Script for audio: Pseudoephedrine and ephedrine Audiovisual training for pharmacy support staff The aim of this presentation is to provide you with information about the changes that are taking place to the sale of products containing pseudoephedrine and ephedrine and how they will affect you and your pharmacy. 1
Objectives After completing this training you will: Know about the changes that are happening to the sale of pseudoephedrine and ephedrine and why these changes are necessary PAUSE FOR 2nd BULLET POINT TO FLY IN Understand what your role will be in the sale of products containing pseudoephedrine and ephedrine PAUSE FOR 3rd BULLET POINT TO FLY IN Know how to explain the changes to customers requesting to buy products containing pseudoephedrine and ephedrine Understand how to ask customers appropriate questions PAUSE FOR 5 th BULLET POINT TO FLY IN Know when to refer requests ests to the pharmacist 2
So, what is the problem with pseudoephedrine and ephedrine? As you will know from your previous training on medicines, pseudoephedrine and ephedrine are decongestants that are found in many different OTC products for coughs, colds and flu. These are safe and effective medicines for most people to relieve their cold or flu symptoms. PAUSE FOR 2 nd BULLET POINT TO FLY IN However, they can also be used in the manufacture of an illegal drug called methamphetamine in so called home labs. This drug is also known as crystal meth, ice, or meth. Methamphetamine is highly addictive and can cause serious, long term harm to people who use it. There are also risks to other people from making methamphetamine in home labs because of the production of highly poisonous gases that can cause fires or explosions or breathing difficulties. The poisonous waste products can also affect the long term health of people living in the surrounding area where the lab is situated, as well as that of police, fire or ambulance crews who may be called to any incidents. 3
So, how big is the problem of methamphetamine use? The use of methamphetamine is currently quite low in the UK. It is relatively easy to make at home from pseudoephedrine or ephedrine and there are many recipes on the web. Meth is easiest to make from solid dose preparations containing only pseudoephedrine or ephedrine although meth cooks can use multi-ingredient preparations and liquids if they cannot get hold of the tablets. The police are concerned that people may start to buy pseudoephedrine or ephedrine in pharmacies to make methamphetamine at home or in small labs. Misusers might buy small quantities from many different pharmacies, which is known as smurfing, or larger quantities from one pharmacy. PAUSE FOR 2 nd BULLET POINT TO FLY IN In other countries like the United States, New Zealand and Australia it is now one of the most commonly used drugs of abuse. There is already a major problem with the manufacture of methamphetamine in home labs using pseudoephedrine or ephedrine obtained from cold and flu products. Methamphetamine is not only harmful to users health but has a devastating impact on their lives. It can have effects on the heart and digestive system, as well as causing extreme weight loss. Users often get a sensation of insects or snakes crawling on their skin, which causes itching and scratching leading to skin infections. Long term use can affect the users mental health, causing hallucinations and paranoia that are similar to those experienced in paranoid schizophrenia. This can lead to aggressive, violent and unpredictable behaviour. These effects obviously make it hard for users to carry on with normal work and family lives. This is why it is so important that we act now to ensure this doesn t happen in the UK 4
What are the changes that are happening to the sale of pseudoephedrine and ephedrine products? PAUSE FOR 1st BULLET POINT TO FLY IN It is important that we are able to monitor and control the sales of pseudoephedrine and ephedrine containing products in pharmacies, to make sure that the risk of people buying them to make meth is contained. PAUSE FOR 2nd BULLET POINT TO FLY IN The MHRA (Medicines & Healthcare products Regulatory Agency the Government agency in control of all medicines) has decided that tighter controls on the sale and supply of products containing pseudoephedrine will take effect from 1 April 2008. PAUSE FOR 3rd BULLET POINT TO FLY IN Firstly, the pack size of Pseudoephedrine will be limited to 720mg, that s 12 x 60mg pseudoephedrine tablets. For ephedrine the pack size will be limited to 180mg. Larger packs of pseudoephedrine and ephedrine tablets will become Prescription Only Medicines. PAUSE FOR 4th BULLET POINT TO FLY IN Sales of products containing containing pseudoephedrine will be limited to a maximum of 720mg to a person at any one time. Sales of ephedrine will be limited to a maximum of 180mg to a person at any one time. The NPA recommends that pharmacy support staff use a rule of thumb that only one pack containing either pseudoephedrine or ephedrine can be sold or supplied to any one person at any one time. PAUSE FOR 5th BULLET POINT TO FLY IN You may not supply a product containing pseudoephedrine at the same time as a product containing ephedrine to any one person - regardless of pack size. PAUSE FOR 6th BULLET POINT TO FLY IN The CHM has made it clear that if there is any evidence that pharmacists and their staff are not monitoring and controlling sales adequately, these products will be switched to POM. 5
