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CHAPTER5 Medicines andprescribing
Controlleddrugs
Misuse of Drugs Act (1971) Controls manufacture, supply, and pos-
session of controlled drugs (CDs). Penalties for oences are graded according to perceived harmfulness of the drug into three classes:
• Class A— e.g. cocaine, diamorphine (heroin), methadone, LSD, ecstasy
• Class B— e.g. oral amphetamines, barbiturates, cannabis, codeine
• ClassC— e.g. most benzodiazepines, tramadol and anabolic steroids
Misuse of Drugs Regulations (2001) Denes persons authorized to
supply and possess CDs while carrying out their professions and describes
the way this is to be done. Five schedules of drug are dened:
• Schedule 1 Drugs not used for medicinal purposes, e.g. LSD. Possession
and supply are prohibited except with special licence
• Schedule 2 Drugs subject to full CD controls (written dispensing record,
kept in locked container, CD prescription regulations), e.g. diamorphine,
cocaine, pethidine
• Schedule 3 Partial CD controls (as Schedule 2, but no need to keep
a register— some drugs subject to safe custody regulations), e.g.
barbiturates, temazepam, midazolam, tramadol, meprobamate,
buprenorphine
• Schedules 4 and 5 Most benzodiazepines, anabolic and androgenic
steroids, hCG, growth hormone, codeine. CD prescription
requirements do not apply nor do safe custody requirements
0 Controlled drugs are identied throughout the BNF by the box symbol
containing the letters CD (controlled drug) together with a number (i.e.
CD1 or CD4- 1). The number refers to the Schedule of the Misuse of Drugs
Regulations (2001) that the drug is classied within.
Controlled drugs register All healthcare professionals who hold per-
sonal stock of any Schedule 2 drugs must keep their own controlled drugs
register, and they are personally responsible for keeping this accurate and
up to date. Out- of- date drugs should be recorded and destroyed in the
presence of an authorized witness (police, PCO ocial).
Prescriber’s responsibilities If prescribing controlled drugs for medi-
cinal purposes, you have a responsibility:
• To avoid creating dependence by unnecessarily introducing controlled
drugs to patients— E p. 168 and E p. 183
• For careful monitoring to ensure the patient does not gradually i the
dose of drug to a point where dependence becomes more likely
• To avoid being an unwitting source of supply for addicts. If you suspect
an addict is going round surgeries with intent to obtain supplies, contact
your PCO so that they can issue a warning to other practices and/ or
the NHS Counter Fraud Authority. F 0800 0284060 M www.cfa.nhs.
uk/ reportfraud
Prescribing for drug misusers E p. 163
Notication of drug misusers E p. 163
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CONTROLLEDDRUGS
Writing prescriptions for CDs Any prescription for Schedule 2 and
3 controlled drugs (with the exception of temazepam) must contain the
following details written so as to be indelible:
• The patient’s full name, address, and age— if the patient is homeless, ‘no
xed abode’ is an acceptable address
• The patient’s NHS (in Scotland, Community Health Index) number
• Name and form of the drug, even if only one form exists
• Strength of the preparation and dose to be taken
• The total quantity of the preparation, or the number of dose units, to
be supplied in both words and gures, e.g. ‘Morphine sulfate 10mg (ten
milligram) tablets, one to be taken twice daily. Supply 60 (sixty) tablets,
total 600 (six hundred) milligrams’
• Signature of the prescriber (currently must be handwritten, although
electronic signatures for EPS prescriptions are likely to be approved
in the near future) and date. It is good practice to include the GMC
number of the prescriber as well
• The address of the prescriber
0 Apart from in exceptional circumstances, prescriptions for CDs in
Schedules 2, 3, and 4 should be limited to a supply of ≤30d treatment. The
validity period of NHS and private prescriptions for Schedules 1, 2, 3, and 4
CDs is restricted to 28d. Schedules 2 and 3 drugs should not be prescribed
on repeat prescriptions or under repeat dispensing schemes.
