Recurring concern
Inadequate safeguards against misuse of medicines with abuse potential
- Reports that mention this concern
- 14
- Times this concern has been raised
- 17
- Stated actions linked to this concern
- 44
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 14 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- NHS South Yorkshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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NHS South Yorkshire Integrated Care Board
Review existing guidance on recording drug-seeking behaviour in clinical records and sharing flags through the Summary Care Record.
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NHS South Yorkshire Integrated Care Board
Circulate the reviewed drug-seeking-behaviour guidance to practices through bulletins and the website.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS South Yorkshire Integrated Care Board
Review of 2022–2025 prescribing data found no outlying opioid-prescribing concerns at the relevant practices.
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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
Linked response
- Addison House & Barbara Castle Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Addison House & Barbara Castle Surgery
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.
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Addison House & Barbara Castle Surgery
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Addison House & Barbara Castle Surgery
The practice disputes that no safety controls existed, stating its repeat prescribing policy already contained restrictions for inappropriate high-risk medication requests.
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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.
Linked response
- The Partners of the Brinnington Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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The Partners of the Brinnington Surgery
Amend incoming-correspondence handling so administrative staff identify controlled-drug prescriptions and ensure prompt GP review without routing letters to absent GPs.
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The Partners of the Brinnington Surgery
Create and implement a workflow map linking incoming correspondence types to relevant protocols and controlled-drug GP-review requirements.
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The Partners of the Brinnington Surgery
Develop a prescribing protocol containing a specific policy on controlled-drug misuse.
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The Partners of the Brinnington Surgery
Develop an EMIS alert to support prescriber adherence to the new prescribing system.
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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
Linked responses
- NHS Greater Manchester Integrated Care Board
- Royal College of General Practitioners
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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NHS Greater Manchester Integrated Care Board
Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
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NHS Greater Manchester Integrated Care Board
Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
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Royal College of General Practitioners
Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
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Royal College of General Practitioners
Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- Limehouse Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Limehouse Practice
Introduce three-monthly face-to-face reviews for patients prescribed dependence-inducing medicines, including Pregabalin, gabapentin, benzodiazepines and oxycodone.
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Limehouse Practice
Review identified patients’ medication and discuss with RESET whether it should prescribe their opiate substitute and other dependence-potential medicines.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Limehouse Practice
There had been no previous early requests or concerns about Pregabalin misuse before the mistaken early-request concern arose.
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Concerns raised1
Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
Linked response
- Alvaston Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Alvaston Medical Centre
Recruit two clinical pharmacists to support patient medication reviews.
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Alvaston Medical Centre
Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.
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Alvaston Medical Centre
Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.
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Alvaston Medical Centre
Prevent prescriptions from being ordered automatically too far in advance of their due dates.
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Alvaston Medical Centre
Continue assessing medications and prescribing areas that would benefit from additional surveillance.
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Concerns raised2
Failure to adequately challenge additional replacement prescriptions
Failure to account for addiction, self-harm and poor substance use when prescribing medication
Linked response
- NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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NHS Greater Manchester Integrated Care Board
Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.
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NHS Greater Manchester Integrated Care Board
Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS Greater Manchester Integrated Care Board
Existing prescribing guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026