Destruction of controlled drugs and unknown substances by pharmacy services staff procedure – Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

1 Aim

This standard operating procedure (SOP) covers the destruction of trust requisitioned:

stock controlled drugs (CDs) including unlabelled and patient dispensed supplies along with any ward stock or leave or discharge CDs
patient own medicines (POM)

2 Scope

Unknown substances located on any wards, teams, or units across the trust which are no longer required or have expired and cannot be returned to the patient

Pharmacy services staff.

3 Link to overarching policy and procedures

4 Controlled drugs destruction requirements

Controlled drugs covered by this standard operating procedure are those covered by schedules 2, 3 (3a and 3b), 4 and 5.

Please refer to appendix C at a glance controlled drugs requirements

4.1 Schedule 2 and 3a controlled drugs

All morphine products other than the lower strength solution (10mg/5ml) are schedule 2 controlled drugs.

All controlled drugs (schedule 2 and 3a) should be recorded in the ward or team-controlled drug register and destroyed as a two-person process.

4.2 Schedule 3b and 4 controlled drugs

No controlled drug register record needs to be made for schedule 3b and 4 controlled drugs.

Two-person process required to destroy schedule 3b and 4 controlled drugs.

Schedule 3b (gabapentin, midazolam, phenobarbital, pregabalin, tramadol) and 4 controlled drugs (benzodiazepines, Z hypnotics, androgenic and anabolic steroids) are to be quarantined separately in either a sealed envelope or oral syringe with the details of the contents (drug, strength, formulation, quantity and reason for destruction) and placed in a destruction box in the bottom of the drug cupboard to be denatured by pharmacy department and recorded in the ward destruction book.

4.3 Schedule 5 controlled drugs

Lower strength morphine solution 10mg/5ml is a schedule 5 which means that the destruction is to take place on the ward, and it is to be recorded in the ward-controlled drug destruction book.

4.4 Unknown substances

Controlled drugs or unknown substances may only be destroyed on the ward or within the community team by the authorised trained named personnel (ATNP) who is appointed by the trust accountable officer (appendix A) in the presence of a second staff member (counter-signatory).

All controlled drugs or unknown substances will be destroyed on the ward or team using a proprietary denaturing kit (DOOP), which can be ordered from Rowlands Pharmacy. The trust pharmacy department will order and store these kits within the pharmacy department.

5 Procedure

Ward or team to contact trust pharmacy department (by phone, email). Having received notification from the ward or team, pharmacy staff should liaise with the nurse in charge or ward administration pharmacy technician prior to their visit to:
- ensure that identified stock controlled drugs are no longer needed
- ensure that identified prescription-only medication controlled drugs are no longer needed, and the patient has consented to the destruction
- check if there are any unknown substances
The authorised trained named personnel (who will destroy those controlled drugs or unknown substances) should liaise with the nurse in charge or ward administration pharmacy technician and set a suitable time to come to the ward or team to carry out the controlled drugs destruction.
On arrival to the ward or team the authorised trained named personnel should identify themselves, using their trust identification. They will ask the nurse in charge or ward administration pharmacy technician to accompany them to the treatment room to obtain the controlled drugs or unknown substances to be destroyed, along with the controlled drug register, having assured themselves of the safety of doing so.
The authorised trained named personnel and counter-signatory should get the controlled drugs (schedule 2 and 3a) or unknown substances from the controlled drug cupboard, then lock the cupboard back up and check controlled drugs to be destroyed against the registry entries.
If multiple destructions are required, this will be done in strict rotation:
- tablets or capsule: remove from packaging and add directly to the proprietary denaturing kit (DOOP kit)
- ampoules: break ampoule, add glass and contents into DOOP kit
- patches: remove packaging, and backing paper, fold the patch in half adhesive side inward and add to DOOP kit
- liquids: empty directly into DOOP kit (till the medication fill line)
- lozenges: remove from packaging and add into DOOP kit, any excess packaging, for example, plastic stick attached to lozenge, should be cut off to save space in the kit
- aerosols: expelled underwater into a small container, solution to be emptied directly into DOOP kit
- unknown substances: remove from sealed envelope and carry out the destruction as stated above, dependent on the formulation of the unknown substance
Controlled drugs (schedule 2 and 3a) or unknown substances will be signed out of the register as being destroyed, by the authorised trained named personnel and counter-signatory. A second sheet (appendix B) will also be completed and kept by the trust pharmacy department.
If there are controlled drugs (schedule 3b and 4) also to be disposed, the authorised trained named personnel and counter-signatory should get the destruction box in the bottom of the drug cupboard and destroy accordingly as per the above guidance for different formulations. Controlled drugs will be signed out of the destruction book by the authorised trained named personnel. A second sheet (appendix B) will also be completed and kept by the trust pharmacy department.
Once all controlled drugs or unknown substances have been placed in the DOOP kit, it should be filled with water to the fill mark on the label, the lid tightly closed and shaken.
Once the liquid has formed a gel, the substances are no longer considered as controlled substances, and the container can be disposed of in the pharmaceutical waste bin on the ward or community team. An entry to be made in the destruction book when the DOOP kit is placed in the pharmaceutical waste bin.
The authorised trained named personnel and counter-signatory should then check the controlled drug register against existing stock (in use) and vice versa (except in St John’s Hospice due to the size or range of their controlled drug holding) and if balance is correct then an entry should be made that the stock levels have been checked and are correct, this must then be signed and dated by both the authorised trained named personnel and the counter-signatory. The relevant section from appendix B should be completed accordingly:
- controlled drug cupboards or controlled drug registers checked
- number of items checked
- stock balance and register match
- any discrepancies found (yes or no)
- additional comments or discrepancies found
Any discrepancies must be reported, via the incident reporting system (RADAR) to the accountable officer and ward manager and investigated accordingly.
All paperwork must be kept for a period of two years from the last entry.
Audit:
- the form (appendix B) will be used to periodically audit, against the trust-controlled drug register books in terms of controlled drug destruction and reconciliation
- the form (appendix B) will also be used for the controlled drug local intelligence network (LIN) report about how many visits to wards or teams have taken place and how many items have been destroyed

6 Appendices

6.1 Appendix A pharmacy services staff sign off sheet to be authorised for controlled drugs or unknown substances destruction by accountable officer

Refer to appendix A: pharmacy services staff sign off sheet to be authorised for controlled drugs or unknown substances destruction by accountable officer (staff access only).

6.2 Appendix B destruction and reconciliation of controlled drugs or unknown substances record sheet

Refer to appendix B: Destruction and reconciliation of controlled drugs or unknown substances record sheet (staff access only).

6.3 Appendix C at a glance controlled drugs

Refer to appendix C: at a glance controlled drugs (staff access only).

Document control

Version: 4.
Unique reference number: 454.
Approved by: Clinical effectiveness group.
Date approved: 13 May 2025.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Chief medical officer.
Date issued: 24 June 2025.
Review date: 30 June 2028.
Target audience: Pharmacy services staff.
Description of change: General review with minor amendments.

Page last reviewed: June 25, 2025
Next review due: June 25, 2026

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