New Zealand community pharmacists’ experiences in collecting information from purchasers of pseudoephedrine-containing products: findings from a qualitative study

Introduction

Methylamphetamine has become well established in the New Zealand illicit drug market and recent research has identified its widespread availability.^[1]
 Much of the methylamphetamine is produced locally in clandestine laboratories and there has been a significant increase in the number of such laboratories detected over recent years.^[2],[3]

Pseudoephedrine is currently the main precursor used in the manufacture of methyl-amphetamine and is an ingredient of many over-the-counter cough and cold medicines. In New Zealand, such products are available only from registered pharmacies (“in either slow release form or in preparations containing not more than 60mg per dose, and when the recommended daily dose is not more than 240mg”^[2]
). There have been reports that 1g of methylamphetamine can be produced from 30 tablets of a nasal decongestant such as Sudafed^[2] and that individuals have been paid up to NZ$100 for each pseudoephedrine-containing product purchased from a pharmacy.^[4]
 As a result, pharmacies have suffered burglaries and threats from customers, and faced armed hold-ups.^[5]
 This has resulted in emotional distress for pharmacists and their staff as well as increased costs for pharmacy businesses — through damage to premises, increased insurance premiums and the installation of security measures.^[5],[6]

Various strategies have been implemented by community pharmacists in their efforts to prevent pseudoephedrine being purchased for illicit use. This has included limiting the number of pseudoephedrine-containing products that can be sold to an individual customer, keeping stock out of sight of customers, and limiting the number of supplies held on the premises. Some pharmacists have stopped stocking these products altogether.^[7]
 Many pharmacists also obtain the identity and contact details of purchasers of pseudoephedrine-containing products and some pass these on to the New Zealand police. This is a voluntary process and, while pharmacy organisations and the police have produced guidelines for this procedure, it remains up to individual pharmacists whether they participate. Recently published research suggests that there is some variance in what pharmacists are currently doing in this regard — with some collecting details of all purchasers, and others keeping records on purchasers who are not known to the pharmacy or who are suspected of being a pseudoephedrine “shopper”.^[8]

The collection and forwarding of such information to the police is likely to have workload, cost and stress implications for pharmacists and their staff. As such, the importance of ascertaining the usefulness of such practices, the risks involved and the value of the information collected was recognised. The then Office of the Commissioner of Police (now Police National Headquarters) made funding available for a study to explore these issues, which was undertaken by researchers at the University of Auckland. The study used a multi-method approach, using both quantitative and qualitative methods. Quantitative results are reported elsewhere.^[8]

This paper presents findings from qualitative interviews with pharmacists and representatives of pharmacy organisations. The aim of the qualitative interviews was to explore pharmacists’ views and experiences with regard to collecting information on purchasers of pseudoephedrine-containing products, and to support the development of a quantitative survey of a random sample of New Zealand’s community pharmacies.

Methods

Interviewees were recruited purposively by the research team either for their involvement in the setting up of data collection processes with the police, their stakeholder views from a pharmacy organisation perspective, or their involvement in data collection in community pharmacy. In addition, a snowball approach developed, whereby interviewees recommended others for participation in the study.

Participants were provided with an information sheet outlining the aims of the research, and informed consent was gained from all interviewees. Ethical approval for the study was granted by the University of Auckland Human Participants Ethics Committee.

Data were collected via face-to-face and telephone interviews. These were semi-structured and followed a discussion guide developed by the research team. The main research questions addressed to pharmacists and representatives of pharmacy organisations appear in the Panel (below). Data collection continued until saturation was reached (ie, no new themes were emerging).

All but one interview was audio-taped, and these were either transcribed or notes were taken by the researcher for analysis purposes. In interpreting the data, a thematic content analysis was conducted.

The data from this stage of the research were also used in the development of the questionnaire for the subsequent national survey of pharmacies.^[8]

Results

Ten interviews (six face-to-face and four telephone) were conducted with pharmacists and representatives of pharmacy organisations. This involved 12 interviewees in total (two of the interviews contained two respondents), the majority of which were based in Auckland and Wellington.

