Forgery: Tips for Identifying Fraudulent Prescriptions

FACT SHEET

Legislative References:

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Definitions

Controlled Substance: A substance listed in the schedules to the Controlled Drugs and Substances Act (CDSA), including narcotics, controlled drugs, benzodiazepines and other targeted substances.

Monitored drug: Controlled substances, any opioids that are not controlled substances, and any drug product designated by the Minister of Health as per the Narcotics Safety and Awareness Act.

Background

Those seeking narcotics or other controlled substances illegitimately can be very creative in developing new methods for obtaining these drugs. Advances in technology using computers and peripherals (scanners, copiers, printers, fax machines, etc.), coupled with the increase in prevalence of electronically-generated prescriptions makes detecting forgery an even more daunting task.

Forgeries can be created in several ways. For example, legitimate prescriptions may be stolen from genuine patients, altered, and/or copied. A prescription may be falsified completely or partially, with elements taken from valid patient and/or prescriber data, or through identity theft. Pharmacy professionals are expected to be familiar with how the province’s Narcotic Monitoring System (NMS) functions and the resources from Ministry of Health in the additional references listed below.

The NMS alerts pharmacies of potential issues such as patients who obtain prescriptions for a monitored drug from more than one prescriber or from more than one pharmacy. NMS also alerts pharmacies when a prescriber has notified the Ministry about a previously identified forged prescription for a monitored drug and/or stolen prescription pad. Ideally, proper use of the system also helps reduce unlawful activities involving controlled substances, such as double-doctoring[1] and forgery[2].

Tips for Identifying Fraudulent Prescriptions

Although the prescription itself is normally the main focus, assessing other elements of the interaction can also provide information useful in determining the authenticity of a prescription as a whole. Pharmacy professionals should develop and implement routine dispensing procedures that reflect the standards of practice. A systematic approach to screening prescriptions, by checking that the strength, dosage, dose regimen, and quantity are reasonable in light of the information gathered, is encouraged.

Forgery perpetrators may purposely target situations where they might catch staff with their guard down. Examples include newly opened pharmacies, holidays or weekends when “regular” staff are not on duty, very early or very late when there may be fewer staff, and who may also be distracted trying to perform other tasks to open/close the pharmacy.

Compromises or shortcuts may lead to errors in judgement. Where there is any question regarding the validity of the prescription, take the time to conduct due diligence and verify the authenticity of the prescription directly with the prescriber as soon as possible.

Assessing the Patient

Prior to dispensing a prescription, the Standards of Practice expect that the pharmacist assesses the appropriateness of the prescribed therapy for the patient, taking into account the indication or intended purpose in light of the patient’s characteristics. This requires the pharmacist to gather relevant information through dialogue and to document the pertinent details in the patient record. Observing the person’s behaviour and body language during this interaction may also provide clues to indicate a potentially fraudulent prescription, especially if the individual is not known to pharmacy staff.

Pharmacy professionals should also maintain objectivity and avoid bias in their assessment. For example, a drug-seeking individual may already have a record in the pharmacy’s computer system. The patient may have successfully obtained drugs at a pharmacy by fraudulent means in the past, or may have filled a legitimate prescription there before. Drug plan information or identification provided by a patient or agent may be legitimate, or it may be stolen or otherwise invalid. Fraudulent prescriptions could include information (such as Limited Use codes for Ontario Drug Benefit) in an attempt to give the perception of authenticity. If in doubt, verify any prescriptions that seem out of context or suspicious directly with the prescriber.

Other questions to consider in evaluating the patient

  • Do you know the patient? Is it reasonable for the patient to be visiting your pharmacy?
  • In the case of an agent picking up a prescription for a patient, the identification of the agent must also be verified and recorded by the pharmacy (NMS)
  • Is this medication consistent with the treatment history?
  • Does the patient seem uncomfortable or nervous? Is the patient evasive, avoiding eye contact or providing vague answers to questions?
  • Is the patient displaying signs of aggression or trying to intimidate staff?
  • Is the patient unusually impatient, in a hurry, trying to rush the process, or unable to return later (whether or not asked or suggested by the pharmacy)?
  • Are there other diversions being used to create a sense of urgency (e.g. crying baby, patient waiting in car, medication/anesthetic from hospital wearing off, etc.)?
  • Are there elements of the situation that don’t align, such wearing a brace, bandages, using crutches or a cane improperly or inconsistent with the indication?
Evaluating the Prescription

When dispensing a prescription for any controlled substance that has been signed and dated by a prescriber, federal regulations expect that the signature, if not known to the pharmacist, has been verified. If the prescription is given verbally, the pharmacist must take reasonable precautions to verify that the person giving the prescription is a prescriber.

Fax numbers, call display/caller ID, and other points of origin can be manipulated, making it essential for dispensers to be diligent in verifying the authenticity of all prescriptions. Fraudulent prescription are often presented late in the evening, or on weekends, when it’s difficult to confirm with the prescriber. Importantly, do not use the fax or phone number on the prescription to contact the prescriber without confirming the number against a reliable, independent source.

The Prescriber:

  • Do you know the prescriber, including their practice or specialty, or if they have any practice restrictions?
  • Does the information on the public register of the prescriber’s regulatory College confirm the information of the prescription?
  • Do you recognize the signature or manner of authorization?
  • Is it reasonable for the patient to be seeing this prescriber (e.g., out of town, or a specialist unrelated to the condition being treated, etc.)?

The Prescription:

Examine the content of the prescription carefully for clues such as:

  • The number and type of identification indicated is inconsistent with the information on the patient’s record or the approved list of identification (NMS)
  • Dosage does not conform to guidelines or differs from the expected or typical prescribing patterns
  • Quantity seems inappropriate or excessive
  • Unusual symbols, terminology, abbreviations, or punctuation; spelling errors
  • Directions are fully written out and no medical or Latin abbreviations and terminology are used
  • Examine any security features of the prescription. For example, some will expose a VOID watermark when photocopied, and some EMRs will print detailed watermarks that are hard to reproduce
  • Use of white-out, overwriting, smudging, or different colour ink on prescription, especially in alterations to quantities or date
  • Changes in font type or size or other inconsistencies in formatting (margins, spacing, etc.)
  • Includes inexpensive non-narcotic items, that might be not needed right now
  • Looks too good, i.e. handwriting, format, all fields or patient information completed
  • Prescription appears to be a photocopy and not an original
  • There is evidence that the prescription was presented to and not filled by another pharmacy

Pharmacists must ensure the authenticity of prescriptions and contact the prescriber for verification when its validity is in doubt. If you identify an altered prescription inform the prescriber whose name appears on the prescription. In the case of confirmed forgeries involving controlled substances, refer to the College’s Fact Sheet – Forgery: Management and Reporting of Fraudulent Prescriptions for further information.

Additional References:

Published: July 2013
Version #: 3.10

College Contact: Pharmacy Practice