The Art of Forging Prescriptions


I’m so excited to host future author and pharmacist, Amy Gale, who will be blogging on the topic of falsifying prescriptions.

Welcome, Amy!

Prescription drug abuse is rapidly growing. A large amount of popular “street drugs” are medications prescribed on a daily basis. It seems more and more people are trying to falsify prescriptions and the new trend is to “pop pills” to get high. Let’s hope this trend is short lived. So, how do you forge a prescription?

The most commonly forged prescriptions are Class III to Class V narcotics. Some popular examples are Vicodin, Valium, and Xanax.  These prescriptions are easier to falsify because they can be forged in two ways. 

First, a prescription can be called in to the pharmacy. As long as the caller has all the pertinent information and knows the physicians DEA number, the prescription is deemed valid. If a pharmacist feels the prescription is falsified, a call to the physician is warranted to verify the information. Some drug abusers are so good at impersonating a physician or office; they can fool even a seasoned pharmacist.
Second, a written prescription can be presented to a pharmacy associate. It must contain all pertinent information such as patient’s name, address, phone number, drug name, quantity, directions for use, refills, physician’s name, and physicians DEA number. A prescription can be written for any medication, but Class II narcotics (some examples are Percocet, Oxycontin, Morphine, Ritalin, and Adderall) must be physically written prescriptions with no additional refills. There are exceptions such as emergency supplies, but most fraudulent prescriptions are written for larger quantities than the emergency supply law allows.
How do I know if a prescription is fraudulent?  There are warning signs indicating a prescription may not be legitimate. The following are some common ones:
1. Prescription is written/or called in for an unusually high dosage or quantity.

2. Prescription is written in pencil or several different colors of ink.

3. Lack of standard abbreviations (every word written or spoken out completely).

4. Different handwriting styles or perfect handwriting.

5. Altered numbers in quantity and/or dosage.

6. Characteristics indicating a photocopy.

7. Out of state physicians. 
 
8. Paper is too smooth, no indentations from pen pressing on paper.

9. Part of physician’s signature is cut off. 

10. No perforation or residual glue at the top of paper.

11. Toner dust rubbing off or smudging on the paper.
Patients presenting fraudulent or forged prescriptions do not act like everyday customers. Here are some signs of unusual patient behavior that flags a pharmacist.
1. Requests early refills (some common excuses are vacations, lost medication, dropped in sink.)
2. Patient is willing to pay full cash price instead of using insurance or attempts to work around the days’ supply and quantity limits imposed by most insurance carriers.
3. A number of patients appear simultaneously, or within a short period of time, all bearing similar prescriptions from the same prescriber.
4. Patient is unusually anxious, out of proportion to the situation.
5. Unusually impatient for prescription to be filled and attempts to rush their prescription through ahead of others.
6. Attempts to persuade the pharmacist not to verify prescription with physician.
7. Drops off prescription right before closing and persuades pharmacist to rush it through.
8. Patient arrives within minutes of the prescription being called in by prescriber.
9. Verification callback number is cell phone or number other than physician office.
When a fraudulent prescription is presented to a pharmacist a few things can happen:
1. The patient fools the pharmacist and obtains the medication.
2. The pharmacist refuses to fill the medication.
3. The pharmacist fills the medication but alerts the DEA or local authorities and the patient is arrested as soon as the fraudulent prescription is sold.

I’d like to say I’ve never been fooled or that my patients would never try and falsify a prescription, but unfortunately that’s not true. I’ve seen it and heard it all! In my twelve years as a pharmacist I’ve even had a few people arrested. I hope you have a better understanding of how prescriptions are forged.  Feel free to ask any questions or pick my brain.

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Amy Gale is a pharmacist by day, aspiring author by night. She attended Wilkes University where she graduated with a Doctor of Pharmacy degree. Her dream is to share her novel, Blissful Tragedy, with the world. In addition to writing, she enjoys baking, scary movies, rock concerts, and reading books at the beach with her feet in the sand. She lives in the lush forest of Northeastern Pennsylvania with her husband, five cats, and golden retriever puppy. Her journey to publication is just beginning, let’s hope it has a happy ending. You can connect with Amy at her website at www.authoramygale.com.

Up and Coming and Vaccine Myths

Hello Redwood’s Fans!

How has your week been? Is everyone else loving Autumn right now? Football season is in full swing and I’m happy to note that my team, the Broncos, are currently undefeated. I was not one that quickly jumped on the Peyton Manning boat. I still am pining the loss of Tebow but I may now be seeing the light. We’ll see if Manning can go all the way this year.

