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

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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.

Readers' comments (6)

  • What training do we provide pharmacists and their teams to deal with this? - in my experience very little and in terms of guidance equally little with the only action being to refuse the sale. This said if pharmacy teams were to offer more support where would they then refer such a patient too? These patients certainly don't fit with the clients attending drug addiction services?

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  • Ahmad  D Atchia

    I always advocate keeping record for item subject to misuse, akLthough it is not a requirement. The record should be supported with checking .ID of the patient/customer at the point of sale.

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  • Bob Dunkley

    What happens when the pharmacist has counselled the patient and sent them on their way hoping that their message has sunk in? The patient just shrugs their shoulders and remembers to add that pharmacy to their list of places not to be visited again.
    Pharmacy's input to the process ends when the patient leaves the premises. How, much better it would be if the pharmacist could offer some hope, to be able to refer the patient to drug services where help could be given if the patient wanted it.
    I had a problem with otc codeine for a number of years and I was always aware of the impotency of the pharmacist in this field. After I was cured, I met a gentlemen who was CEO of a drug services who shared my concern. Together, we started a scheme whereby anyone suspected by a pharmacist or staff with an OTC problem could be referred to drug services for help.
    We held an evening information meeting for all pharmacists in the locality to tell them of the scheme. However, our audience is not at all easy to reach. These are the people who are "respectable addicts" who if asked, would not identify with being an addict and certainly would not want to be treated alongside Schedule 2 addicts. From reports I have had the scheme is working well, because the people referred by pharmacists are treated with respect for their feelings.
    Thus, while it is good to be alert to people who, may be misusing otc products, pharmacy has a much bigger part to play. After all you wouldn't send someone away with a new inhaler without explaining how it works. Pharmacy extends much further than the shop door.

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  • @ Bob Dunkley... You've hit the nail right on the head. The situation is far more complicated than what it may seem to some. The most crucial point, where pharmacists can provide pivotal help, is when a customer/abuser is refused/denied this particular medication and it's at this point when further, valuable help should be offered in a very methodical manner rather than to just validly refuse service. The situation is very sensitive as far as the abuser/addict is concerned!

    There's much to be learned in terms of patient care. Situations can be very diverse and handling these situations appropriately is key. Your efforts to help those who are in need but who are unable to ask, is so hopeful. If it wasn't for this intangible thing called 'hope', we humans would have been extinct a long time ago!

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  • Slow and steady wins the race 🏁

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  • I am another 'patient' like the one mentioned above. If she was taking 160 x 0.5g of paracetamol she'd be dead in the ground by now. There's very very simple physics that can be used to remove most of the paracetamol. I'm not going to spell out the process here, but it takes about 25 minutes from start to finish.

    I've been addicted to morphine for about a decade now, swinging between buying poppy heads from the net to turn into crude opium tea. Whenever I quit that horrible stuff, I end up in the same loop as the person above, going from pharmacy to pharmacy, usually getting through ~240mg all the way up to ~900mg a day.

    As I understand it, codeine converts to morphine after first pass metabolism. I quit the opium tea about 5 weeks ago before the Covid problem got bad, now I'm down to ~300mg.

    I've done buprenorphine replacement therapy, that was out of the frying pan into the fire for me. My issue is that I'm a functioning addict, much as I'd imagine the person above is.

    Speaking of new ways to help, last year I went to my GP, explained my bind and asked for help. Unlike somebody who's already been prescribed, say, morphine, she absolutely refused to help. My idea was a pure codeine taper controlled via prescription. My only option was the local drug treatment place who got me in trouble with Subutex previous (they had the best of intentions, I'm just a unique case). That instantly triggers social service and I'm a good father, just addicted to morphine and forever battling it.

    I hope things change and addiction is treated as less of a moral issue. Anybody can make a stupid decision one night, I challenge anybody reading this to not be able to be able to think of an example in their life. Had that GP decided to help me, I'd have felt safer (I don't like putting unknown quantities of paracetamol inside me, but I've been doing it for 10 years now without any issue) but more importantly listened to.

    It's interesting, now all you pharmacists are busy with Covid problems (thanks to all of you for all the hard work), nobody has asked me a single question about what I'm doing with the codeine. If you see someone you suspect of abusing it, please don't deny them. All that is going to result in is making their day even harder, driving from pharmacy to pharmacy.

    Instead - I would recommend you ask if they know what the CWE is (acronym for the method I won't describe above). If they do, please do sell it to them and offer local drug treatment support if they want it. I'm 40 now and dealing with it for hopefully the last time, but I've learned that to do it on my own is best.

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