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11 August 2003
Mr Naim Siddiqui
Drugs unit (DLEU)
Home Office (Room 243)
50 Queen Anne's Gate
London
SW1H 9AT

 

Dear Mr Siddiqui,

PUBLIC CONSULTATION: COMPUTER GENERATED PRESCRIPTIONS, REGISTERS AND REQUISITIONS FOR CONTROLLED DRUGS. Ref: DDA/99 2/131 2

I am writing to you on behalf of the UK Harm Reduction Alliance (UKHRA) in response to the above consultation. UKHRA is an alliance of drugs workers, drugs activists, drug users and ex-users, health professionals and academics. Our website can be found at: www.ukhra.org

The proposals in the document are welcomed by UKHRA. The modernisation of the process of controlled drug prescribing and record keeping is welcomed as it will allow modern and efficient practice in the prescribing and dispensing of medication that is subject to such controlled e.g. methadone. UKHRA has no concerns over what is proposed.

However, we would like to raise further a matter which should be considered which falls under the same legislation. At present if there is an error made by the doctor when writing or generating controlled drugs (schedule 2) prescriptions the pharmacist cannot accept verbal confirmation of the instructions from the doctor and receive the amended prescription at a later date. This can lead to considerable delay for the patient and considerable stress for the pharmacist. We ask you to consider amending the legislation to allow pharmacists to receive verbal amendments to schedule 2 controlled drugs prescriptions followed at a close date by the revised written version.

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There are literally hundreds of examples which I could give you from my own practice and from the experiences of some of our members who receive drug treatment. However, as means of illustration I will describe one scenario only:

It is Friday 5:25pm and a patient presents a prescription to the pharmacist for their weekend's medication supply. The prescription was written by the half an hour ago during a routine GP appointment. The patient has travelled from the clinic to their local pharmacy to have the medication dispensed. In the meantime the clinic is preparing to close at 5:30pm. There is an error in the writing of the prescription (for example the doctor has forgotten to date it). This means that because no date has been written on the prescription it is technically illegal for the pharmacist to dispense it. As the clinic closes in 5 minutes it is not possible for the patient to be sent back across town to have the prescription amended.

a) Taking the above scenario, for drugs not subject to controlled drugs (schedule 2) requirements, such as lofexidine or naltrexone, the pharmacist is legally allowed to confirm the error and correct instructions with the prescriber by telephone and dispense the prescription immediately after clarity has been sought. The amended prescription can follow later. This means the patient can receive their medication for the weekend and treatment can continue without any break, which may jeopardise the patient's recovery.

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b) Taking the above scenario, for drugs subject to controlled drugs (schedule 2) requirements, such as methadone, the pharmacist currently cannot legally dispense the prescription after verbal confirmation with the prescriber. This means that in this scenario the patient would not receive a further dose of methadone until a new prescription could be obtained when the clinic opens again on Monday. This seriously jeopardises recovery. The patient's steady-state plasma level of methadone will have dropped by 50%1 by Monday morning, meaning sub-therapeutic plasma levels. This in turn is likely to force the patient to use illicit opiates such as heroin to avoid acute withdrawal. As a consequence of this legal restriction possible outcomes, with reference to the evidence-base for methadone, include:

  • Patient at risk of overdose from using illicit drugs
  • Patient at risk of overdose when methadone restarted, if illicit drugs have not been used
  • The doctor will need to re-titrate the maintenance dose increasing pressure on doctor time, NHS costs and unpleasant experience for patient
  • The patient may have lost trust in the service or pharmacist
  • The patient may have been angry with the pharmacist causing the pharmacist stress and verbal abuse.
  • The patient may need to commit crime to obtain money for street drugs
  • The patient will need to re-establish networks with illicit drug suppliers
  • The patient's motivation for treatment may be changed
  • The patient may bring litigation against the doctor for suffering caused.
  • The patient may contact the on-call doctors or hospital Accident & Emergency department seeking treatment which, in most cases is refused due to lack of ability to confirm the treatment.

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c) Taking the above scenario and using a clinical example outside that of our representation. If the prescription were for morphine sulphate tablets for a terminally ill patient's cancer pain, as this is also a schedule 2 drug, the pharmacist would also not be able to supply the prescription. This would mean the on-call doctors are likely to be called upon to supply another prescription or the hospital contacted for help. Again whether medication is supplied or not depends on the response of these groups.

d) Taking the above scenario with a schedule 2 drug and altering the times to earlier in the day so that it is possible for the patient to return to the clinic to have the prescription amended. This still raises issues over whether the patient should be sent back and forth to correct the error, especially where there are mobility issues or costs incurred.

In summary, we welcome the proposals in the consultation document but ask that the legislation goes further to allow pharmacists to receive verbal confirmation of prescription intention when an error has been made in the writing of a schedule 2and 3 controlled drug prescription. Such verbal advice may be supported in good practice by faxed and/or email copies of the amended/replacement prescription until the original is received, say within 24 hours, as per emergency CD requisition requirements.

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Such changes in legislation would resolve an absolutely huge issue, which cannot be overstated. This causes pharmacists on a daily basis to be at the receiving end of verbal abuse from angry suffering patients who understandably want their medication. Our proposals would prevent patient suffering in so many cases and contribute hugely to improved patient care.

Thank you for your consideration of this request,

Yours sincerely

 

 

Jenny Scott, PhD MRPharmS
On behalf of the UK Harm Reduction Alliance

 

1 The half-life of methadone is 24 -36 hours in the majority of the population. Taking 24 hours as the usual half-life, for every half-life time band which passes, the body clears 20% of the drug from the plasma. Hence in the 60 hours between Friday evening and Monday morning, the plasma level will have dropped by 60/24 x 20% = 50%. This will have induced acute opiate withdrawal in the individual.

 

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