Drug Categories and Classifications PDF

Main content 49-1 Drug Categories and Classifications Drugs are divided into different categories or classifications by the chemical type of the active ingredient contained in the drug or by how it is used to treat a disease or symptom. Many classifications of medications produce similar results...

Main content 49-1 Drug Categories and Classifications Drugs are divided into different categories or classifications by the chemical type of the active ingredient contained in the drug or by how it is used to treat a disease or symptom. Many classifications of medications produce similar results but do so through different mechanisms of action. For example, in the category of pain relievers, drugs classified as analgesic, anesthetic, and narcotic all provide relief from pain. An analgesic drug relieves pain by blocking prostaglandins and providing a longer duration of pain control without significant, if any, decrease in alertness. Narcotics relieve pain by interfering with the central nervous system's recognition of pain impulses, which provides a greater level of pain relief than analgesics but also causes drowsiness and sometimes respiratory depression, with the possibility of developing dependence. Anesthetics block sensation at the nerve ending, being very useful for site-specific, local pain relief but providing a very limited and shorter duration of action. Additionally, a single drug can also provide multiple effects, placing it in several categories. In addition to many classifications having similar uses and effects, there are often many medications working through different mechanisms of action within each classification. Antihypertensives, for example, control blood pressure through blocking calcium channels, inhibiting conversion of angiotensin 1 into angiotensin 2, relaxing arterial smooth muscle and slowing heart rate. Although the intended result is the same for all, the final effect is achieved through a different chemical action; the best approach must be determined by the prescribing provider. For this reason, among many others, patients should be advised of why they are given a particular medication and that it may not be substituted, changed, or stopped without consulting their provider. 49-1a Commonly Prescribed Medications Certain medications will be prescribed and administered more commonly in certain practices and specialties than in others. The medical assistant should prepare and maintain, in consultation with the prescribing providers, an updated list of these medications tailored to the use of that particular practice and make it readily accessible to all staff. The list should include the usual dosage, possible side effects, contraindications, and possible drug interactions that might be experienced when taken with other commonly used medications or foods. After becoming familiar with the different categories and classifications of drugs mentioned previously, refer to Table 49--1 to review a list of common classes and examples within each class of medication, which might vary from region to region and practice to practice. You can use this table as a guide to develop one appropriate for the particular specialty your practice serves. Drug Actions Although many complex and intricate processes are involved in the way different drugs affect the body, we will attempt to provide an easily understandable listing of these actions. Drugs may have a therapeutic response that helps cure disease, but drugs cannot restore lost function of organs that are damaged beyond repair, and it is very important for medical personnel to keep this in mind. Medications can enhance remaining function of a damaged organ or replace hormones and chemicals the body can no longer produce on its own. Drugs are divided into main groups by types of action on the body: chemotherapeutic, pharmacodynamic, and miscellaneous agents. 49-2a Chemotherapeutic Drugs The chemotherapeutic group includes drugs used to cure a disease caused by an infectious organism or cancer. Chemotherapeutics are used to treat: Infections by killing microorganisms or preventing them from reproducing. Allergic diseases. Autoimmune diseases. Metabolic disorders. Cancer. Toxic diseases as a result of poisoning. Mental illness. 49-2b Pharmacodynamic Drugs Pharmacodynamic drugs treat noninfectious processes by acting on different systems in the body to suppress chemicals or hormones being released by the body in excess or to augment chemicals or hormones that are being produced in insufficient amounts. By changing actions that normally occur in the body or interfering with unwanted actions, certain drugs exert their effects by: Preventing the action of naturally occurring enzymes or by mimicking the actions of enzymes, as one example of a pharmacodynamic drug. In this way, they can trick the body into either producing more or preventing the production of an enzyme that is causing or worsening a disease process. Agonists and antagonists. Drugs can compete for a certain receptor site to stimulate or prevent the action of that particular receptor. An agonist stimulates a particular action, whereas an antagonist acts to prevent an action or effect on a receptor site. Drugs can also be synergistic to each other, meaning that they enhance or multiply the effects of other drugs or have additive effects, simply adding each drug's effects to the other. Nonspecific actions of drugs can be less distinct. They may be used to relieve itching on the skin or reduce stomach acids by changing the pH levels, as examples. 49-2c Miscellaneous Agents Miscellaneous agents include all products that are not classified elsewhere. They include medications such as certain pain relievers, smoking cessation agents, and antipsoriatics which are medications used to treat psoriasis. 