NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

PostScript Primary Care December 2012

Holiday Addictions Services

There are more “take-home” doses for methadone, buprenorphine and other Controlled drugs (CDs) around Christmas and New Year. Prescriptions for instalment dispensing of CDs must state the dose plus the amount to be supplied per instalment and the interval between instalments. Directions for take home instalments must be unambiguous. The wording approved by the Home Office to cover supplies when pharmacies are closed is included on the stamps supplied to practices. Use of the Home Office wording allows pharmacies to make supplies to patients in advance of any pharmacy closure.

Please remind patients of the importance of safe storage of methadone, buprenorphine and other CDs and the risks of overdose when taken with alcohol and other illicit or prescribed drugs. Medicines should be kept out of reach and out of sight of children, locked away if possible.

Please ensure that your Addiction Services local contact lists are updated and procedures in place for emergency closures. The pharmacy team at the Addictions Services can be contacted on 0141 277 7660 for further help, advice and for extra supplies of safe storage leaflets and take-home dose warning stickers if needed.

Festive Community Pharmacy Arrangements

As in previous years, there will be a number of pharmacies open across the four Festive public holidays to provide pharmaceutical services during some of the out of hours period. Please note that opening times will vary from normal hours for these pharmacies and details will be found on http://www.nhsggc.org.uk/content/default.asp?page=s1187

In addition, all pharmacies are able to provide the Unscheduled Care service if patients run out of their medication or are unable to access their repeat prescription whilst GP surgeries are closed. Pharmacists can provide up to a normal prescription cycle for most repeat medications, excluding controlled drugs and injections, via a Patient Group Direction. Practices are asked to inform patients of this service to help ease burden of patients being unable to access their medication.

If the patient is unsure what medication they are on when they access the service, pharmacists can contact NHS 24 to seek clarification from the Emergency Care Summary, providing the patient is able to give consent. Please note that this is a verification of the patient’s medication and is not a means of seeking permission to supply. Pharmacists must use their own professional judgement as to whether a supply is required.

Details of all supplies made using the unscheduled Care PGD will be communicated to the patients’ GP within 3 days (usually by fax) for practices to updates their records.

Jext® Adrenaline auto-injector 

Jext® is the preferred brand of adrenaline injection for self-administration in the Greater Glasgow and Clyde Formulary (SMC advice can be accessed click here). Expiry date is 24 months compared to Epipen® 18 months, it is as easy to use and has no restrictions to storage.
It should be noted that different devices differ in the practicalities of administration, and if a patient's device is changed for any particular reason then training needs to be provided to ensure that the dispensed device is used correctly by all who are likely to be required to administer it.

Pregabalin and Gabapentin Prescribing and Misuse Potential 

Gabapentin and pregabalin are licensed for the treatment of epilepsy and neuropathic pain with pregabalin also licensed for general anxiety disorder. Across NHS GGC pregabalin prescribing particularly is increasing.

NHS GGC guidelines HERE  recommend two first line treatments for treatment of neuropathic pain: Tricyclic antidepressants e.g. amitriptyline or the antiepileptic drug gabapentin.

Pregabalin is an alternative to gabapentin but SMC HERE  states “Pregabalin is restricted to use in patients who have not achieved adequate pain relief from, or have not tolerated, conventional first and second line treatments for peripheral neuropathic pain. Treatment should be stopped if the patient has not shown sufficient benefit within 8 weeks of reaching the maximally tolerated therapeutic dose. NHS GGC neuropathic guidelines will be reviewed in the near future and will include dose tapering guidance.

Recent reports have highlighted the potential for misuse of gabapentin / pregabalin in order to enhance mood level, to augment the effects of other drugs or to substitute other drugs such as cocaine. The pregabalin SPC has listed euphoric mood, confusion, irritability, disorientation, insomnia as common adverse effects, occurring in between 1 to 10% of patients and notes that cases of abuse have been reported. Caution should be exercised in patients with a history of substance abuse and the patient should be monitored for symptoms of pregabalin abuse. There is no similar statement in the gabapentin (Neurontin) SPC, although there have been several abuse cases reported concerning gabapentin.
Prescribers and pharmacists should be aware of the potential for misuse of this prescribed medication. Concerns should be clearly communicated and frequent monitoring is essential.