Let s now look at pseudoephedrine and ephedrine products in your pharmacy. Which products containing pseudoephedrine or ephedrine do you stock? There are over 100 OTC products that contain pseudoephedrine and ephedrine, including many common cold and flu remedies although your pharmacy will probably not stock them all. PAUSE FOR 2 nd BULLET POINT TO FLY IN It s now time for an activity. Before going on to the next page, take 5 minutes to go and look at your OTC products and write down the 5 most popular ones containing pseudoephedrine or ephedrine that you sell. PAUSE FOR 3rd BULLET POINT TO FLY IN You and your colleagues will also need to think about where products containing pseudoephedrine or ephedrine will now be kept can customers pick them up themselves? If so, this will have to be changed immediately. Another activity. Either before the next slide or when you ve completed the training, discuss with your pharmacist and colleagues where the best place will be to keep pseudoephedrine and ephedrine products both those on sale in the pharmacy and any additional overstock you have in the store room. You could perhaps think about a way of flagging up these products to remind you of new restrictions - maybe by using stickers or shelf edge labels. Remember, the products most likely to be targeted by amateur meth cooks are tablets containing pseudoephedrine / ephedrine only. 6
What will your role be in the sales of pseudoephedrine and ephedrine containing products? As you spend part or all of your time working on the medicine counter, you are likely to be involved with the majority of the OTC sales of these products. PAUSE FOR 2 nd BULLET POINT TO FLY IN Therefore, you need to ensure that these products are only supplied to those customers with a genuine need, that is they need them to treat cough, cold or flu symptoms. You will be able to do this by using appropriate questions, like 2WHAM. As sales restrictions are put into place your customers will notice a difference when they ask for medicines containing pseudoephedrine or ephedrine. You will need to explain to them about the changes and why you have to ask so many questions. Your role will also involve recognising requests that are not genuine and we will be coming on to this later. 7
How should you deal with requests from customers for products that contain pseudoephedrine or ephedrine? You need to remember that the majority of people will want these products to use as they are meant to be used to treat their cold and flu symptoms. PAUSE FOR 2 nd BULLET POINT TO FLY IN You can use the 2WHAM questions as usual to identify whether the product is appropriate for the customer and their symptoms. Remember that the customer may be buying the product for someone else, or requesting a product to keep in their medicine cabinet for future use. You will need to explain the reasons if customers ask why they are being asked so many questions. Try and put customers at ease so that they don t feel as though they re being interrogated. Tell customers that there are new restrictions to the sale of these products because they can be used in the manufacture of illegal drugs. Most customers will probably appreciate why you have to be so vigilant. You can reassure them that there is no threat to their health from using medicines containing pseudoephedrine or ephedrine. As with all over the counter medicines, they are safe and effective e when used according to the instructions in the patient information leaflet and on the pack. 8
If customers ask you why they are being asked questions, or don t understand why they can only buy one pack, you can use the following phrases to help explain the changes. You don t have to use these you may be able to come up with some of your own. Remember it is important to get customers acceptance; make them feel that they are co-operating in the fight against illegal drugs. I m Im sorry I have to ask you lots of questions, but there are now tighter controls on the sale of these products because some people can misuse them. PAUSE FOR 2 nd BULLET POINT TO FLY IN Pseudoephedrine (the decongestant in this product, which helps to relieve nasal congestion) has been used in the manufacture of illegal drugs this is why the pack size has been reduced and we now only sell one pack at a time.. If customers have to be referred, you could say you need to check with the pharmacist that the product is right for their symptoms. Remember to be polite, even if you think the customer is not genuine. 9
How will you be able to recognise requests that t are not genuine? Misusers of pseudoephedrine or ephedrine will try to look and act like genuine customers, so you will need to look for clues! The people buying pseudoephedrine and ephedrine products to manufacture methamphetamine are probably not users themselves, so will not look like typical methamphetamine addicts. In fact, in the US, Australia and New Zealand, the so-called pseudrunners have tended to be well dressed business people. PAUSE FOR 2 nd BULLET POINT TO FLY IN If they are requesting the product for themselves, do they look or sound as though they need a treatment for cough, cold or flu symptoms? Do they sound blocked up, have a red runny nose, etc.? Remember that they may be requesting the product for someone else, so are they able to describe what symptoms the person has? What does their body language tell you? They may be aggressive in their manner and stance or they may speak quietly. Do they seem nervous or on edge? They may not be able to look you in the eye or be comfortable about answering your questions. Are they asking for a product by name or one that only contains pseudoephedrine or ephedrine? It is easier to make methamphetamine from tablets containing only pseudoephedrine or ephedrine, so misusers will try to obtain these if possible. They will only purchase liquid or capsules if the tablets t are not available. PAUSE FOR 5 th BULLET POINT TO FLY IN Are they asking for more than one pack of the same product containing pseudoephedrine or ephedrine? Or they may request more than one pack of different products. Try to be aware of the same customers requesting products on a regular basis. PAUSE FOR 6 th BULLET POINT TO FLY IN Remember that if anything at all makes you suspicious, then you should refer to the pharmacist. 10