49-2d Considerations of Drug Action Several considerations can affect how the body responds to a drug: age, weight, body surface area (BSA), method of administration, tolerance, allergies, time, and interaction. Pediatric and geriatric patients and individuals with certain illnesses require a smaller dose than an average adult. Another consideration is the rate at which the body responds to a drug. Medications given by injection reach the bloodstream more rapidly than other routes, whereas transdermal patches deliver small amounts of medication in a sustained, time-release manner. Additionally, when a patient takes a medication for a long time, they can develop a tolerance that requires an increase in dosage or a different medicine to obtain a desired effect. A medication allergy may occur at any time in an individual, even if they have taken the same medication several times before. Careful attention must be given to the medical history and to the patient's responses during the interview. The MA should document any allergies---whether food, environmental, or drug allergies---in the EHR in the appropriate location. If a patient phones you to let you know that a new or recently started medication gave them a reaction, the MA should describe the reaction and its severity as clearly as possible in the patient's chart. Occasionally, a patient might experience intolerance to a medication and not a true allergic reaction. Medication intolerance (e.g., nausea or upset stomach) should also be charted. Many patients take several medications daily and tend to avoid those that cause them undesirable effects. Helping the patient determine when and how best to take medicines to avoid intolerances or manageable side effects encourages them to continue with the prescribed therapy. 49-2e Drug Effects The effects of drugs are generally categorized as: Local: having its effect restricted to the area in which it was administered. Remote: its effect takes place in areas other than the place of administration. Systemic: the effect is generalized throughout the body. Drug Forms Drugs can come in a single form or in a variety of forms (see Table 49--2). The choice of which form to use can depend on the age of the patient, medical conditions, desired rate of absorption, or inability to tolerate one route or another. Capsules Cylinder-shaped enclosure for medication of either a gelatin-coated or time-released coating Drops Sterile solution that contains medication intended to be delivered directly into the area to be treated, e.g., eyes, ears, nose, etc. Inhalants Medications prepared to be delivered in either a fixed or nonfixed dose to be breathed in through the nose or the mouth. May be oxygen delivery, sprays, or aerosolized medications. Liquids Medication suspended in alcohol or water. Liquid forms may be prepared for oral, intramuscular, subcutaneous, intravenous, intra-arterial, intrathecal, nasogastric, or orogastric delivery as well as for irrigation of body cavities, wounds, or external sites. A less common site of delivery is by intraosseous administration. An implantable device may provide a constant and consistent delivery of a specific dose of medication. Examples of implantable drug delivery include pain medication and insulin pumps. Powders Fine particles intended to be dissolved in liquids or foods just prior to being taken Skin Preparations Ointments, creams, or lotions that can be applied directly to the skin Suppositories Bullet-shaped tablets that melt easily at body temperature for administration through the vagina, urethra, or rectum Tablets Medication that is bound together by substances that dissolve in stomach acids; some may have flavorings added to make them more palatable. Transdermal patches Courtesy of Novartis. Adhesive patch with time-released dose of medication to be worn for a specified period of time Drug Names Drugs are identified by four names: generic name, trade name, chemical name, and official name. Chemical name: When a drug is first discovered, it is described by its atomic or molecular structure. This name is too complicated for everyday use, so researchers assign a shorthand or abbreviated version of its chemical name for easier discussion. Generic name (also official name): When the drug is approved by the Food and Drug Administration (FDA), it is assigned a generic name or official name by the United States Adopted Names (USAN) Council. Generic names are not capitalized. Trade name: The drug manufacturer assigns a unique name to each drug for marketing. To avoid having more drug names that sound or look alike, which leads to medication errors, the FDA must approve all proposed trade names. Trade names are usually easier to remember than generic names and are capitalized. Newly approved drugs are granted a non-compete status as a trade name drug for seven years, following approval, to give the manufacturer the opportunity to recover development costs, which are often in the millions of dollars. Unless the manufacturer introduces a new indication warranting renewal of the non-compete status before the seven-year patent period expires, another company may produce a generic formulation that is usually sold at a lower cost. (An orphan drug, one that is the only approved drug available for treatment for a given indication, is the exception to this rule.) Generic drugs contain the same active ingredients as trade name drugs; however, a trade name drug may have a different coating that controls the rate of release in the body or it may have a different type of preservative, which can make a patient intolerant to a generic versus a trade name drug or vice versa. Table 49--3 gives some examples of familiar medications. Table 49--3 ### **Generic, Trade, and Chemical Names of Four Common Medications** **GENERIC NAME** **TRADE NAME** **CHEMICAL NAME** **Indication** ------------------ ---------------- ----------------------------------------------------------------------------------------------------- --------------------------------------------------------- acetaminophen Tylenol N-(4-hydroxyphenyl) acetamide Pain relief, fever reducer aspirin Ecotrin acetylsalicylic acid, 2-(acetyloxy)benzoic acid Pain relief, fever reducer, decrease platelet adherence captopril Capoten 1-\[(2 S)-3-mercapto-2-methylpropionyl\]-L-proline Hypertension morphine sulfate Roxanol Morphinan-3,6-diol, 7, 8-didehydro-4, 