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At the heart of general practice since 1960

Excessive prescribing demand

Good records are essential for detecting abuse, writes Dr Melanie Wynne-Jones

Handbags do get stolen, but perhaps not as frequently as patients say~

he computer says the patient had a month's supply last week; the patient says he's run out already.

Practice computers and receptionists are primed to flag up patients who appear to be over-using their medication. Common ploys including putting in a request before the next prescription is due, or to add a note asking for additional supplies, then turn up as an extra when the request is turned down. Patients who have deliberately been refused a repeat prescription, and have to make appointments so the practice can monitor their usage or response, may appear early or unannounced.

Responsible prescribing includes monitoring for patient safety, clinical governance, audit, and prescribing incentive schemes.

Drugs commonly requested ahead of time include medication that may be abused, sold or used excessively in an attempt to control symptoms:

 · Painkillers, especially opiate-based

 · Anxiolytics and sleeping tablets

 · Inhalers

 · Glyceryl trinitate sprays

 · Steroid creams

 · Methadone

 · Thyroxine (for weight loss)

Reasons for extra medication requests and possible solutions

For genuine prescribing errors, adjust quantities. Patients may simply not have been prescribed enough to meet their needs.

Someone for whom 'PRN' means taking four doses of paracetamol daily will need 240 tablets a month.

For poor disease control, talk to the patient. A request for additional asthma or angina sprays may indicate serious undertreatment or deterioration in someone's condition.

For natural fluctuations in symptom or disease severity with, say, irritable bowel syndrome, find out the patient's true needs.

With compliance problems, where a patient misunderstands, forgets or is deliberately using the medication other than as prescribed, check their understanding, ideas, concerns, expectations and dosage regime and consider monitored dosing systems such as NOMAD.

Spilt bottles, scrips washed in trouser pockets and stolen handbags do happen, but perhaps not as frequently as patients say. If their story seems genuine, replace the script but document the circumstances in case of further requests.

Patients often request more medication for holidays or if they have left pills at home or abroad. These are usually genuine. It is helpful to remind them to carry medication in their hand luggage.

Sometimes dodgy records ­ yours or the patient's ­ are to blame. Check practice systems, including records of handwritten scripts, and the patient's understanding of repeat prescribing arrangements.

Pharmacies often cannot supply enough tablets to fulfil the

prescription; patients get IOUs and may forget to return for the rest. Remind patients to check whether any medication is owed.

Hospitals still confiscate medication without returning it, leaving the

patient short after discharge. In these instances prescribe and even consider speaking to LMC.

Most patients are genuine, so you may decide to give them the benefit of the doubt on the first occasion; make a clear record so if it happens again, you or the next doctor can be sure of events. Repeated incidents may alert you to

the fact that someone is developing memory problems.

If you decide to challenge a patient's request they may:

 · Deny the request is premature (good records are invaluable).

 · Manipulate/plead with you. How you respond will depend on the facts, previous incidents, the drug in question, and possibly the law.

 · Threaten you (violence is a real risk; always be aware of your own safety and that of patients and staff).

 · Go to another doctor in the practice (make sure you get there first) or the out-of-hours provider, which should have policies to prevent this.

It is vital everyone in the practice is made aware of

such events; any attempt to manipulate or threaten must be dealt with decisively, as these patients are usually quick to exploit any weaknesses in the system.

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