Last week I posted about some common fall/winter illnesses: flu and RSV. I got this comment from a reader (Yes! I absolutely read them.) I thought I’d expand here.

From Andrea:

Here’s my thinking on the flu shot. If everyone around me gets it, then why should I? LOL I am always on the fence. I’ve only had the shot once. They always guess at the strain of flu that will come so you have a 50-50 shot. (ha pun not intended but it works!) I’ve also heard if it isn’t given correctly, there can be other complications. Truth??

Jordyn says:

There are a couple of myths around vaccines I’d like to speak on here. I am pro-immunization. I know others who read this aren’t and I know why you are– because I’ve been in pediatrics for seventeen years and have heard your reasons. What frustrates me is that I think there is little voice to the other side. Anti-vaccine people get a lot of lime light and it does risk lives when people choose not to immunize.

This is a common myth– if everyone else is vaccinated– why should I be? They’ll protect me.

For one– more and more people are choosing not to vaccinate so you can’t rely on “herd immunity” that much anymore. Herd immunity is the number of vaccinated individuals in a population. The problem is for certain diseases, you need a high percentage of herd immunity to afford protection. For something like measles– the herd immunity needs to be 95%. This news story reports immunization rates in Colorado dropping to 85% in 2011. What that means is that if measles breaks loose in CO– people are going to be infected. Here’s a recent news story about a measles outbreak in Alberta, Canada.

As a physician is quoted in the above article: “Some have become more afraid of the vaccine than they are of the disease.”

And the reason for this is partly due to the success of immunizations preventing the disease and the general population not seeing children sickened, ill and dying from these diseases.

Which I have seen— and why I believe in immunizations.

The second part to Andrea’s question was even if the vaccine is given properly– there can be complications. Yes, this is true. As with any shot there is risk of localized shot reaction (which some may think is cellulitis but often times is not), pain, tenderness, swelling and risk for infection.

Most physicians think the benefits (not getting measles) is worth these possible side effects.

Do they just guess as to what goes into the flu shot? Yes and no. You can read about that here

It’s like predicting a football game– you look at the data for both teams and make a prediction. It is still a guess but it’s based on data.

One last myth: It’s better to get the actual disease. This is absolutely not true.

Ask those who lost kids to H1N1– about 90% weren’t vaccinated. They might have a different
opinion.

Here is the series I did on immunizations if interested:

http://jordynredwood.blogspot.com/2011/11/pediatric-controversies-immunizations.html

http://jordynredwood.blogspot.com/2011/11/pediatric-controversies-immunizations_30.html

http://jordynredwood.blogspot.com/2011/12/pediatric-controversies-immunizations.html

There ARE risks to vaccines– so educate yourself and decide if you think the risk is worth it. But also read about the complications of diseases you’re choosing not to protect your child against and decide if you can live with that risk as well.

For you this week:

Tuesday: Just exactly how do people forge prescriptions? This is a must-read article for every writer/author.

Thursday: Signs of child abuse. Just what are we in pediatrics looking for?

Have a GREAT week– and get your flu shot.

Jordyn

What is Influenza?


Since we’re getting into “respiratory season” I thought I’d do some public service/illness education. Of course, you can always inflict your characters with these illnesses.
Just make sure you pick the right time of year. 
Most often when patients sign in with a complaint of “flu” they are really having vomiting and/or diarrhea. Flu has become a commonplace term for just not feeling well.
If this is the concern you have in bringing your child to the ER they likely have gastroenteritis which is generally caused by a viral infection of the intestinal tract. Your child should be seen in the emergency department for concern for dehydration, if any blood is noted or if they are vomiting bright yellow or green– and this was not caused from them eating a pile of yellow or green crayons.
How do we know you don’t have the flu? Like RSV, flu is a seasonal illness. It comes out to play in late fall and early winter. This is why flu shots are given around September, October and November.
Fine. But it is that time of year. The second reason we know it’s gastroenteritis is that flu is a respiratory illness . . . not an intestinal one.
Influenza is transmitted through droplets by coughing and sneezing. Typical associated symptoms are high fever (generally 102 and up), generalized muscle aches and cough.
In children, what can happen is what we term post-tussive emesis. This is when the child coughs so hard that they trigger their gag reflex and vomit. It’s more a mechanical issue than a viral one.
Do I need to go to the ER? Not necessarily. Fever can be managed with appropriate dosing of acetaminophen and ibuprofen. Remember that ibuprofen should not be given to children less than six months and no aspirin for children under 21 unless specifically prescribed by your doctor. Lots of fluids. Don’t worry too much if they’re not eating but they must drink. They should be hydrated if they are peeing at least every six hours. Don’t just give water. If you have an H2O lover at home at least alternate it with something that has some sugar and electrolytes. This can be Pedialyte or equivalent for children under 2 years and sports drinks for kids over 2. Juices are good but if you are concerned about the amount of sugar you can cut it in half with plain flavored Pedialyte.
Are you getting your flu shot this year?

