Prescription shopper scams

Background

Problems associated with the misuse and abuse of fentanyl patches include:

• extraction and injection of the fentanyl (sometimes resulting in fatalities)
• overdoses (associated with too-frequent topical application)
• extensive prescription-shopping and numerous fraudulent prescriptions.

As such, the TGA tightened the indications for use of the preparation to the management of pain associated with cancer, palliative care and other conditions in opioid-tolerant patients where:

• other treatment options have failed, are contraindicated, not tolerated or are otherwise inappropriate to provide sufficient management of pain and
• the pain is opioid-responsive and
• the pain is severe enough to require daily, continuous, long-term opioid treatment.

Current and recent prescription-shopper issues

There has been a significant increase in people using identity fraud and fraudulent prescriptions to get higher-strength fentanyl patches.

• One group of offenders used fraudulent prescriptions and fraudulently obtained prescriptions for hundreds of fentanyl (50 mcg, 75 mcg and 100 mcg) patches.

The use of fentanyl patches (100 mcg/hour) every 3 days represents a morphine-equivalent dosage (MED) of 300 mg daily.

• The risk of opioid overdose is dose related. Patients prescribed more than 100 mg MED/day may have an 11-times greater risk of opioid overdose death than those prescribed lower doses. [Ref: Gwira Baumblatt JA, Wiedeman C, Dunn JR et al. High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths. JAMA Intern Med. 2014;174(5):796-801]

Because of this, guidelines recommend consulting a specialist before prescribing more than 100 mg MED daily. Most GPs will need to apply for a Schedule 8 treatment permit before prescribing higher-strength fentanyl patches.

Steps you must take before prescribing fentanyl patches

• Ensure there is a therapeutic need for fentanyl and confirm the identity of the patient.
• Do not prescribe for an unfamiliar patient without confirming their identity, preferably by reliable photo ID. A Medicare card does not provide incontrovertible proof of identity and does not include date of birth. Medicare cards have been used to obtain prescriptions in the names of people's dependants, or in the names of people whose cards have been stolen. If an unfamiliar patient is unable or unwilling to provide photo ID, take a photo of the person. This will help identify them if prescriptions have been obtained by false representation.
• Record patients’ names and dates of birth accurately on prescriptions and on the SafeScript database. Some patients use spelling variations and different dates of birth to attempt to hide the extent of their drug use.
• You must review the patient’s SafeScript dispensing records unless a specific exception applies.
• You must apply for a Schedule 8 treatment permit to prescribe higher-strength fentanyl patches (such as 50 mcg/hour or greater than 100 mg MED daily). The exception to this is if you or another practitioner at your clinic already holds a permit to prescribe for that patient or a specific exception to the permit requirement is applicable.
  

A woman used the names of various friends and associates to establish herself as a patient at many clinics in the Bayside area. She then used those names to get prescriptions for oxycodone (Endone or Targin) and some Schedule 4 medicines (including diazepam).

During a 3-month period, she obtained prescriptions from multiple practitioners at 30 different clinics using 12 different names.

It's believed the woman found people's dates of birth through social media, and got their Medicare card numbers at clinics they had visited.

Medical practitioners must ensure there is a therapeutic need and to confirm the identity of the patient before prescribing a drug of dependence.

Medical practitioners must handwrite significant components of computer-generated scripts for all drugs of dependence. They must not manually alter computer scripts.

An offender successfully presented more than 40 forgeries during a 2-month period. He used his printer to copy the details of genuine prescriptions onto stolen script pages.

Another offender successfully presented more than 100 computer-generated prescriptions for morphine ampoules. The prescriber had issued each prescription for 5 ampoules but the patient manually altered the prescriptions to obtain between 25 and 75 ampoules on each prescription.

Some patients request ‘private’ prescriptions (such as non-PBS prescriptions) or a larger quantity than can be prescribed as a Pharmaceutical Benefit. They may also mislead the prescriber by indicating that rules relating to the PBS do not apply to private prescriptions.

This is not correct. Permit requirements for Schedule 8 medicines and other Victorian regulations are applicable, regardless of whether it is issued under the Pharmaceutical Benefits Scheme.

Many medical practitioners have been prosecuted for prescribing in contravention of Victorian legislation because they believed the legislation did not apply in some cases.

It is many years since prescriptions for Schedule 8 medicines could not be dispensed in Victoria unless the prescriber was registered in Victoria. Since the introduction of national registration, prescriptions from medical practitioners are valid in Victoria, provided the prescriber is appropriately registered in Australia.

Many drug-seeking patients have fraudulently claimed to be visiting from interstate in order to obtain prescriptions for Schedule 8 medicines from general practitioners in Victoria. Some patients presented medicine containers which had been dispensed at interstate pharmacies, to convince the medical practitioner that they were from interstate.

Interstate visitors can be advised to obtain prescriptions from their regular prescribers or, in an emergency, have their regular prescribers phone a Victorian pharmacy to authorise supply of Schedule 8 medicines.

Some drug seekers claim that their ‘regular doctor’ is unavailable (on leave, away sick, retired or another reason) or that they have just moved and that their previous clinic is too far away to visit. Such claims are commonly used by drug-seeking patients to obtain prescriptions for drugs of dependence from medical practitioners to whom they are not known.

One Victorian resident, with a genuine therapeutic need and genuine documents, obtained prescriptions from more than 200 general practitioners on more than 300 occasions. Some clinics phoned Medicare Australia’s Prescription Shopper Information Service, but the patient was not identified as a prescription shopper because the cost of his medicine was not being subsidised under the Pharmaceutical Benefits Scheme.

It is easy to make a fraudulent document appear authentic by cutting and pasting banners or other information found on the internet. Medical practitioners should always check the authenticity of documents. You should keep a copy and, if the document is found to be fraudulent, report the matter to the Department of Health.

One drug-seeking Victorian resident created many fraudulent letters that contained accurate details of different interstate clinics. But an after-hours phone number was included that went directly to an accomplice who pretended to be the author of the letter.

Prescription pads and pages for computer-generated prescriptions should be locked away. They must never be left unattended where members of the public, staff or anyone else can access them. See these examples of forgeries:

• A patient wrote forged prescriptions by taking pages from the prescription pad in the consulting room when he was waiting for the medical practitioner.
• A clinic receptionist created fraudulent computer-generated prescriptions and used them at multiple pharmacies. When pharmacists phoned the clinic, the receptionist claimed the prescriber was unavailable and confirmed the prescriptions had been issued. Ensure your passwords for generating prescriptions are not known or accessible to anyone.
• A GP's spouse created fraudulent computer-generated prescriptions in the name of one of the other medical practitioners at the clinic. Pharmacists did not contact the purported prescriber because the patient was known to be the practitioner's spouse.
• A courier for a pathology service took prescription pads from an unlocked area when she attended a clinic. She successfully presented multiple forged prescriptions.
• Several health practitioners (including nurses and doctors) have also misappropriated prescription pads from clinics where they worked, and used these to present fraudulent prescriptions.