Title 21, Code of Federal Regulations

Title 21, Code of Federal Regulations, Section 1306.04 provides, in pertinent part, that: “A prescription for a controlled substance to be effective must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a corresponding responsibility rests with the pharmacist who fills the prescription. An order purporting to be a prescription issued not in the usual course of professional treatment or in legitimate and authorized research is not a prescription within the meaning and intent of section 309 of the Act (21 U.S. C.829) and the person knowingly filling such a purported prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the provisions of law regulating to controlled substances.” A pharmacist who has any doubts whatever concerning the legitimacy of a prescription order presented to him/her should not dispense it. The pharmacist is required to exercise his/her own professional judgment with respect to the legitimacy of prescription orders he/she dispenses. The law does not require a pharmacist to dispense a prescription order of doubtful origin – to the contrary, the pharmacist who deliberately closes his eyes when he/she has every reason to believe that the purported prescription order had not been issued for a legitimate medical purpose may find himself/herself prosecuted, along with the issuing physician, for knowing and intentionally distributing controlled substances, a felony offense which may result in the loss of one’s business or profession. See United States v. Kershman, 555 F.2d 198 (U.S. Ct of App., Eight Circuit, 1977)

Indications of Prescription Legitimacy

Indications of prescription legitimacy The following is a list which may indicate that a purported prescription order was not issued for a legitimate medical purpose in the course of the physician’s professional practice. This list is admittedly not exhaustive. Pharmacists are encouraged to suggest additional techniques by which they have been able to detect illegal and fraudulent prescription orders.

  • Does the purported prescription order contain an indication other than one found in the package insert?
  • Does the prescriber write significantly large numbers of prescription orders (or in larger quantities) as compared to other practitioners in your area?
  • Does the prescriber write for antagonistic drugs, such as depressants and stimulants, at the same time? Drug abusers often request prescriptions orders for “ups and down” at the same time.
  • Do a number of people appear presenting prescription orders written in the names of other people?
  • Do a number of people appear simultaneously, or within a short time, all bearing similar prescription orders from the same practitioner?
  • Are numerous “strangers,” people who are not regular patrons or residents of your community, suddenly showing up with prescription orders from the same physician?
    Typically, you will find that these individuals are in the 18 to 25 year age group, although drug abuse does not necessarily end with the achievement of chronological maturity.
  • Are your purchases of controlled substances rising dramatically? If so, it is time to look at your prescription counter policies. Drug abusers may have found a “vendor” who dispenses prescription orders mechanically, without using professional judgment.

Having found one or more of the above-described symptoms, what is the pharmacist expected to do? Like most people, pharmacists are reluctant to “get involved”. Unlike most people, though, the pharmacist really has no choice- he or she is involved, with responsibilities as a professional, a licentiate, and a DEA registrant. In the case of one or two prescription orders which appear to be irregular, the best remedy may well be a call to the concerned physician. Often, a friendly bit of advice from a fellow professional may be all that is needed to nip a prescribing problem in the bud. However, where there appears to be a pattern of prescription order abuses, a word to the wise and the mere refusal to dispense certain prescription orders may not be enough. Abusers will simply go elsewhere, possibly to another pharmacist with whom the prescriber has an understanding. In such cases, the pharmacist should waste no time in contacting the State Board of Pharmacy or the local office of the Drug Enforcement Administration. Both DEA and State authorities consider retain-level diversion as diversion as priority problems. Your information will be handled confidentially and will receive prompt attention. DEA cannot, however, get to the source of the diversion without your cooperation.

Dealing with Forged Prescription Orders

The only way a passer of forged prescriptions can obtain drugs is by presenting a prescription order – written or oral – to a pharmacist. Thus, it is important that the dispensing pharmacist maintain a constant vigilance against forged prescriptions. A prescription order represents any request by an authorized prescriber for the dispensing, or the administration, to a particular patient – or a particular quantity of a particular drug, in a particular dosage form and strength, for use according to particular directions, to treat a particular condition of health, at a particular time. The problem of the diversion of legitimately – manufactured drugs is a source of constant concern to the Drug Enforcement Administration. Repeatedly, state and local law enforcement agencies, as well as pharmaceutical industry representatives, city prescription fraud as a substantial part of this problem. The DEA recognizes that attempts to obtain legitimately – manufactured controlled drugs by misrepresentation- i.e., forged prescriptions and stolen prescription blanks – are significant problems confronting pharmacists and local law enforcement agencies. With the passage of the Comprehensive Drug Abuse Prevention and Control Act of 1970, more stringent controls were placed on the dispensing of controlled drugs by pharmacists. There is no doubt that these restrictions have served to somewhat curtain the fraudulent prescription problems.