5-epoxy-17-methyl,(5α-,6α)-, sulfate(2:1)(salt), pentahydrate 49-4a Look-Alike, Soundalike Drug Names Beware! Many drugs have similar, sometimes identical-sounding names. Even more confusing, a number of medication names can look alike when handwritten. For this and other reasons, it is important for health care workers to be well versed in the medications most common to their particular practice or specialty. According to the Guidance for Industry document published by the FDA in February 2010, the FDA updated and reiterated previous recommendations to drug manufacturers to evaluate the proposed names for new drugs to reduce soundalike names. Table 49--4 provides examples of look-alike or soundalike drug names. Table 49--4 ### **Look-Alike or Soundalike Drug Names** Atarax (antihistamine) may be confused with... Ativan (used for anxiety and sedation) ------------------------------------------- -------------------------- -------------------------------------------------------------------------------------------- Benylin (cough suppressant) may be confused with... Benadryl (antihistamine) Diovan (treats high blood pressure) may be confused with... Zyban (smoking cessation) enflurane (inhalation anesthesia) may be confused with... isoflurane (also inhalation anesthesia but used WITH enflurane) Lamictal (epilepsy control) may be confused with... Lamisil (antifungal treatment) nelfinavir (antiretroviral used for HIV) may be confused with... nevirapine (reverse transcriptase, used for AIDS also but to be used WITH antiretrovirals) prochlorperazine (antinausea, antiemetic) may be confused with... trifluoperazine (antipsychotic) Drugs and Supplements All medications, whether they are prescription or non-prescription drugs, are regulated by the FDA in the United States. Dietary supplements on the contrary are not regulated. This means that dietary supplements do not have standards or regulations, whereas medications you purchase, whether over-the-counter (OTC) or by a prescription, have to be proven safe and effective before use can occur. Prescription Drugs Prescription drugs are those that may be purchased or given to a patient only with written instructions, known as a prescription, from a licensed health care provider. For a prescription to be considered valid, it must be issued for a legitimate medical purpose by a licensed practitioner. As mentioned, the FDA is responsible for ensuring that products available for consumption by the public are safe. This includes food, drugs (both prescription and over the counter), and cosmetics. When a drug is developed by a pharmaceutical company, it is evaluated through laboratory and animal testing and then, finally, through a series of controlled clinical trials in humans prior to being approved by the FDA for availability to the general public. The FDA verifies that the data presented regarding the drug's safe use, its ingredients, and what conditions it should be used for are correct and that all these are accurately reflected in its labeling. Sometimes a drug can be recalled, which is a voluntary act of the manufacturer on the recommendation of the FDA, not because the drug was unsafe but because its labeling was inaccurate. A drug available for prescription is considered safe by the FDA for use but only so long as its use is determined appropriate and is monitored by a health care provider, therefore requiring a prescription. Many drugs requiring a prescription have serious side effects even when used appropriately. Levels of the drug or other blood tests may need to be performed periodically to ensure that the effects are not more detrimental than the condition the drug is being used to treat. Main content 49-5b Nonprescription Drugs Nonprescription drugs, or over-the-counter (OTC) drugs, are considered safe and effective for use by the general population without requiring a prescription. Many nonprescription drugs have required prescriptions prior to being transitioned to OTC status. Over time, these drugs might have been found to show a low incidence of any serious side effects or may be formulations of prescription drugs in a reduced strength. The FDA still monitors these medications for reports of problems and ensures that the labeling accurately reflects the ingredients and in what conditions they should be used. It should be stressed to patients, however, that improper use of over-the-counter medications can still be harmful even though these medicines do not require a prescription. Main content 49-5c Vitamins, Herbal Supplements, and Alternative Remedies The FDA provides little if any oversight regarding vitamins, herbal supplements, and alternative remedies. Many patients choose to take herbal remedies either instead of or in addition to prescription medications. This is an acceptable practice but only so long as these herbal remedies are revealed to the patient's provider and recorded accurately in the patient's record. Herbal remedies may be derived from naturally occurring substances that are the same as or similar to the substances found in many prescribed medications. When taking herbal preparations, it is critical not to duplicate the same compound by the use of prescription medications. Just as important, the provider must also be aware of herbal remedies the patient is using that might counteract prescription medications, because lack of such knowledge can lead the provider to presume the dose is insufficient or the patient isn't responding to that particular medication, falsely altering the diagnostic process. Toxicity can also develop when a supplement is similar to or mimicking the effects of a prescription medication. Quick Tips Practical Application When working within an EMR system, many have applications that provide preloaded commonly prescribed medications. A dropdown box is used to access these medications. You must use extreme caution in your selection due to the drugs that are similarly spelled. A click of the button is all it takes to choose the wrong medication, creating a medication error in the patient's chart and perhaps the incorrect medication being prescribed or refilled. Controlled Substances