addition to a health care provider’s unique identification number, some states require that prescriptions for controlled substances be written on tamper-resistant security prescription forms. The purpose of this legislation is to prevent forgeries and to tighten the control of prescription order forms.
The concept of a “secure” prescription form was expanded by the federal government in 2008 to all prescriptions written for Medicaid patients. Any prescription for a Medicaid patient must be written on a security form if the pharmacist is to be compensated for the prescription service. In turn, the use of “triplicate” prescription forms was eliminated and replaced with an online electronic transmission system whereby orders for Schedule II, Schedule III, and Schedule IV prescriptions are transmitted to a company that acts as a repository for these transactions. In California, it is called the CURES program (Controlled Substances Utilization Review and Evaluation System). Prescribers are provided with a record of who prescribed which controlled drug to which patient. Additional information about CURES may be found at http://oag.ca.gov/cures-pdmp.
In the USA, prescription drugs are controlled by the US Food and Drug Administration (FDA) as described in Chapter 1. The federal legend statement as well as the package insert are part of the packaging requirements for all prescription drugs. The package insert is the official brochure setting forth the indications, contraindications, warnings, and dosing for the drug.
The prescriber, by writing and signing a prescription order, controls who may obtain prescription drugs. The pharmacist may purchase these drugs, but they may be dispensed only on the order of a legally qualified prescriber. Thus, a prescription is actually three things: the prescriber’s order in the patient’s chart, the written order to which the pharmacist refers when dispensing, and the patient’s medication container with a label affixed.
Who May Prescribe?
The right to prescribe drugs has traditionally been the respon-sibility of the physician, dentist, podiatrist, or veterinarian. Prescribing now includes—in a number of states and in varying degrees—pharmacists, nurse practitioners, nurse midwives, phy-sician’s assistants, and optometrists (see below; Table 65–2). In the future, physical therapists may be licensed to prescribe drugs relevant to their practice. The development of large health main-tenance organizations has greatly strengthened this expansion of prescribing rights because it offers these extremely powerful economic bodies a way to reduce their expenses. The primary organizations controlling the privilege of prescribing in the USA are the state boards, under the pow-ers delegated to them by the state legislatures. Many state boards have attempted to reserve some measure of the primary responsibility for prescribing to physicians by requiring that the ancillary professional work with or under a physician according to a specific protocol. In the state of California, this protocol must include a statement of the training, supervision, and docu-mentation requirements of the arrangement and must specify referral requirements, limitations to the list of drugs that may be prescribed (ie, a formulary), and a method of evaluation by the supervising physician. The protocol must be in writing and must be periodically updated. The following rules govern prescribing by nonphysicians in the various states at the time of this writing. In almost all states, nurse practitioners (NPs) and physician assistants (PAs) may prescribe with or without physician supervi-sion depending on the state. Likewise, optometrists may prescribe selected formulary drugs for ophthalmologic indications. Pharmacists can initiate prescriptions in three states: Montana, New Mexico, and North Carolina. They may practice with physicians in collaborative drug therapy management (CDTM) programs in 47 states—all except New York, Maine, Oklahoma, and Alabama. Pharmacists may prescribe controlled substances under physician supervision in California, Massachusetts, Montana, New Mexico, North Carolina, Ohio, and Washington. New Mexico grants prescribing authority to medical psychologists with advanced training.