dental prescribing

8/10/2019 dental prescribing

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Combining the strengths of UMISTandThe Victoria University of Manchester

The wrong prescription?

Prescribing and the LawSafe prescribing


The wrong prescription?Prescribing and the Law

The Medicines Act of 1968

Misuse of Drugs Act 1971

The NHS Act 1977 The Misuse of Drugs Regulations 2001


THE LEGISLATIONAdditional Limitations

GDPs in NHS

NHS contracts

Dentists in community dental service (CDS)

National Health Service Act 1977: Primary Care

Trust Dental Services Directions 2006[2].


THE MEDICINES ACT OF 1968

Medicinal Product:

any substance that is manufactured, sold, supplied, imported or

exported for specific purposes including the diagnosis, treatment orprevention of disease and anaesthesia induction


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Unlicensed Medicines

e.g. Licensed medicine but unlicensed use

Betnesol dispersible tablets used as a mouthwash



Medical Devices

NHS restrictions

GDPs cannot prescribe under the NHS

GMP prescribing restricted

e.g Gelclair



GSL Medicines

Sold or supplied other than under the direction of a

pharmacist.

Retails outlets including dental practices


What Can Patients PurchaseGeneral Sales List

e.g.

Ibuprofen (up to 16 tab/cap packs)

Aciclovir cream (2g, not all brands) Chlorhexidine/Corsodyl mouthwash

Fluoride mouthwashes

Fluoride toothpastes containing no more than 1500ppm fluoride

Paracetamol (up to16 tab/cap packs)

THE MEDICINES ACT OF 1968 What Can Patients Purchase


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POM

only from a pharmacy *

under the direction of a pharmacist *

only supplied against a prescription (patient specific

direction)


What DPF Medicines Do Our Patients Need aPrescription for?

POM

e.g.

All oral antibiotics

Topical and systemic antifungals

Aciclovir tablets

Duraphat toothpaste

Diclofenac tablets

En-de-Kay Fluorinse

Topical steroids (except Corlan pellets)

NB local anaesthetics, drugs used for the purposes of sedation and emergency drugs

are POMs, dentists can administer POMs to their patients



P Medicines and POM*

Exemption:

can be sold or supplied by dentists and doctors

but

restrictions as far as NHS practice concerned


P Medicines and POM*NHS Restrictions

Supply of drugs:

those required for immediate use before the issue of a prescription e.g.emergency use

personally administer to a patient any drug or medicine required for thetreatment of that patient

neither dentist or doctors can act as pharmacists - The NHS Act 1977



4/44


INFORMATION FOR DENTAL PRESCRIBERS

British National Formulary incorporating the DentalPractitioners Formulary

Other sources of information:

Monthly Index of Medical Specialities (MIMS)

Summary of Product Characteristics (SPC)

Patient Information Leaflets (PILS)


THE MISUSE OF DRUGS Regulations 2001

Controls drugs liable to abuse e.g. morphine,amphetamines. i.e. controlled drugs

Class A

Cocaine, diamorphine, lysergide, methadone, opium, pethidine

Class BOral amphetamines, barbiturates, cannabis, codeine and

pentazocine

Class C

Most benzodiazepines


THE MISUSE OF DRUGS REGULATIONS, 2001

Dentists can possess, supply, prescribe, or administer

controlled drugs in the course of their profession.

Record-keeping, custody of drugs and prescription

writing is regulated by this legislation.



5 schedules:

Schedule 1 cannabis, lysergide, mescaline.