A controlled substance is any drug, whether prescription or illegal, that has the potential for abuse or addiction. Controlled substances come under a category of prescription drugs that have an elevated level of restrictions for the public's protection. The 1970 Controlled Substances Act established the Drug Enforcement Administration (DEA), under the Department of Justice, which maintains oversight for legally prescribed and used narcotics drugs and for containment of illegal drugs. This legislation was designed to implement controls on drugs that were commonly abused by society, control prescriptions provided for these drugs, and require prescribers of these medications to be registered with individual DEA numbers. These drugs are categorized into five schedules, which are regulated under the Controlled Substances Act. The schedules are arranged by most dangerous drugs in Schedule I (illegal substances that are not available for prescription) to least dangerous in Schedule V (see Table 49--5). The drugs in schedules with lower numbers have stricter controls for prescribing and obtaining. All drugs that fall under any schedule II--V category will be represented in the literature with a symbol known as the controlled substance symbol (refer to Figure 49--1). The "C" refers to it being a controlled substance, and the Roman numeral inside it indicates what schedule it falls under. There are subcategories within each schedule, and the DEA may alter levels of a drug if there is evidence of increased abuse. ### **Schedules of Controlled Substances** **DRUG CATEGORY** **POTENTIAL FOR ABUSE (ADDICTION)** **MEDICAL USE** **POTENTIAL FOR DEPENDENCE** **EXAMPLE** ------------------- ------------------------------------- --------------------------------- ------------------------------------ --------------------------------------------------------------- Schedule I High Unaccepted; limited to research High Heroin, LSD, marijuana, peyote Schedule II High Accepted; tightly restricted Severe psychic or physical Amphetamines, morphine Schedule III Less than I or II Low to moderate Acceptable High psychological Certain opioids, barbiturates, and some depressants Schedule IV Low Acceptable Limited physical and psychological Phenobarbital, propoxyphene Schedule V Low Acceptable Limited physical and psychological Small amounts of codeine in cough preparations and analgesics The five schedules include: Schedule I: These drugs have no recognized medicinal use in the United States, and prescriptions for such drugs are prohibited. Examples include heroin and ecstasy. Schedule II: These drugs must have a written or typed prescription order with the provider's personal signature and DEA registry number and may not be refilled. In an emergency, the doctor may phone in a limited amount of the medication to the pharmacist. However, a written, signed prescription order for the controlled substance must be presented to the pharmacist within 72 hours in compliance with DEA regulations. Examples include cocaine and Demerol. Schedule III: Prescriptions may be written or phoned in for these drugs, and they may be refilled five times within six months. Examples include anabolic steroids and testosterone. Schedule IV: Prescriptions may be refilled up to five times in six months. Examples include Xanax and Tramadol. Schedule V: These drugs are subject to state and local regulations. A written prescription for Schedule V medications may not be required. Examples include Robitussin AC and Lyrica. Each licensed prescriber must display their DEA registration certificate at each place of practice where they prescribe controlled substances. The registration for prescribers must be renewed every three years. The website for the DEA's Office of Diversion Control, www.deadiversion.usdoj.gov, contains various forms online to apply for and renew DEA registration. There are strict guidelines not only for prescribing controlled substances but also for their storage in the medical office, which is discussed in the next chapter. 49-6a Storing Controlled Substances The storage of controlled substances is of particular concern and bears a great deal of not only ethical and professional responsibility but legal oversight as well. Controlled substances and the records of their prescribing and dispensing must be protected from misuse by storing them under double lock (Figure 49--2). This double-lock system can be a combination of two keys, as to an outer and inner cabinet; the keys are accounted for by each user, whose possession of them is recorded on a daily basis. Figure 49--2 Controlled substances must be kept secure in a double-lock system. A photo shows a substance placed inside a storage unit with two doors. The storage unit is positioned within a wall-mounted cupboard with a door. Electronic dispensing systems, such as Pyxis, meet the double-lock criterion by requiring unique user identification and password combinations for an appropriate professional to access controlled substances. To meet these requirements, controlled substances may not be kept in the same compartments or cabinets as uncontrolled pharmaceuticals in the office setting. Records of daily counts reconciled by two parties who have legally authorized access to controlled substances must be maintained for DEA review on demand for three years and submitted every two years. Due to an increase in theft and substance abuse, many offices no longer keep controlled substances in the office. Main content 49-6b Controlled Substances and the Medical Assistant The medical assistant must be well informed about the regulations that encompass controlled substances. They might be responsible for the following Knowledge of federal and state laws that manage controlled substances, drugs, and pharmaceutical samples Keeping a thorough record and inventory of all drugs and samples Keeping all drugs, including controlled substances, in a secure location Reminding the provider of DEA registration or renewal Keeping track of all prescription pads and ensuring their safekeeping in secured areas where only staff may access them Properly disposing