Angela (51) is a regular visitor to your pharmacy. You have noticed she seems paler than usual, and rather withdrawn. For the past two years Angela has been collecting her prescription for Tramadol from you (Clinical pharmacology of tramadol ). You recall overhearing a conversation she had with a fellow customer. They were sympathising with each other about their chronic lower back pain. You remember Angela saying something like ‘I’m not sure what I’d do without my pain tablets.”
For the last three months or so Angela has not been collecting prescription Tramadol. A couple of weeks ago you politely asked her why. She told you her GP had called her in for a medication review and said that after two years she was no longer sure that Tramadol was helping Angela much, if at all. She said the doctor explained that Tramadol can get less effective over time and in some patients it can become a habit.
Instead she suggested a trial period using over the counter medications like low-level co-codamol, Nurofen plus and Solpadeine, more physiotherapy and an exercise programme she could do at home. As she was relating this decision Angela appeared disgruntled. You observe that she seems quite lethargic, that she has lost weight in her face and her lips are slightly blue.
She is now buying low strength co-codamol from you over the counter. You have asked staff to monitor her use since you suspect she may be using more than the recommended dose. You are of course aware that there is nothing to stop Angela buying co-codamol and similar drugs from other pharmacies in the area, or by post via the internet.
Overuse of OTC medications is seen as a significant problem: “295 patients (mean age 48.5 years, 68.5% of women) having used one of the studied drugs during the previous month were included. Misuse and dependence to codeine analgesics concerned 6.8% and 17.8% of the patients exposed to these drugs, respectively, (n = 118), which was significantly higher than for paracetamol. 19.5% had used codeine analgesics daily for more than six months. Headache was the most frequent reason for persistent daily use. A high prevalence of persistent daily users of sedative H1 antihistamines was also observed. Whereas these drugs are recommended only for short treatment courses of occasional insomnia, 72.2% of the participants having taken doxylamine (n = 36) were daily users, predominantly for more than six months.” Misuse of codeine
Further examples and discussion can be found here: Non-clinical use of medicines
As a pharmacist, what if anything should you do to or for Angela? What is your role? To continue supply as she requests? To talk to her about her use, and her health? To call her doctor to express your concerns? To call her husband, whom you know vaguely? Or do you simply refuse to sell the co-codamol to her anymore?
As things stand, she is the customer and you are the shopkeeper, but you are also her chosen health professional. She has a stated need and you are in a position to meet it.
You are fully aware of the GPhC advice: “Person-centred care is delivered when pharmacy professionals understand what is important to the individual and then adapt the care to meet their needs – making the care of the person their first priority.”
At face value this is unambiguous – the patient knows what is important to them and the patient should be your central concern.