Methods patients use to purchase over-the-counter medicines for misuse

I recently had the opportunity to interview one of my GP colleague’s patients. From this I learnt about her method of obtaining over-the-counter (OTC) medicines for misuse.

She was misusing co-codamol 8/500 tablets, taking 96 tablets on a daily basis and, occasionally, up to 160 (surprisingly, her liver coped). Once she disclosed to her GP about her misuse, her blood was frequently tested and her liver function, surprisingly, remained in normal limits.

The patient did not trust herself to have any quantity of the tablets in the house and would purchase the medicine daily. Her misuse of co-codamol began when she was a student. She generally visited three or four community pharmacies a day. The patient noticed that few pharmacy staff or pharmacists asked many questions when selling co-codamol.

The patient said she was now able to identify people in pharmacy queues who are misusing or inappropriately purchasing medicine because they share similar behaviours and use similar techniques.

The patient discussed her technique for obtaining the medicines, which include:

• Being polite and looking respectable
• Visiting local pharmacies no more than once or twice weekly (in line with maximum dosing of medicine). If the pharmacy is further away, space the visits two weeks apart. There is no fixed rota, day of the week or time. 
• No forward planning of what symptoms or answers to give to the healthcare assistant or pharmacist 
• Considering the staff’s perspective when purchasing the medicine
• Remembering pharmacies that were not good to go to because they were either unfriendly or more challenging when requesting the medicine 
• Not giving preference for any pharmacy chains. It depends on the staff and pharmacists
• Preferring to visit smaller towns and not the city centre pharmacies, although she acknowledged that busy city centre pharmacies may offer more anonymity
• Generally requesting unbranded or generic forms of the medicine

One technique was to go into the pharmacy to purchase something for a different condition, asking advice from the pharmacist or pharmacy staff (eg, dry skin) and building a relationship with them. When she was about to pay, she requested the co-codamol.

When asked who the medicine is for, the answer was usually “for a friend/relative”. If she was asked why she was taking the medicine, she would often reply “I don’t know what they are talking them for” or would give minor conditions she knew co-codamol was appropriate for (such as back pain).

The patient would sometimes ask if she could buy two boxes of 32 tablets, using reasons such as going on holiday or that she lives a distance from the pharmacy and is unable to return easily. Frequently this request would be honoured.

Very seldomly, friends or family were asked to get the medicines. The patient remembered who had previously been asked but did not have a pattern of asking other people to obtain the medicine.

The patient was once questioned by pharmacy staff and prevented from buying the medicine and advised to arrange a GP appointment. The patient did this, received a prescription for co-codamol and took it back to the same pharmacy thus appearing to validate the patient’s request.

I am sure many reading this will recognise the strategies used by patients misusing OTC medicines. As a profession, could we be doing more to reduce the misuse of OTC medicines? What are your strategies in dealing with these patients? If it is just refusing the sale, we need to change this to ask how we can help. Pharmacy needs to engage with these patients proactively but there may be training needs that need to be addressed for pharmacists and pharmacy staff.