The Controlled Drugs National Group Sub-Group Newsletter

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The Controlled Drugs National Group Newsletter

Joint Sub-Groups Newsletter - December 2017. Number 2

Latest news from CQC

Can we please take this opportunity to remind all Controlled Drugs Accountable Officers (CDAOs) to ensure that your contact details are correctly shown on the published CDAO Register.  This is important because NHS England Lead CDAOs use the register to update mailing lists for circulation of controlled drugs local intelligence meeting invites, network papers and alerts. The CDAO Register can be found on our website here

Please note that if you have not notified the CQC of your appointment you will not be entered onto the CDAO Register. To notify us please complete a CDAO notification. Our on-line CDAO notification form along with further information can be found on our website here.  

News from the Policy Sub-Group

T-28 Exemption Certificates- A reminder

Recent inspections by the CQC have highlighted that some providers are not aware they need to have an Environment Agency issued T-28 Exemption Certificate to dispose of CDs. The exemption is free of charge and allows pharmacies and other similar places, including healthcare settings, to comply with the requirements of the Misuse of Drugs Regulations 2001 by denaturing controlled drugs (making them unsuitable for consumption).

The information about this waste exemption, including how to apply for it, can be found here. Please also note that the exemption only lasts 3 years so after this period the exemption needs to be renewed.

Controlled Drugs (Supervision of Management and Use) Regulations 2013

The Department of Health are continuing to review the Controlled Drugs (Supervision of Management and Use) Regulations 2013. An initial meeting was held during the autumn of 2016 to consider the effectiveness of the regulations and potential areas to include as part of the review. The Department is in the processes of planning the next stages of the review. 

The review of the Safe Custody Regulations 1973

The Home Office held the first round of meetings to review the 1973 Regulations in early 2017. Meetings have been held with representatives from both the healthcare and non-healthcare (i.e. museums and universities) sectors. A set of targeted meetings took place in August 2017 to drill down into some of the specific issues such as new technology and exemption certificates and the Home Office are about to send out a questionnaire to form the basis for their impact assessment.

Home Office pregabalin and gabapentin consultation

This consultation seeks views on options whether, and how, to schedule pregabalin and gabapentin under the Misuse of Drugs Regulations 2001 following the recommendation by the Advisory Council on the Misuse of Drugs (ACMD) that these 2 drugs should be controlled as Class C drugs under the Misuse of Drugs Act 1971 (‘the 1971 Act’) and placed in Schedule 3 to the Misuse of Drugs Regulations 2001.

The consultation is aimed at members of the public, healthcare professionals, institutions, all sectors within the supply chain including the pharmaceutical industry, wholesalers and community pharmacies in the UK. The consultation opened from 13th November 2017 and runs until 22nd January 2018.

News from the Patient Safety Sub-Group 

One of the issues that is frequently raised at the Patient Safety sub-group is that of patients going home without some of their medicines because they are stored in a different place such as the controlled drugs cupboard or the medicines fridge. One way of helping to reduce this risk is by using a discharge check list such as the one below and by adding coloured notes to the drug chart: 


Medicines discharge checklist


There have also been some initiatives to encourage reporting of and learning from controlled drug related incidents:

The Community Pharmacy Patient Safety Group is made up of passionate community pharmacy Medication Safety Officers (MSOs) from across the sector, with representation from all community pharmacy chains with over 50 branches, as well as the National Pharmacy Association to represent independent pharmacies.  It provides a forum for these community pharmacy organisations to openly share and learn from each other when things go wrong, as well as from other sectors and industries, so that they can collectively improve patient care and reduce harm. 

They’re coming up to their third year of collaborative sharing and learning now, and are looking to make their work more accessible and transparent to anyone who is interested!  In this spirit, they have just published their priorities for 2018 at

Further information about the Group and their resources can be found on the website. 


Another initiative, shared at The Berkshire CD LIN:

Reading Public Health renewed the contracts with Pharmacies for Supervised Consumption in 2017/18. A requirement of the contract is to record patient safety incidents. Since 2005, pharmacies have been required to record patient safety incidents in an incident log and report these to the National Reporting and Learning Service (NRLS). The Reading Public Health Supervised Consumption Contract also requires pharmacists to report the CD incident to the CDAO via the NHS England CD reporting tool at  

News from the Prescribing Sub-Group 

Prescribing of Diconal 

The prescribing sub-group have been keeping an overview of diconal prescribing across England over the past year  and are pleased to report that overall prescribing is going down and new patients are not being started on it:

Dipipanone is a strong opioid analgesic drug, used for very severe pain. The main preparation of the drug commercially available is mixed with cyclizine (Diconal®) which has the advantage of reducing nausea, vomiting and histamine release associated with strong opioid therapy. As of November 2011 Amdipharm stopped making the Diconal brand tablets for the UK due to undisclosed commercial reasons.

