A Faxed Schedule II Prescription for a Hospice Patient
A 67-year-old man with metastatic pancreatic cancer is enrolled in hospice. His hospice nurse faxes a new prescription to your community pharmacy for morphine sulfate extended-release 30 mg PO every 12 hours, quantity 60, no refills. The prescription is signed by the hospice medical director, whose DEA registration is active. The nurse asks you to fill it today because the patient's pain is poorly controlled. A check of the pharmacy record shows the patient received oxycodone immediate-release 5 mg from a different prescriber 10 days ago; that prescription is still active. The pharmacy does not have a signed hospice certification on file, but the nurse can provide one.
1. Is the faxed Schedule II prescription valid for dispensing? Explain.
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Generally yes. DEA regulations permit a Schedule II prescription to be faxed for a patient in a long-term care facility or hospice, provided it is a genuine prescription for a legitimate medical purpose, is signed by an authorized prescriber, and the patient is actually enrolled in hospice. This is not an emergency oral order, so the 7-day follow-up rule does not apply. Verify hospice status and obtain the signed certification the nurse offered; retain the fax and document the verification. Check state law, because some states impose additional requirements. The quantity (60 tablets for 30 days at one every 12 hours) and zero refills are consistent with a C-II order.
2. What steps must you take before dispensing, given the active oxycodone prescription?
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Reconcile the opioid regimen before dispensing. Check the PDMP, verify the patient’s current opioid use and pain control, and assess for duplicate therapy. The active oxycodone from another prescriber does not automatically make the morphine prescription invalid, especially in hospice, but it requires documented rationale. Contact the hospice prescriber or nurse to confirm whether the oxycodone should be discontinued and whether the morphine dose is appropriate for the patient’s current tolerance. Assess constipation prophylaxis, naloxone availability, and caregiver understanding. If the prescriber cannot be reached and the duplication poses risk, hold the prescription and explain the delay.
3. What documentation and counseling are required?
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Document hospice verification, prescriber DEA, patient identification, PDMP review, the duplicate-opioid discussion, and the dispensing decision. Counsel the caregiver that morphine ER must be swallowed whole and not crushed or chewed, that alcohol and other sedatives increase overdose risk, and that constipation is expected unless a bowel regimen is started. Review signs of overdose and naloxone use, safe storage, and disposal. Confirm the patient is not opioid-naive and that the dose matches the current opioid tolerance. Provide a written medication schedule and a single point of contact for after-hours questions.