Schedule 2 diamorphine (heroin), cocaine, morphine, pethidine

Schedule 3 barbiturates, pentazocine, temazepam, midazolam

Schedule 4 Part 1 all other benzodiazepines Part II anabolicsteroids, somatotrophin

Schedule 5 low strength preparations e.g dihydrocodeinetartrate 30mg


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RECENT CHANGES

Since 1998:

Community Practitioner Nurse Prescribers (NPF)

Since May 2001:

Extended Formulary Nurse Practitioners (NPEF)

From May 2006:

Nurse Independent Prescribers

Pharmacist Prescribers

Ongoing:

Recommendations of The Shipman Enquiry


Future DevelopmentsPrescribing and DCPs

HSC 2000/026 (August 2000)

Patient Group Directions

Enables nurses, midwives, pharmacists, optometrists, chiropodists,radiographers (and others) to supply or administer medicines

Consultation closed Nov 2009:MLX 362: Sale, supply and administration of medicines by Dental

Hygienists and Dental Therapists under a Patient Group Direction(PGD)


Patient Group Directions (PGD)

What is a PGD:

a written instruction for the supply and/or administration of alicensed medicine (or medicines) in an identified clinical situation,

signed by a doctor or dentist and a pharmacist. It applies to groupsof patients who may not be individually identified beforepresenting for treatment.


Patient Group Directions (PGD)

What is a PGD:

legal mechanism by which medicines can be supplied and/oradministered to patients by a specified range of healthcare

professionals, without first seeing a doctor or dentist. by registered, authorised health professionals

to a well-defined group of patients

for the condition described in the PGD

Future Developments


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PrescribingThe Drug History

Significance:

Barriers:



Significance:

Patient safety

Diagnostic significance

Effective and appropriate treatment

Hidden medical history

Barriers:

Perceived relevance by patient

Non-prescription drugs

Supplements, herbal remedies etc


PrescribingAllergic Reactions

Are you allergic to anything?

Knowledge:




Tell me what happened?

Was the reaction investigated, did you have any tests for it?

Knowledge:

Types of hypersensitivity (I immediate and IV delayed)

Investigations (prick testing, patch testing, direct challenge, RAST)

PrescribingSafe Prescribing



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Know your drugs:

Use BNF

Check indications, cautions, contra-indications, side-effects

Check interactions Appendix 1

Check dose

Give appropriate warnings



Know your limitations:

use drugs you are familiar with

if in doubt consult patients GMP

seek adv ice

local Max Fac or Oral Med consultant


PrescribingAdverse Reactions

If things go wrong

good record keeping

good history

explain to patient let GMP know

report the adverse reaction

Medicine and Healthcare Regulatory Agency MHRA

www.mhra.gov.uk

referral for further investigation if appropriate


PrescribingResources

British National Formulary http://bnf.org

Wray,D and Wagle SMS. A dentists guide to using the BNF: part I. British Dental Journal, 2008;

204: 437-439,

Wray,D and Wagle SMS. A dentists guide to using the BNF: part I. British Dental Journal, 2008;204: 487-491

Scottish Dental Clinical Effectiveness Programme. Drug Prescribing For Dentistry

(published April 2008, latest update November 2009)

http://www.sdcep.org.uk/index.aspx?o=2334

Can dentists supply medicines? Prepared by UK Medicines Information (UKMi) pharmacists forNHS healthcare professionals Expiry: April 2010 National Electronic Library for Medicines

http://www.nelm.nhs.uk

The above references are essential reading

Other useful sources of information include:

UK Medicines Information http://www.ukmi.nhs.uk

North West Medicines Information Centre, Medicines in Dentistry Specialist Advisory Service

http://www.ukmi.nhs.uk/activities/specialistservices

Medicine and Healthcare Regulatory Agency MHRA www.mhra.gov.uk


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Combining the strengths of UMIST and

The Victoria University of Manchester




9/44



The wrong prescription?Prescribing and the Law

The Medicines Act of 1968

Misuse of Drugs Act 1971

The NHS Act 1977

The Misuse of Drugs Regulations 2001


10/44



THE LEGISLATIONAdditional Limitations

GDPs in NHS

NHS contracts

Dentists in community dental service (CDS)

National Health Service Act 1977: Primary CareTrust Dental Services Directions 2006[2].


