Baclofen tampered with? What do you make of this?

Well, here’s an odd thing.

I’ve just opened what I thought was a new box of Baclofen - one that was delivered before Christmas.

It was still in the pharmacy bag it came in, although the bag wasn’t sealed, as I’ve definitely had other stuff out of it - but not the Baclofen, that I know of.

So it’s a box of 84 - that should be three cards of 28.

But one of the cards has six tablets missing! What’s more, they’re not missing in a pattern I would take them, because I normally follow a method of sorts - start at one end of the card and work all the way down. Six pills are randomly missing from approximately the middle of the card.

I know that sometimes the pharmacy manually remove a few if the prescription wasn’t an exact multiple of the default box/card size - but they normally do that by snipping them off the card, so they’re still in the foil - and can be issued to someone else. They don’t do it by just popping them out of the blisters.

I checked in case the card just got damaged somehow, and they were lying loose in the bottom of the box - not there either.

And the prescription label on the box definitely says 84, not 78!

Do you think I should take any pills from this particular box, given the suspicious appearance?

I do have another box which looks OK - all 84 present and correct - but unfortunately from the same batch, so if one is suspicious, are they ALL suspicious? I don’t have much choice but to take them anyway, as it’s dangerous to stop suddenly.

I’ve moaned about the pharmacy many times on this forum, but this is one of the weirdest things so far. Are they trying to palm me off with part-used drugs somebody has returned for disposal? Doesn’t anybody check?

A problem is that I can’t absolutely prove I didn’t raid the stash, put the card neatly back, and forget all about it. But the only argument against that is it would be most unlike me to pop random pills right out of the middle.

Think I will be having words about this, but can’t 'til Monday anyway.



I quite understand your anxiety, and would also have reservations about taking the pills.

I’d use the unopened box and return the other to the pharmacy next week. Surely all scripts are double checked by a second member of staff before issue; errors could be very serious indeed.

I’m sure they’ll replace the box - if you were to take things further they wouldn’t be happy at all. Ask to see the manager, otherwise s/he may not hear about it. I’ve always understood that all returns are destroyed and never re-dispensed, but I could be wrong.

Good luck


Thanks Ben,

You know, it’s probably true of all pharmacies, as I don’t think their profit margins are very high (if they make anything) on NHS 'scrips, but I’ve always had the impression this pharmacy was keen to cut costs/corners wherever possible.

I know, according to the theory, returned drugs should never be re-dispensed, because once they’ve left the pharmacy, you’ve lost all traceability of how or where they’ve been stored. You don’t know if they’ve been subjected to extremes of temperature, sunlight (Baclofen says to protect from light), or even deliberately interfered with.

But I wonder if, sometimes, the temptation is a little bit too much for outfits trying to operate on a shoestring, and they ask themselves: “Who would be any the wiser?”

Of course, it could be an innocent mistake - something someone has returned for safe disposal somehow ends up back on the shelf - but even that would be pretty slack practice. They should have strict procedures in place for making sure returned drugs can never re-enter the supply chain.

I’ve always had the impression they don’t routinely keep Baclofen in stock, but try to source it as needed by ringing round other branches, to see who’s got any spare. That could be one of the reasons it always takes a long time to get any, and I’ve more than once been down to my last few tablets, and having to ration, despite ordering a fortnight ahead of time.

If my hunch is right that they don’t stock any, but phone around for the cheapest price, once they have a prescription to fulfil, that could explain how they might end up with cheap second-hand drugs that haven’t been through proper assurance checks.

But I would have thought visual inspection would be mandatory before sending anything out, and they wouldn’t just trust that a box saying 84 on the label necessarily has 84 intact pills inside it.

It has been Christmas, there has been alcohol, I could be mistaken. But I can’t understand why I’d open a box and start a card only to put it neatly back in the box again, AND with the patient instruction leaflet (which I usually just chuck away, as I’m on them permanently), AND suddenly ditch my habit of methodically popping the tabs in order, but take six randomly from the centre of the card. It doesn’t look like it was me, even if I’ve got no way of proving it.


I would have thought that if it was the pharmacy reusing them then they would have cut the strip to make it look as though they were using odd bits of stock. I can’t see any sensible pharmasist thinking it is acceptable to use part used strips. My suspicions would be towards the people delivering your script not the people dispensing. Either way I would speak to the pharmacy, if only so they know you don’t find this acceptable practice. I also have a pattern I follow when removing tablets a friend thinks I’m OCD about it, follow your instinct Tina you know you didn’t remove them in a random way.