Kinds of Forged Prescription Orders

Pharmacist should be aware of the various kinds of forged prescription orders which may be presented for dispensing:

  • The Forged Physician’s Rx Order
    • (a) Legitimate prescription pads are stolen from physicians’ offices, and prescription orders are written for fictitious patients.
    • (b) Some patients, in an effort to obtain additional amounts of legitimately-prescribed drugs, alter the physician’s prescription.
  • The Forged Hospital Rx Order
    • (a) Many times, prescription pads are stolen from hospitals, and the forger uses names and addresses of fictitious patients.
  • Phoned-In Fraudulent Rx Orders
    • Some forgers prefer to telephone the prescription order to the pharmacy, and then send an accomplice to obtain the drug.
  • The Bogus Physician’s Rx Order
    • Using completely false data, some forgers may have prescription pads printed to appear genuine, and then attempt to have the prescription orders dispensed.

The practiced forger of prescription orders is usually very adept at his/her job. He/she knows what information is needed on the prescription order to make it appear authentic. When a prescription order looks too good, the dispensing pharmacist should be alerted to a possible forged prescription. Consequently, it is important that the pharmacist be familiar with the prescriber’s signature and method of writing prescription orders.

Proper Controls

The more difficult the pharmacist makes it for the forger to alter, forge, and pass a fraudulent prescription order; the less likely he is to experience a forged prescription problem. This can best be accomplished by the following common sense, good professional practice, and proper dispensing procedures and controls. Loose or routine dispensing procedures, without control and professional caution, are an invitation to the forger to make your business his. By increasing the forger’s risk of detection and apprehension, you will make him look elsewhere. The pharmacist must be alert for forged or altered prescription orders or “prescriptions” written by (1) non-existent prescribers or for (2) non-existent patients. A prescription order for a controlled substance must be issued for a legitimate medical purpose by an individual practitioner, acting in the usual course of his professional practice. The law holds the pharmacist responsible for knowingly dispensing a prescription issued not in the usual course of professional treatment. The DEA also expects the pharmacist will make a reasonable effort to determine the identity of a prescriber – if they are not known to the dispensing pharmacist.

MD’s Signature Reference File

Some pharmacists maintain a reference file of physician’s signatures. Also, a list of physicians’ addresses, telephone numbers, and DEA registration numbers is a helpful aid and a time-saving idea. Similarly, the use of a patient profile card or any similar pharmaceutical record system also facilitates patient identification. Although the maintenance of a patient drug profile card is somewhat time-consuming, it does enable the pharmacist to better perform his/her professional duties. Certainly, a passer of forged prescriptions would not entertain having a patient history taken while they wait for the medication to be dispensed. Anytime you are in doubt, require proper identification. Although the procedure isn’t foolproof (identification papers can also be forged), it does increase the forger’s risk potential. If you believe that you have a forged, altered, or bogus prescription order – don’t dispense it. If you have a question, call you local police.

Eight Ways to Detect Fraudulent Prescription Orders

  • Know the prescriber.
  • Know the prescriber’s signature.
  • Know the prescriber’s DEA registration number.
  • Know the patient.
  • Follow good professional practice and dispensing procedures; compromises or shortcuts may lead to errors in judgment.
  • Check the date of the prescription order. Has it been presented to you in a reasonable length of time since the prescriber wrote it?
  • When there is a question about any aspect of the prescription order, telephone the prescriber for verification or clarification.
  • Should there be a discrepancy; the patient must have a plausible reason before the prescription medication is dispensed.

Seven Characteristics of Forged Prescription Orders

  • The prescription order looks too good. The prescriber’s handwriting is too legible;
  • Quantities, directions, or dosages that differ from the usual medical usage;
  • Prescription orders written on hospital blanks (if you don’t know the prescriber, check with the hospital to verify presentations;
  • Photocopied prescription blanks;
  • Directions written in full – with no abbreviations;
  • Use of different color inks or written in different handwritings.

Seven Suggestions to Prescribers

Listed below are 7 recommendations which you can pass on to the physicians about the care and security of prescription pads. These will help reduce the number of forged prescription orders:

  • Treat prescription pads like a personal checkbook.
  • Maintain adequate security for prescription pads.
  • Stock only a minimum number of prescription pads.
  • Keep prescription pads in your possession when you are actively using them.
  • Do not leave prescription pads “unattended”. When not in use, place them in a locked desk or cabinet.
  • Store surplus prescription pads in a locked drawer or a safe, appropriate area.
  • Report any prescription pad theft to local pharmacies as well as the State Board of Pharmacy.

Reverse Distributor Registrants

New registrants for reverse distributors/returns processors continue to be issued and changes in the registration is likely to occur. Inquires about returns processors/reverse distributors should refer to the appropriate local DEA office or to the Returns Industry Association.