PHARMACOEPIDEMIOLOGY AND PRESCRIPTION

M.E. Llau M. Lapeyre-Mestre L. Plas

C. Damase-Michel J.L. Montastruc
Forged medical prescriptions in a community pharmacy network
in Midi-Pyre ne es area: assessment of a falsication ratio
Received: 23 July 2001 / Accepted in revised form: 31 October 2001 / Published online: 29 January 2002
Springer-Verlag 2002
Keywords Forged medical prescriptions Pharmacy
Drug abuse
Introduction
Following the report of Bergmann et al. from Sweden
[1], the French Centres for Evaluation and Information
on Pharmacodependence (CEIP), created by the French
health authorities in 1990, have begun a prescription
forgeries survey within several community pharmacy
networks [2, 3]. This system provides information about
potential abuse liability of marketed drugs in France. In
order to compare the dierent medications between each
other, Baumevieille et al. rst proposed, in 1997, as-
sessment of a falsication ratio [2]. This ratio is obtained
by dividing the number of falsication reports for a
specic drug by the sale data of this drug during the
same period. Sales data are easily available from
wholesalers in the area. Their use leads to extrapolation
of the number of falsied prescriptions in the whole area
from a few reports potentially exposing to a lack of
precision. Moreover, this method of calculation could
also be biased by the representativeness of participating
pharmacists. Another method consists of obtaining sales
data directly from the sample of pharmacists enrolled in
the survey. Thus, the aim of the study was to compare
the results obtained from these two dierent sources of
sales data collected during an intensive survey of pre-
scription forgeries.
Methods
Of 1090 pharmacies located in the Midi-Pyre ne es area (South-
western France), a sample of 62 community pharmacies was en-
rolled in the prescription survey as previously described [3].
Between January and March 1999, they were requested to collect
and report all forged prescriptions with falsication criteria iden-
tied by the pharmacy sta [3]. For each drug, two falsication
ratios were calculated with sales data obtained independently from
two dierent sources: the 62 pharmacies enrolled in the study and
wholesalers of the area concerning all the 1090 pharmacies. Sales
data were expressed as treatment-months [4] using the dened daily
dose (DDD). When DDD was not available or if the French in-
dication was a country-specic one (example: buprenorphine high
dosage), the DDD was the daily dose recommended in the French
Drug Formulary (Dictionnaire Vidal).
Demographic data were expressed as meanSD. Assuming a
small number of expected cases of falsication, the two-tailed 95%
condence interval (CI) of falsication ratio was calculated ac-
cording to Poisson distribution [4]. Falsication ratios were com-
pared using the v
2
test with continuity correction or two-tailed
Fischer exact test.
Results and discussion
The participation ratio (98%) was very high during the
whole 3-month period. Seventy falsied prescription
forms were collected; the men (56%) who falsied pre-
scriptions were noted to be younger than the women
(307 years versus 4021 years, P<0.05). Criteria of
falsication reported by pharmacists were mainly writ-
ing over (20%), self-lled prescription form (18%), ab-
normal dosage (13%), spelling mistake (8%), robbery
(6%), copy (5%). According to the Anatomic, Thera-
peutic and Chemical (ATC) classication system, the 95
dierent drugs belonged to nervous [61%; including
analgesic (8.5%) and psychotropic (61%) drugs], respi-
ratory (10%), cardiovascular (5%) or musculo-skeletal
(5%) systems.
