Recurring concern
Inadequate safeguards against misuse of medicines with abuse potential
Pin
Get email alerts
Request correctionFirst reported 8 May 2018•Latest report 4 Dec 2025
What this concern includes
Includes prescribing, repeat-prescribing, replacement-prescription, monitoring, review or escalation controls specifically intended to identify and manage misuse or abuse risks for medicines with abuse potential, including where a patient's substance-use history is relevant.
Not included
- Excludes ordinary prescribing errors, dose or formulation mistakes and drug interactions where misuse or abuse risk is not the identified unsafe condition.
- Excludes excessive medication quantities unless the report specifically links them to controlling misuse or abuse risk rather than quantity governance alone.
- Excludes physical medication-security failures involving storage or unauthorised access where prescribing or clinical misuse-risk controls are not deficient.
- Excludes generic incident investigation, documentation or governance failures unless they directly concern management of misuse or abuse risk for a medicine.
- Reports
- 14
- Individual concerns
- 17
- Date range
- 2018–2025
- Stated actions
- 44
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
-
Concerns raised1
Failure of the primary care prescribing regime to identify potential addiction and drug-seeking behaviour
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Review existing guidance on recording drug-seeking behaviour in clinical records and sharing flags through the Summary Care Record.
Stated by NHS South Yorkshire Integrated Care Board -
Action
Circulate the reviewed drug-seeking-behaviour guidance to practices through bulletins and the website.
Stated by NHS South Yorkshire Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Review of 2022–2025 prescribing data found no outlying opioid-prescribing concerns at the relevant practices.
Stated by NHS South Yorkshire Integrated Care Board
-
Concerns raised1
Lack of medication review controls for repeat prescriptions to vulnerable patients with histories of addiction, self-harm, suicidal ideation or prescription medication overdose
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Audit all registered patients coded at risk of self-harm or suicide and receiving repeat medication, complete medication and risk reviews, and restrict repeats to seven-day supplies.
Stated by Addison House & Barbara Castle Surgery -
Action
Update the Polypharmacy and High-Risk Prescribing Policy to require pharmacist review of relevant correspondence, seven-day high-risk medication supplies, and three-monthly or earlier reviews for high-risk patients.
Stated by Addison House & Barbara Castle Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The practice disputes that no safety controls existed, stating its repeat prescribing policy already contained restrictions for inappropriate high-risk medication requests.
Stated by Addison House & Barbara Castle Surgery
-
Concerns raised1
Lack of specific policies or procedures to flag or review fentanyl abuse
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
Action
Amend incoming-correspondence handling so administrative staff identify controlled-drug prescriptions and ensure prompt GP review without routing letters to absent GPs.
Stated by The Partners of the Brinnington Surgery -
Action
Create and implement a workflow map linking incoming correspondence types to relevant protocols and controlled-drug GP-review requirements.
Stated by The Partners of the Brinnington Surgery -
Action
Develop a prescribing protocol containing a specific policy on controlled-drug misuse.
Stated by The Partners of the Brinnington Surgery
-
Action
Develop an EMIS alert to support prescriber adherence to the new prescribing system.
Stated by The Partners of the Brinnington Surgery
-
Concerns raised2
Failure to monitor patients with former opioid addiction prescribed opioid painkillers
Failure to consider the risks of prescribing opioids to patients with former opioid addiction
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
Action
Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
Stated by Royal College of General Practitioners
-
Action
Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
Stated by Royal College of General Practitioners
-
Concerns raised1
Unavailability of practice warning flags at the three-month stage of morphine prescribing
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to monitor Pregabalin for signs of abuse
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Introduce three-monthly face-to-face reviews for patients prescribed dependence-inducing medicines, including Pregabalin, gabapentin, benzodiazepines and oxycodone.
Stated by Limehouse Practice -
Action
Review identified patients’ medication and discuss with RESET whether it should prescribe their opiate substitute and other dependence-potential medicines.
Stated by Limehouse Practice
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
There had been no previous early requests or concerns about Pregabalin misuse before the mistaken early-request concern arose.
Stated by Limehouse Practice
-
Concerns raised1
Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
-
Action
Recruit two clinical pharmacists to support patient medication reviews.
Stated by Alvaston Medical Centre -
Action
Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.
Stated by Alvaston Medical Centre -
Action
Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.
Stated by Alvaston Medical Centre
-
Action
Prevent prescriptions from being ordered automatically too far in advance of their due dates.
Stated by Alvaston Medical Centre -
Action
Continue assessing medications and prescribing areas that would benefit from additional surveillance.
Stated by Alvaston Medical Centre
-
Concerns raised2
Failure to adequately challenge additional replacement prescriptions
Failure to account for addiction, self-harm and poor substance use when prescribing medication
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Action
Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing prescribing guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.
Stated by NHS Greater Manchester Integrated Care Board
-
Concerns raised1
Failure to scrutinise repeat prescription requests
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026