Winner!

Over the last couple of months I’ve been preparing for my newsletter launch that happened yesterday!

My goal for the newsletter is to treat subscribers to items that I don’t do anywhere else. Fun prizes. Deleted chapters that will only be published there and a more personal look at my writing life.

Those inaugural subscribers were eligible for a prize worth over $75.00 and I’m happy to announce that Andrea Skaggs is the winner!!

Congratulations, Andrea! I’ll be contacting you for your address.

All others– don’t despair but get signed up! There is more fun to be had.

Jordyn

What is RSV?


Looking for some seasonal illnesses to inflict upon your characters? Or perhaps, their children?
It that time of year when we’re gettting into “respiratory season”. The time of year many pediatric medical professionals dread because it is when all the respiratory viruses come out to play and our patient volumes increase.
RSV is a virus that causes bronchiolitis. It is the causative agent but not the only virus that causes bronchiolits.
RSV stands for respiratory synctytial virus. It has a confined season that lasts approximately 20 weeks and starts in late fall/early winter and lasts until spring.
The concern with RSV is that it is easily transmitted through touch. Someone coughs into their hands and then touches another on the face would be an example of its transmission. Unfortunately, the RSV virus can live on surfaces and clothing for several hours. The best way to prevent its transmission is with good hand washing.
The virus causes inflammation and increased mucous production in the smaller airways. This can lead to respiratory distress in a child.Young infants are more apt to develop respiratory distress.
But how can you tell if your child is having difficulty breathing and needs medical attention?
1. They are breathing fast. Count their breathing over a period of one minute. One breath is in and out. Infants should be breathing less than 60 times per minute.
2. You see retractions. Retractions are when skin is pulled inward during breathing. It my be pulled in between the ribs, above the sternum, above the collar bones, and below the rib cage. The more evident the skin tugging is, the more difficulty they are having. Retractions are a sign the child is using additional muscles to help them breathe. Their belly may bob up and down as well.
3. You hear extra noises when they are breathing. They might be musical, barmy like a seal, or high pitched like when  the top of a balloon is squeezed when the air escapes through a smaller passage.
4. They have color changes. Their skin is pale or blue.
5. They are not interested in eating or drinking or are having difficulty eating and drinking. Children, particularly babies, that are having trouble breathing will pull of the breast/bottle to take breaths. Young babies breath just through their nose, so if it’s clogged with secretions, they can’t breath and nurse at the same time.
The more symptoms the baby has, the more significant their difficulty breathing. If you see signs such as these, you should have them checked by their pediatrician or local emergency department.

Up and Coming

Hello Redwood’s Fans!

How’s your week been?

Mine . . . a little like the photo. I survived the ACFW conference in Indianapolis a few weeks ago. I didn’t win the Carol Award which is a little sad but I got to meet the other two great women authors in my category: Katie Gansert and Courtney Walsh (the award went to Katie like I thought!) Katie is the gorgeous one in the pink.

If you are an aspiring author I highly recommend these conferences. They are a great way to network and just be amongst other like-minded individuals. I mean really– does your family really understand your characters talking to you?

One of the highlights of the conference was meeting Frank Peretti. I think he could be considered the grandfather of the Christian suspense/paranormal novels with his groundbreaking books This Present Darkness and Piercing the Darkness. These books remain popular after their debut almost twenty years ago.

He was very kind and generous. I think he probably did take a photo with every conferee– and there were almost 600 of us there. Worse than wedding photo day– I’m sure his cheeks hurt for weeks.

This is also the last week to subscribe to my newsletter to be eligible for my mega-prize worth over $75.00! You can subscribe here.

For you this week I’m doing a little fall/winter health education. What exactly are flu and RSV?

Anyone else excited for autumn?!? Me, yes. Not so much geared up for what we call respiratory season though.

Have a great week!

Therapeutic Hypothermia: Part 2/2

Last post I discussed a little bit about situations where therapeutic hypothermia might be indicated.

This post I thought I’d discuss exactly how it’s done. The highlighted points came from this article. It focuses on a research protocol for adults but is a nice jumping off point for scene writing if you wanted to do this for one of your characters.