of expired drugs and keeping a record of their disposal Main content 49-7 Handling Medications in the Medical Office The proper storage and preparation of medication is important, not just for the patient's safety but also for the safety of members of the health care team. Main content 49-7a Stock Medications Medication storage involves more than simply putting away packages. Many necessary forms, prescription blanks, and records must be kept. Medications must be rotated according to their expiration dates. They may be stored according to their classification (refer to Table 49--1) or alphabetically, as long as the method used is consistent and known to all who have access to the medications. The MA might label shelves or have pullout shelves installed to increase efficiency. The medication storage cabinet, closet, or room must be locked and accessed only by a qualified member of the health care team. Main content 49-7b Samples Pharmaceutical companies send their representatives to visit medical facilities on a regular basis. They often provide samples of new or frequently used medications along with information about the cost. Most representatives are more than willing to answer questions from the provider and medical assistant to provide them with the most up-to-date information. Samples allow the provider to introduce a new medication to a patient to determine whether they can tolerate it prior to obtaining a full prescription and allow for an immediate loading dose to be given. When samples are given to patients, the quantity and dosage strength must be recorded in the patient's chart. Maintaining samples is an ongoing task, and they should be stored separately from other medications. The MA may wish to categorize them, just like other medications, but it should be clear that they are samples and not stock medications. Pay careful attention to the product's expiration date and properly discard outdated substances. Check with local regulatory agencies on how to discard expired medications in your area. Main content 49-7c Refrigerated Medications Special attention should to be given to the many medicines that require refrigeration, such as antibiotics and immunizations. Sometimes refrigeration is necessary only after the bottle or vial has been opened or after it has been reconstituted; these containers should be clearly labeled with the date and time of opening or reconstitution to determine expiration. The office might maintain medications that must be stored in the freezer, so it is imperative that the storage guidelines per the manufacturer are strictly followed to maintain efficacy. Also be sure to note whether medications or vaccines that are to be stored under refrigeration actually arrive in shipment refrigerated properly by the carrier or packed appropriately by the shipper. For example, if the dry ice is no longer present or the packaging or packing material feels warm, contact the supplier immediately for instructions concerning the safety of the contents for use or to have replacements issued. Daily temperature logs for both refrigerators and freezers where medications are stored are required to ensure that the necessary temperatures are maintained and your office is in compliance with Material Safety Data Sheet (MSDS) regulations. The appropriate temperature range for each may be determined by your state's laboratory certifying agency or your parent company if your office is part of a larger health care system. A procedure should also be in place concerning what to do in the event of a failure to maintain a prescribed temperature. Check labels, directions, and package inserts to determine the proper method of storage for all products because storage requirements can change. It is imperative that medications and immunizations kept for patient administration not be stored in the same refrigerator with office staff food and medications. This is an unsafe practice for staff members and is contrary to accrediting agency regulations. Main content 49-7d Disposing of Drugs The proper disposal of drugs varies considerably from state to state and is generally influenced by regulations of the FDA and the Environmental Protection Agency (EPA) but also by the type and size of the facility that is disposing of the unused medications. Local communities also have significant variances in the manner of disposal. The best practice is to contact the local municipal government for small practices or to consult with pharmacists in the case of a practice that is part of a larger health care system. Some communities and pharmacy chains have a take-back program by which unused drugs may be returned for disposal. Again, check with the local government agencies, either wastewater treatment departments or trash and recycling services, for guidance. Controlled substance disposal also varies, and most states require witness of destruction by licensed pharmacists, nurses, and, sometimes, even law enforcement personnel. Your state's drug enforcement authority can provide you more detailed information, but a general listing is available in the Health Services Industry Study: Management and Disposal of Unused Pharmaceuticals, published on the EPA's National Service Center for Environmental Publications at www.epa.gov. As websites change and are reorganized, use the search term "unused pharmaceuticals" to find links to the most current guidelines. You may also contact the EPA with specific questions by using the contact links provided on their website. A number of drugs are still considered suitable for disposal by flushing down the toilet or sink drain. Based on concerns of news stories in the past few years, flushing certain types of drugs into the local sewage system became a concern. However, a number of scientists and pharmaceutical experts report that more drugs actually enter the sewage and water systems through normal body excretion due to incomplete absorption by the body than through intentional disposal of unused drugs in their manufactured forms. A continuously updated list of drugs suitable or recommended for flushing down the toilet or drain can be