Prescribing of dipipanone is discouraged apart from in exceptional circumstances, because of the perceived risk of abuse - the BNF marks the substance as "less suitable for prescribing" along with other older compounds such as pethidine and pentazocine with unusual abuse patterns. The combination with cyclizine leads to a very strong "rush" if the drug is injected. During the late 1970s to early 1980s in the UK, many deaths were blamed on misuse of this preparation.

The number of NHS prescriptions for dipipanone/cyclizine has reduced dramatically in the UK in recent years, which is great news for patients. Safer, more effective treatments are being used instead where there is a clear indication for treatment, and those patients with dependence and addiction problems (and no clear indication) have been offered support or treatment for their addiction

Prescribing of oral morphine solution 10mg/5ml

We have also continued to monitor the prescribing of oral morphine solution 10mg/5ml since we reported on high volume prescribing in our 2016 Controlled Drugs Annual Report:  

Morphine sulfate 10mg/5ml oral solution (commonly known by the brand name Oramorph®) is a short acting preparation of the strong opiate morphine, and is used for breakthrough analgesia in chronic pain, or sometimes for short term pain relief in acute pain. The concentration of morphine in this preparation is relatively low, and as a result the preparation is only listed as a Controlled Drug in schedule 5 of the Misuse of Drugs Regulations 2001. Schedule 5 CDs have the least regulation of all controlled drugs and consequently morphine sulfate 10mg/5ml oral solution is perceived as being easier to obtain inappropriately. A large number of incidents take place each year in which the preparation is stolen or diverted, and furthermore the prescribing is less closely monitored as a result of its scheduling. People who obtain even small volumes of the preparation will still be able to consume a significant amount of morphine in order to experience a high; morphine is a highly addictive substance.

In recent months the Controlled Drugs Accountable Officers (CDAOs) have taken a renewed interest in the prescribing trends for this preparation and have worked with the CQC and NHSBSA to benchmark prescribing data. From this work it became evident that huge volumes of the preparation are prescribed on individual prescriptions – sometimes as much as 10litres on a single prescription. This makes clear the huge quantities of morphine sulfate that are being dispensed and in the possession of patients, and clearly demonstrates a significant risk. CDAOs are working with individual practices and CCG colleagues to challenge risky prescribing and identify forged prescriptions. This will provide assurance that the risks of harm are being mitigated.

News from the Vigilance Sub-Group 

Pharmacy delivery driver errors.

We would like to highlight a recent coroner’s inquest that involved the use of a community pharmacy delivery driver.  In summary, a prescription for morphine sulfate capsules, intended for another person living close to the deceased at a similar address, and with an almost identical name was delivered in error alongside other medicines which were correctly prescribed and intended for the deceased. Unfortunately the patient who received the morphine sulfate capsules was partially sighted and took it with fatal consequences. The findings were that the checks that should have been undertaken on the name and address and the obtaining of a signature as set out in the standard operating procedure for delivery of controlled drugs were not followed.

With this in mind we would like to share some guidance which gives practical information around the use of delivery drivers.




Links to key organisations and relevant Guidance  

CQC is the health and social care services regulator with responsibilities for oversight of safe arrangements for controlled drugs across England. Website

The Department of Health (DH) helps people to live better for longer. They lead, shape and fund health and care in England, making sure people have the support, care and treatment they need, with the compassion, respect and dignity they deserve. Website

The Home Office leads on immigration and passports, drugs policy, crime policy and counter-terrorism and works to ensure visible, responsive and accountable policing in the UK.Website

NHS England leads the National Health Service (NHS) in England. We set the priorities and direction of the NHS and encourage and inform the national debate to improve health and care. Website

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. Website

NHS Counter Fraud Authority (NHSCFA) (formerly known as NHS Protect  The NHSCFA) began in shadow form in April 2017. It will be established as an independent special health authority in autumn 2017. The NHSCFA will provide a clear focus for both the prevention and investigation of fraud across the health service and will work with NHS England and NHS Improvement to properly uncover fraud and tackle it effectively. Website

Report NHS Fraud online here or by phoning the FCRL on 0800 028 4060

and guidance on Security of Prescription Forms -  August 2015

Public Health England’s advice for local authorities and local partners on widening the availability of naloxone to reduce overdose deaths from heroin and other opiate drugs.

Talk to Frank. Offers an educational and confidential advice service on drugs and legal highs. Details can be found here