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The eyes of pharmacists are crucial in spotting medicines abuse

“Most GPs would admit to an episode of a pharmacist pointing out one of their mistakes”

Pharmacists are crucial in noticing when patients may be misusing their prescription drugs such as benzodiazepines and salbutamol inhalers, says Dr Toni Hazell

I’m not sure whether I can name names in this column, but if a certain pharmacist – let’s call him “S” – from a north London branch of the national pharmacy that sounds like something you wear on your feet is reading this, thank you very much.

S rang me up last week to express his worries about a patient of mine, whom I will call Jenny. Jenny has schizophrenia, and S had noticed that she hadn’t been picking up her medication lately. When she visited the pharmacy, she seemed dishevelled and unwell. In addition, her speech demonstrated a flight of ideas and she appeared to be responding to hallucinations.

The last time S rang me to express his concern about Jenny, he was spot on and she was admitted to a mental health ward not long after. Her care coordinator is now keeping a much closer eye on her, thanks to S having called me.

Before the comments start, yes, I know that GPs can be hard to get hold of. I try very hard to take calls from other healthcare professionals, but it’s not always possible. If I’m in the middle of a sensitive mental health consultation or gynaeological examination, then I just can’t answer the phone, but I’ll ring back as soon as I can.

GPs really do appreciate the role of pharmacists in bringing things to our attention. Most of us would admit – in private – to some episode when a pharmacist gently pointed out a mistake in a prescription and prevented the patient coming to harm.

As well as errors, and patients getting more unwell, another area in which your eyes and ears are crucial is that of medication misuse. This is a hot topic at the moment, with concerns having been raised over the last few years about patients becoming dependent on codeine, which is of course be available both on prescription and over the counter.

Online pharmacies are a potentially easy way for patients to acquire these drugs. Changes to guidance have tried to address this by requiring proof of identification from the patient. It’s not only opiates – benzodiazepines and gabapentinoids are also rife for abuse and have a street value. I understand that even the seemingly innocuous salbutamol inhaler can be abused.

Pharmacists aren’t the police and neither are GPs. We have very limited powers – other than refusing to prescribe or dispense, there is not much that GPs or pharmacists can do. However, the ability to refuse further prescriptions is at least a start, and in my practice we will be really firm if we know that something is going on.

In the past, I’ve had a pharmacist ring me to say that a patient of mine was selling his prescribed Viagra. He wasn’t the sharpest knife in the box, as he conducted the transaction – including an exchange of cash – in front of the glass window of the pharmacy, in full sight of the pharmacist. I have also been informed of patients who are buying significant amounts of over-the-counter strength co-codamol, on top of the 30/500mg preparation that I had prescribed them.

GPs do take action on these things – that might include stopping prescribing, enforcing a weaning off from larger quantities, or switching to daily or weekly dispensing, as well as involving social services. Sadly, it isn’t uncommon for grandchildren to take a very keen interest in their grandparents as soon as they start to be prescribed a drug with a street value. Social services do get involved in these situations, often with good effect.

So, please don’t be put off by difficulties getting through to your GP – please keep your antennae twitching and let us know if you have worries. If you can’t get through on the phone, then trying later in the day may help. Despite adding many more phone lines over the last few years, my practice is still fighting an uphill battle for phone access at busy times.

However, most practices will have an email address on their website that pharmacy teams can try. This is an area in which GPs and pharmacists working together can have real benefits for our patients, even if the patients may not appreciate it at the time.

Toni Hazell is a GP based in a practice in London

7 Comments

A England, Manager

Want to spot codeine abuse- look at your prescribing habits ...... of codeine.

Leon The Apothecary, Student

It sounds to me Toni, and forgive me if I sound like a broken record on this topic, that what pharmacy and surgery need is an in-service line of communication that is universally accepted?

Toni Hazell, GP

of course. IMO every practice should have a well publicised email address. Ideally the phones would always be answered but it is tricky to have enough phone lines and people on the end of them for this to be the case at busy times.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I still say Toni is the exception rather than the rule - I've reported potential misuse to GPs many times and not once has anything ever been done about it. Literally the only time a GP has ever acted on something I have reported is when an old lady wrote (in the days of hand written prescriptions) an extra item on her script because she'd forgotten to ask the GP for it. Yes, we are good at seeing the signs of prescription drug misuse but we CANNOT refuse to dispense against a valid prescription, so therefore if the GPs aren't on board as well, acting on our advice, we might as well not bother.

Toni Hazell, GP

I didn't say you should refuse to dispense! I'm sad if nothing is done on genuine reports. 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

 'We have very limited powers – other than refusing to prescribe or dispense, there is not much that GPs or pharmacists can do.' - actually, you sort of did....

As an example of what I'm on about - a patient that I dispensed for had been having 224 co-codamol 30/500 2 qds every three weeks for about six months. I highlighted this to their surgery who did precisely sweet FA and continued to issue scripts every time the patient requested. Why should I put myself in the firing line and refuse or query this supply? I did it once, my advice was ignored so as far as I'm concerned, I have discharged my responsibility, such that it ever was, and the responsibility for this patients clear overuse now lies with whoever signs the prescriptions. If they don't look into it, it is now no longer my problem. Cynical maybe, but thats what pharmacy makes you. I'm not disrespecting you in any way Toni, but in my experience, you are very much in the minority among your colleagues who seem to view pharmacy and pharmacists in a similar way as the fly crawling around and smacking it's head repeatedly against their window - at best indifference and at worst outright hostility.

Kevin Western, Community pharmacist

Thanks Toni Its refreshing to know we can make a difference. I refuse codeine sales on a daily basis. 

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