Pharmacists’ views on pseudoephedrine purchasing and data collection 

Pharmacist interviewees expressed support for police efforts in preventing the diversion of pseudoephedrine-containing products. The role of pharmacists in collecting and recording the personal details of purchasers of these products was seen to be central to this, and viewed by some as part of their professional duty:

Most pharmacists have a responsibility in this area. We are the stewards of medication and therefore we have a role to play in isolating illegitimate purchasers, reporting them to authorities — that’s just part of our professional role. (Interview 2)

Some were also motivated by the desire to assist in reducing the availability of methylamphetamine in the community:

I still personally feel that the [methylamphetamine] problem is so bad and so destructive, and it is destructive often to innocent people, that I think ‘no I am going to do this, because it might help’. (Interview 1)

It is interesting to note that most interviewees believed that levels of pseudoephedrine “shopping” had declined. This was attributed both to the impact of the data collection processes introduced by pharmacists to deter illicit purchasers, as well as changing trends in the manufacture of methylamphetamine:

It’s been very, very quiet, and I’m sure that the precursor materials are not coming from packets of Coldrex in pharmacies at the moment. Most of this year there hasn’t been a lot of activity since the big lab bust. [Interview 1]

For some interviewees, this meant that information collection processes had been “relaxed”, with purchaser details not being recorded as often as they had previously, or sent to the police as often. Others, however, maintained that their procedures had not altered, despite the apparent reduction in the number of illicit purchasers targeting pharmacies. One interviewee acknowledged that the situation could easily change, and it was therefore important not to become complacent:

Everybody’s very relaxed at the moment. It’s very quiescent. And it could bounce back again, all you need is a couple more robberies… . It seems to be cyclical, and there will be something else that comes along. [Interview 5]

Data collection processes 

The interviews revealed a range of documentation approaches being adopted by pharmacists with regard to purchases of pseudoephedrine-containing products. Procedures varied in terms of the type and level of information collected, when and of whom this was asked, and whether or not it was forwarded to the police. Pharmacists themselves acknowledged that in-house procedures and systems for collecting information were amended and adapted over time. This was generally driven by factors such as the perceived seriousness of the problem within an individual pharmacy or region, and the personal level of interest of pharmacy staff in the issue:

In my store the policy was ‘if I knew you, if you’d been a customer of mine for 20 years, I know you’re not going to be abusing it’ then that was fine, we didn’t bother recording names and addresses. Anyone we didn’t know, anyone who was slightly suspicious, we took a name and address and some sort of ID. As time went on, we got more and more stricter and it was driver’s licence only, and then it had to be a current licence. (Interview 4)

Some interviewees asked for identification (and recorded personal details) of every customer who purchased pseudoephedrine-containing products, regardless of whether or not they were known to the pharmacy or were perceived to be making a legitimate purchase. These pharmacists believed that such an approach ensured a consistent and fair process — and avoided them having to make “judgement calls” as to whether or not people were purchasing the product for illicit means:

You try and be consistent — otherwise it makes it really hard. At the beginning authentic people would get really upset at being asked, so the only way to avoid that was to say we ask everybody. (Interview 1)

Other interviewees stated that they collected details only from customers they did not know or those whom they considered suspicious. Indeed, some interviewees thought that asking for (photographic) identification sometimes assisted in detecting suspect purchasers:

The ID part is helpful — because if they don’t want to give it they pretend it’s in the car, and never come back. (Interview 1)

Some also thought it was easier to record personal details, as compared with refusing a sale from a suspected illicit purchaser, given the potential for the latter option to prompt an aggressive or abusive response:

If they are buying precursor stuff, they can rough you up. And police have said that — they’d much rather we sold it and got the information and gave it to them. They don’t want us to put ourselves at any risk. (Interview 3)

Assessing the legitimacy of requests

Given that some pharmacists were only recording the details of those whom they considered suspicious, the research investigated how interviewees assessed the perceived legitimacy of requests.

While there was evidence of some reluctance to acknowledge that they did so, a number of interviewees spoke about physical appearance being one of the main criteria used:

In this PC age we don’t judge people — but we do. It’s pretty clear to us what their intent might be. It’s a judgment call on their dress, their tattoos etc. (Interview 2)

Pharmacists monitored the behaviour of customers as a means of identifying illicit activity. Suspicious conduct highlighted in the research included purchasers being highly specific about what they wanted, uncertainty over symptoms, nervous body language and requests for large quantities of pseudoephedrine-containing products. One interviewee described the lengths that some purchasers would go to in their attempts to procure supplies of the substance:

When they are real desperate to get it, they will come in with all the symptoms of a cold. Stuff stuck up their noses.You couldn’t tell that they didn’t have a cold. (Interview 1)

Forwarding information to the police

Most pharmacists who took part in the qualitative phase of the study recorded the information on a paper-based form that had either been developed by pharmacy staff or supplied by the police or a pharmacy organisation.

