Substance misuse: raising awareness, new referral pathway and developing a new flowchart for sale of codeine-containing medicines in the community pharmacy

Substance misuse is a treatable condition that affects a person’s brain and behaviour, leading to their inability to control their use of illicit drugs and alcohol​[1]​. Illicit drugs could be illegal (e.g. heroin and cocaine) or legal drugs (e.g. co-codamol and morphine)​[2]​. 

Substance misuse in Wales is rising rapidly. The latest data on substance misuse published in Wales revealed that:

• There’s an increase of 119% in school exclusions as a result of drug use amongst school-aged children in 2022/2023 compared to 2020/2021
• 38.3% of hospital admissions for illicit drugs in Wales in 2022–2024 were due to opioids
• Drug misuse deaths were the highest in the 40-49 age category, accounting for 33.7% of all drug misuse deaths registered last year​[3]​

Treatment of substance misuse on the NHS depends on patients’ personal preferences and the substance used​[4]​. A key worker under a local drug service (i.e. CDAT and PSALT) will usually work together with the patient to come up with the best treatment plan. CDAT and PSALT work very closely together with community pharmacies, and I suggest we take advantage of this partnership to form a referral pathway for patients who repeatedly show signs and symptoms of substance misuse in the community pharmacy setting. 

I propose that pharmacists should use their discretion to initiate a friendly and non-judgemental conversation with a patient they suspect might be abusing P/POM medicines in the consultation room. Patients that open up to pharmacists about substance misuse could then be referred to CDAT/PSALT if they consent. Substance misuse is a highly stigmatised issue and it is important that pharmacists and pharmacy staff are intentional about displaying empathy and patient-centred care. 

When codeine linctus was reclassified from a P to POM medicine earlier this year, I wondered if other codeine-containing products (CCPs) would follow due to their high risk of addiction and tolerance. I would recommend that  CCPs that are P medicines should only be purchased after patients are taken through a developed flowchart/checklist by a trained pharmacy technician or pharmacist based on the WHO Pain ladder and Biopsychosocial Model of Pain​[5,6]​. This should enable safe sale of CCPs to the targeted patient demographic. 

More awareness needs to be raised about substance misuse using tools like targeted public health campaigns. This will result in meaningful engagement, impactful education and patient empowerment, which I believe will make a positive and long lasting impact.

Mercy Adeyemi