Travelling abroad with controlled drugs For patients or doc-
tors travelling abroad with Schedule 2 or 3 drugs, an export licence may
be required. Further details are available from M www.gov.uk/ travellingcontrolled- drugs. Patient applications to the Home Oce for an import/
export licence for a CD must be accompanied by a supporting letter from
the prescribing doctor stating the:
• Patient’s name and address
• Quantities of drugs to be carried
• Strength and form in which the drugs will be dispensed
• Country of destination
• Dates of travel to and from the UK
For clearance to import the drug into the country of destination, it is advisable to contact the Embassy or High Commission of that country prior
to departure
Further information
Advisory Council on the Misuse of Drugs M www.gov.uk/ government/
organisations/ advisory- council- on- the- misuse- of- drugs
BNF Controlled drugs and drug dependence. M https:// bnf.nice.org.uk/
guidance/ controlled- drugs- and- drug- dependence.html
Faculty of Pain Medicine Opioids aware:a resource for patients and
healthcare professionals to support prescribing of opioid medicines for
pain M https:// www.rcoa.ac.uk/ faculty- of- pain- medicine/ opioids- aware
NICE Controlled drugs:safe use and management M www.nice.org.uk/
guidance/ ng46
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CHAPTER5 Medicines andprescribing
Prescribing forspecialgroups
Borderline substances (BNF Appendix 2)For certain conditions, foods
and toilet products can be regarded as drugs and prescribed via NHS prescription (e.g. gluten- free foods for coeliac disease, nutritional supplements
for disease- related malnutrition). The Advisory Committee on Borderline
Substances advises on which products are available for certain specied conditions. Products should not be prescribed for any other condition. Use form
FP10 (GP10 in Scotland) and endorse with the letters ‘ACBS’.
Renalimpairment
Degree of renal impairment Estimated glomerular ltration rate (eGFR),
based on serum creatinine, age, gender, and ethnic origin, is now provided
to GPs when renal function tests are done.
• Mild renal impairment eGFR 60– 89mL/ min/ 1.73m
• Moderate renal impairment eGFR 30– 59mL/ min/ 1.73m
• Severe renal impairment eGFR <30mL/ min/ 1.73m
For some drugs (e.g. DOACs) dosage recommendations are based on calculation of creatinine clearance. This can be calculated as follows:
[(140 − age in years) × weight in kg] ÷ [72 × serum creatinine in mg/ dL]
Creatinine clearance can only be calculated if the creatinine level is stable.
For ♀, the result is multiplied by 0.85.
0 Renal function d with age but may not be reected by raised creatinine
due to d muscle mass. Always assume mild to moderate renal failure if prescribing for the elderly.
Drug eects ofimpaired renalfunction
• Inability to excrete the drug— may cause toxicity. Dose reduction or
increase in interval between doses may be necessary
• Increased sensitivity to drugs— even if elimination is unimpaired
• Poor tolerance of side eects— nephrotoxic drugs in particular may
have more serious side eects
• Lack of eectiveness when renal function is reduced
0 For patients on dialysis, consult your local renal unit if unsure.
Hepatic impairment Problems do not tend to arise until late stages of
liver failure when there is jaundice, ascites, or evidence of encephalopathy.
Problems are due to:
• Impaired drug metabolism— many drugs are metabolized by the liver. In
severe liver failure, dose may need to be d ± dosage interval i. Afew
drugs are excreted in the bile unchanged and may accumulate in patients
with obstructive jaundice (e.g. rifampicin, fusidic acid)
• Hypoproteinaemia— liver failure is associated with d plasma protein.
This aects binding of drugs. Highly protein- bound drugs (e.g.
phenytoin, prednisolone) can become toxic in normal dosage
• Hepatotoxicity— any liver toxicity of drugs (e.g. diclofenac) will have
ieect if hepatic reserve is already d
• Clotting— blood clotting factors are made in the liver. In liver disease,
eects of oral anticoagulants are i
• Encephalopathy— drugs that depress cerebral function (e.g.
benzodiazepines, opioids) can precipitate encephalopathy
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PRESCRIBING FORSPECIALGROUPS
• Fluid retention— drugs causing uid retention (e.g. NSAIDs) make
oedema and ascites worse
Palliative care E p. 1011 Drugs and sport E p. 475
Prescribing for the elderly E p. 194
Pregnancy E p. 764. Drugs taken by the mother can harm the fetus at
any stage in pregnancy. Mechanisms:
• 1st trimester— teratogenesis causing congenital malformations.