Most pharmacists interviewed forwarded the information to the police via fax. However, the frequency with which they did this and the level of detail provided varied. Some pharmacists sent all the recorded information; others only faxed details of those whom they considered suspicious. This was either identified at the time of the sale, or following in-house analysis by the pharmacist.

Other interviewees stated that they submitted information only if the police sent a fax alert requesting data on specific individuals. One pharmacist also sent the details of suspicious non-purchasers to the police, ie, those who enquired about products but did not end up making a purchase.

Collaboration among pharmacists

The research revealed informal networks in operation across pharmacies. These involved collecting and sharing information on suspicious purchasers – both in a bid to deter the diversion of the products and to protect their colleagues:

One thing that does happen is that in most pharmacies, both pharmacists and their staff get a feel for what might be a dodgy request — then they’ll ring around and tell other pharmacists. That’s how quite a few are picked up, they’ll notify the police. And that, in many ways, short of providing evidence of a purchase which could be put forward in a trial, is probably more useful. (Interview 8)

In one case, a respondent reported that the pharmacy deliberately sold pseudoephedrine-containing products to suspected “shoppers” before contacting other pharmacists in the area:

There’s only [number] pharmacies in town. Often one will sell and then ring the other pharmacy and say ‘we’ve sold it, we’ve got the details’ and then they won’t [sell], but it kind of confirms that ‘yes it’s suspicious’. (Interview 1)

Barriers to collecting and forwarding information 

Although this research revealed underlying support for information collection processes, interviewees identified a range of barriers that they faced which sometimes impacted on their willingness to participate, or influenced their level of involvement. These included summonses to appear in court cases, the impact on the business, negative reactions from customers and concerns about the legality of the process.

Summonses to court cases 

A key barrier highlighted by interviewees was the potential for pharmacists to be summoned to provide evidence at a court case, to verify pseudoephedrine-related information they had supplied to the police. One of the main deterrents was the expense incurred, due to the need to employ additional staff in place of the absent pharmacist. Court cases were frequently deferred or delayed, thus compounding the financial costs:

At times you were just held swinging — you may have to go any day, you may have to go some time on the Wednesday. So you’d ring, book a locum, that’s an expense.You’d take the day off and the guy never came to court, didn’t show up. So you’d go to court at 10 o’clock in the morning and they’d be ‘oh you don’t need to come to court today’. Well, I can’t just ring up my locum and say ‘sorry I don’t need you, I’m coming to work’. It doesn’t work like that. It just pissed you off basically.You had no choice in the matter. (Interview 4)

Impact on the business 

There were other facets of information collection that impacted on community pharmacy business. These included the time-consuming nature of collecting information from purchasers, as well as (in some cases) analysing and forwarding it to the police. This, along with the potential for prolonged periods spent appearing in court cases, raised questions for some interviewees about the impact of this on the pharmacy as a business:

It’s fair to say that if I were doing it [collecting and analysing data from customers] I’d probably say ‘I can’t be bothered’, to be honest. Because it’s an imposition on time, and the fact that [pharmacy staff member] has to go to court on Monday, we don’t know at what time etc. It’s public service, but we’re running a business as well — how much of this is an imposition on people’s time and energies really? (Interview 7)

Negative reactions from customers 

Pharmacists thought that it was important that legitimate purchasers of pseudoephedrine-containing products were not inconvenienced, and a number expressed a reluctance to collect personal information or photo-identification from this group (who were often known to them) and who sometimes took offence at being asked to provide personal details. This was either because they were insulted by the implication that they could be purchasing the product for illicit means or because, on a philosophical level, they did not agree with their personal details being passed over to the police:

I can think of three stand-out bad abusive incidents with people who were buying it for precursor use — whereas I’ve had twice as many with people who have just got a cold, being abusive.You feel real bad. (Interview 1)

Several interviewees had also experienced negative or aggressive reactions from suspected “shoppers”:

If they’re addicts, they’re usually quite aggressive. If they’re doing it for someone else, they’re usually a bit resigned to it. (Interview 1)

Legality of the process 

A number of issues surrounding the legality of requesting and storing personal information were raised by interviewees. The legality of using a driver’s licence as a form of photo-identification during transactions for pseudoephedrine-containing products was of concern for one respondent. Others were of the view that storing this information in a database — particularly where an individual’s name and address was recorded together with their licence number — is a breach of the law.