found on the FDA's Website. To access updated information, go to www.fda.gov and click on the "Drugs" tab at the bottom of the webpage. How to Dispose of Unused Medications is a general set of guidelines for consumer disposal of prescription drugs issued by the FDA in conjunction with the White House Office of National Drug Control Policy (ONDCP) in February 2007. To access, go to www.fda.gov and type "How to Dispose of Unused Medicine" in the search bar. The guidelines recommend first looking for specific disposal instructions on the label and flushing drugs down the toilet only when the information specifically indicates that it is acceptable to do so. In the absence of specific instructions, drugs may be disposed of in the trash after taking a few precautions: They should be removed from the original container and mixed with an undesirable substance to discourage accidental ingestion by humans or animals if found. They should be placed in a plastic bag to prevent leakage. To protect the patient's identity, the label of any containers should have all personal information scratched off or obliterated in some manner. Main content 49-8 Pharmaceutical References So far in this chapter, different types of medications have been discussed as well as the importance of verifying the accuracy of the medication order or prescription. So how does a medical assistant ensure that this information is correct, particularly when new drugs seem to be released almost on a daily basis? Because the medical assistant is legally, ethically, and morally responsible for ensuring that the information is correct to promote patient safety, it is necessary to verify the information personally. A number of references are available that provide the necessary information, both in print and online. Bear in mind that none of these is absolutely comprehensive, so more than one source might need to be referenced, depending on the drug, to find the needed information. By familiarizing yourself ahead of time and learning the organization of different available references, you will be more effective and more efficient in finding the information. Main content 49-8a Prescriber's Digital Reference The Prescriber's Digital Reference (or PDR) is a valuable resource provided online at www.pdr.net. This resource used to be known as the Physician's Desk Reference and was available as a print resource. The last print form of the Physician's Desk Reference was published in 2017. The purpose of the PDR is to provide accurate, reliable, and current information about most prescribed medications and related products. The MA might need to consult the PDR for the proper spelling, strength, or other information concerning medications that are not given frequently to verify accuracy of a medication order prior to administering medications. Not all medications are included in every edition of the PDR, particularly if they have been in use for a long period of time. For this reason, keeping older editions as well as other supplemental resources is highly recommended, which will be discussed a little later in this chapter. Using a Print Physician's Desk Reference Learning to use the PDR seemed like a daunting task at first but was usually mastered with a systematic approach to understanding its organization. If you are using an older edition of the Physician's Desk Reference in print form, you will need to understand its organization. The PDR in book form contains full, FDA-approved drug label information, including warnings and precautions, drug interactions, and hundreds of full-color pill images. There are six color-coded sections: Section 1: Manufacturer's Index (white pages)---Includes an alphabetic listing of all manufacturers listed in the PDR along with their addresses, phone numbers, and emergency contact information. Also contains a listing of each manufacturer's products and the page number for each product in the PDR. Section 2: Brand and Generic Name Index (pink pages)---Lists the page number of each product by both brand and generic name. Section 3: Product Category Index (blue pages)---Lists all products by category. Also includes a key to controlled substances categories, key to FDA use-in-pregnancy ratings, U.S. FDA contact numbers, poison control centers listing by states, a section on drugs that can cause photosensitivity, and a listing of drugs that should not be crushed. Section 4: Product Identification Guide---Displays full-color photo image examples of different forms of the products. This section is organized alphabetically by manufacturer. Section 5: Product Information Section---Includes an alphabetic listing by manufacturer of products. Section 5 is arranged by manufacturer, and the content is presented for each product in the following sequential format: Brand name: Name assigned by manufacturer. Description: Chemical composition of the drug and its origin. Clinical Pharmacology: Drug's effects on the body and mechanism of action. Indications & Usage: Conditions for which the drug is prescribed. Contraindications: Conditions and situations in which the drug should not be given. Warnings: Potential dangers associated with the drug. Precautions: Describes measures to be taken if prescribed in patients with certain conditions (e.g., blood levels or equipment to have available in event of emergency, etc.). Adverse Reactions: Side effects or undesirable effects patients might experience when taking the drug. Dosage & Administration: Usual daily dosage for adults and children with recommended time intervals for dosing. Also includes recommended routes for administration or routes that should not be used. How supplied: Available forms of the drug. Section 6: Dietary Supplements In addition to the PDR online website, which is integrated into many EHR systems, there is also a mobile app that is free for use to all health care professionals; you may wish to install the mobile PDR app. It allows for quick drug look-up as well as saves your frequent searches. There is a pill identifier within the app and a drug interaction checker, which is very useful. The free app can be downloaded