Self prescribing

From Ganfyd

Self prescribing and prescribing for your own family are not generally recommended. Most cases in the public domain involve fraud or opioids, with ethical conflicts being dealt with by other mechanisms. Multiple international studies have shown that self prescribing of opioids is most commonly identified as an issue in primary care^[1]^[2]. As there is evidence that a pattern of self prescribing behaviour is established early in doctors professional lives advice, education on this issue is probably best targeted early^[3]. A particular issue is that junior doctors may not have a patient relationship with a primary care physician^[4]. Individual states and employers deal with the situation differently, so the act itself can be a disciplinary offense in some jurisdictions. In other jurisdictions there may be an implicit duty to prescribe in emergency exceptional situations where there are no reasonable alternatives.

The situation in the U.K.

Doctors writing prescriptions in the UK should adhere to Good practice in prescribing and managing medicines and devices (2013)

Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.
Controlled medicines present particular dangers, occasionally associated with drug misuse, addiction and misconduct. You must not prescribe a controlled medicine for yourself or someone close to you unless:
1. no other person with the legal right to prescribe is available to assess and prescribe without a delay which would put your, or the patient’s, life or health at risk or cause unacceptable pain or distress, and
2. the treatment is immediately necessary to:
  1. save a life
  2. avoid serious deterioration in health, or
  3. alleviate otherwise uncontrollable pain or distress.
If you prescribe for yourself or someone close to you you must:
1. make a clear record at the same time or as soon as possible afterwards. The record should include your relationship to the patient (where relevant) and the reason it was necessary for you to prescribe.
2. tell your own or the patient’s general practitioner (and others treating you or the patient, where relevant) what medicines you have prescribed and any other information necessary for continuing care, unless (in the case of prescribing for somebody close to you) they object. - GMC guidance (2013)

The evolution of current guidance is interesting:

Objectivity is essential in providing good care; independent medical care should be sought whenever you or someone with whom you have a close personal relationship requires prescription medicines.GMC guidance (2006)^[5]
It is hard to lay down an absolute rule: it makes sense for a doctor to treat minor ailments, or take emergency action where necessary.... But doctors should avoid treating themselves or close family members wherever possible. This is a matter of common sense as well as good medical practice. GMC 1998

While doctors registered with the General Medical Council (GMC) may prescribe medicines to anyone, there are some finer points to this statutory right. Your prescribing must be responsible and able to be seen to be reasonable by others, including the GMC. Provisional or limited registration only allows the prescription of medicines in line with the supervisory conditions of the registration.

Present GMC guidance, published in 2013), is stricter than previous guidance from 1998, 2006 and 2008 (see boxes).^[6]

Pharmacists and hospital pharmacies will tend to have their own rules for handling the situation. Pharmacists may be very cooperative in an emergency situation (they actually have rights of supply themselves in emergencies but are far more likely to ask you to write your own script if the situation is explained). Any registered doctor can write a private prescription, but of course the pharmacist will be expected to take steps to verify it is legitimate. This may be trivial if you are already known to the pharmacist, through say your private practice and using your private practice letter head, but may be challenging otherwise.

Catches as defined by GMC misconduct hearings

Fraud
- Writing an NHS script for a non-NHS patient (relative)
- Writing a request for supply with the intention of supply to an individual (relative overseas)
Inadequate assessment
- Writing a private script for a patient you have not assessed appropriately (relative overseas)
Situations where loss of objectivity would be obvious to peers
- eg narcotics

The situation in the U.S.A

USA specific

The AMA has an opinion which is likely to be endorsed by State regulators.

See AMA Code of Medical Ethics Opinion 8.19 - Self-Treatment or Treatment of Immediate Family Members

There is more known about the current extent of this practice in the USA and the ethics have been analysed, particularly around the issue of inadequate assessment^[7].

The situation in Canada

Canada specific

The CMA has guidance which is re-enforced by State regulators. It is a common issue.

See The College of Physicians and Surgeons of British Columbia Resource manual Self‐treatment and Self‐prescribing 2009

The situation in Australia

Australian specific: Do not do it in Victoria

Victorian government regulations prohibit doctors from self prescribing prescription only drugs. However the other federal states do not. This has allowed an analysis of the impact of such legislation, suggesting it may be counter productive^[8].