Not all interviewees were comfortable about providing information to the police. In particular, some differentiated between providing information on all purchasers, as opposed to those who were deemed suspicious. Although the latter was considered acceptable — and in keeping with pharmacists’ ethical obligations to prevent the misuse of drugs — there were concerns that the police did not have the right to request this information from all buyers of these products. It was noted by some interviewees that if there were grounds for suspicion, then the sale should not be completed — unless the pharmacist felt under threat by the purchaser:

If it was a suspicious sale, what pharmacist worth their annual practising certificate will undertake that sale unless there is a threat? If threatened, yes, one would make the sale and provide whatever information possible to police. (Interview 3)

Other barriers 

Some interviewees thought that collecting information was beyond the remit of their role as a pharmacist and that the police should not expect them to take on this added responsibility. Other barriers included the challenge of ensuring that all staff follow the same procedures in tackling this issue, and the inconvenience of “tying up” the business’s fax machine when sending information through to the police on a regular basis. One interviewee also highlighted that misconceptions around the purpose of data collection, and its subsequent use by the police, appear to have been the source of some frustration for pharmacists, and may have acted as a barrier to providing further information:

Particularly in the early days, Police resources were such that they were using this information for intelligence, they weren’t using it to bust that particular person. Now pharmacists took a long time to appreciate that. They thought that as soon as they rang, or sent off a fax, there’d be a squad car outside the door immediately, and someone would be marched off in handcuffs. (Interview 3)

Feedback from the police to community pharmacists 

This study also explored community pharmacists’ experiences of receiving feedback from the police, as a result of information provided on purchasers of pseudoephedrine products. Findings suggest that the level and nature of feedback has been variable. Most interviewees stated that the information flow had generally been one way, with the police providing little feedback on how well pharmacists were doing with regard to providing information or how information was being used.

Some claimed that the only time they heard from the police was when a case went to court and they were required to give evidence. This perceived lack of feedback raised questions about the value of the information to the police, with some of the view that it revealed a lack of appreciation of the time and effort made by community pharmacists:

When messages were stacked up on the answerphone and when [pharmacists] didn’t get any feedback from the messages they left on the answerphone they got pissed off and said “why are we doing this?”. Nothing ever happens. (Interview 3)

A number of interviewees stated that a lack of feedback from the police had negatively affected their attitude to collecting the details of purchasers of pseudoephedrine products. One interviewee predicted that they would have continued collecting data for longer, had they received some level of feedback from the police:

If they had come to us and said ‘you’re doing a great job — we don’t want to tell too many people, but you’re doing a great job, and we’ll try and protect you from the judicial system as much as possible. And we’ll arrange that you’ll get costs etc, then the whole process would have probably spun out a lot longer. The actual collection process and the sending process would have continued for a lot longer. I would have been much happier with that. (Interview 4)

Where pharmacists had received feedback from the police, the positive effects of this were clear:

It’s like the blood banks — they used to send a letter that said thank you, and tell you how your blood was used. It gave you a swollen chest and made you rush to do it again. It’s the same situation — a little bit of thank you goes a long way. (Interview 3)

When questioned on the nature of feedback they were seeking, pharmacists generally were not looking for in-depth or personalised information on individuals or outcomes, and most felt that a standardised letter or similar type publication (eg, newsletter) distributed two to four times a year would be appropriate. It was thought that this should explicitly acknowledge the role played by pharmacists in assisting the police, and provide some level of information on the outcomes (eg, level of arrests and prosecutions, and number of methylamphetamine laboratories discovered).

Discussion

This paper has identified the underlying support that pharmacists have for assisting the police in preventing the diversion of products containing pseudoephedrine. However, they face a range of challenges and barriers in gathering this information from customers, which is impacting on some pharmacists’ willingness to participate in this process. The perceived lack of feedback received from the police appears to be compounding this issue.