onto all Apple and Android devices. References for Nonprescription Drugs Several online resources are also available to find information on OTC medications and supplements. www.drugs.com and www.medscape.com are two common ones. Information includes dosing, uses, side effects, interactions, patient handouts, pricing, and more. 49-8b Additional Drug References Although the online PDR is among the most up-to-date and comprehensive references available for verifying medication information, other references designed for everyday practice are also available to look up most-used information and might also contain older drugs no longer included in the PDR. Although a few of these are discussed in the following text, understand that there are a number of reliable sources. If the MA is unsure of the usefulness or reliability of a particular resource, consider consulting with the provider or other advanced practitioners who work in the office to determine which resource materials might be appropriate for that particular practice. Refer to Procedure 49--1 for the steps to assist you in using the PDR or other drug references. Quick Tips Practical Application WebMD Pill Identifier is an application on the website that will help health care providers identify a pill by using its physical characteristics. This may be a very helpful tool in cases of accidental poisoning when a sample of the pill is provided but its name is unknown. Note: This application should not take the place of calling 911 or the National Poison Help Line in cases of emergency. Product Inserts Drug information is provided by the manufacturer with medications. When a prescription medication is sent to a pharmacy for dispensing, the product insert is sent along with the original packaging for review by the pharmacist. This information is used for preparation and dispensing purposes, and only the required information is printed on the label. OTC medications package inserts are included with every container of medication and contain the information found in the PDR regarding structure, description, indications, side effects, and dosing. Quick Tips Practical Application When package inserts are received with bulk medication shipments in the office setting, prepare a notebook or file that contains these for easy reference and replace with updated ones as they arrive with new shipments to create your own condensed office PDR. Main content 49-8d Professional Drug Handbooks The medical assistant might also find a nursing drug book an excellent supplementary resource to the PDR because the language and organization are often more readable and more focused on dose, route, side effects, and cautions. A number of companies offer drug handbooks based on different professional perspectives such as that of nursing, provider, or even veterinary. These drug handbooks provide condensed, most frequently used information in an easy-to-find format with an alphabetical index of both trade and generic drug names. Besides being organized by discipline, handbooks can also be organized by specialized areas of medical practice: oncology, emergency, obstetrics and gynecology, pediatrics, and so on. They will include the prescribing information; dosage calculations; and recommended dose ranges, warnings, precautions, and side effects. They do not generally include elaborate chemical structural information. These types of references make an excellent addition to the office library as a supplement to the PDR, and it is often much easier to locate basic information. Main content 49-8e Electronic and Online Resources USP-NF The U.S. Pharmacopeia-National Formulary (USP-NF) is a compilation of standards related to medications, drug substances, medical devices, and vitamins. It is provided in print form, and the online version can be found at www.usp.org. Revisions are issued as supplements as information becomes available. The USP also maintains monographs or structural information on medications and issues reference standards for evaluating drugs and laboratory samples, providing these to laboratories all over the world. PDR.net provides access to the PDR information online and can be found at www.pdr.net. It requires registration with a DEA or NPI number for access by a provider, advanced practice nurse, provider assistant, or medical student or resident. Separate, less inclusive access may be obtained by patients and other health care workers. Downloadable applications Many drug information applications are available in downloadable versions that can be readily accessed on handheld devices, providing portable references for medical professionals to use during the course of practice. Online drug websites When using an online reference site, you must be very careful to verify its validity. Not all websites provide accurate information. RxList.com and WebMD are two helpful Internet drug index resources. Caution in using online websites for drug referencing cannot be emphasized enough. Wikipedia, for example, is not a reliable resource because it can be changed by input of information from variable and nonvalidated sources. **Drug Labels** --------------- **Figure 49--3** [[Main content]](https://ng.cengage.com/static/nbreader/ui/apps/nbreader/nbreader.html#header) **49-9**Prescriptions ===================== - Practitioner's name and address - Date of issue - Patient's name and address - Drug name - Dosage form - Quantity prescribed - Directions for use - Number of refills if any are authorized and are permitted under the law - Line or check box indicating whether it should be dispensed as written or substitutions are permitted by the prescriber - Manual signature of prescriber **Figure 49--4** Change font size [**[help]**](javascript://) **49-9a Preparing Prescriptions** --------------------------------- In the past, prescriptions were predominantly handwritten by the provider, especially those for narcotics, but with the advent of electronic medical records, it is now more prevalent for many prescribers to transmit prescriptions directly to the pharmacist. Only the original hard-copy handwritten prescriptions may be