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Controlled drugs

From 1 June 2015, physiotherapists who are annotated with the HCPC as independent prescribers will be able to prescribe from a limited list of seven controlled drugs. 

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CSP members can use this page to find all key information about the use of controlled drugs in advanced physiotherapy practice.

Why is an understanding of Controlled Drugs relevant to my physiotherapy practice?

All physiotherapists with relevant education, training and competence may advise on, or use, medicines in their practice. Prescribing in physiotherapy practice is an advanced practice activity that requires further post-registration qualification and annotation.

If you are a prescriber, you need to understand the differences in what you can prescribe using supplementary or independent prescribing frameworks. If you use medicines through a Patient Group Direction (PGD) you need to be clear which controlled drugs can be included in a PGD. Prescribing rights are not the same across all the prescribing professions and you must be clear what rights physiotherapists have. Some Schedule 5 controlled drugs are available to buy over-the-counter, others can be Pharmacy sale. Most controlled drugs are available to patients only on prescription and will have additional controls to ordinary POM medicines.

How are medicines regulated?

Three different pieces of law control the use of medicines in the UK and these laws overlap. Physiotherapists need to be aware of this because some medicines that they use in practice will be controlled by all three pieces of law.

The Human Medicines Regulations 2012 controls the use of all products defined as medicines and those professions which are authorised prescribers.

The Misuse of Drugs Act 1971 controls all substances, not just medicines, that are considered to be open to abuse and dangerous. These substances are collectively referred to as 'controlled drugs'.

The Misuse of Drugs Regulations 2001 categorises controlled drugs to ensure that patients who require controlled drugs for prescribed medical needs can have access to them under special prescribing controls known as 'scheduling'.

What is a controlled drug?

It is a substance that is regulated by both the Misuse of Drugs Act and The Misuse of Drugs Regulations because it is known to be particularly dangerous or open to abuse. Some medicines that physiotherapists prescribe and/or administer in their practice will be regulated as 'controlled drugs' and will have additional controls in place to monitor their use.

How are controlled drugs regulated?

The Home Office maintains the central list of UK controlled drugs and reviews this list periodically. Changes to the list can only be made after the Advisory Committee on the Misuse of Drugs (ACMD) has advised the Home Office that changes should be made and a full Public Consultation has taken place. Drugs can be 'up-classified' if stronger controls need to be in place, or can be down-classified if a substance has been shown to pose less of a safety risk to patients and the public. The re-classification of substances can affect how physiotherapists prescribe and/or administer controlled drugs, particularly if the drug is moved into a higher classification that has tighter controls on its use.

You must always consult the British National Formulary (BNF) or your local Pharmacist for current advice on the use of controlled drugs.

What do the 'classes' of controlled drugs refer to?

This is the grouping system used by the Misuse of Drugs Act to reflect how dangerous the substance is. Drugs are grouped into a 'Class' - either A, B or C according to their risk level, with Class A substances the most dangerous. The 'class' of a drug mainly affects the severity of the penalty for misuse of the drug, and it does not have a practical relevance in clinical practice, but is useful background information.

For example, this table shows the classes of some controlled drugs that physiotherapists may come across in their practice. IP indicates the drug is on the list of 7 controlled drugs for physio independent prescribing.

Class A Morphine (IP)
Morphine Salts
Fentanyl (IP)
Oxycodone (IP)
Any Class B substance that is administered by injection
Class B Codeine in all preparations
Dihydrocodeine (IP)
Class C Tramadol
Diazepam (IP)
Lorazepam (IP)
Temazepam (IP)

Why can the class of a controlled drug vary?

The route of administration of a controlled drug can affect how dangerous it may be, with intravenous routes regarded as more dangerous. The form of the preparation can also affect how easy it may be to extract the active ingredient, and therefore how easy it may be to abuse the substance. It is easier to extract active ingredients from liquids compared with solids. Therefore, all controlled drugs for injection are Class A, even if the product also exists in Class B or C as a tablet form.

What do the 'schedules' of controlled drugs refer to?

This is the grouping system used by the Misuse of Drugs Regulations to reflect the different restrictions that apply to the prescription and monitoring of controlled drugs used for medical purposes. Drugs are grouped into a 'Schedule' - either 1,2,3,4 or 5, with Schedule 1 having the tightest controls. For example, this table shows the schedules of some controlled drugs that physiotherapists may come across in their practice. IP indicates the drug is on the list of 7 controlled drugs for physio independent prescribing.

