Professional and legal issues: pharmacy medicines 3.2

Question 1

Pseudoephedrine and Ephedrine (Decongestants) 3.2.1

Answer 1

Can be used to make methylamphetamine (Crystal meth) (Class A CD)

Unlawful to supply:
>720mg Pseudoephedrine OR 180mg of ephedrine at any one time, without a prescription
AND to sell/supply any pseudoephedrine product at the same time as an ephedrine product without a prescription

Sales/supplies to be done by pharmacist or trained staff and need to know when to refer to pharmacist.

Even when a request is made for a lawful quantity, the sale or supply can be refused where there are reasonable grounds for suspecting misuse.

MISUSE SIGNS:
Lack of symptoms (No cough/flu)
Rehearsed answers
Impatient/aggressive
Opportunistic (coming in only when busy/less exp staff are in)
Specific products (only pseudoephedrine or ephedrine brands)
Paraphernalia (Wishes also to purchase other items which can be used to make crystal meth (e.g. lithium batteries, chemicals such as acetone)
Quantities are large
Frequent purchases

Question 2

Oral emergency contraception 3.2.2

Answer 2

3 methods of emergency contraception:

      Copper intrauterine device (Cu-IUD)
      Oral ulipristal acetate
      Oral levonorgestrel.

pharmacist should be involved in: providing advice on all methods, assessing suitability, approving sales or signposting to alt providers.

Levonorgestrel 1500 mcg tablet and ulipristal acetate 30mg tablet are licensed as pharmacy medicines for EHC. Levonorgestrel is licensed for women aged 16 years or + for emergency contraception within 72 hours of unprotected sexual intercourse or failure of a contraceptive method.
Ulipristal acetate is licensed for emergency contraception within 120 hours (five days) of unprotected sexual intercourse or failure of a contraceptive method.

Pharmacist can give advance supply of them. Patient should be assessed to ensure they are competent, intend to use the medicine appropriately and it is clinically appropriate.

If your religious or moral beliefs impact on your willingness to supply oral emergency contraception, inform your employer, your locum agency and colleagues you will be working with, ASAP.
Referral is an option. GPhC outlined factors to consider.

Some situations oral emergency contraception could be linked to abuse (non-consensual intercourse) of children or vulnerable adults. There is a hand book (responding to domestic abuse).

supply of ulipristal acetate to patients under the age of 16 years is not contraindicated by the manufacturer. However, pharmacists may wish to consider the following additional factors:

 Child under 13 are legally too young for consentual sex. Should be reported to social services unless there is a documented reason.
 Sex under 16 is a offence but can be consentual. 
 Pharmacist can provide conetraception to under 16. Confidentially applies. So to share info consent is needed. However need to judge case by case. Some cases it's better to share. Btw it is possible to seek advise without breaking confidentiality.

There are other ways to get contraception ie family planning clinic, general practice clinics and providers of PGDs for oral emergency contraception and genitourinary medicine (GUM) clinics.

Question 3

Paracetamol and Aspirin. 3.2.3

Answer 3

Both marketing authorisations as POM, P and GSL medicines – depending upon pack size and formulation.

PARACETAMOL OTC
Not more than 100 non effervescent* tablets or capsules can be sold to a person at any one time. Since most OTC pack sizes are for 16/32 dose units, = in practice, 96 is the maximum that can be sold.
*NO LEGAL LIMIT ON EFFERVESCENT BUT need to use professional judgment to decide when there is enough being supplied

ASPIRN OTC
SAME AS PARACETAMOL

Question 4

Codeine and dihydrocodeine 3.2.4

Answer 4

More strict on solid dose OTC meds with codeine/dihydrocodeine.
Done to minimise risk of addiction and misuse.
Changes include:
Indications for solid dose OTC codeine and dihydrocodeine products are now restricted to the short-term treatment of acute, moderate pain that is not relieved by paracetamol, ibuprofen or aspirin alone. All other previous indications, including cold, flu, cough, sore throats and minor pain have been removed.
Pack sizes Any pack containing >32 dose units (including effervescent formulations) is a POM.
PiL and labels need warning ‘Can cause addiction. For 3 days use only’ must be positioned in a prominent clear position on the front of the pack. AND both the PIL and packaging must state the indication and that the medicine can cause addiction or headache if used continuously for more than 3 days. The PIL must also contain information about the warning signs of addiction.

MEP recommends only 1 pack be sold.

Need to ask right QS to ensure patients are referred for long term pain.