Jan x

It is difficult to imagine the pharmacy OR delivery person removing pills on purpose like that, because yes, of course it is obvious - the recipient is clearly going to notice - and probably make a fuss! So if somebody was knowingly doing it, I think they’d take more steps to conceal it - like you say, Jan - cutting up the card to remove the empty blisters, and make it look like they had a few oddments (this happens too, sometimes, which has made me suspicious of that now - when I get silly little ones and twos of tablets in a box, which obviously don’t come that way from the manufacturer, are they just making up the numbers, or reusing stock that has been out once, and come back?)

I think what has happened is they’ve done their trick of phoning round to get the cheapest deal (they have a number of other branches around the country, but I think they probably have reciprocal deals with rivals too). Someone has offered them a bargain, which they’ve accepted, and they’ve probably either not checked them on receipt, or not checked properly. Because the missing pills were in the middle, you’d have to take ALL the cards out of the box and really look at them to notice pills were missing. If all you did was slide the cards out part-way, check there were three cards in there, and yes, all appear to be Baclofen, you wouldn’t notice one card had six pills missing. You might pop them back in and confirm there were 84 in there, without ever having really counted - just assuming a box of 84 contains what it says.

Coincidentally, I heard on the radio this week that Gabapentin and Pregabalin are part of a new trend in recreational drugs - with heroin users users mixing them to intensify their “hit”, apparently. So if it had been Gabapentin that was short, I’d be more suspicious it had been stolen - for use or for black market sale. But although Baclofen, like most prescription drugs, does have some potential for abuse, I’ve certainly not heard of it being the latest drug craze, so I wouldn’t have thought there was big money to made by pinching six tablets.

You are right about trusting my instincts. Coincidentally, this morning, I just started another new card of tablets - not prescription ones - my vitamin D. Without even thinking about it, I popped the first couple of pills - and realised I had started at a corner - the same way I always do. I NEVER start by popping one in the middle somewhere, or halfway down one side.

Yes, I know it’s a bit OCD, but there’s a method in it too - if you pop the tablets out in a definite order, it’s easier to see how many you’ve got left, and you are also less likely to miss any by mistake. I’m sure, even if it was Christmas Day and I was sloshed, I didn’t open the box, remove six pills in a random manner, then carefully put card and box away again. That’s the other thing - once I’d started a card, why would I put it away again and begin another? Once a card is in use, it’s in use. I’m taking them all the time, so it makes no sense to start a card, then carefully put it away again!



Hi Tina follow your instincts you know that you would never stat taking the medication in the way you described, i would contact the chemist and ask his opinion on this.

I have had something like this happen to me and went back to the chemist like you pills had been popped out and another time i was missing 2 boxes of the same medication,the chemist swore they were in the bag but the bag was stapled up and it caused a big upset at the practice eventually the dr issued another script and the missing pills were replaced i never found out where they went or indeed if they ever turned up. now i check everything when i get my delivery just to be sure its all ok and if i have any more problems i think i will change chemists.

I hope you get this sorted soon because as it stands your 5 pills short of the prescribed amount and thats going to put you out off sinc for your reordering.


Thanks Barbara,

I am a trusted patient and often order ages in advance anyway (mostly because of existing problems and delays with this same chemist).

The surgery do not monitor me to the tablet, and I take six a day anyway - so six is just a single day. I’m sure they would challenge me if I consistently renewed what seemed to be weeks in advance, but they don’t challenge me running a slight stockpile to prevent ever being caught out - I’m sure a day wouldn’t ring alarm bells one bit, fortunately.

I’ve had a really naff day today, and spent most of it in bed, so still not been anywhere or done anything about the problem. But I know it needs reporting as an incident, because yes, as you and others have said, I already know, deep-down, it couldn’t have been me that used just six tablets in that pattern, then carefully put the card back in the box. There’s just no sensible reason I would.

It is a safety issue, as the tablets must have been somewhere that wasn’t the pharmacy, and wasn’t in my care either, so who knows where they were, or how they were looked after? They might have been lying on a hot radiator, or dropped down the toilet, or really anything you can think of!

Also, how do I know they’re in date? The outer box says they are, but if a new-looking box has been filled with a part-used prescription someone took back, how old are the tablets themselves?

I’m getting quite paranoid now, because I’ve even thought I’d forgotten my Baclofen a couple of time recently. It turned out I hadn’t, but if they haven’t been stored properly, or are out of date, would they still work OK?

I am going to photograph the part-used packet before taking it back, because I have a nasty feeling that once I part with the evidence, I will never hear anything again, and it will all be swept under the carpet. I even Googled today, to see if there’s a place to report it that doesn’t involve going back to the pharmacy, to give them the opportunity to cover it up.

I couldn’t find anything, but obviously it’s not in their interests to have it on record, so what incentive do they have to not just give me a replacement box, and then keep quiet? If the people I report it to are the same ones who made the mistake, where’s the transparency? They can do what they like about it, including nothing.

