8.12.1. Community Pharmacy

A Community Pharmacist is the most readily available healthcare professional, with contact being made outwith an appointment being made. They can also be seen at weekends.

CDs will be ordered from a local wholesaler and stored securely in the pharmacy before supplying to patients. Access to CDs should be stored appropriately and access to the CD Cabinet should be restricted. Similarly, access to the keys to the CD Cabinet should also be restricted. CDs should not be stored out with the Cabinet unless under the direct personal control of the Pharmacist.

Methadone (Schedule 2) and Buprenorphine (Schedule 3) are CDs often prescribed in instalments to substance misuse patients and complications can arise where the pharmacy is closed, for example at weekends or at bank holidays, if the prescription is not appropriately written.

The Home Office has provided some recognised wording which can be appended to the prescription to help avoid these difficulties. All instalment prescriptions for CDs including, for example, those supplied in monitored dosage systems are subject to the same legal requirements.

Pharmacists may also supply other professionals with CDs including GPs who may order them from a community pharmacy for use in their practice. Orders for CDs within the NHS will be written on controlled stationery (GP10A).

A CD Register is required to record all transactions involving Schedule 2 drugs. Some Community Pharmacies now use an electronic CD Register. During a CD destruction, the Authorised Witness must log into the system following the Pharmacist to confirm CDs have been destroyed. The Authorised Witness must log out of the electronic Register before leaving the Community Pharmacy.

Community Pharmacies are inspected by the General Pharmaceutical Council Inspectorate, not by the CD Team, however, the team will provide support and guidance regarding all CD matters. It is also a legal obligation to share information and have regular communication between each professional body regarding any incident/issues/concern.

8.12.2. Controlled Drug Prescriptions in Community

It is the responsibility of the patient to collect their Controlled Drugs from the Community Pharmacy. In situations where this is not possible, arrangements should be made by the patient to have the Community Pharmacy deliver their medication. Only in exceptional circumstances, e.g. urgent requirement to administer medication, should the practitioner organise to deliver the Controlled Drugs themselves.

The person collecting the medicine from the dispensing Pharmacy will be required to sign the back of the prescription form when collecting Schedule 2 or 3 CDs. Legislation states that the Pharmacist must ascertain whether the person collecting is the patient, patient’s representative or healthcare professional. If the person collecting the Schedule 2 Controlled Drug is a healthcare professional acting in their professional capacity on behalf of the patient, the Pharmacist must also obtain the name and address of the healthcare professional and evidence of identity (unless he/she is acquainted with that person).

If a patient wants a representative to collect a dispensed CD on their behalf, Pharmacists are advised to obtain a letter from the patient that authorises and names the representative. This also includes those detained in Police custody who should supply a letter of authorisation to a police custody officer to present to the Pharmacist).

A separate letter should be obtained each time the patient sends a representative to collect and the representative should bring identification with them. The Pharmacist must be certain that the letter is genuine.

It is good practice to insist on seeing the patient at least once a week unless this is known not to be possible.

The record of supply in the CD Register must include the details of the patient’s representative.

If the prescription states the dose must be supervised, the Pharmacist should contact the prescriber before the medicine is supplied to the representative as the supervision will not be possible. It is legally acceptable to confirm verbally with the prescriber that they are happy with this arrangement as supervision is not a legal requirement under the Misuse of Drugs Regulations 2001 http://www.legislation.gov.uk/uksi/2001/3998/contents/made.

It would not be necessary for the Pharmacist to contact the prescriber if the patient has been detained in Police custody and the representative collected would be a police custody officer or custody healthcare professional. This is because the administration of any CD in custody will be supervised by a healthcare professional.

If the dose is usually supervised, but has been supplied the Pharmacist should consider annotating the prescription and patient mediation records to advise other that the dose has not been supervised in Pharmacy.

It is good practice for the person collecting the CD to sign the space on the reverse of the prescription form, specific for this purpose. A supply can be made if this is not signed, subject to professional judgement by the Pharmacist.

Instalment prescriptions need only be signed once.

A representative, including a delivery driver, can sign on behalf of the patient, however, a robust audit trail should be available to confirm successful delivery of medication to the patient.

8.12.3. Administration of Controlled Drugs in the Community

Controlled Drugs may only be administered to patients in accordance with the directions of the qualified practitioner in charge of the patient.

A Registered Nurse or Doctor in the community may administer, without witness, a CD which has been obtained on prescription by the patient. A GP may administer a CD from stock.  In this case, an entry must be made in the appropriate CD Register. A prescriber may complete a Controlled Drug record form, authorising the community nurse to administer a particular CD. A record of that administration must also be made on the accompanying form. 