This study was conducted with a small number of community pharmacists and representatives of community pharmacy organisations in New Zealand, most of whom were located in two large urban centres. It is not known if pharmacists in more provincial areas face different challenges and have had different experiences with regard to this issue — or whether the results are generalisable to pharmacists across New Zealand. In considering this issue, it is worth highlighting that many of the issues raised have been corroborated in the findings from the national quantitative survey of pharmacies which was also undertaken as part of this study. These findings have been reported elsewhere.^[8] Furthermore, even though numbers are small, data saturation was reached after 10 interviews, indicating the appropriateness of stopping at this point.

The concept of collecting information on purchasers of potential substances of misuse is not new to pharmacists in New Zealand. Data collection in relation to pseudoephedrine-containing products has been occurring for some time and, before this, other pharmacy medicines have been monitored in this way.^[9],[10]
 Although the research has revealed general support from pharmacists and a willingness to assist the police, there was dissatisfaction with the level of feedback received, an issue which was generally considered important by interviewees.

The research has identified the ad hoc manner with which policy and procedures relating to the collection of these data has developed. It appears that different pharmacies have adopted varying procedures, and there are significant differences in the level of data being collected, and the frequency with which it is submitted to the police. A key issue in the current climate is the mixed messages being given to pharmacists with regard to whether they should be providing information on all shoppers, as opposed to those who appear suspicious. For those being encouraged to send in information on suspicious shoppers only, this is believed to be at odds with pharmacists’ code of ethics, which states that products should not be sold to doubtful customers or known misusers (although it is acknowledged that sales are not always able to be halted, due to aggressive or threatening customers). This may also mean that those people purchasing just one product from a range of pharmacies, in a non-suspicious manner, may be overlooked in this system. At the same time, requesting data on all purchasers (legitimate or otherwise) is believed to be contradictory to current legislation. The use of driving licences as a form of identification in this context is also in question, alongside the legality of recording an individual’s name and address together with his or her driving licence number in a database. Clarification on these matters is urgently required.

In standardising procedures, the development of a memorandum of understanding or code of practice outlining the role and rights of community pharmacists and the police could be explored. This could initially have a pseudoephedrine focus, but there is the potential for the framework to be adapted in the future if other over-the-counter medicines were to become sought-after precursors. Given that data can be collected either in paper or electronic format at present, a review of this process and standardisation may be useful (eg, a national, brief form for collecting the minimal amount of relevant information could be piloted and implemented).

The requirement for pharmacists to appear in court cases creates a number of issues, including finding locum cover, the costs incurred as a result of this, and inconvenience when court case dates are changed or arranged at short notice. There is a clear need for the police to provide thorough support during this process. The issue of financial compensation may need to be explored. In the UK, for example, the Crown Prosecution Service has agreed that “discretion will be exercised in certain circumstances”, to allow single pharmacist businesses to be reimbursed locum costs.^[11]

The research has revealed the importance of police officers building relationships with pharmacists — and the positive impacts this can have on their propensity to provide information. This would appear to fit with the New Zealand police strategy, which outlines one of its goals as being “community reassurance” — with a focus on community engagement and participation in policing.^[12]
 In particular, there is potential for the police to provide general feedback on how best to collect and document information and on how information is being used by the police in relation to their role in combating the manufacture of methylamphetamine. This does not need to impart sensitive information or be overly detailed, and could acknowledge the role of pharmacists within the police’s overall chemical diversion prevention. Pharmacy publications may be an appropriate platform for this.

Importantly, although some pharmacists who participated in the research thought that the issue had abated to some degree, the recent targeting of a pharmacy in Auckland, whereby the premises were raided in an attempt to obtain pseudoephedrine-containing products,^[13]
 is a timely reminder that the problem has not diminished and, indeed, is likely to continue for some time. This reinforces the importance of clarifying procedures and ensuring that pharmacists are adequately supported in their efforts to eliminate the purchasing of pseudoephedrine-containing medicines for illicit drug manufacture.

Conclusion

The collection of information from purchasers of pseudoephedrine-containing products has workload and potential financial and stress implications for pharmacists. Current procedures vary greatly and some pharmacists face not insubstantial barriers in gathering and forwarding the information to the police. A review and standardisation of current systems, along with increased communication from the police, may be timely.

This paper was accepted for publication on 5 April 2007.