I’m not on a crusade to get anyone sacked, but on the other hand, if anyone in the system is pilfering, or running a racket where returned drugs are re-dispensed as new, that’s not OK, is it?



It’s not quite the same, I know, but like Barbara, my pharmacy staple the bags shut.
Now, if its a good day for both of us, I drive to the pharmacy and my wife hops out and collects the medication.
Then we open the bag before we leave the carpark (combined surgery/pharmacy) and do a quick check.
On one recent occasion, I had been issued with the one item I had not requested and none of the items I had.

Of course, this was “the surgery’s fault”, but a new script was issued immediately and the medication was ready in 10 minutes.

Taking a photo is always a good idea, Tina, but do take another that shows the label with the issue date on it (or combine the two). My pharmacy runs on locum pharmacists, so the person in charge can change from day to day. It was an award winning small pharmacy, when it had a full-time pharmacist/manager - now it runs out of common things like Gabapentin for me, and Sinemet for my wife.

There is a page (or 10) on an NHS website where you can complain (I have used it in the past for the notorious Healthcare at Home), but if you are complaining about one of our highstreet chains, you have to be determined to wade through a lot of B**ts to find a particular one (for example).


Tina, I’m sorry you weren’t well enough to get to the pharmacy today, here’s hoping you have a better day tomorrow. Please keep the forum informed, as this could happen to any of us on meds, which is most of us.

My gabapentin (Neurontin) has the expiry date and batch number imprinted on each strip of pills as well as on the box. Have you checked that your strip matches the box it came in?

There must be an official body of some kind with responsibility for pharmacies, I’ve been wondering if your local ‘Healthwatch’ would be any help.

Good idea to photograph the evidence, by the way.


Hi Geoff,

Mine come in a sealed bag, too (another reason I don’t think it’s the delivery guy, as the seal was unbroken), but I broke the seal ages ago. I usually do a quick reccy to check everything’s in there I was expecting - occasionally it isn’t, but there’s an IOU for the missing component, which usually turns up within another couple of days.

One thing I don’t do, however, is open every box and check every card. If I seem to have about the right number of boxes of the right stuff (and there can be a lot at once - up to about six different different drugs in any one delivery), I don’t go through the lot checking it all. Following this, that may have to change, much to my annoyance, but 'til now, I’ve assumed that if the boxes were present and correct, what was in them would also turn out to be OK. I would not be worried and would not report it if there had been a miscount of perhaps one or two tablets, but six quite clearly missing from the blisters is a different matter, as it’s clearly not a simple “miscount”, but the integrity of the drugs themselves has been compromised - someone’s had them before me.

No, it’s not Bts (but rhymes, funnily enough). I quit Bts ages ago over frequent administrative errors and safety concerns. They just could not seem to get it that I am on a mixture of permanent and ad hoc medication - which means that some things should be on auto-repeat, but others I will get through at a faster or slower rate, depending how I’ve been, so those should be at customer request only. Quite straightforward, really, and can’t be unique, but a big problem for them, apparently.

And I was still borderline to break even with prepay back then, so was paying per prescription. That meant that if they ordered stuff I didn’t need, I was paying £7+ (whatever it then was) for the privilege of taking it home and stockpiling it! It was all stuff I would use eventually, but who wants to pay £7 up-front for something they won’t need for another six weeks? And by that time, yet another lot would come, and they’d get shirty with me for saying: “I don’t want it; I’ve still got six boxes at home!”

But I’ve mentioned here before that even that I put up with. The final straw came when they tried to give me a complete stranger’s prescription, and insisted I’d agreed to collect it for him. When I denied it, they acted as if I was somebody with mental health issues, and clearly didn’t remember what I’d agreed to. Never any acknowledgement that they must be confusing me with someone else. I was even told, very loudly and slowly, as if I were a halfwit: “YES, BUT YOU LIVE WITH HIM, DON’T YOU? YOU AGREED TO PICK UP HIS PRESCRIPTION?”

“NO! I’ve never heard of him in my life!”

So that was the end of my relationship with B**ts. Despite telling them I was terminating our agreement, I still got at least another two reminders of drugs I didn’t need or want, that they said were waiting for me.

I thought things could only get better by switching, but now I’m stuck with this lot, who persistently go right to the line with repeat prescriptions, so that I’m afraid of being home alone going cold turkey, because I’ve run out completely. When I’ve rung them for the third time in a week, to report I now have no pain relief for that night, they’ve replied: “But tomorrow morning will be OK, yeah?” And now this!


Hi Ben,

Never mind - I’ve not really been that awful - just an attack of the glums, I think. I might have gone out if it hadn’t been so damn cold all the time.

You can report pharmacy concerns to their professional governing body:

They do say you should speak to the pharmacy first, which I suppose is only just and fair, and is the expected first step for most types of complaint, whether legal or otherwise.