The following process must be followed:

·         Check the identity of the patient. The patient's name and date of birth corresponds with the prescription and wherever possible is confirmed by the patient.

·         Check the patient is not allergic to the medicine prior to administration.

·         Ensure that the intended drug and dose for the patient is correct.

·         Know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications.

·         Check the prescription and/or the label on the medicine dispensed is clearly written and unambiguous.

·         Check the expiry date of the medicine.

·         Check the strength, dosage, weight, where appropriate method of administration, route and timing, frequency, start and finish dates.

·         Contact the prescriber or another authorised prescriber without delay where contra-indications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine, or where assessment of the patient indicates that the medicine is no longer suitable.

·         Where a nurse is administering a Controlled Drug that has already been prescribed and dispensed for that patient, obtaining a witness and second signature must be based on the local risk assessment. 

·         Although normally the second signatory should be another registered health care professional, in the interest of patient care, where this is not possible a second suitable person who has been assessed as competent may sign e.g. Student Nurse or family member.

·         A stock check of Controlled Drugs must be taken and recorded as part of the administration procedure.

8.12.4. Recording Administration of CDs in the Community

CD administration must be entered in the relevant CD Register. In the case of administration within a patient’s home, the practitioner performing the administration must complete the record sheets and stored in the patient held record.  The full signature must be recorded of the person who administered the CD and the person who carried out the check with the patient’s name and the time the dose was administered. Where CD was not given, refused or dropped, this information must be clearly recorded in the CD Register. Entries and errors must be indelible and must never be altered or obliterated.

Any errors must be bracketed and the correct entry made in an adjacent space or next line. A brief explanation eg entered in error must be made in the margin or at the bottom of the page and then signed and dated. Pages or part pages must never be torn out of the Register.

When only part of an ampoule containing CD is used, or dose refused/dropped, this is placed into a 0.78l Pharmacy blue lidded pharmaceutical waste container (held within OOH GP CD bag). Vernagel sachet is added to each bin to absorb the discarded liquid. The amount discarded must be recorded appropriately in the correct CD Register. Where there is a witness to the administration, this person must also sign the CD Register as witness to the destruction/ discard.

Any errors or incidents in relation to the administration of CDs must be recorded and reported via the relevant manager and a DATIX entry submitted. This must also be detailed in the patient’s record.

8.12.5. NHS Tayside Drug and Alcohol Recovery Services

The NHS Tayside Drug and Alcohol Recovery Service is responsible for providing specialist clinical services to patients and professional support to Community pharmacies and prescribers in all aspects of substance use.

The CD Team work closely with the local Drug and Alcohol Recovery teams to ensure legal requirements are met and that the highest standards of the service provision are delivered.

8.12.6. Patients on Opioid Replacement Therapy who are Admitted or Discharged from Hospital

Patients who are receiving prescribed Methadone or Buprenorphine for opiate dependence in the community may be dispensed instalments daily or on a weekly basis by their Pharmacist. Consumption of the dose may be supervised by the Pharmacist. Frequency of dispensing takes into account the individual patient’s dose, stability and personal circumstances.

8.12.7. On Admission

Contact the patient’s Community Pharmacist or NHS Tayside Drug and Alcohol Recovery Service to confirm that the patient is prescribed Opiate Replacement and to inform them of the admission. Obtain the following information:

·         Current dose.

·         If on supervised or daily pick-ups.

·         When last dose was dispensed / supervised.

·         Number of days supply given (if not daily dispensing).

Patient’s Own CDs must be stored appropriately (see Section 8.15.1.).

On admission to Hospital, Patient’s Own liquid CDs should only be used in exception circumstances as the contents cannot be checked.

8.12.8. On Discharge (Nurse or prescriber dealing with patient’s discharge)

Contact the GP or NHS Tayside Drug and Alcohol Recovery Service to inform them of the agreed discharge date and time, confirming the current dose and when the last dose will be administered before discharge.

Confirm that the Prescriber will make the necessary arrangements with the Community Pharmacist to provide a new prescription or re-instate the suspended prescription. If the Prescriber is not available contact the Community Pharmacist directly for who should be able to advise whether a community prescription is still current and to agree arrangements for continuation and when next dose is due.

Administer the daily dose on the Ward before the patient is discharged, unless alternative arrangements have been made. Inform the patient of the arrangements for the next dose.

Do not return any unused supplies that were brought in on admission, and do not provide a discharge supply unless a supply is required until the regular arrangement in the community is put in place (for example, over holiday weekends).