_ISSUES and ANSWERS

Orders by PAs for Schedule II Drugs Illegal

by Elizabeth Scott, Assistant Attorney General

At the May 11, 2000 meeting of the Oklahoma State Board of Medical Licensure and Supervision, representatives from the Oklahoma Academy of Physician Assistants made a presentation regarding the prescribing practices of Physician Assistants in a hospital setting. In particular, the Physician Assistants contended that they had the ability to issue orders for Schedule II controlled dangerous substances in a hospital setting only. Several members of the Board did not agree that Physician Assistants had the ability to issue orders for Schedule II drugs under any circumstances and asked that the Board staff request an official Attorney General opinion on this issue.

Board staff posed the following question to the Attorney General:

May a licensed physician assistant legally order and/or administer Schedule II controlled dangerous substances in a hospital setting, to be subsequently countersigned by his or her supervising physician?

On July 5, 2000, Board staff received a response to its question as follows:

…A licensed physician assistant may not legally order and/or administer Schedule II controlled dangerous substances in a hospital setting, to be subsequently countersigned by his or her supervising physician.

The result of this Attorney General Opinion is that it is now absolutely clear that a Physician Assistant may not order, administer or prescribe Schedule II drugs under any circumstances.

". . . this may cause a logistical problem for Physician Assistants who work with nurses in rural emergency rooms without a physician on site."

The result of this Attorney General Opinion is that it is now absolutely clear that a physician assistant may not order, administer or prescribe Schedule II drugs under any circumstances.

As a practical matter, this may cause a logistical problem for Physician Assistants who work with nurses in rural emergency rooms without a physician on site. Neither the Physician Assistant nor the nurse may order or prescribe Schedule II drugs. However, situations may arise when optimal patient care requires the ordering and administering of a Schedule II drug in the emergency room.

In response to this apparent dilemma, in September, representatives from the Oklahoma Hospital Association, the Board of Medical Licensure and Supervision, the Osteopathic Board of Examiners, the Board of Nursing and the Academy of Physician Assistants met to discuss possible solutions. After considering all options, the group concluded that in situations where there is no physician on site and the administering of a Schedule II drug is indicated, the Physician Assistant must telephone the supervising physician and describe the situation. At that point, the Physician Assistant must give the telephone to the nurse, who may accept a verbal order over the telephone from the physician to administer a Schedule II drug. Alternatively, a nurse may initiate any available standing orders from the physician applicable to the situation.

This scenario appears to be the only way under current law that a patient may legally receive Schedule II drugs in a hospital setting when the physician is not physically present. As such, under these circumstances, physicians should make every effort to be immediately available for consultation with their Physician Assistants and nurses.

Where have all the Flowers Gone?

by Gerald C. Zumwalt, M.D.

With the political scene in full swing (when is it not?) and accusations and assertions bandied back and forth like shuttlecocks in a badminton game, comes the realization that civility and politeness are as rare as grace at a camp meeting. But it isn't just in the contentions of elections that those admirable qualities have disappeared. The genteel companionship and respectful manners of yesteryear are now also absent from medicine.

Not so long ago on moving into a new locality and opening a practice, doctors were restricted to a small, formal notice, usually two inches tall and two columns wide, in the local paper running for a set period _ usually seven days. Information expected to be printed included name, address, telephone number, field of interest and business hours. Now MDs run daily to weekly ads with audacious claims and leering illustrations, so extreme that they would make a personal injury attorney blush, if such action were possible.

On arriving in a new town a practitioner was expected to make courtesy calls on their peers introducing themselves and offering to be of assistance to already established professionals. Now in many small towns there are MDs who have been practicing for years without joining the county society or ever speaking to other doctors. I suspect this community is not unique.

Once a doctor/patient relationship could be established and expected to last for the lifetime of either the doctor or the patient. Now both groups jump in and out of managed care plans like popcorn kernels in a pan of hot grease.

Once patients claimed emotional ownership of a doctor and doctors looked on patients with filial pride. Today both groups seem more interested in financial relationships than friendship. Comparative prices have replaced communal pride.

Once doctors bought their spouses Cadillacs but drove Chevrolets. Now Mercedes SUVs compete for hospital parking with Lincoln Navigators.

We won't even mention the disappearance of "professional courtesy."

No one wants to return to the pre-penicillin days of sitting and watching patients die of simple pneumonia, but is it really too much to ask for some of those apparently forgotten attributes of gentleness, kindness and pride in profession?

Defining "Dispensing" and "Dangerous"

There is on each MD licensee renewal form the statement, "I wish to be registered to dispense dangerous drugs." The definitions of "dispense" and "dangerous" as used in this sentence are found in Oklahoma Statutes, Title 59, Chapter 8 _ Drugs and Pharmacy, §355 and §355.1.