11/44




Medicinal Product:

any substance that is manufactured, sold, supplied, imported or

exported for specific purposes including the diagnosis, treatment orprevention of disease and anaesthesia induction


12/44




licensing

sale

supply

labelling

packaging


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General sales list medicines (GSL)

Pharmacy medicines (P)

Prescription-only medicines (PoM)

Unlicensed medicines

Medical Devices


14/44



THE MEDICINES ACT OF 1968Unlicensed Medicines

e.g. Licensed medicine but unlicensed use

Betnesol dispersible tablets used as a mouthwash


15/44



THE MEDICINES ACT OF 1968Medical Devices

NHS restrictions

GDPs cannot prescribe under the NHSGMP prescribing restricted

e.g Gelclair


16/44



THE MEDICINES ACT OF 1968GSL Medicines

Sold or supplied other than under the direction of apharmacist.

Retails outlets including dental practices


17/44



What Can Patients PurchaseGeneral Sales List

e.g.

Ibuprofen (up to 16 tab/cap packs)

Aciclovir cream (2g, not all brands)

Chlorhexidine/Corsodyl mouthwash

Fluoride mouthwashes

Fluoride toothpastes containing no more than 1500ppm fluoride

Paracetamol (up to16 tab/cap packs)


18/44



THE MEDICINES ACT OF 1968P Medicines


under the direction of a pharmacist * can be sold over the counter without a prescription

can be prescribed by a dentist, doctor or recognised

non-medical prescriber


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What Can Patients PurchasePharmacy Medicines

e.g. Aciclovir cream (2g)

Miconazole oral gel (15g tube)

Corsodyl dental gel Ibuprofen (>16 tab/cap packs)

Paracetamol (up to 32 tab/cap packs)

Fluoride tablets

Fluoride drops

Corlan pellets


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THE MEDICINES ACT OF 1968POM


under the direction of a pharmacist * only supplied against a prescription (patient specific

direction)


21/44



What DPF Medicines Do Our Patients Need aPrescription for?

POM

e.g. All oral antibiotics

Topical and systemic antifungals

Aciclovir tablets

Duraphat toothpaste

Diclofenac tablets

En-de-Kay Fluorinse

Topical steroids (except Corlan pellets)

NB local anaesthetics, drugs used for the purposes of sedation and emergency drugs

are POMs, dentists can administer POMs to their patients


22/44



THE MEDICINES ACT OF 1968P Medicines and POM*

Exemption:

can be sold or supplied by dentists and doctors

but

restrictions as far as NHS practice concerned


23/44




Supply of drugs:

those required for immediate use before the issue of a prescription e.g.

emergency use personally administer to a patient any drug or medicine required for the

treatment of that patient

neither dentist or doctors can act as pharmacists - The NHS Act 1977


24/44





Issue of prescription forms:

A prescriber shall order listed drugs, medicines or appliances as areneeded for the treatment of any patient to whom they are providingservices by issuing to the patient a prescription form.

The prescription form shall

(a) be signed by the prescriber; and

(b) be issued separately to each patient to whom theclinic/contractor is providing services.


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DENTAL PRESCRIBING

Use form FP10D

Only those items listed in the Dental PractitionersFormulary

No limits on the number and variety of substanceswhich may be administered to patients in the surgery

No limits on the number and variety of substances

which may be ordered by private prescription


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INFORMATION FOR DENTAL PRESCRIBERS

British National Formulary incorporating the DentalPractitioners Formulary

Other sources of information:

Monthly Index of Medical Specialities (MIMS)

Summary of Product Characteristics (SPC)

Patient Information Leaflets (PILS)


27/44



THE MISUSE OF DRUGS Regulations 2001

Controls drugs liable to abuse e.g. morphine,

amphetamines. i.e. controlled drugs

Class A

Cocaine, diamorphine, lysergide, methadone, opium, pethidine

Class B

Oral amphetamines, barbiturates, cannabis, codeine and

pentazocine Class C

Most benzodiazepines


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Dentists can possess, supply, prescribe, or administer

controlled drugs in the course of their profession.

Record-keeping, custody of drugs and prescriptionwriting is regulated by this legislation.


