‘Silly brain fart’: active ingredient woes continue

Tales from the front lines of prescribing.

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GPs continue to warn of potentially dangerous scenarios arising from active ingredient prescribing legislation.

The legislation, which kicked into gear early this year, has required all practice management software to change the ways in which prescription medications are listed when printed out.

Now, no matter what brand name is typed into the computer, the print-out will just list the active ingredient.

The only way to get it back is for the prescribing doctor to go back into the script list, delete the entry, and rewrite it, remembering to tick a “no substitutions” box while they’re there.

Issues with the system have been varied, ranging from patients assuming they’ve been incorrectly prescribed a new drug to a patient with a serious egg allergy almost receiving a generic flu vaccine.

In a recent survey from HealthEd/Pulse, both doctors and pharmacists said the new requirements were a “retrograde and negative step”, “difficult”, “very bad” and “a really silly brain fart from Canberra”.

Of the roughly 850 participants, approximately 40% found the changes “moderately” or “extremely frustrating”, 40% found them “mildly frustrating” and the remainder found them “not at all frustrating”.

“Patients regularly bring back scripts as they think I have made a mistake,” one respondent wrote.

“Waste of time and money and whichever idiot thought this was a good idea should be made to apologise for the time he/she has wasted and the confusion he/she has caused.”

A recurring theme among the responses related to prescriptions for Targin.

“Dangerous? How, you ask? Targin is an example of where it is dangerous … as the [active ingredient prescribing software] flips the ingredients into alphabetical order, not the medically correct order … so everyone gets confused with a dangerous commonly used opioid,” wrote one respondent.

“I am worried about the potential for mixing up dose forms, even when the brand name is included on the script e.g. Endone, OxyContin and Targin,” another response read. 

“Confusing for patients: e.g. Targin and Keppra – patients have trouble with these ones and other combinations where the less important ingredient is written first,” a third survey participant wrote.

Although hiccups are expected with the rollout of any new process, it appears that problems may persist for certain patient groups.

“This has created a big problem for non-English speaking background/elderly patients, who will commonly understand their medicines by trade name,” one respondent wrote. 

“Ticking the ‘include the brand name’ box is not always possible and time consuming.”

Dr Richard Waluk, a Melbourne GP told The Medical Republic about one instance where a patient was sent to a compounding pharmacy with a prescription for a stool softener.

“The patient went with the script to the chemist, the chemist looked at it and – because it is a multi-ingredient suspension, it contains some liquid paraffin and a few other ingredients – the chemist said, ‘well, this is a compound medication, you have to go to a compound pharmacy,’” Dr Waluk told TMR.

“So the patient went to compound pharmacy and the compound pharmacy dutifully made the concoction of 500 mL of this suspension and charged the patient $97.

“The patient then came to me next time and said ‘your medication helped, but why didn’t you tell me that it is going to cost me $97?’”

More seriously, another of Dr Waluk’s patients presented in a hypertensive crisis because they hadn’t filled their most recent blood pressure script, not recognising the generic name for their medication.

“I said, ‘why for God’s sake did you not ring me about this?’” Dr Waluk said.

“They said ‘oh, I just didn’t want to bother you, I thought I would survive’, and then they come with the blood pressure over 200 – this is dangerous, basically.”

Not all responses to the survey were negative, however – some prescribers wrote that they preferred generic names in the first place, or that they felt it was a good opportunity to educate patients.

“I do not think that active ingredient prescribing process has had a negative impact on my patients as far our staff and pharmacist takes special interest explaining why chemical name awareness is important for the patients,” one respondent wrote.

“I think causing early initial confusion for a moderate number of patients but when they get more familiar as time goes by, it’s an excellent idea and will lead to less confusion and cases of multidosing with different brands,” another response read.

Others felt generics were “less exploitative to patients” and welcomed the measures.

“It is better practice to have the active ingredient rather than the brand name even though obviously the companies who make the drugs may not feel that way,” one response read.

Dr Waluk, on the other hand, said it seemed redundant to use generic names when the “whole world uses trade names”.

“It almost sounds like somebody was trying to invent an Australian wheel and that Australian wheel is a square, but it is our wheel,” he said.

“It doesn’t matter that it cannot turn.”