The type of adult who would be eligible:

1. Adult resuscitated from witnessed arrest from cardiac cause. This is important because then the down time is known and the likelihood of preserving good brain function is more likely versus just prolonging a vegetative state.
2. They are comatose and intubated (on a breathing machine.)
3. Initial rhythm of v-fib/v-tach– which are lethal heart rhythms that require electricity for conversion to a normal perfusing rhythm. 
4. Have a stable blood pressure after resusitation.

Not eligible:

1. Temperature less than 86 degrees Fahrenheit. This is probably because you are really dead.
2. Pregnancy.
3. Terminal Illness.
4. In a coma prior to arrest.
5. Inherited blood clotting disorder.

How do you cool?

1. Insert a core temperature monitor (into the bladder, heart, or esophagus.)
2. Infuse 20-30cc/kg of normal saline cooled to 39.2 degrees Fahrenheit over 30 minutes.
3. Maintain temperature at 89.6- 93.2 degrees Fahrenheit for 24 hours with cooling blankets.
4. Use sedation as needed and paralytics if the patient is shivering– the point of this would be that shivering causes expenditure of energy and we wouldn’t want that to happen.
5. Nursing care includes lubricating eyes, monitoring urine output, watching blood sugars closely.
6. Rewarm the patient 0.3-0.5 degrees at a time.
7. Don’t provide nutrition during this phase– I’m assuming they mean putting food into someone’s gut which makes sense as it wouldn’t be getting good blood flow and would just sit there undigested causing problems.

What do you think? Would you ever use therapeutic hypothermia in a scene?

You can further read the article for more in-depth information.

The Four Day Frozen Baby: Therapeutic Hypothermia 1/2

In the last couple of months, I recently heard a news story about the “Baby Frozen for Four Days”. I don’t know what it is, perhaps it’s the suspense author in me, but I immediately began to imagine those that have had their heads disconnected from their body and frozen until a point in time comes where they can be attached to another disease free body.

And just what happens to those other people who “donate” a whole body without their head? I’m sure there is a suspense novel in there somewhere. Probably already has been.

But I digress. Instead, I’ll keep the vision of Hans Solo in my mind.

Therapeutic hypothermia is actually a reasonable therapy to consider when the medical staff is concerned about potential brain damage.

But to say the patient is frozen is a little bit of a misnomer. If the tissue were truly frozen it would crystallize and be damaged– this would not benefit the patient.

Instead, the body temperature is dropped to around 33 degrees Celsius or 91.4 degrees Fahrenheit. Normal body temperature is 37 degrees Celsius or 98.6. Next post will discuss how this might be accomplished.

Generally, therapeutic hypothermia is used when there is a concern for brain injury, usually after an anoxic event, which means the patient potentially suffered from a lack of oxygen.

Common situations where this could occur would be during birth (for infants) and after cardiac arrest (for adults) which is currently how the therapy is employed. It came out recently to consider therapeutic hypothermia in instances of pediatric arrest though it’s not widely employed at this time.

The reason therapeutic hypothermia is effective is that it slows brain metabolism and protects brain tissue from oxygen free radicals which are release during tissue injury.

In recent news, however, there were two different instances where infants were placed in therapeutic hypothermia. One was after repair of a complex heart defect where perhaps the infant did arrest or was on bypass for longer than desired– though this is speculation and not stated in the article. Case two was an infant that had a very fast heart rhythm called SVT and I’d not heard of using hypothermia anywhere as treatment for this heart condition.

All very interesting.

So keep therapeutic hypothermia in mind for use in fiction after a patient suffers cardiac arrest as I did in my recently released novel Peril— it will definitely add to the tension.

Check out the follow links to read more about therapeutic hypothermia:

1. Infant who had heart surgery.
2. Infant with SVT.
3. Use of hypothermia in infants post traumatic delivery.

Thoughts on NY Med: Part 2/2

This week, I’ve been analyzing some episodes of NY Med. Last post I discussed Dr. Oz’s view on some requirements for surgery. And they didn’t involve the patient’s state of health.

Today, I’m going to look at another aspect. Let’s call it . . . expectations.

We, as medical providers, have a set of expectations for our patients. We assume, rightly or not, that when you come to the ER you’ll generally be on board with what the medical game plan is. After all, we’ve been through medical training and most of our patients haven’t. There is the thought that you’ll defer to our training and years of experience when we give you the medical game plan for your complaint.

Conflict arises in this scenario when a couple of things happen that I’ll highlight below.