So how will you deal with requests for pseudoephedrine or ephedrine products in your pharmacy? Before moving on to the next slide, try the following activity: think about the types of questions that you will use when customers request pseudoephedrine or ephedrine products in your pharmacy. You can do this on your own or with colleagues. Write down some example phrases that you could use. PAUSE FOR 2 nd BULLET POINT TO FLY IN Either before the next slide or after the presentation, discuss with your pharmacist exactly how requests are going to be dealt with in your pharmacy and if there is a procedure they want you to follow. For example, do they want to be alerted to all requests? How will this alter your Standard Operating Procedure or sales protocol for OTC medicines? You could also try doing some role play, where you and a colleague practise dealing with requests by acting out different scenarios. Some people feel uncomfortable about doing role play but once you get started you will probably relax, especially if there are only two of you doing it at once. It is a very good way of practising how you will deal with specific situations, and will make sure that if it happens for real you will not be flustered or panic. How will you deal with a customer who genuinely wants to buy two different products, for example a pseudoephedrine or ephedrine product for an adult and one for a child. What about those who request a pack for themselves and one for their partner? Discuss these scenarios with your pharmacist. 11
When will you refer to the pharmacist? PAUSE FOR 1 ST BULLET POINT As we ve mentioned, you may have a specific procedure to follow in your pharmacy, but in general you should refer customers to the pharmacist who: PAUSE FOR 2 nd BULLET POINT Are acting suspiciously is there anything about their manner or body language that doesn t seem quite right? Does everything add up when they are describing the symptoms? PAUSE FOR 3 rd BULLET POINT If they are requesting more than one pack of the same product or similar products containing pseudoephedrine or ephedrine PAUSE FOR 4 th BULLET POINT If they become aggressive when you explain that they can only have one pack of a pseudoephedrine or ephedrine product PAUSE FOR 5 th BULLET POINT If they are regularly requesting pseudoephedrine or ephedrine products. Are they coming in to the pharmacy once a week or more often? 12
Dealing with difficult customers Your pharmacist may have a specific way in which they wish you to deal with difficult customers, but the following provides some general guidance. You may get genuine customers who become upset or frustrated about being asked questions. PAUSE FOR 2 nd BULLET POINT TO FLY IN With these customers, keep calm and polite and try to explain the reasons for the changes and why they are so important. Remember that unless the problem of pseudoephedrine and ephedrine misuse is controlled then these products may be reclassified to POM status, which would mean customers having to visit their GPs to obtain a prescription and that would be less convenient than being asked a few questions. Remember it may be easier to try to get customer acceptance if they understand that they are doing their bit in the fight against illegal drugs. You may get customers who become aggressive or insistent, especially if you have to deal with non-genuine requests. In these situations, try to keep calm. PAUSE FOR 5 th BULLET POINT TO FLY IN Advise them that you will refer them to the pharmacist and then walk away from the medicine counter. PAUSE FOR 6 th BULLET POINT TO FLY IN Make sure that you check with your pharmacist about how they want you to deal with difficult customers so that you know what to do in these situations. 13
So, in summary, you now know that: t The sale of pseudoephedrine and ephedrine containing products is under stricter control PAUSE FOR 2 ND BULLET POINT TO FLY IN Pharmacy staff have an important role to play in dealing with requests for these products You are able to question customers carefully without interrogating them and know how to explain changes Sales of products containing pseudoephedrine or ephedrine are now limited to one pack per customer, unless there are specific circumstances PAUSE FOR 5 th BULLET POINT TO FLY IN Pack sizes will soon be limited to 720mg. That is a box of 12 pseudoephedrine 60mg tablets. PAUSE FOR 6 th BULLET POINT TO FLY IN You are able to recognise non-genuine requests PAUSE FOR 7 th BULLET POINT TO FLY IN You know when to refer to the pharmacist If you have any questions after completing this training, then please discuss them with your pharmacist. Remember that if you are at all unsure about dealing with requests for pseudoephedrine or ephedrine products you should discuss your concerns with your pharmacist and colleagues. 14