During a routine inventory of a clinic’s medication storage, the medical assistant notes that nearly all of the supply of oxycodone is not to be found. Distressed, he brings this news to you (his manager and clinic partner) at the end of a busy day. You ask him to reconcile the month’s prescriptions with the actual inventory, and his findings show that the vials are indeed missing. Do you know what you might do next?
Physicians who know what to do when they become aware of potential illegal activity concerning medications they prescribe, or that are otherwise under their control, are better prepared to resolve the matter effectively—and more likely to avoid possible medico-legal difficulties. For this reason, physicians should know their obligations, which include taking reasonable steps to help prevent drug diversion—the transfer of controlled substances from lawful sources to the illicit marketplace—and related fraudulent activity.
When deciding what steps to take, physicians need to consider their professional obligation to protect the confidentiality of patient health information. Improper disclosure to the police of information about a patient may expose a physician to a complaint to a regulatory authority (College) or privacy commissioner.
The fact that obtaining controlled drugs is lawful only with a physician’s prescription sometimes places physicians at the intersection of medicine and the law. Diversion of prescription medication can occur in many ways such as drug theft, prescription forgery, or a patient obtaining multiple prescriptions from various doctors (i.e. “double-doctoring”).
What is a controlled drug?
The federal Controlled Drugs and Substances Act1 lists the items that are defined as controlled drugs and substances in Canada. In general, these are drugs that can have a detrimental effect on a person’s health and well-being, as well as substances that are prescribed by licensed medical practitioners and sold through pharmacies and dispensaries for legitimate medical treatment. Possession of these substances is legal only with a prescription or other lawful authorization.
Loss or theft of drugs
Controlled drugs must be stored securely to mitigate the possibility of theft. If drugs are lost or stolen, this must be reported to Health Canada’s Office of Controlled Substances (OCS) within 10 days of the discovery. Physicians may also consider notifying police of the loss or theft. When speaking to OCS and the police, physicians should be careful not to identify any individual patient, while providing the necessary details about the incident.
Loss or theft of prescription pads
When theft of prescription pads is suspected, physicians should contact the CMPA and consult any guidance or policies from their College. Physicians may consider notifying the police of the loss. When speaking to the police, physicians should be careful not to identify any individual patient, while providing the necessary details about the incident.
Prescription monitoring programs (PMPs) in some jurisdictions require that physicians use special paper prescription pads in which there are multiple copies: a pharmacy copy, a prescriber copy, and a copy that is submitted to the PMP for tracking purposes. Physicians may be required to report any missing or stolen prescription forms to the program and potentially others, including the College. Similarly, electronic prescriptions are automatically submitted directly to the PMP and pharmacy, which ensures timely data collection and helps mitigate the possibility of fraud.
If a pharmacist or other practitioner notifies a physician of a patient attempting to obtain controlled drugs from various doctors (double-doctoring), the physician may consider discussing the matter with the patient if doing so does not put the physician or others at risk. Physicians may need to consult with other treating doctors, but broader notification to pharmacies or the police could breach doctor-patient confidentiality. If physicians are suspicious about a patient’s access to drugs from other practitioners, prior to prescribing or renewing a prescription, physicians may ask the patient if they have sought or obtained a controlled drug from another physician in the past 30 days.
Suspected unlawful prescription activity can create tension in the physician-patient relationship. Depending on the circumstances, you may wish to end the relationship. Ending the relationship may also be appropriate if a patient is persistently uncooperative and where there is a breakdown in trust. Physicians should be familiar with any policies or guidelines from their College on steps to take in ending the doctor-patient relationship.
Responding to enquiries
Physicians may be contacted on occasion, by the police or by pharmacists, to verify the information on a prescription. In these circumstances, the physician should ask to see the prescription prior to any response. The physician’s response should be limited to confirming whether or not the signature is authentic, i.e. made by the physician in question.
CMPA members are encouraged to contact the CMPA for further guidance before volunteering information to the police.
Prescription monitoring and safe prescribing
Each province and territory operates some form of prescription monitoring program. These programs monitor outpatient prescription dispensing activity—collecting information about the prescriber, pharmacist, and patient involved in each prescription transaction. Some systems also identify the person picking up the prescription.
PMPs typically alert the pharmacy (and in some cases the physician) in real time when unusual activity is detected. In some jurisdictions, clinicians within a patient’s circle of care may also proactively access PMP data. This can assist in clinical decision-making and assessing risk, including whether and how to prescribe and dispense a controlled drug. In other jurisdictions, however, physicians and pharmacies do not have point-of-care access to patient information (i.e. a patient’s prescription history) via the PMP. In such cases, physicians will want to refer to the patient’s electronic health record if available.
The bottom line
- Report the theft or loss of a controlled substance to Health Canada’s Office of Controlled Substances no later than 10 days after its discovery.
- If you suspect a patient of drug diversion or other unlawful prescription-related activity, consider discussing the matter directly with that individual—but only if this is not likely to put you or your staff in any danger.
- If a suspected prescription fraud involves a known patient, it is important to respect the confidentiality of patient health information. If it does not involve your patient, confidentiality is not an issue and you may report the incident to the police, if appropriate, and if the pharmacist or others have not already done so. Note that a physician does not have an obligation to report to the police.
- Physicians who are unsure about how to proceed in responding to suspected unlawful prescription activity are encouraged to contact the CMPA for individual advice.
- Controlled Drugs and Substances Act, S.C. 1996, c. 19