Two Customers, One Counter, a Suspected Diversion
It is a busy evening at a pharmacy in Kabul. A man presents a prescription for a strong opioid (morphine tablets) written by an oncologist for his elderly mother, who has terminal cancer. The prescription is valid, correctly completed, and within the lawful quantity. While you are processing it, a second customer - a young man you recognise as having bought large quantities of a cough syrup containing codeine three times in the past two weeks - asks for 'the same again, no prescription, my uncle needs it'. He becomes agitated when you hesitate and offers to pay double. The pharmacist is briefly away from the counter. Your stock of the opioid is low and the wholesaler cannot deliver for four days.
1. How do you handle the second customer's request, and what legal and ethical principles apply?
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Refuse the sale. A codeine-containing cough preparation supplied without a valid prescription, and in repeated large quantities, is exactly the pattern of abuse and diversion that pharmacy law and professional codes exist to prevent. The offer of double payment is a bribe and must be declined and, if the behaviour continues, reported to the pharmacist in charge. Principles at stake:
- Legality: controlled or prescription-only medicines may only be supplied against a valid prescription; supplying otherwise is a criminal offence and would put your registration at risk.
- Non-maleficence and public safety: codeine is an opioid; repeated large-volume use carries dependence, respiratory depression, and overdose risk. You have a duty to protect the patient and the public, not just to satisfy a request.
- Professional integrity: financial inducement must never influence a supply decision.
- Duty to act on suspicion: document the incident (date, time, description, request, refusal) and inform the pharmacist, who may need to notify the relevant authority under the national controlled-substances reporting framework. Be calm and non-confrontational; do not accuse, but do not negotiate. If the person threatens staff, follow the pharmacy's security procedure.
2. The opioid prescription is valid but your stock will not last four days. What are your options, ranked, and what must you NOT do?
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Ranked options:
- Partial supply with a legal record. Dispense the quantity you have, record the partial supply on the prescription and in the controlled-drugs register, tell the patient/carer exactly how many days it covers, and arrange the balance when stock arrives. Check local rules on whether a partial supply of a controlled drug requires prescriber or authority notification.
- Source from another pharmacy. Contact a nearby pharmacy with stock and arrange a lawful transfer, with the required documentation and, where applicable, a prescription or transfer record.
- Urgent wholesaler/emergency order. Ask the wholesaler for an emergency or direct delivery, or contact the regional medical store.
- Contact the prescriber to discuss alternatives (a different strength or formulation that is in stock, or a short bridging prescription) if supply truly cannot be met. Must NOT do: borrow, lend, or 'loan' controlled drugs between patients; alter the quantity on the prescription; substitute a different opioid or strength without prescriber authorisation; dispense from an unrecorded source; or leave the patient with no supply and no plan. The elderly patient's pain control is the priority - an interruption in opioid supply causes real suffering and withdrawal, so act the same day, not 'when stock comes in'.