Greatest risk is from 3– 12wk gestation
• 2nd/ 3rd trimesters— toxic eects; eects on growth/ development
• Around labour— may aect labour or have adverse eects on the
newborn baby
Only prescribe if essential, especially in the 1st trimester. Stick to tried and
tested drugs when possible; use smallest eective dose; avoid new drugs.
0 Lack of information does not imply safety.
Breastfeeding Drugs taken by a breastfeeding mother can aect the
child by inhibiting lactation or entering the milk and causing toxicity to the
infant. Therapeutic doses in the mother can cause toxicity in the infant if
the drug is concentrated in milk (e.g. iodides). Avoid prescribing, wherever
possible and stick to tried and tested drugs.
Driving while taking drugs E p. 99
Prescribing forchildren Keep all medicines out of the
reach of children (and, preferably, in a locked cupboard).
Dispose of unwanted medicines by returning them to a
pharmacy for destruction.
• Children dier from adults in their response to drugs. Consult the BNF
for Children or before prescribing unfamiliar drugs. Always check doses
carefully. Many drugs commonly used for adults are not licensed for
use with children
• Paediatric suspensions may contain sugar. For long- term use or
children having frequent prescriptions, consider sugar- free versions
• Do not advise adding medicines to infant feeding bottles— they may
interact with milk and the dose will be d if not all contents are drunk
• Report serious adverse reactions and adverse reactions to new drugs
marked in the BNF for Children with a ▼ on Yellow Cards E p. 120.
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Furtherinformation
BNF M https:// bnf.nice.org.uk/ guidance/
• Prescribing in the elderly • Prescribing in hepatic impairment
• Prescribing in pregnancy • Prescribing in renal impairment
• Prescribing in palliative care • Prescribing in breastfeeding
• Prescribing in children • Drugs and sport
BNF for Children M https:// bnfc.nice.org.uk/
Electronic Medicines Compendium M www.medicines.org.uk
UK Teratology Information Service F 0344 892 0909 M www.uktis.org
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CHAPTER5 Medicines andprescribing
Non- drug interventions and
complementarymedicine
Across the world there has been a shift away from the traditional ‘pill- forevery- ill’ approach to medicine. Antibiotic resistance and frequent press
stories about adverse side eects of medication have led to patients seeking
alternative ways to manage their medical problems. In the UK, ~90% of
the population have tried complementary or alternative medicine (CAM) at
some time (Table 5.2). But, although CAM undoubtedly helps many individuals, its use remains controversial.
Reasons for caution Lack of:
• Evidence of eectiveness Although almost half of all clinical trials
examine the eectiveness of non- drug and complementary therapies,
unlike drug information, until recently access to independent
appraisals of eectiveness of these treatment has not been easily
accessible to GPs
• Regulation of practitioners Some practitioners oering non- drug
and/ or complementary treatments have professional registration
(e.g. physiotherapists, osteopaths, and chiropractors). However, at
present, anyone can set up as a practitioner of alternative medicine.
Therefore, it is important to stress to patients contemplating CAM
that they should nd a reputable practitioner with accredited training
who is a member of a recognized professional body and carries
professional indemnity insurance
• Regulation of products At present, most complementary ‘medicines’
are sold as foods rather than medicines and do not hold a product
licence. No licensing authority has assessed ecacy, safety, or
quality, and interactions with conventional medicines are unknown.
Complementary medicines can, and do, cause adverse eects— just
because they are ‘natural’ does not mean they are safe
Legal position of GPs practising CAM Conventionally trained
doctors can administer alternative treatments. The ‘Bolam test’ applies— in
other words, if a doctor has undergone appropriate training and practises in
a way that is reasonable and would be considered acceptable by a number
of other medically qualied complementary practitioners, his or her actions
are defensible.
