1. Lead Pharmacists Controlled Drugs Team Anne Taylor & Lesley Thomson September 2012 Non Medical Prescribing Conference CONTROLLED DRUGS AND THE INDEPENDENT PRESCRIBER

2. Objectives To review Controlled Drugs Schedules Refresh awareness of Government responses to Shipman Inquiry and the role of the Accountable Officer/CD Team To be aware of the changes in legislation regarding Independent Prescribers and Controlled Drugs (CDs) To highlight the issues surrounding prescribing of CDs in relation to non medical prescribers and individual responsibilities To increase awareness regarding security of prescription stationery

3. What Are CDs? CDs are medicines that are controlled under the Misuse of Drugs Legislation. They are classified (by law) based on their benefit when used in medical treatment and their harm if misused. They are controlled more strictly than other medicines which may prescribe in terms of how the prescription is written, who can write it and the quantity to be supplied.

4. The Misuse of Drugs Regulations 2001 These regulations divide into 5 schedules Schedule 1 – CD Lic POM Schedule 2 – CD POM Schedule 3 – CD No Register POM The Misuse of Drugs Act 1971

5. The Misuse of Drugs Regulations 2001 Schedule 4 part I – CD Benz POM part II – CD Anab POM Examples: Schedule 4 (part 1) include clobazam, clonazepam, diazepam, loprazolam, lorazepam, lormetazepam, nitrazepam, oxazepam and zolpidem. Schedule 5 – CD Inv POM or CD Inv P Examples: Schedule 5 include co-codamol, codeine linctus BP, codeine phosphate tablets, co- dydramol, DHC Continus ®, Oramorph ® oral solution 10mg in 5mL,

6. Government Response to Shipman Enquiry Hand writing requirements Private transactions/PPCD/CDRF Signature on collection of CD prescriptions Registers /record keeping requirements 30 day supply 28 day validity

7. Government Response to Shipman Enquiry Accountable Office Role: –Information Sharing & co-operation between bodies –Inspection –SOPs –Monitoring prescribing of CDs –Requirement to report incidents to AO –Sharing lessons learnt

8. Reporting Incidents, Near Misses and Concerns Involving Controlled Drugs or Controlled Stationery Record Keeping and Stock Discrepancies Clinical Governance and Professional Practice Fraud & Possible Criminal Issues

9. Controlled Drugs Team Monitoring of PRISMS Prescribing Information

11. Nurse Independent Prescribers are able to prescribe any medicine for any medical condition including all Controlled Drugs – within their competency Pharmacist Independent Prescribers are able to prescribe any medicine for any medical condition Supplementary non medical prescribers are able to prescribed any CD (Schedule 2-5) providing this is covered by a Clinical Management plan (CMP) Non Medical Prescribers

12. New legislation came into force on 23 rd April 2012 which allows: Nurse independent prescribers to prescribe any schedule 2-5 controlled drugs for any medical condition, within their clinical competence, removing previous limitations Pharmacist independent prescribers to prescribe any schedule 2-5 controlled drugs for any medical condition, within their clinical competence Non Medical Prescribers -

13. New legislation came into force on 23 rd April 2012 which allows (cont.): Nurse and pharmacist independent prescribers, and supplementary prescribers when within a clinical management plan, to mix controlled drugs for administration and provide written directions to others to do so These changes DO NOT apply to the prescribing of cocaine, diamorphine or dipipanone for the treatment of addiction. Non Medical Prescribers -

14. Things to consider: Role and remit Competency, appraisal & review process Discuss with health care team e.g. secondary care physicians e.g. primary care GP/practice team Job description/professional indemnity Local policies/formulary Legal & best practice requirements The patient/patient group Non Medical Prescribers Can I just go ahead and prescribe controlled drugs?

15. Must include clear dosage instructions on a prescription to avoid uncertainty on administration. Extra care must be given when syringe drivers are being used Must ensure do not prescribe beyond limits of competence and experience Must inform relevant individuals of any restrictions on prescribing May use computer generated prescriptions for all controlled drugs if clear audit trail Quantity should not exceed 30 days supply (Sch 2-4) NMC – Standards of Proficiency for nurse and midwife prescribers Practice Standard 16

16. Must not prescribe a controlled drug for self Must not prescribe controlled drugs for someone close to you unless: –No other person with legal right to prescribe is available AND it is immediately necessary to save life, avoid significant deterioration, alleviate otherwise uncontrollable pain You must be able to justify actions and document relationship and emergency circumstances NMC – Standards of Proficiency for nurse and midwife prescribers Practice Standard 16

17. Apply to all schedule 2 Apply to all schedule 3 (except temazepam) It is an offence for a prescriber to issue an incomplete prescription. By law a pharmacist cannot dispense an incomplete prescriptions. Incorrectly written prescriptions can cause inconvenient Prescription Writing Requirements

18. Be indelible State patient name and address State drug name, form and strength State dose – ‘as required’ or ‘as directed’ are not acceptable State the total quantity in words and figures (can be number dose units or total drug quantity) Instalment information if required, must include instalment amounts and interval Sign and date Pharmacists may supply and amend if minor typographic errors or spelling mistakes A legal prescription must:

19. Prescription Stationery Published May 2012 Highlights: Security culture Secure storage Individual responsibility Practice responsibility Board responsibility Deterring and identifying theft/fraud e.g. lost and stolen prescriptions (pads/computer paper) http://www.psd.scot.nhs.uk/professionals /pharmacy/documents/security_of_prescri ption_form_guidance- final_July2012_000.pdf

20. Any questions? Now onto some tasks……..

21. Task 1 - What Schedule – if any? Ecstasyoxycodonetemazepam Buprenorphinezopiclonecocodamol 30/500 LorazepamdiazepamOramorph 10mg/5ml Ketaminemidazolamdihydrocodeine Zolpidem cocodamol 8/500 Sativex Sevredoltramadolmethylphenidate

