Manipulation of prescriptions by patients – what must a doctor do?

Over-the-counter use of medication via chemists, including the use of psychiatric medication, has always been a cause of worry in the Indian subcontinent (1). Over the last two years, the rules on dispensing psychiatric medication have become stringent and chemists have to dispense the exact amount of medicine written on the prescription for the time duration mentioned. The chemist also stamps the prescription with the amount of medicine dispensed so that the patient does not use the prescription at another chemist’s or counter to obtain more than the amount prescribed. This means that patients must follow up with the psychiatrist regularly, have themselves evaluated, and get a fresh prescription that must be signed by the doctor and also carry his seal. There are many patients who do not adhere to this rule. Many a time, chemists who have known a patient over the years tend to continue dispensing medication to the patient for durations which far exceed that prescribed by the doctor. This is rather dangerous as the patient may end up taking antidepressants, antipsychotics and sedatives for months or at times, years, without a valid prescription. They may also develop side-effects that could ensue under unsupervised consumption.

At times, patients manipulate the prescription when chemists adhere to the rules and dispense the exact dose specified. They increase the dose on their own so that their medicines last longer and they can avoid follow-up for reasons best known to them. Sometimes, they increase the duration of the prescription on their own and may thus continue with their medication without visiting the doctor. As a doctor, this bothers me as it is the doctor who would bear the responsibility were there some mishap. We are in an era in which doctors are governed by strict rules and are not spared the consequences of the slightest negligence (2). Do we have rules in place for bringing to book patients who take the law into their own hands and manipulate prescriptions? Even though it is their fault, they blame doctors for the long-term side-effects of medication and give excuses for not following up and manipulating a doctor’s prescription. These include having to travel long distances, lack of finances and family problems. It has been reported in the scientific literature that patients with a drug abuse problem may manipulate a prescription to procure certain opioid drugs or sedatives (3). When, however, patients who seek help for other psychiatric problems do the same, what are the doctors supposed to do? Should they continue treating such patients with the same vigour even when a patient has threatened the integrity of the doctor–patient relationship? Is there a tribunal or a body where doctors can be warned of such patients? Patients who manipulate their prescriptions are committing a serious ethical violation and this needs to be looked into from the perspective of healthcare.