faxed to a pharmacist, providing they are not schedules of narcotic medications. Narcotic medications, whether handwritten or electronically prepared, must be delivered to the pharmacy in person by the patient (electronic submissions are only allowed after the provider's EHR system has been audited and approved as compliant with the DEA's requirements). For more information on this, refer to the "Electronic Prescriptions for Controlled Substances" topic on the U.S. Department of Justice website at [www.deadiversion.usdoj.gov](http://www.deadiversion.usdoj.gov/). The practice of telephoning in a prescription to the pharmacy has declined in recent years to avoid medication errors made with verbal communication. A copy of the actual prescription should be entered in the patient's chart. In addition to this, a running log of prescriptions with all pertinent information should be included in the medical record for ease of tracking. This is one of many very useful tools included in most electronic medical record software packages. In offices without electronic medical records, preparing the handwritten prescription may be delegated to the medical assistant except for the final review and signature. Because the prescription is a legal document, the provider is obligated to verify that the information is accurate before signing the prescription. [Figure 49--5](https://javascript://) shows an example of a prescription blank. **Figure 49--5** Sample blank prescription pad for handwritten prescriptions. These may be printed in many variations, including provider letterhead information at the top in a preprinted pad or an electronic record, as long as all the legally required information is included. Prescriptions for controlled substances may contain only the controlled substance and no other drugs on the same document. The quantity must appear in both numerical and written form. [Procedure 49--2](https://javascript://) describes the steps taken to prepare a prescription. ### **Prepare a Prescription** -- -- -- -- -- -- When patients have their prescriptions filled by a pharmacist, the container often has a supplementary label(s) on it. Pharmacists frequently use one or more of these brightly colored labels to alert the patient of special instructions or warnings regarding a particular medication ordered by the doctor. Bright colors attract attention to important information ([Figure 49--6](https://javascript://)). The medical assistant should encourage patients to read and comply with the warning labels. Main content 49-9b Calling in a Prescription to a Pharmacy Although not very common now that EHR systems are being used, when telephoning in prescriptions, the medical assistant must provide the pharmacist with ALL the information contained in the prescription. To ensure accuracy, the pharmacist should repeat back this information to avoid dangerous misunderstandings. This practice of repeating back prescription or medication order information is recommended by the Joint Commission in all areas of medical practice. In addition to encouraging the patient to read all warning labels, the medical assistant should ask patients whether they have any questions about the medications and are able to read the instructions completely. If the patient is not literate enough to read the label completely or has a visual impairment that prevents reading small print, the medical assistant may ask the pharmacist to print a second label in the patient's native language, in addition to English, or in larger type. 49-9c E-Prescribing With the advancement in health information software, prescriptions can be printed by selecting a particular drug from a drop-down menu in the electronic medical record application with the appropriate strength, dosage, and the quantity to be supplied or days' supply, as ordered. The prescription is printed on special prescription paper with tamperproof watermark. Computer-generated prescriptions reduce the possibility of forgery through decreasing availability of the prescription document through password controls and tracking of users authorized to print the prescriptions. The most significant benefit of electronic prescriptions is most likely in the elimination of errors that result from illegible handwriting. Refer back to Procedure 49--2 for the steps detailed in this process. Quick Tips Practical Application Many patients, not just older adults, might have arthritis or other fine-motor problems that make it difficult for them to open childproof caps. If this is the case, the medical assistant may request the prescription to be dispensed in a non-childproof bottle. The pharmacist will likely add an additional warning of the importance of keeping an unprotected bottle out of the reach of children. Quick Tips Practical Application You might notice different medications prescribed for the same disease process in patients of different color, race, or gender. The clinical decision behind this practice is based on evidence that suggests different medications have varying effectiveness and differing side effects in various races and genders and is not just a random choice. Quick Tips Practical Application Providers occasionally prescribe a medication for a particular disease or symptom that is considered off-label use. This does not mean that the drug should not be used in this manner or that it is necessarily an improper prescribing practice. It simply refers to the fact that controlled clinical trials have been done to determine whether the drug is safe or effective for the indication for which the medication is being prescribed. Medications are prescribed every day, so it is very important to comply with all of the laws that are associated with prescriptions. From making sure that sample medications are logged in and dispensed correctly to following the DEA guidelines, legal actions can be taken against not only the prescribing provider but the clinical organization when compliance issues occur. Always be sure and follow your policies and procedures when it comes to working with prescriptions and never work outside of your scope of practice.