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To sell or not to sell?
Blogs are not edited by PJ staff*. The opinions expressed in this blog do not necessarily reflect those of The Pharmaceutical Journal.
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By Nicholas Thayer
7 Sep 2011
During my first week in my new store I had a patient asking for Phenergan liquid, which I'm sure you are aware, can be used for 'un-intended reasons'. The patient asking for the supply seemed knowledgeable about what she wanted, as well as why. The entire story seemed reasonable - she had found that it was the most effective OTC treatment for hay-fever and that the pharmacy she usually visits has no stock. Indeed, there was a full and colourful medical history that had led her to use Phenergan. Of course the doctor was already aware of her use of it.
Now I'm sure the more experienced of you will pick up on one of those comments as a warning sign, people who move around pharmacies for a particular item are sometimes in too much need of the product.
Luckily a pharmacist from another branch nearby had already contacted me and warned me of a person who had been in to them on three separate occasions and on one occasion sent in their son to buy Phenergan. This meant that I was prepared and as I didn't have any stock either I was unable to supply with a very good reason as to why I couldn't supply. I tried providing as much help as possible offering other products but as the conversation progressed I became more certain of the patient's desired off-license use.
My question is how do you truly know if someone is abusing medication either OTC or on prescription? If they are abusing it should you supply? If someone is addicted to a medicine, depriving them of it could potentially cause some harm and a determined addict will get it somewhere. Is it better to supply so that you know how much they are getting and how regularly?
Of course, you can never be certain someone is abusing. This delicate subject could cause great offence to someone. There are 'text book signs' which you do sometimes see, but often the signs are hidden or just confused with other things.
I wonder what methods other people use to deal with people they suspect of abuse. My current feeling is that if they are unlikely to cause immediate harm then I will sell/supply a small quantity and advise them a) to see a GP if they continue to need the medication and b) that I will not supply them the medication again until a suitable period has elapsed.
Still, a difficult conversation at the best of times.
That "Naked Lunch" moment
As the patient in the blog above is more than likely abusing the medicine, if not actually addicted to it - by virtue of the statement that: "a pharmacist from another branch nearby had already contacted me and warned me of a person who had been in to them on three separate occasions" I will use the term "addict " in what follows.
In my experience, there is very little a pharmacist can do when presented with a determined patient who requests a medicine that can be abused. We can counsel patients, but whether they take our advice is a matter for conjecture.
Until the patient has a "Naked Lunch" moment, ie they see what is on the end of their fork, and admit they have a problem, very little can be done. Of course this moment may come as a result of pharmacist counselling , but more often than not it doesn't.
Because of my experience in substance misuse management, and selling otc medicines open to abuse, I have a very jaundiced view of the abilities of pharmacists (and indeed GPs) to influence the activities of the determined otc addict. Even when presented with the bald facts about medicine that is open to abuse- usually opiates; that it is highly addictive if taken for long periods, and that the cure is not pleasant, and that the addiction is likely to re-occur, people still want to take the medicine. Short of flatly refusing the sale, there is little to be done.
I have found that otc addiction is a very solitary"vice" and getting a patient to see that they have a problem is very difficult. Addiction, in the popular mind is something that: a) happens to someone else and b)only happens to people in the lower social strata. Every pharmacist reading this knows that these attitudes are wrong, as addiction - to whatever substance or behaviour, is no respecter of person.
Having painted a bleak view of our expertise in dealing with otc addiction, what can be done? In a study by Dr R. Cooper at the University of Sheffield on the subject of otc addiction, of which I was a part:
Chemist +Druggist
I said that better treatment for otc addiction outside of normal treatment centres was the way to go, as the people we are dealing with do not see themselves as addicts. Also a campaign to educate the public in the real dangers of otc addiction would help. (The danger in taking otc opiates is not in the opiate, rather in the paracetamol it contains)
Mr Thayer presents a senario that is familiar to every community pharmacist in the land, and even I with some experience of the matter don't have a solution that is going to work. What would I do? I would of course counsel them,sell them whatever, and spend the rest of the day beating myself up for doing so, because the realisation that there is a problem has to come from the patient.
Lastly, two points:
1) I was alarmed by the comment: " Is it better to supply so that you know how much they are getting and how regularly?" This has led more pharmacists to appear before the Statutory Committee than I care to remember over the years -DON'T DO IT!!
2)The problem is not in the drug itself, be it Phenergan, codeine diphenhydramine or what - the problem is in the patient themselves. Until the patient admits that they have a problem, until that Naked Lunch moment occurs, no-one can do anything.
Abuse of OTC meds