Handbook for Non- drug Interventions (HANDI) Launched by
the Royal Australian College of GPs in 2015 to promote eective non- drug
treatments, making them visible and easy to use. HANDI is an online formulary of non- drug interventions for use in primary care, which have solid evidence of their eectiveness. Based on the idea of modern pharmacopoeias,
each HANDI entry includes indications, contraindications, side eects, and
‘dosing’. Some interventions require referral to other practitioners, e.g.
physiotherapists. Others (e.g. use of auto- ination for glue ear) can be
administered directly by GPs. The HANDI project is freely accessible via
M www.racgp.org.au/ handi
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NON-DRUG INTERVENTIONS AND COMPLEMENTARY MEDICINE
Table5.2 Commonly used complementary therapies
Therapy Features
Acupuncture Needles are used to alleviate symptoms or cure disease.
Homeopathy From the Greek, meaning ‘treatment of similars’. Works on the
Herbal
medicine
Dietary
manipulation
Osteopathy and
chiropractic
Hypnotherapy Consists of training the patient to relax very deeply— often with a
Mechanism of action remains unclear. Two broad forms:
• Traditional acupuncture Based on Chinese medicine where
health is a balance between ying and yang. Illness is imbalance,
and treatment aims to restore balance
• Modern acupuncture Uses modern anatomy and physiology
Evidence Mixed— good evidence for back pain, idiopathic headache,
and migraine; knee pain; and postoperative nausea/ vomiting
Variants Auriculotherapy; transcutaneous electrical nerve
stimulation (TENS); reexology
principle that like cures like. Aremedy is chosen that mimics
symptoms displayed by the patient. Most remedies are serially
diluted in steps of 1:10 (decimal x) or 1:100 (centesimal c).
Manufacture is controlled by the Medicines Act
Evidence With higher dilutions (>12c), a theoretical problem
arises as the solution may not contain any molecules of the
mother substance
Use of plants for medicinal purposes. Although many traditional
medicines were developed from herbal sources (e.g. digoxin,
morphine), herbal medicines use plant extracts and not isolated
constituents. All herbal medicines must be registered to be sold
in the UK
Evidence Trial evidence supports use of many herbal remedies,
including:saw palmetto (benign prostatic hyperplasia); echinacea
(common cold); St John’s wort (depression); feverfew (migraine)
Variants Aromatherapy is the use of concentrated aromatic
plant oils. Oils commonly used include:lavender (insomnia,
burns, blisters); tea tree (skin infection, head lice); peppermint
(indigestion); valerian (anxiety, insomnia)
Healing foods Are commonly used, e.g. cranberry juice for UTI;
soya to d menopausal symptoms; ginger to d nausea
Nutritional medicine Involves giving supplements of vitamins,
minerals, amino acids, or essential fatty acids. There is some
evidence of eectiveness, e.g. glucosamine for OA; calcium and
vitamin D supplements to d osteoporosis risk; vitamin B6 for PMT
Probiotics Orally administered microbial cell preparations. Some
evidence of eectiveness for prevent of diarrhoea for patients
taking antibiotics, and treatment of GI conditions
Environmental medicine Based on the premise that individuals
develop intolerances to environmental substances— most
commonly foods. Exclusion diets improve symptoms. May be
eective treatment for IBS and migraine. Most common culprits
are caeine, milk, gluten, and citrus fruit
Physical treatments aimed at restoring the alignment of joints
and improving functioning of the body. Already under statutory
regulation. Good evidence of eectiveness, particularly for back pain
focus, a scene, smell, touch sensation, or colour to aid this process.
Frequently used for smoking cessation. May be helpful for pain relief
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Chapter6
Minorsurgery
‘A minor operation:one performed on someone else’
Providing minor surgery 132
Basic techniques 134
Removal of skin lesions 136
Commonly performed injections 138
Penguin Dictionary of Humorous Quotations (2001)
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CHAPTER6 Minorsurgery
Providing minorsurgery
Minorsurgery Under the GMS contract, minor surgery can be provided
as an additional service or directed enhanced service. Arrangements for minor
surgery may be dierent for practices with other contractual arrangements.
