Over the last year, US-based compounding pharmacies have been subject to a lengthy debate over the semantics of their operations. Are their operations compounding, or are they really de-facto manufacturers? Should new categories like "outsourcing pharmacy" be created to deal with large-capacity compounders?

But now the state of Missouri has raised the semantics state even further, granting one anonymous compounding pharmacy an unusual title: state executioner.

The development is part of a long-running and wide-ranging battle between proponents and opponents of the death penalty, which is still legal in some US states. Opponents of the practice have increasingly been targeting pharmaceutical regulations and companies as a means of delaying or halting executions, and have thus far succeeded in pressuring many companies to stop making the drugs used in the executions.

In response, states have turned to compounding pharmacies to make the drugs they need.

Executioner

But at least one of those states, Missouri, appears to be wary of its compounding supplier being subjected to pressure-public, private or legal-from outside groups.

So the state has developed an unusual workaround, according to reports from the Guardianand St. Louis Post-Dispatch. For obvious reasons, those involved with the physical execution of an inmate are granted anonymity to protect them against retribution or other reprisals, such as from family or criminal associates of the deceased.

Faced with similar pressures, Missouri last month reportedly made its anonymous compounding pharmacy of choice a de facto member of its "execution team," shielding its identity from being made public.

While at least one organization, the American Civil Liberties Union (ACLU), has sued the state in an attempt to make public the name of the pharmacy, that case appears to have had little success. As for the compounding pharmacy, its drug was used in an execution for the first time on 20 November.