In this part of the series I’m going to show you the system we use in Canterbury to deal with OTC codeine misuse. This system has been endorsed by the Police and three of our professional bodies (Guild, PDA, and PSNZ), and it is built on a close co-operation between pharmacies in Canterbury. The most interesting aspect of the system is the way it enables pharmacists to fulfil their duty of preventing harm to the patient and the public while addressing all health information privacy concerns, outlined in Part II – A Practical Analysis.

If you haven’t read Part I – The Codeine Problem, and you would like a brief overview of why this is an important issue, please click and have a quick read.

From speaking with a few colleagues about this issue, I got the impression that most pharmacists are concerned about OTC codeine misuse, but many are even more uncomfortable about sharing the sales information with other pharmacies. If this sounds like you, I hope that by laying out the issue here, plain and simple, I can help you realise that it can be done right, in which case there is nothing to be uncomfortable about, quite the contrary. If your intuition tells you that there must be something we can do to help curb medicine misuse, I believe you are right. Pharmacists have a key role in the community in identifying those people who need help with their drug addiction.

They will know the right answers to the pharmacists’ questions, they will say whatever you need to hear

Some of those people that come to the pharmacy to buy codeine containing products are in dire need of help and they may not even realise it. But if the pharmacist is not aware of how much a particular person bought in other pharmacies, they will have no understanding of the true extent of the problem. Some buy it for their own use, but some are coerced into buying these products for other people. If they buy it to feed their own addiction or curb their withdrawal, they will have already lost their autonomy, and have little conscious control over their drive to obtain codeine. Similarly to those who are buying for someone else, whether due to coercion or for financial reasons, they will know the right answers to the pharmacists’ questions, they will say whatever you need to hear. Of course, most of us have heard the stories and have a pretty reliable gut feeling when it comes to telling legitimate patients from those whose motives are doubtful. But often, even though you have a strong feeling that selling the medicine to the customer would not be appropriate, you have nothing to hang your hat on.

Buying painkillers frequently creates strong grounds for referral

Without something concrete, it can be very difficult to refuse the sale. This is where the co-operation between pharmacies comes in to provide the pharmacist with the full picture. How often and how much the person buys these strong painkillers is a highly relevant piece of information in deciding the appropriateness of the sale, because these medicines are only indicated for short courses. The treatment of chronic pain should be monitored by the patient’s GP. Buying painkillers frequently from multiple pharmacies creates strong grounds for referral. Further, it enables the pharmacist to try and initiate an open conversation with the patient about the true nature of their condition. While some of these people may feel embarrassed, it may well be the eye-opener for them. In Canterbury, thanks to the abuse prevention network, many addicts have been successfully referred to the appropriate services.

The key is to inform the customers about what happens to their information

Of course, as I discussed in Part II – A Practical Analysis, the use and sharing of information about pharmacist-only medicine sales between pharmacies cannot be done indiscriminately, it requires a properly organised system. Our patients rightly expect us to respect the privacy of their health information. In other words, we are bound by the Health Information Privacy Code (HIPC), and we must give effect to it. The key in dealing with our obligations under the HIPC is to inform the customers that as part of pharmacist-only medicine sales the pharmacist may request and record identification information. Pharmacies participating in the network must have a prominently displayed poster to convey this message. The poster also states that the information and details of the sale transaction may be shared with pharmacies are part of the abuse prevention network, or, in more serious cases the information may be passed on to the Police.

There is big emphasis on the customer being aware of all this.

This method ensures that customers are aware of the fact that certain information may be requested of them, also the reason for the collection of that information, and, most importantly, the purpose for which it may be used. This way, if the information does get passed on within the network, there can be no question that this was a legitimate use and disclosure. If a pharmacy has a “No ID, no sale” policy, the poster can appropriately explain why the policy is in place and why the pharmacist may ask for information that is, strictly speaking, not required by law. It makes the policy enforceable, so to speak. But as you can see, there is big emphasis on the customer being aware of all this. The Achilles’ heel of this method is that if there is miscommunication, or the customer cannot see or read the poster, it doesn’t work. Pharmacies that are part of the network have to have all staff properly trained so as to avoid this.

The Canterbury model for the prevention of drug abuse is a working example of a ground-up initiative that has proven to be successful. I think pharmacists are in a perfect position to deal with this issue, and it shouldn’t be necessary to take these strong painkillers out of our toolbox. Be well informed and do it right.

You can find the first two parts of the series here, read them and share your thoughts in the comments section, if you haven’t yet.

Drug Abuse Prevention vs Health Information Privacy – Part I – The Codeine Problem

Drug Abuse Prevention vs Health Information Privacy – Part II – A Practical Analysis

If you would like to suggest a correction, please do so in the comments, or contact me directly via email: mate@pharlaw.nz