Schedule 1 Research drugs only No medical use
Schedule 2 Codeine (>100mg)
Dihydrocodeine (IP)
Co-codamol
Morphine (IP)
Morphine salts
Fentanyl (IP)
Oxycodone (IP)
Special measure in place:
- Special prescription
- Registers of use
- Safe custody arrangements
- 28 day prescribing only
Schedule 3 Tramadol
Temazepam (IP)
Special measure in place:
- Special prescription
- Safe custody arrangements for some drugs
- Invoice records
- 28 day prescribing only
Schedule 4 Diazepam (IP)
Lorazepam (IP)
Special measure in place:
- Invoice records
- 28 day prescribing only
Schedule 5 Codeine (<100mg)
Dihydrocodeine (IP)
Co-codamol eg 15/500 or 30/500
Morphine salts
Special measure in place:
- Invoice records

Why can the schedule of controlled drug vary?

As well as route of administration, the dose of the controlled drug can affect how potent it may be. All controlled drugs for administration by injection will have a Schedule 2 rating. The schedule rating of a drug depends, amongst other things, on the dose of the active ingredient. Of relevance to physiotherapists, controlled drugs containing morphine or codeine can be either Schedule 2 or Schedule 5 depending on their strength.

Classification of controlled drugs commonly used in physiotherapy practice

You should always check with the Home Office or you local pharmacist for the most up to date information on controlled drug classification. The following information was correct as of 21st May 2015:

  • Morphine : all morphine products are Class A regardless of route of administration. They will be Schedule 5 if the preparation contains not more than 0.2% morphine and the active morphine cannot be easily recovered from the preparation. All other preparations are Schedule 2.
  • Codeine : all codeine products are Class B. They will be Class A if the product is for injection. They will be Schedule 5 if the preparation contains not more than 100mg (or 2.5%) codeine per dose unit. All stronger preparations are Schedule 2.
  • Tramadol : Tramadol is Class C, Schedule 3 controlled drug.
  • Co-codamol : Co-codamol is a Class B controlled drug. Depending on the strength of dose prescribed, it will be either Schedule 2 or Schedule 5.

What is the impact of controlled drug classification, or reclassification, on physiotherapy practice?

The classification will affect how you can supply and administer and/or prescribe controlled drugs, or medicines containing controlled drugs in your clinical practice. An 'up-classification' of a product may mean you have to find an alternative prescribing mechanism, if you do not have the associated independent prescribing rights yourself.

For example, Tramadol was up-classified to a Class C- Schedule 3 controlled drug in June 2014, from a general Prescription Only Medicine. It is not on the list of 7 controlled drugs that physiotherapists can independently prescribe. It can no longer be supplied and administered under a PGD. Tramadol can only be prescribed by physiotherapists as part of a supplementary prescribing clinical management plan, or be administered by physiotherapists as part of a prescription by another professional with full CD prescribing rights.

For example, Codeine in is a Class B controlled drug. It is either Schedule 2 or Schedule 5 according to its strength. It is not on the list of 7 controlled drugs that physiotherapists can independently prescribe. Codeine products can only be prescribed by physiotherapists as part of a supplementary prescribing clinical management plan, or be administered by physiotherapists as part of a prescription by another professional with full CD prescribing rights. Schedule 5 codeine products can be supplied and administered by physiotherapists under a PGD.

What controlled drugs can independent prescriber physio's prescribe?

HCPC annotated physiotherapist independent prescribers can *only* prescribe the following 7 controlled drugs, by the routes listed:

  1. Morphine (oral and injectable)
  2. Fentanyl (transdermal)
  3. Oxycodone (oral )
  4. Dihydrocodeine (oral)
  5. Temazepam (oral)
  6. Diazepam (oral)
  7. Lorazepam (oral)

What controlled drugs can supplementary prescriber physio's prescribe?

HCPC annotated physiotherapist supplementary prescribers can prescribe any controlled drug, provided it is listed within the Clinical Management Plan agreed with a Doctor, before the prescribing activity occurs.

What controlled drugs can physio's supply and administer under a Patient Group Direction?

Schedule 4 and 5 controlled drugs only.

Can physiotherapists mix controlled drugs prior to administration to the patient?

No. There would need to be a specific provision in the Misuse of Drugs Regulations to enable mixing of controlled drugs by physiotherapists. Physiotherapists are only able to prescribe, and administer where appropriate, the limited list of CDs in isolation.

Further information

Please refer to the following websites:

Page updated: 22 May 2015

The CSP is pleased to acknowledge Mr Wing Tang MRPharmS GDL, senior professional support pharmacist of The Royal Pharmaceutical Society as an external reviewer of this page.

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