Superintendent Pharmacist Suspended for Inappropriate and Excessive OTC Sales of Codeine Linctus to Opioid Addicts

Date of Decision: January 30, 2019

Registrant's Role: Pharmacist

Allegations:

• Inappropriate supply of codeine linctus between January 2012 and May 2018.
• Supplied for unlicensed purposes.
• Supplied to patients in managed addiction programmes without consulting their prescriber.
• Failed to consider:
• Volume and frequency of purchases.
• Misuse or addiction potential.
• Possible codeine dependency.
• Adverse health and wellbeing effects.

Outcome: 12-month suspension from the Register

GPhC Standards Breached:

• Standard 1 – Provide person-centred care: Failed to ensure safe and informed patient care.
• Standard 2 – Work in partnership with others: Did not engage with prescribers or safeguarding services.
• Standard 5 – Use professional judgement: Did not appropriately assess medication suitability.
• Standard 6.6 – Comply with legal and professional requirements: Breached legal standards for medicine supply.
• Standard 7.4 – Take responsibility for all work: Did not ensure responsible supply practices.
• Standard 1.1 – Ensure safe, quality services: Supply endangered vulnerable patients.
• Standard 1.2 – Protect wellbeing: Placed addicts at risk.
• Standard 1.3 – Promote health: Undermined patient health by fueling dependency.
• Standard 1.4 – Assess needs appropriately: Did not assess or record rationale for supply.
• Standard 1.5 – Refer appropriately: Failed to refer addicted patients to medical professionals.
• Standard 1.6 – Provide timely, safe medicines: Supplied large quantities without proper checks.
• Standard 2.1 – Act in best interest: Acted contrary to patient welfare.
• Standard 2.2 – Avoid conflicts of interest: Let habitual practice and profit compromise judgement.

Case Summary

Allegations
The registrant, a superintendent and responsible pharmacist, was found to have supplied excessive quantities of codeine linctus—a Pharmacy (P) medicine—to patients between January 2012 and May 2018, often in inappropriate and unsafe circumstances. Key issues included supplying it for non-licensed purposes (primarily for its sedative or addictive properties rather than as a short-term cough suppressant), supplying it to individuals in managed addiction programmes without consulting prescribers, and failing to adequately consider the implications of codeine misuse, addiction, or potential harm.

The concern initially arose from an anonymous complaint in March 2018. During a subsequent inspection, 40 bottles of codeine linctus were discovered stored under the pharmacy counter—well beyond the norm for routine pharmacy operations. The inspector observed a total stock of 10.2 litres during the visit, with stock levels suggesting significant recent sales activity.

Sales records were largely absent, which is not uncommon for P medicines, but troubling in context. The registrant admitted selling to a core group of five or six known addicts, describing his judgment process as ad hoc. He sometimes refused sales to those he deemed “too young” or “vulnerable,” but made no consistent or documented assessments. He conceded: “once you are the boss, if you have a bad habit it is likely to continue … it became a habit in the Pharmacy … I slipped into a dangerous practice.”

Findings
The Committee found the registrant’s behaviour amounted to serious misconduct. He had routinely supplied large amounts of codeine linctus to patients he knew were managing addiction—sometimes selling more than one bottle at a time and often without clinical assessment or record-keeping.

The inspector reported seeing unusually large stock quantities and receiving the registrant’s admission that sales were regular and deliberate. Pharmaceutical wholesalers confirmed that the pharmacy had received 1399.8 litres over six years and 160.2 litres in a mere five months—a significant figure compared to the typical monthly volume for cough-related conditions. A bottle typically lasts ten days under standard dosing guidance.

By failing to consult with prescribers, ignoring patterns of misuse, and neglecting professional duties, the registrant’s conduct fell well below the expected standards. The Committee described his actions as “totally irresponsible” and “a total disregard for patient safety.”

GPhC Determination on Impairment
The GPhC Fitness to Practise Committee found that the registrant’s fitness to practise was impaired due to misconduct. While he expressed some remorse and had ceased codeine linctus sales following the inspection, the Committee noted a concerning lack of full insight or proactive remediation. He had not undertaken any targeted continuing professional development (CPD) or training, nor had he produced any documentation demonstrating steps toward understanding or preventing future misconduct.

The Committee cited the risk of recurrence, the potential for significant patient harm, and a need to protect public confidence in pharmacy practice. They determined that the registrant had failed to uphold key tenets of the profession, particularly the responsibility to act in the best interest of patients, even in challenging circumstances such as high-addiction localities.

Sanction
The Committee imposed a 12-month suspension, citing the need to protect the public and uphold professional standards. While they considered removal from the register, they decided to give the registrant an opportunity for rehabilitation due to his unblemished prior record and long career.

Nonetheless, they emphasised that any return to practice would require demonstrable remediation and insight, including:

• Written reflections on his misconduct and its impact.
• Testimonials and character references.
• CPD evidence related to the sale of P medicines and addiction risk.

The suspension, described as the maximum permissible under the order, was deemed appropriate given the seriousness of the misconduct and its duration. A review was scheduled prior to the end of the suspension to assess whether the registrant had taken meaningful steps to remediate.

Key Learning Points for Pharmacy Professionals

1. Understanding Licensed Use of P Medicines: Codeine linctus should only be supplied for short-term use in treating dry coughs. Pharmacists must evaluate whether requests align with licensed indications.
2. Recognition of Addiction Risk: Even P medicines can have significant potential for abuse. Pharmacists are gatekeepers and must be vigilant, especially in areas with known addiction prevalence.
3. Documentation and Consultation: While recording sales of P medicines isn’t mandatory, it becomes crucial when repeated requests arise. Failure to consult prescribers or document justifications is a serious oversight.
4. Responsibility Cannot Be Delegated: Blaming staff or environmental pressures is not a defence. A superintendent pharmacist holds ultimate accountability.
5. Insight and CPD Are Vital: Remediation is not simply acknowledging wrongdoing—it requires demonstrable action to address the underlying knowledge or behavioural gaps.

“The Registrant clearly put patients at risk of harm, brought the pharmacy profession into disrepute by his actions, and breached a fundamental tenet of the profession, namely to put patient safety first.”

This case underscores the imperative that pharmacists must continually reflect on their practice, especially when supplying medicines with abuse potential. Even well-intentioned efforts to meet local needs must be balanced with the ethical duty to safeguard public health.

Original Case Document

The full determination transcript is available to logged in users.

Log in or Register for free to access.