Time to rethink our approach to misuse of over the counter medicines
If pharmacists were to take a greater role in helping OTC medicines misusers towards recovery, the public’s view of them as health professionals would be strengthened
Adam Mackridge School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University Jenny Scott Department of Pharmacy and Pharmacology, University of Bath and Richard Cooper School of Health and Related Research, University of Sheffield
Pharmacists have recognised misuse of over-the-counter medicines for many years. Historical approaches to tackling this problem have centred on refusing sales or restricting quantities purchased. This has led to some medicines, where concern of misuse is high (eg, cyclizine), being effectively treated as prescription-only medicines with widespread refusal of sale. In other cases, products have been hidden from open display, with enhanced questioning of potential purchasers (eg, kaolin and morphine, and promethazine). More recently, legislation has led to restrictions in pack sizes and maximum quantities per sale (eg, opiate containing analgesics). These approaches share a common theme of restricting supply and are a seemingly natural extension of the medicines and drugs legislation in the UK and beyond. However, this approach has proved inadequate and we suggest that it is time for our profession to take a more proactive approach in supporting patients who misuse OTC products.
Misuse of OTC medicines is increasingly gaining recognition in government. The All Party Parliamentary Drugs Misuse Group published a report in 2009 in response to this1 and questions have been asked in both Houses of Parliament. More recent reports,2,3 have also highlighted increasing presentation at drug treatment services of individuals who are misusing OTC medicines, in the absence of any illicit substance misuse.
These individuals are often older than the usual individuals seen by these services and more likely to be women. In addition, data from the US suggest that misuse of some OTC medicines is increasing in adolescents.4 Furthermore, anecdotal reports from health professionals working with these individuals suggest that they are more likely be professionals and demographically disparate from a typical stereotype of a substance misuser.
They often hide their use from their friends and family and obtain their medicines through “pharmacy shopping” (visiting multiple pharmacies) and online pharmacies. A brief search on Google reveals products liable to misuse or dependence being sold legitimately from UK registered pharmacies and also from less reliable international pharmacy sites. In addition, such a search reveals many discussion forums giving advice on how to circumvent usual questioning employed by pharmacy staff to avoid suspicion.
Given the continuing shift in tackling all substance abuse away from a “war” approach to one of harm minimisation, treatment provision and recovery, it is now time for pharmacists to take a more proactive approach to individuals suspected of being dependent upon or misusing OTC medicines. Such an approach should include taking a more tailored approach to requests for medicines with potential for misuse, opening discussions about the harms caused by misuse and, in particular, making appropriate suggestions for referral.
To date, there has been only limited tailored support for individuals with misuse and dependency problems in relation to OTC or prescription medicines but, increasingly, local drug partnerships are developing specialised services aimed at misusers. However, these are still not universal and drug services where such specialists are not available may not always be appropriate to misusers of OTC medicines. Some support is also available through user-led online support networks in the form of Over Count (over-count.weebly.com) and Codeine Free (www.codeinefree.me.uk). Pharmacists, as providers of OTC medicines, should ensure that they are aware of what support is available and how to refer patients for help.
The range of doses among people misusing OTC medicines has been shown to vary among users.5,6 Some individuals take doses regularly, at just above therapeutic levels, and these cases could potentially be tackled by supportive GPs and pharmacists; whereas others consume doses far in excess of recommended levels, where more specialist treatment may be required. A more comprehensive approach to managing OTC misuse would also need to recognise contributing factors in the development of a problem, such underlying mental health issues or suboptimal management of pain through their GP. These pharmacy-based signposting opportunities could form part of an even wider rethink of approaches to OTC misuse that could extend to promotion of support organisations or provision of further information on risks of misuse and how to identify dependence. In the case of UK-based internet pharmacies, such information and links could be placed on pages relating to medicines with known misuse and dependence potential.
Those affected by OTC medicines misuse need more support than is currently provided and every sale or supply of a medicine offers a possible opening to help these individuals recognise that they have a problem, possibly before it has a detrimental effect on their own lives and the lives of those around them. Furthermore, engagement with individuals is needed to identify their recovery goals, in line with current Government drugs policy, and enable relevant and appropriate support, both to address underlying issues and help move these individuals towards a recovered state.
If pharmacists were to take such an approach, their role in this increasingly worrying issue would be strengthened and the profession highlighted as better than the popularist “shopkeeper” label, showing us to be trained and caring health professionals, offering much more than a simple supply service.
1 Reay G. An inquiry into physical dependence and addiction to prescription and over-the-counter medication. London: Houses of Parliament, 2008.
2 Reed K, Bond A, Witton J, et al. The changing use of prescribed benzodiazepines and z-drugs and of over-the-counter codeine-containing products in England. London: King’s College London, 2011
3 National Treatment Agency for Substance Misuse. Addiction to medicine: an investigation into the configuration and commissioning of treatment services to support those who develop problems with prescription-only or over-the-counter medicine. London: NTA, 2011.
4 Bryner JK, Wang UK, Hui JW, et al. Dextromethorphan abuse in adolescence: an increasing trend: 1999–2004. Archives of Pediatrics and Adolescent Medicine 2006;160:1217–22.
5 Nielsen S, Cameron J, Pahoki S. Over the counter codeine dependence final report 2010. Victoria, Australia: Turning Point,2010.
6 Cooper R. “Respectable addiction” — a qualitative study of over the counter medicine abuse in the UK. Sheffield: University of Sheffield, 2011.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11115990
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