Pharmacist Removed from Register for Supplying Codeine Linctus and Phenergan Without Clinical Justification

The registrant, a pharmacist first registered in 2015, was employed at a London pharmacy. Concerns arose when another pharmacist (“Pharmacist 1”) was suspected of diverting medicines for misuse. Investigators discovered text message exchanges between Pharmacist 1 and the registrant, discussing the supply of Codeine Linctus and Phenergan.

These medicines, when combined, form a substance known as “Lean” or “Purple Drank,” which is abused recreationally. Given the known potential for misuse of these drugs, many pharmacies refuse to stock them. The registrant, however, repeatedly supplied these medicines upon request.

Investigation and Evidence

• The investigation revealed multiple messages over several years (2017-2020) where the registrant arranged to supply the medicines.
• Witness testimony confirmed the registrant’s phone number matched the contact in Pharmacist 1’s messages.
• Expert witnesses testified about the misuse potential of these medicines, particularly in combination.
• The registrant did not request clinical justification for the supplies, reinforcing the view that he was aware of their misuse.

Findings

The Fitness to Practise Committee found that:

1. The registrant engaged in conversations offering to supply the medicines.
2. He did in fact supply or facilitate the supply of these medicines.
3. He did so without a legitimate clinical purpose, knowing or believing they would be misused.

The Committee ruled that the registrant’s actions constituted serious misconduct, breaching fundamental principles of the pharmacy profession.

Sanction

The Committee determined that removal from the register was the only proportionate response. The registrant’s repeated misconduct over several years, lack of engagement with proceedings, and failure to show insight or remediation were all aggravating factors.

An interim suspension was also imposed, preventing him from practising while the decision takes effect.

Key Takeaways for Pharmacy Professionals

• Supplying medicines without due diligence, especially those with misuse potential, can lead to serious regulatory action.
• Text message exchanges alone can serve as evidence of professional misconduct.
• Engaging with regulatory processes is crucial—failure to do so can result in harsher outcomes.
• Pharmacists have a duty to use their professional judgment responsibly, ensuring that medicines are supplied only when clinically appropriate.