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CQC calls for better labelling of liquid opioids

Ensure labels support appropriate dosing

July 20th 2021

Tagged: Dispensary guidance news CQC

By Ailsa Colquhoun

Better dispensing labelling for liquid opioids is highlighted in the CQC’s latest guidance on the safer management of controlled drugs.

The annual update for 2020 highlights that liquid formulations can be easy to ingest in large quantities, resulting in both intentional and accidental overdose.

The guidance asks prescribers and dispensers of opioid liquids to prioritise clear instructions for dosage and securely attached dispensing labels that can be referenced by patients as needed.

The update finds that during 2020, NHS primary care services prescribed a total of 74.2 million controlled drug items, which was an increase of 6 per cent compared with 2019. The cost of this was £565,908,615, an increase of 9% compared with the previous year.

This larger than usual volume increase is attributed to the rescheduling of the gabapentinoids to Schedule 3 controlled drugs during 2019. The following are the overall prescribing trends of controlled drugs compared with 2019:

  • Schedule 2: up by 2%

    (9,149,292 total items in 2020)


  • Schedule 3: up by 19%

    (25,650,246 total items in 2020)


  • Schedule 4: down by 2%

    (13,734,624 total items in 2020)


  • Schedule 5: down slightly by less than 0.5%

    (25,704,139 total items in 2020)

Generally, the Safer Management of Controlled Drugs annual update makes four recommendations for healthcare teams:

  • The need to include controlled drugs governance as part of COVID-19 recovery plans, particularly around any changes that were necessary while responding to the pandemic
  • Health and care staff to take part in activities that support reflection and learning – with a focus on sharing their experience and innovation to drive improvement
  • Health and care leaders to reduce risks associated with controlled drugs. For example, understanding and mitigating risk when people move between services
  • Care involving controlled drugs meets individual patients’ needs safely.