When patients seek advice about illicit substances, pharmacists must figure out how to balance harm reduction and safety with their duty to provide non-judgemental care.
What would you do if a patient asked whether an illegal substance might interfere with their regular medicines? For pharmacists, the response involves more than clinical knowledge.
A question many pharmacists may face
A young man walks into a community pharmacy and asks to speak privately with the pharmacist, Sofia.
Once in a consultation room, he asks whether it is safe to take MDMA in combination with sertraline.
Before responding, it’s essential that Sofia has a clear understanding of the clinical picture. MDMA and selective serotonin reuptake inhibitors (SSRIs) have an additive serotonergic effect, so a patient taking both is at significant risk of serotonin toxicity.
This condition is potentially life-threatening and is characterised by:
- agitation
- hyperthermia
- tachycardia
- tremor
- seizure or death (severe cases).
What else must be taken into account?
Despite these risks, the clinical concern is not the main issue Sofia needs to grapple with.
The primary ethical dilemma centres on avoiding the perception of endorsing illicit drug use while fulfilling the professional duty to protect patient safety – regardless of the choices they choose to make. If the patient feels judged, trust may be eroded, increasing the risk that they disengage from the healthcare system and experience preventable harm.
Then there are the legal responsibilities and professional obligations that must be adhered to, including supporting the safe, appropriate, judicious and efficacious use of medicines while recognising and respecting patients’ diversity, culture, gender, beliefs, values, characteristics and lived experience.
What are the options?
During her consultation with the patient, Sofia identifies three possible pathways.
The first option Sofia considers is to discuss the safe use of MDMA. This falls within pharmacists’ scope of practice, as pharmacists have both the clinical expertise and professional responsibility to provide evidence-based information about drug–drug interactions and their potential consequences.
Pharmacists can interpret and communicate information from clinical references such as the Australian Medicines Handbook to individual patients.
The second option Sofia considers is refusing to provide advice to the patient. Some pharmacists might consider this on the grounds that providing advice on recreational drug use falls outside their role, or that doing so could be perceived as endorsing illegal behaviour.
Thirdly, Sofia considers whether to refer the patient to the police, but this action has no sound ethical or legal basis.
What’s the right approach?
While not set in stone, addressing the safe use of MDMA with the patient is the preferred course of action. By taking a harm-reduction approach, Sofia can provide clear, evidence-based and non-judgmental information about the risk of serotonin syndrome when SSRIs and MDMA are combined.
This approach aligns with multiple principles in PSA’s revised Code of Ethics, released earlier this month:
- Care principle 1f: requiring pharmacists to act to prevent harm to the patient.
- Care principle 2a: requiring respect for patient dignity and autonomy.
- Care principle 2b: supporting shared decision-making.
- Care principle 2j: requiring pharmacists to create and maintain a safe, welcoming, respectful and inclusive environment.
Importantly, pharmacists should rest assured that offering advice about the safer use of a recreational substance is distinct from encouraging its use.
What are the next steps?
Having decided to practice harm reduction, Sofia should ensure the patient understands the specific signs and symptoms of serotonin syndrome, and knows when and how to seek emergency medical attention.
She should also take the opportunity to refer the patient to local alcohol and other drug (AOD) support services, providing pathways to specialist help without pressure or judgment.
Documentation of the interaction, including the clinical information provided and referrals made, is appropriate and protects both the patient and the pharmacist. The PSA’s GUIDE framework provides a structured approach for pharmacists to formulate ethical decisions and appropriately document them.
If Sofia is not already familiar with local AOD services, this patient encounter should serve as a prompt to develop that knowledge. Understanding local referral pathways and support options enables timely, person-centred responses when similar situations arise.
Unfamiliarity with ethical responsibilities can place pharmacists in hot water. Stay up to date with your professional obligations by exploring real-world ethical scenarios in PSA’s upcoming webinar, ‘The new Code of Ethics for Pharmacists’ on Tuesday 21 July, 7:00–8:30 pm AEST. Register here to attend.
