Pharmacists know it happens. Patients give prescribed medications to other people, usually people they know well: a sister about to go overseas – “have a few of my sleeping pills”; a friend who has run out of hypertension medication – “here, have a few of mine”; even a colleague who has a nasty infection – “why not try some of my leftover antibiotics”. Medicine-diversion or medicine-sharing can include drugs such as vapes, insulin, steroids, medicinal cannabis and ADHD medicines, those used in high-risk Opioid Dependence Treatment (ODT), as well as antibiotics and hypertension medicines of unequal dose and ingredients.
People share medicines for medical and non-medical reasons, with what they think are altruistic motives, and for profit. According to the 2022-23 National Drug Household Strategy Survey, about one in twenty people in Australia aged over 14 had taken a pharmaceutical for non-medical purposes in the previous 12 months, and about one in nine had similarly misused a pharmaceutical in their lifetime. 6
Pharmacists’ responsibilities in terms of responding to medicine-sharing can be complex, ranging from ensuring conformity with specific made-for-purpose regulations to investigating the illegal giving or selling of Schedule 8 diversion-risk medicines. Schedule 4 medicines such as codeine and sleeping tablets are also diverted for illicit use and can cause serious physical harm.
Sharing medicine for whatever reason can cause significant harm to others, including adverse reactions, misuse and interactions with other medications, says a spokesperson from the South Eastern Sydney Local Health District. The district encompasses the Albion Centre, an interdisciplinary health care facility with a primary focus on HIV management.
“If someone would like to access PrEP or have run out, we encourage them to visit their prescribing doctor or sexual health physician who will assess if it is safe and appropriate to prescribe the medication,” the spokesperson says. “When a patient requests PrEP, their doctor will confirm their HIV and other STI status, check their renal function is within a healthy range, and exclude the use of medications which interact with PrEP.”
Gary West MPS, senior professional officer at Pharmaceutical Defence Limited, says he suspects pharmacists rarely warn patients not to share medicines. He thinks this is mostly because in nearly all cases pharmacists assume consumers realise prescription medicines and doses are individualised for different patients, according to their illnesses, their age, their height and weight and their gender.
“Even though many people take the same medicines, they’re still individualised,” he says. “There’s still a clinical decision made by the doctor and considered by the pharmacist to make sure it is still appropriate medication.”
Pharmacists might suspect patients are sharing or diverting medicines if the medicine is being supplied at more frequent intervals than justified by the dose and the product, or if it’s consistently being supplied earlier than expected, West adds.
They should then initiate a conversation with the patient to elicit more details, he says, “to understand if that’s the case and why that might be the case”. He adds the pharmacist can then suggest solutions or alternatives: “If it’s been done for altruistic reasons, perhaps trying to assist that person to understand there might be other options available that wouldn’t be considered diversion.”
Records are vital, West says. If there is any risk of harm to a patient, or action against a pharmacist, the encounter should be documented on the patient profile and/or in an incident report in the pharmacy. The pharmacist should also consider approaching the prescriber if they feel there’s sufficient evidence to support their concerns.
Pharmacists can be investigated in cases where medicines are supplied outside therapeutic indications, he adds. A pharmacist may be asked to explain the considerations he or she gave to that situation, the actions taken and what the records are of that process.
“There are certain classes of medicines where diversion for concerning reasons, for illicit reasons or financial gain is more likely,” West says. “So the pain relievers, the sedatives, there can be an illicit market for them.”
Casual medicine sharing can lead to unfortunate and unexpected problems. The late Australian cricketer, Shane Warne, admitted he took a diuretic tablet (or two) provided by his mother, saying he took the tablets in order to look slimmer. Banned because it can mask steroid use, the drug was detected in Warne’s drug tests.
“[It was] to get rid of a double chin with a bit of banter from Mum,” he told Channel 9. “I said, ‘Look, I’m doing OK, I’m training very hard here.’ She says, ‘You’ve been burning the candle at both ends. Get rid of that double chin.’ And that fluid tablet, that’s what it does.” 7
In 2003 the banned medication led to Warne’s 12-month suspension from cricket.
A paper published last year in the British Journal of General Practice,
“Understanding non-recreational prescription medication-sharing behaviours: a systematic review”, 8 assessed 19 studies of medicine-sharing around the world. The paper’s findings “suggest medicine-sharing behaviour is common”, the authors wrote.
“Lifetime sharing ranged from 13 per cent to 78 per cent,” they found. “People shared medication with family members (87 per cent); friends only (26 per cent); neighbours only (63 per cent); friends and/or acquaintances (7 per cent); and colleagues (8 per cent).
“The most common motivation for sharing was avoidance of the cost associated with visiting a medical professional and/or obtaining prescription medication. This was followed by not wanting to visit a medical professional and to access medicines/medical services when needed.”
In Australia, medicine sharing can sometimes arise from cultural norms such as sharing within families, or it can be a response to an emergency – such as peer sharing of STD treatments. As both care providers and custodians of pharmaceutical regulation, pharmacists have to tread a fine line.
Bill Wallace MPS, professional support adviser at the Pharmaceutical Society of Australia, says high use of PBS medicines that does not correspond to the usage directions would “potentially be an alarm bell”.
Sometimes people fill a number of repeats at the same time, which could mean they are travelling but also could indicate improper and illicit medication usage.
“If people are potentially sending PBS medicine to their relatives overseas, that certainly is a problem,” Wallace says. “That does certainly happen: countries where they don’t have subsidised medicine, or good access to medicines. Sometimes it’s hard to pick up, depending on how they do it as well.”
Medicine-sharing in Australia is largely opaque as well. Wallace says pharmacists often only hear about the adverse consequences of medicine-sharing after there’s been a problem.
Patients usually understand there are rules against sharing, he adds. “They often won’t tell you if they’re doing something they suspect is not quite right,” he says. “If they’re giving people different medications, sometimes they can have adverse effects, and sometimes they end up in hospital.” The original illness then needs further care, he adds, because it hasn’t been treated properly.
Occasionally people are genuinely confused about their medication regimes, he says. “Sometimes it’ll be because they might have other conditions, such as Alzheimer’s or dementia that causes problems in that regard, and it can be inadvertent sharing,” he says. “If they’re on Webster packs and they’re not truly confident, they sometimes may mix those up as well.”
Pharmacists need to take care with patients they believe are sharing medications, Wallace says, noting that if family members on the same medication have run out for just a few days, pharmacists might be a little more lenient.
But he points out that emergency provisions such as continued dispensing can cater for those situations, and doctors can provide emergency authorisations.
“There are many mechanisms where it can be supplied under that person’s name without having to use someone else’s prescription,” he adds.
A pharmacist who is concerned about a particular patient’s prescription can gently ask for more information. “That’s where it’ll open that conversation, hopefully in a non-threatening way, rather than saying, ‘I’m not giving it to you, you don’t need it’,” Wallace says. “The more information you can tease out of the person before making a decision is always useful, because sometimes there are scenarios where you don’t have all the information.”