So it looks like I’ve got to give them a chance, but I do have a lingering concern about reporting it to the very people who would have most to gain from hushing it up. I think I will let it be known that I expect a formal response about how this could have happened, and that I do know how to complain to the professional body if I’m not satisfied with the answers.

If they are knowingly recycling returned meds, and it’s not just a stray pack that has found its way back into the supply chain accidentally, wouldn’t it be a fraud on the NHS, as well as a patient safety issue?

I’m not sure exactly how it works, but presumably they get reimbursed by the NHS for every “free” prescription, and for any shortfall between what patients like myself have prepaid, and how much they actually use.

So if they dispense something once, and claim it back from the NHS - then it comes back part used, and they dispense the remainder a second time, and claim it back, instead of disposing of it safely, haven’t they been reimbursed twice for the same drugs? Fraudulent, surely?

I cannot quite make out the edge strips, but it looks as if all three cards, including the one with pills missing say something 17 (i.e. 2017), and the outer box says FEB 17, so it looks as if they’re all still in date, but the issue is where exactly they’ve been, as it’s clearly not just in storage at the pharmacy if someone’s been popping pills out of them - unless they have a thief on the staff.



Thanks for the link to, I wasn’t aware of their existence but knew there had to be a regulatory body of some sort.

I’m feeling that your pills have been re-dispensed after being returned. As you point out, pharmacies frequently run out of some drugs and ring around looking for supplies, so the offending box of pills could easily have come from another chemist, or even been through two or three, who knows? And whoever decided, quite wrongly, to re-use them in the first place, hadn’t even bothered to check them properly. If I’m right, then this is nothing short of unprofessional, and certainly a safety issue, you’re right to complain.

…I notice it’s often the same few suspects loitering around this forum after midnight. Happily, I much prefer the company of owls to larks…


The other report you can make is by going to:

then scroll down to “pharmacies”, and wait, and wait … (yes, it is a very slow server) for the list,

Then select your pharmacy, and you can leave a review (bit like Trip Advisor).

If, Tina, it’s the one that I am thinking of (“sounds like”) they are national as well, so yes the dubious cards could have come from another branch - and that implies that they were never checked. That in turn implies that there is something wrong …


And if it is the “sounds like” that I am thinking of, I see that they also run a “residential lettings” company.


you need to keep this in perspective - you are 6 tablets short - no way of knowing why 6 tablets missing from one of the cards.

Of course the pharmacy should have checked but they didn’t. There are more important issues to worry about.

It’s not the missing tablets that’s the issue - it wouldn’t cause me to run out.

It’s that the missing tablets are evidence that the drugs obviously haven’t been checked or stored under proper conditions. I think you’ll find this is a serious regulatory breach. OK, no harm has come of it - this time. Do you think I should wait until I hear somebody has died, and then say: “Oh yeah, I noticed a few months back that there was something a bit odd about my prescriptions from them, too”?

That’s a bit like not worrying that aircraft maintenance is sloppy, until anybody gets killed.


1 Like

Hi Tina

I’ve had the odd strip cut off of my Baclofen which I am used to now.

Was your missing tabs popped out of their blister pack or cut like mine have been? If they were popped out and empty slots were there I would be really suspicious.

Take care.

Shazzie xx

Hi Shazzie,

Popped out and empty blisters - that’s the whole point! No chemist intentionally dispenses that way.

A few cut off bits and oddments I am quite used to and have never challenged - it’s often because of something silly like the GP has a habit of prescribing multiples of 30, but the standard card size is 28, or vice versa, so they end up having to snip off part of a card, or add a fraction of a card.

But this is the first time I’ve ever had a card with popped blisters on it.

I’ve tried to persuade myself I must have started the card myself, and forgotten - but I’m a creature of habit. I don’t start tablets in the middle. I’ve looked at all the cards of different things I’ve currently got in use, and not a single one is used from the centre out. They all start neatly at one corner, and progress in sequence down the card. It’s not something I even think about - I just do it that way. So whoever popped the pills, I’m pretty sure it wasn’t me.

It’s a shame I didn’t discover it on the day of delivery, or quite soon afterwards. I’ve had the pills over a month before opening the affected box, so I’m sure they will try to argue I took them myself, and forgot - which is exactly the debate I’ve been having with myself, but I honestly don’t think I’m going that crazy yet!




Oh Tina. I get what you are saying now. I would be really concerned too. Chemists shouldn’t pop them out of the blister packs. That is really bad. I don’t think I would touch the others until I checked it out with the Pharmacist. Like you say though they will probably say that you took them but stand your ground (I know you will).

I honestly don’t think it would have been you starting the pack half way through when you usually start from one end and work your way through.

Good luck and let me know how you get on.

Shazzie xx