Minor surgery asan additionalservice
• Includes curettage and cautery and, in relation to warts, verrucae, and
other skin lesions, cryocautery
• In all cases a record of consent of the patient to treatment and a record
of the procedure itself should be kept
• Payment is included within the global sum payment. If a practice does
not want to provide this service, it must ‘opt out’ and global sum
payment is d by 0.6%
Minor surgery asa directed enhanced service Extends the range of procedures beyond those practices are expected to do as an additional service. For
purposes of payment, procedures are divided into 3 groups:
• Injections— muscles, tendons, bursae, and joints
• Invasive procedures— including incisions and excisions
• Injections of varicose veins and piles
Payment Treatments are priced according to the complexity of the procedure, involvement of other sta, and use of specialized equipment. Terms
for this must be negotiated locally.
Qualication toprovide minorsurgery Practices can provide ex-
tended minor surgery (as a directed enhanced service or equivalent) if they
can demonstrate they have appropriate facilities and personnel (partner,
employee, or subcontractor) with the necessary skills. This includes:
• Adequate equipment
• Premises compliant with national guidelines as contained in ‘Health
Building Note 46:General Medical Practice Premises’ (DH)
• Nursing support
• Compliance with national infection control policies— sterile packs,
disposable sterile instruments, etc.
• Ongoing training for involved personnel in minor surgery, related skills,
and resuscitation techniques
• Regular audit and peer review to monitor clinical outcomes, rates of
infection, and procedure
Location andequipment A suitable room, adequate lighting, the ap-
propriate equipment, and sucient uninterrupted time is needed for successful minor surgery. An experienced assistant is also a great help. Sterile
instruments and gloves, and aseptic technique are essential.
• Basic minor surgery sets Usually contain a scalpel; several sizes of blade
(e.g. sizes 11 and 15); toothed forceps; needle holder; ne scissors;
artery forceps; skin hook; curette
• Additional equipment required Skin preparation liquid (e.g.
chlorhexidine); local anaesthetic (e.g. lidocaine 1%); suitable- sized
needles and syringes; sterile towels; swabs; sterile specimen pots; suture
materials and dressings for the wound. For joint injection, ensure that
you have steroid and local anaesthetic drawn up and suitably sized
needles available before starting
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PROVIDING MINORSURGERY
• Always make sure you know how many blades, sutures, needles, and
swabs you have, and ensure that you have accounted for and safely disposed of them at the end of the procedure.
Consent E p. 48. Patient consent for the procedure must be sought
and recorded in the notes. This involves giving enough information about
the procedure and other possible treatment options to allow the patient to
make an informed decision about whether to proceed; the patient and consenting doctor should then both sign the consent form and the form should
be led in the patient’s medical records.
Histologicalexamination All tissue removed by minor surgery should
be sent for histological examination unless there are exceptional or acceptable reasons for not doing so.
Documentation Maintain full, legible, accurate records. Include:
• History of the complaint
• Examination ndings
• Diagnosis
• Full details of the procedure undertaken— include dose, batch number,
expiry date and quantities of drugs, size and number of sutures
• Follow- up arrangements
If the patient is not registered with the practice undertaking the minor surgery, then a complete record of the procedure must be sent to the patient’s
registered practice for inclusion in the GP notes.
Follow- up andoutcome Should be recorded in the patient’s notes.
Advise the patient:
• What to expect after the procedure
• Precautions to take after the procedure
• When to return for suture removal
• Signs that would indicate the need for reconsultation
• About the expected recovery/ healing time
Arrange a follow- up appointment (e.g. with a practice nurse) for all but the
most straightforward procedures. Ensure that histology results are checked
and communicated to the patient.
Further information
Primary Care Dermatology Society Skin surgery guidelines. M www.pcds.
org.uk/ images/ downloads/ skin_ surgery_ guidelines.pdf
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