"Dangerous drugs" include all drugs labeled "Caution-Federal law prohibits dispensing without prescription." This includes all prescription (or legend) drugs as well as controlled dangerous substances (or scheduled).

"Dispensing" is defined as giving in an appropriate container any medicine to a patient. This implies that the drugs are originally in a stock bottle and then issued in a smaller quantity and does not address whether or not a charge is made for this exchange. The section goes on to exempt samples furnished in the original package and does give requirements as to the labeling of dispensed medication.

To be redundant, the Pharmacy Act equates dangerous and legend drugs as any drug requiring a prescription prior to issuing.

Alabama Physician Indicted for Unlawful Internet Prescribing

[Reprinted with permission from the Federation of State Medical Boards' NewsLine (September 2000).]

Last month, Roger D. Eiland, M.D., a family practitioner from Clanton, Ala., and three others were charged with illegally offering prescription drugs over the Internet to consumers from around the globe.

The federal indictment, following an investigation by the U.S. Justice Department and the U.S. Food and Drug Administration, accuses the four individuals and a pharmaceutical supply firm of conspiracy, mail fraud, violation of the Federal Food, Drug and Cosmetic Act (FDCA), obstruction of justice and conspiracy to commit money laundering.

The indictment charges the group conspired to sell prescription drugs, including Viagra, Xenical, Propecia and Claritin-D, to consumers without valid prescriptions. The Web site charged a medical consultation fee and indicated that a physician would review online questionnaires, but prosecutors said no such review or consultation took place.

Defendants Anton Pusztai and Anita Yates, both of Alabama, are accused of creating phony prescriptions on a computer that bore the name of a foreign doctor. Dr. Eiland is charged with rewriting the phony foreign prescriptions on Alabama prescription forms from December 1998 to August 1999. The prescriptions were then filled by a licensed pharmacy in Alabama.

Eiland has been charged with obstruction of justice for allegations that he made misrepresentations to the FDA concerning the number of prescriptions he rewrote, the amount of money he received and his efforts to verify the existence of the foreign physician whose name was on the computer-generated prescriptions.

The Alabama Board of Medical Examiners conducted its own investigation that led to Eiland being disciplined in June of this year. Eiland reached a consent agreement with the Alabama Medical Licensure Commission that resulted in a 90-day suspension of his medical license and a $5,000 fine. Following the suspension, Eiland faces five years of probation and must complete continuing medical education courses in medical ethics, prescription writing and computer medicine.

Watch Your Writings

by Gerald C. Zumwalt, M.D.

Newspapers and TV screens are full of horrifying statistics on medical mistakes. And, although as a profession we tend to regard these attacks as false and unfounded, there sneaks into our consciousness the thought that if there weren't some truth there wouldn't be any story.

On every basic and simple level, nationally and statewide, there have been calls and proposed legislation for mandated prescription practice (typed, electronic, relays from pharmacy to doctor and back to pharmacy, etc.). There exists the very real possibility that in the law of unintended results, if the writing of prescriptions becomes too complicated and mandated, there will result an increase in telephonically transmitted prescriptions with a possible increase in mistakes of sound-alike drugs, e.g., Zantac and Xanax.

The best solution to this aspect of medical maladventures is so simple that even describing it is ludicrous.

Write legibly.

From the time of the first gag writer, doctor's handwriting has been a source of humor. These jokes have worn thin and when patients are harmed, laughter dies. The day when doctors could operate drunk, yell at nurses, pinch females' bottoms and write illegibly is gone.

In this time when hospitalized patients are seen by multiple doctors and ward clerks, secretaries and duty nurses are more often than not temps, it is mandatory that orders and progress notes be readable by other than the original scribe.

The amount of time it takes to write (or print) in an understandable font is little more than that to produce an indecipherable scrawl.

Slow down and save lives.

Board Meeting September 28, 2000

Disciplinary decisions included a reprimand for conviction of trespassing and filing a false police report. One complaint was tabled and the licensee required to obtain a second evaluation following arrest for lewd acts. One licensee was put on standard terms of probation for substance abuse following a nine-month suspension. Two licenses were surrendered in lieu of prosecution for personal substance abuse and violations of narcotic regulations. One license was revoked for sexual misconduct with patients. One license was revoked for practicing medicine while the license was suspended.

At the regularly scheduled meeting of the Board of Medical Licensure and Supervision, the group modified, for two licensees, terms of probation to allow limited use of scheduled drugs after several years of successful supervision. The Board also approved the public assertion of Board Certification by the American Board of Cosmetic Surgery of one M.D.

Two special training licenses were granted, one under terms of agreed monitoring following a DUI conviction in 1998. One application for a special training license was tabled to allow time to take the USMLE Step 2 since the applicant had twice failed this test.

One full medical license was approved after personal appearance. One application was denied since the applicant had been deemed unsafe to practice following an evaluation occasioned by mishandling controlled substances. One application was tabled to allow for psychiatric evaluation.