22. Task 1 - What Schedule- if any? ANSWERS Ecstasy (1)oxycodone (2) temazepam(3) Buprenorphine (3)zopiclone (POM)cocodamol 30/500 (5) Lorazepam (4/1)diazepam (4/1)Oramorph 10mg/5ml (5) Ketamine (4/1)midazolam (3)dihydrocodeine (5) Zolpidem (4/1) cocodamol 8/500 (5) Sativex (1/2/4) Sevredol (2)tramadol (POM)methylphenidate (2)

23. Task 2 – MORPHINE EQUIVALANCE Morphine sulphate 20mg orally, twice daily would convert to the following 24hour subcutaneous dose: 1. 10mg 2.20mg 3.30mg 4. 40mg

24. Task 2 – MORPHINE EQUIVALANCE Morphine sulphate 20mg orally, twice daily would convert to the following 24hour subcutaneous dose: 1. 10mg 2.20mg 3.30mg 4. 40mg

25. Task 2 – MORPHINE EQUIVALANCE Tramadol 50mg, 2 capsules taken four times daily would be the equivalent of: 1.5-15mg oral morphine daily 2.20-35mg oral morphine daily 3.40-100mg oral morphine daily 4. 110-150mg oral morphine daily

26. Task 2 – MORPHINE EQUIVALANCE Tramadol 50mg, 2 capsules taken four times daily would be the equivalent of: 1.5-15mg oral morphine daily 2.20-35mg oral morphine daily 3.40-100mg oral morphine daily 4. 110-150mg oral morphine daily

27. Task 2 – MORPHINE EQUIVALANCE Co-codamol 30/500, 2 tablets taken four times daily would be the equivalent of: 1.5-15mg oral morphine daily 2.20-35mg oral morphine daily 3.40-100mg oral morphine daily 4. 110-150mg oral morphine daily

28. Task 2 – MORPHINE EQUIVALANCE Co-codamol 30/500, 2 tablets taken four times daily would be the equivalent of: 1.5-15mg oral morphine daily 2.20-35mg oral morphine daily 3.40-100mg oral morphine daily 4. 110-150mg oral morphine daily

29. Task 3 You see an asthma patient who is a poor attendee at clinic. You haven’t seen her before but can see from records she has been uncooperative in past. At this visit she agrees to your suggested management plan and expresses interest in stopping smoking. Just before leaving, having agreed an asthma plan, she mentions she has previously had diazepam tablets to help with stress and thinks this would be useful to manage to stop smoking. It is on her repeat record. Would you: 1 – prescribe small quantity and arrange to see her next week 2 - refer to smoking cessation team 3 – prescribed one months supply, the same as her other asthma medication, add to repeat and 4 – tell her diazepam has no role in smoking cessation and you will not prescribe

30. Task 3 You see an asthma patient who is a poor attendee at clinic. You haven’t seen her before but can see from records she has been uncooperative in past. At this visit she agrees to your suggested management plan and expresses interest in stopping smoking. Just before leaving, having agreed an asthma plan, she mentions she has previously had diazepam tablets to help with stress and thinks this would be useful to manage to stop smoking. It is on her repeat record. Would you: 1 – prescribe small quantity and arrange to see her next week 2 - refer to smoking cessation team 3 – prescribed one months supply, the same as her other asthma medication, add to repeat and 4 – tell her diazepam has no role in smoking cessation and you will not prescribe

31. Task 4 You are visiting a palliative patient and their family. The patient is comfortable, on a syringe driver. As you are leaving the daughter asks if you could help as she has forgotten her medication from home, down south, in her rush to come to father’s bedside. She asks for a small supply of diclofenac, dihydrocodeine, lansoprazole and microgynon. She has missed today’s doses. She says it is no problem if you can’t help she could get from a pharmacy, she thinks. Would you: 1 – supply a prescription for the medication. You know the family and dad is very ill and this is a stressful time and this would help review some pressure. 2- advise her to contact GP surgery 3-write a private prescription for all the items 4 – send her to the community pharmacy to get an emergency (CPUS) supply

32. Task 4 You are visiting a palliative patient and their family. The patient is comfortable, on a syringe driver. As you are leaving the daughter asks if you could help as she has forgotten her medication from home, down south, in her rush to come to father’s bedside. She asks for a small supply of diclofenac, dihydrocodeine, lansoprazole and microgynon. She has missed today’s doses. She says it is no problem if you can’t help she could get from a pharmacy, she thinks. Would you: 1 – supply a prescription for the medication. You know the family and dad is very ill and this is a stressful time and this would help review some pressure. 2- advise her to contact GP surgery 3-write a private prescription for all the items 4 – send her to the community pharmacy to get an emergency (CPUS) supply

33. Patient Factors - questions to determine whether drug use is appropriate or constitutes abuse Intent: Is the drug used for a legitimate medical purpose? Is the need still there? Effect: Does the drug improve the quality of the patient's life? How have the symptoms been controlled? Evidence of benefit? Control: Are you helping the patient maintain control over use of the drug? Evidence concordance/use/abuse/refusal supplies? Legality: Is use of the drug legal and uncomplicated by illegal drug use? Pattern: Is the pattern of use one of appropriate medicinal doses or is it one of excessive doses? Why are you being consulted? Just because it has been prescribed before doesn’t mean it is right.

34. So can I just go ahead and prescribe controlled drugs?.................................

35. Contact Details Accountable Officer – David Pfleger Lead Pharmacists Controlled Drugs Team Anne Taylor & Lesley Thomson Ext. 56601 / 56800 anne.taylor5@nhs.net lesley.thomson6@nhs.net grampian.cdteam@nhs.net