The Misuse of Drugs Regulations 2001 provide a legal framework which dentists rely upon when prescribing patients with and managing controlled drugs.[1] The act gives healthcare professionals the ability to possess, produce, supply and administer some drugs that would otherwise prompt prosecution under the Misuse of Drugs Act 1971.[2]
Dental professionals should be aware of their responsibilities when supporting patients with these pharmaceutical products. This includes aspects of the General Dental Council’s ‘Standards for the Dental Team’, which requires clinicians to provide patients with treatment that is in their best interests,[3] including the provision of controlled drugs exclusively when they are deemed necessary.
Clinicians must be knowledgeable about when these medications should be utilised. They should also recognise how to dispose of them safely and in line with waste workflows, to protect clinicians, patients and the wider world. This is just as important as the initial use of these products.
Current clinical uses of controlled drugs
The Misuse of Drugs Regulations 2001 feature multiple schedules, the first five detailing seemingly endless lists of controlled drugs and the regulations to which they are subject. Dentists can prescribe select products to some patients on an NHS prescription form. This includes temazepam tablets and oral solution, from Schedule 3; diazepam tablets and oral solution, from Schedule 4; and dihydrocodeine tablets, from Schedule 5.1 In addition, clinicians can provide midazolam, a Schedule 3 controlled drug, but an FP10D prescription is not required as it is not for use outside of the practice.1
Three of these (temazepam, diazepam and midazolam) fall under the umbrella group of benzodiazepines. These are used to reduce anxiety over a short period, making them ideal for nervous patients. Individuals may be advised to take the drug at home or in the practice.[4] Clinicians should ensure patients are aware of all possible side effects, including increased anxiety, drowsiness and headaches, as well as trouble thinking clearly or making judgements in the ensuing 24 hours.4
Dihydrocodeine is an example of an opioid, used for pain relief. Its use in NHS dentistry is poles apart from the wider prescription of opioids worldwide, especially in the United States. In 2016, dentists in England only prescribed dihydrocodeine from the opioid group, in a total of 0.6% of dental prescriptions. In the United States, the rate of opioid referral (including other solutions such as hydrocodone, codeine and oxycodone) was 37 times greater, at 22.3% of US dental prescriptions.[5] This suggests a vastly different relationship with these medications amongst the two clinical populations and offers insights into the extent to which current legislation in the UK limits the prescription of controlled drugs.
Each medication mentioned can be dangerous in the wrong quantities and the hands of an unsuitable patient. In the outside environment, they can be threatening to wildlife too. For these reasons, clinicians must keep controlled drugs appropriately (whilst midazolam does not need to be kept in a controlled drug cabinet, temazepam does, for example), and dispose of them correctly.
Denaturing processes
Denaturing processesAll Schedule 2, 3 and 4 (part 1) controlled substances mentioned in the Misuse of Drugs Regulations 2001 must be denatured or rendered irretrievable before disposal.1
Dental practices that store controlled drugs and expect needing to denature them – for example, when they have expired, or been partly used – must be covered by the Environment Agency exemption “Waste exemption: T28 sort and denature controlled drugs for disposal”.1 If practices or groups are set up across multiple locations, then a separate T28 exemption is needed for each site.1
This waste can be stored in the practice for up to six months, and clinicians should organise collection by a specialist waste management service.[6] Denatured pharmaceuticals, once unrecognisable as a drug, should be stored ready for disposal in a blue-lidded pharmaceutical container as per the Health Technical Memorandum 07-01 waste colour code.[7] The blue waste stream is dedicated to medicinal waste, and as it can present chemical and environmental hazards it must be taken for incineration.
Initial Medical provides clinicians with safe and regulatory-compliant Controlled Drug Denaturing Kits. These are available in different sizes and are simple to implement in your practice, alongside pharmaceutical waste bins, like those in the small Eco Pharmi bin range. These are manufactured from 100% recycled plastic for environmentally-friendly impacts, or their new paper based Bio-bin range maximise safety against controlled drug waste within the dental practice.
The prescription, storage and disposal of controlled drugs must be managed safely to support patient populations and the wider environment. This requires clinicians to regularly review the regulations that impact their practice, and recognise how current workflows may be optimised to improve everyday care.
To find out more, get in touch at 0808 304 7411 or visit the website today www.initial.co.uk/medical
Author: Rebecca Waters
Rebecca has worked in the healthcare sector for the past 20 years and earned a BSc Chemistry (Hons) prior to joining Rentokil Initial in 2003. She works within the Research and Development team and keeps up-to-date on all changes within the clinical waste management industry, as well as the specialist hygiene and infection control industries, and is an active member of the CIWM and HWMA. Following roles as an Analytical Chemist and Hygiene Chemist, she has worked in a variety of leading marketing roles since 2006, making her an expert within the industry. She is a Fellow at the Chartered Institute of Marketing, an FCIM. Rebecca loves spending time outdoors and in the water – whether walking, camping, or swimming – and completed a focus on environmental studies during her university degree. She is proud to be pushing a sustainability agenda throughout her work.
About Initial Medical
Initial Medical set the standard in healthcare and infectious waste management in the UK, providing a reliable, effective and fully compliant service built around customer needs and delivered by our highly trained local teams. We are ISO 9001:2015 accredited, with technology fully integrated into our operations, providing full traceability of service delivery, electronic waste documentation and the best customer experience possible. We also offer innovative healthcare waste management services and infection control products, to help break the chain of transmission and prevent cross contamination.
Initial Medical are a company with a ‘World Class’ Health and Safety record, and ISO 45001:2018 accreditation. We are also accredited to ISO 14001:2015 environmental standards and pride ourselves on our sustainable approach with a focus on delivering eco-friendly products and operational solutions.
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[1] UK Medicines Information pharmacists for NHS healthcare professionals, (2016). How should dentists prescribe, store, order and dispose of controlled drugs? (Online) Available at: https://www.sps.nhs.uk/wp-content/uploads/2016/06/NW-QA178.4-Controlled-drugs-for-dentists-1-1.pdf [Accessed January 2025]
[2] Gallagher, C. T. (2022). The Misuse of Drugs Regulations 2001: A case study in poor legislative drafting. Drug Science, Policy and Law, 8, 20503245221112582.
[3] General Dental Council, (2019). Standards for the Dental Team, (Online). Available at: https://www.gdc-uk.org/standards-guidance/standards-and-guidance/standards-for-the-dental-team [Accessed January 2025]
[4] NHS Sussex Community NHS Foundation Trust, (N.D.). Dental treatment with an oral sedative. (Online) Available at: https://www.sussexcommunity.nhs.uk/patients-and-visitors/resources/patient-resources/dental-treatment-with-an-oral-sedative [Accessed January 2025]
[5] Suda, K. J., Durkin, M. J., Calip, G. S., Gellad, W. F., Kim, H., Lockhart, P. B., … & Thornhill, M. H. (2019). Comparison of opioid prescribing by dentists in the United States and England. JAMA network open, 2(5), e194303-e194303.
[6] Environment Agency, (2014). T28 waste exemption: sort and denature controlled drugs for disposal. (Online) Available at: https://www.gov.uk/guidance/waste-exemption-t28-sort-and-denature-controlled-drugs-for-disposal [Accessed January 2025]
[7] NHS England, (2022). Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste. (Online) Available at: https://www.england.nhs.uk/wp-content/uploads/2021/05/B2159iii-health-technical-memorandum-07-01.pdf [Accessed January 2025]