29/44




5 schedules: Schedule 1 cannabis, lysergide, mescaline.

Schedule 2 diamorphine (heroin), cocaine, morphine, pethidine

Schedule 3 barbiturates, pentazocine, temazpam, midazolam

Schedule 4 Part 1 all other benzodiazepines Part II anabolicsteroids, somatotrophin

Schedule 5 low strength preparations e.g dihydrocodeinetartrate 30mg


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Dentists may administer to a patient any drug specified inSchedule 2, 3 or 4.

Dentists may direct another person, other than a doctor or adentist, to administer such a drug to a patient under their care.

Any person may administer to another any drug specified underSchedule 5


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Dentists may prescribe on the NHS: Schedule 3: temazepam tablets, temazepam oral solution

Schedule 4: diazepam tablets, diazepam 2mg/5ml oral solution,

nitrazepam tablets

Schedule 5: dihydrocodeine 30mg tablets


32/44



RECENT CHANGES

Since 1998:Community Practitioner Nurse Prescribers (NPF)

Since May 2001:

Extended Formulary Nurse Practitioners (NPEF) From May 2006:

Nurse Independent Prescribers

Pharmacist Prescribers

Ongoing:

Recommendations of The Shipman Enquiry


33/44



Future DevelopmentsPrescribing and DCPs

Consultation closed Nov 2009:MLX 362: Sale, supply and administration of medicines by DentalHygienists and Dental Therapists under a Patient Group Direction

(PGD)

February 2010:

Commission on Human Medicines (CHM) reommended amendment of

legislation

CHM recommendations accepted by ministers.

Now awaiting change to legislation


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35/44




Significance:

Barriers:


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Significance:

Patient safety

Diagnostic significance

Effective and appropriate treatment

Hidden medical history

Barriers:

Perceived relevance by patient

Non-prescription drugs

Supplements, herbal remedies etc


37/44





Knowledge:


38/44





Tell me what happened?

Was the reaction investigated, did you have any tests for it?

Knowledge:

Types of hypersensitivity (I immediate and IV delayed)

Investigations (prick testing, patch testing, direct challenge, RAST)


39/44




Know your patient

Know your drugs

Know your limitations

Know what to do when things go wrong


40/44




Know your patient

Medical history

Drug history

Allergy

Do you require additional information from GMP?


41/44




Know your drugs:

Use BNF

Check indications, cautions, contra-indications, side-effects

Check interactions Appendix 1

Check dose

Give appropriate warnings


42/44




Know your limitations:

use drugs you are familiar with

if in doubt consult patients GMP

seek advice

local Max Fac or Oral Med consultant


43/44



PrescribingAdverse Reactions

If things go wrong

good record keeping

good history

explain to patient

let GMP know

report the adverse reaction

Medicine and Healthcare Regulatory Agency MHRA

www.mhra.gov.uk

referral for further investigation if appropriate


44/44



PrescribingResources

British National Formulary http://bnf.org

Wray,D and Wagle SMS. A dentists guide to using the BNF: part I. British Dental Journal, 2008;204: 437-439,

Wray,D and Wagle SMS. A dentists guide to using the BNF: part I. British Dental Journal, 2008;

204: 487-491

Scottish Dental Clinical Effectiveness Programme. Drug Prescribing For Dentistry

(published April 2008, latest update November 2009)

http://www.sdcep.org.uk/index.aspx?o=2334

Can dentists supply medicines? Prepared by UK Medicines Information (UKMi) pharmacists for

NHS healthcare professionals Expiry: April 2010 National Electronic Library for Medicines

http://www.nelm.nhs.ukThe above references are essential reading

Other useful sources of information include:

UK Medicines Information http://www.ukmi.nhs.uk

North West Medicines Information Centre, Medicines in Dentistry Specialist Advisory Service

http://www.ukmi.nhs.uk/activities/specialistservices

Medicine and Healthcare Regulatory Agency MHRA www.mhra.gov.uk

Documents

dental prescribing