Flunitrazepam (40%), bromazepam (4%), acetylsal-
icylic acid (2%), fenoprofen (2%), buprenorphine (2%)
and salbutamol (2%) were the most frequently requested
drugs. Flunitrazepam, morphine sulfate and ergotamine
Eur J Clin Pharmacol (2002) 57: 911912
DOI 10.1007/s00228-001-0412-7
M.E. Llau M. Lapeyre-Mestre (&) L. Plas
C. Damase-Michel J.L. Montastruc
Service de Pharmacologie Clinique,
Centre Midi-Pyre ne es dEvaluation et dInformation sur la
Pharmacode pendance, Centre Hospitalier Universitaire,
Faculte de Me decine, 37 alle es Jules Guesde,
BP 7202, 31073 Toulouse Cedex 7, France
E-mail: lapeyre@cict.fr
Tel.: +33-5-61145903
Fax: +33-5-61255116
exhibited the highest falsication ratios when sales data
provided by participating pharmacists were used
(Table 1). Drugs with the highest ratios were known for
their abuse potential. Flunitrazepam was largely in-
volved in drug abuse among opioid abusers [5], leading
the French authorities to a reduction of prescription
duration and delivery in January 2001 [6]. Morphine
sulfate abuse had already been described in other nearby
areas of Southern France [7]; however, this was the rst
time in the Midi-Pyre ne es area. Although it is dicult to
conclude from one citation, these data may suggest an
extension of morphine sulfate abuse in the Southern
French area.
Using both approaches, falsication ratios were not
statistically dierent. Although in the calculation of
falsication ratios from wholesalers data the number of
falsication reports needs to be extrapolated, results are
not dierent from those obtained with more accurate
data given directly by participating pharmacists. Results
with unitrazepam are reliable due to the high number
of citations. For other drugs, comparison must be made
with caution since the number of citations is low and the
95% CIs have wide ranges. However, the falsication
ratios of buprenorphine and bromazepam obtained
during surveys performed in 2000 were in the same range
of values for pharmacists sales data as for wholesalers
data [8]. Data from wholesalers are more easily available
than data from pharmacists. Thus, this kind of approach
could be extended to other areas, allowing geographical
and temporal comparisons. In few cases, wholesalers
data cannot be totally exhaustive. Several medications
are provided directly to pharmacies from pharmaceuti-
cal rms or central purchasing oces, in a signicant
way for some drugs with a mass of sale, such as for
acetylsalicylic acid. For this drug, the falsication ratios
were not comparable between pharmacists [3.9 (0.514)]
and wholesalers [198 (140277)] data (P<0.001). Thus,
results of this type of survey must be carefully analysed
and conrmed by specic study on suspected drugs.
In conclusion, this study shows that, except for a few
cases, the falsication ratios are similar, regardless of
what method of calculation is used (wholesaler data or
pharmacy sales data). Thus, regional sales data from
wholesalers and national sales data could be used in the
systematic survey of falsication prescriptions. This ex-
tension may permit comparison of geographical partic-
ularities.
References
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Table 1 Falsication ratios [and their 95% condence intervals (CI)] calculated from pharmacists and from wholesalers sales data,
expressed as 1000 treatment-months with dened daily dose (DDD) for all drugs and also with mean French dosage for buprenorphine
Drug involved DDD Number of
citations
Falsication ratio (95% CI)
(1) From pharmacists (2) From wholesalers P value
Flunitrazepam Rohypnol 1 mg 1 mg 38 40 (2855) 28 (2630)* 0.06
Morphine sulfate Ske nan 100 mg 0.1 g 1 23 (0.7125) 60 (3595) 0.49
Ergotamine-caeine Gynerge` ne
cafeine
4 mg 1 18 (0.5101) 36 (2258) 0.71
Bromazepam Anxyrex 10 mg 1 14 (0.479) 27 (1644) 1.00
Fenoprofen Nalge sic 1.2 g 2 10 (137) 20 (1428) 0.58
Mefenamic acid Ponstyl 1 g 1 7 (0.240) 11 (718) 1.00
Buprenorphine** Subutex 1.2 mg
a
2 5 (0.114)
a
7 (511) 0.77
8 mg
b
0.8 (0.012.1)
b
1 (0.81.6)
Salbutamol Ventoline 0.8 mg 2 0.6 (0.12.1) 0.9 (0.61.3) 0.77
Furosemide *** Lasilix 40 mg 1 0.24 (0.011.3) 0.40 (0.20-6) 1.00
*For unitrazepam, 95% CI was calculated according to the standard normal distribution
**For buprenorphine, falsication ratios were calculated from
a
DDD and
b
mean French dosage
***Drug with the lowest falsication ratio of the study
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