1. The family has a preconceived idea of what the medical care should be and thinks, perhaps, we’re not doing our jobs correctly if we don’t do their medical game plan. A good example of this in pediatrics is the use of CT scans for concussion. We don’t need a CT scan to diagnose a concussion– or grade a concussion. A physician can diagnose that from your symptoms. The use of CT in head injury is to look for something that would require a neurosurgeon to fix. Like a clot that would need to be evacuated. Generally, the patient will exhibit a focal neuro deficit (I can’t move one arm) that gives a hint this might be occurring. Oddly, vomiting in head injury is not the gold standard of solely determining need for CT scanning– neither is LOC or amnesia though these will play into the whole picture. We actually don’t want kids to get exposed to radiation unnecessarily because they have long lives ahead of them for potential mutations to occur that could lead to cancer.

2. The family disagrees with the proposed game plan. In kids– a good example would be us suggesting IV fluids for vomiting and/or diarrhea. “But, I don’t want her to get an IV!” We sort of stand back and scratch our heads. Then why did you bring her in?

We like to fix things . . . and when you don’t let us . . . we do wonder why you came to visit.

In episode #4 of NY Med– a young gentleman gets shot in the leg. The physician goes on to explain that he’s going to leave it in place.

“This kid’s so lucky he got shot in the thigh. I mean, there’s no better place for him to get hit. There’s nothing there but muscle. He will have no permanent issues from this.”

He goes onto explain that “bullets travel so fast that they’re sterile. He gets a dose of antibiotics and a tetanus and we just let it heal.”

Then mama bear shows up and the conversation goes something like this . . .

Mama Bear: “I would like you to remove the bullet.”

Surgeon: “Once it’s healed we can electively take it out. That’s better with less chance of infection.”

Mama Bear: “What do you mean? I cannot understand. You mean when he’s 50 and can’t heal as good? You do it when he’s young.”

Surgeon: “This is pretty standard . . . not taking (the bullet) out at this point.”

Mama Bear: “This is not standard to me.”

Surgeon: “This is why you’re not a doctor. He has a high chance of infection right now (if we do the surgery.)

Father Bear: “Let’s just work with the doctor.”

There is sometimes a very fine line, or balance, to maintain between the family and the medical teams expectations and these types of situations can definitely add to tension in your novel.

What do you think?

Thoughts on NY Med: Part 1/2

About one year ago, ABC news ran a documentary series entitled NY Med where TV cameras followed around medical personnel to show real life in the hospital setting. This is the medical institution where Dr. Oz works which I’m sure was one of the reasons the hospital was chosen– I mean, right?

And of course– you knew I’d be watching. You could have called me up. Oh right, I wouldn’t have answered.

Watching medical documentaries is a true source of entertainment.

There were several situations from the show that were interesting to me that I thought we’d discuss here in this forum that I would LOVE to know your thoughts on.  I found the episodes for free on Hulu. Here is the link to the first situation we’ll be discussing. It is the very first segment so you wouldn’t have to watch far.

Situation One:
A male patient comes in for a consult with Dr. Oz in regards to possibly needing heart valve surgery. He’d begun to experience some shortness of breath (SOB is how it is sometimes annotated in medical charts– so if you see this the doctor was not trying to insult you.)

The conversation goes like this:

Dr. Oz: Are you here by yourself?

Jack: Yea.

Dr. Oz: Why?

To which the patient responds with something indiscernible.

They begin to discuss the surgery.

Dr. Oz: Who is going to have your power of attorney in case something bad happens to you?

Jack: Uh, I’ll probably give it to my ex-wife.

Dr. Oz: You’re still close to her?

Jack: Yea, Yea.

Dr. Oz: Can I call her?

Wow– and he really does call his ex-wife on the phone– speaker and everything.

He later explains the following:

“I’m very concerned when a patient walks into my office and they don’t have family with them. It is a very concerning sign because it means that they may be isolated socially. I have made the mistake of operating on people who had no one who loved them. So I now insist that that person identify one person who they love and who loves them back because if you don’t have a reason for your heart to keep beating . . . it won’t.”

Wow.

On a personal note, some of you know I had a family member in the hospital for a month. He’d had a big abdominal surgery and suffered some complications. I was in relieving my aunt one day when the doctors were rounding. A necessary discussion ensued about my relationship and if they could discuss his medical case in front of me. This led to the doctor commenting about how much better patients do when they have family visiting and helping to care for them.

What do you think about this stance? Do you think it should be a requirement for surgery?