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Tackle prescription drug dependency with improved clinician training, says review

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5497 (Published 10 September 2019) Cite this as: BMJ 2019;366:l5497
  1. Elisabeth Mahase
  1. The BMJ

A landmark report into prescription drugs that have a risk of dependency has concluded that more high quality research is needed on withdrawal effects—especially of antidepressants—as well as on the harms of dependence and withdrawal and how to avoid them.

Public Health England’s major review of prescribed drugs1 is the first of its kind. Commissioned by the government in 2017, it looked at dependence on benzodiazepines, z drugs, gabapentinoids, opioids for chronic non-cancer pain, and antidepressants.

It found that one in four adults in England—11.5 million people—were prescribed at least one of these classes of drugs in primary care in the year ending March 2018. Of those receiving a prescription in March 2018, between 22% and 32% (depending on the medicine class) had been taking the drugs for at least the previous three years.

Altogether 930 000 people in England were continuously prescribed antidepressants from April 2015 to March 2018 while 540 000 were continuously prescribed an opioid. Meanwhile, 160 000, 120 000, and 100 000 people were continuously prescribed gabapentinoids, benzodiazepines, and z drugs respectively.

While long term use of these drugs was likely to result in dependence or withdrawal symptoms, it was not possible to put an exact figure on the prevalence of these problems from the current data, said PHE.

But it did say that long term prescribing of opioids and benzodiazepines went against guidelines and the evidence.

Women and older adults (particularly over 75s) were most likely to be prescribed one of these drugs long term, while those living in areas of greater deprivation had higher rates of opioids and gabapentinoids prescriptions, the report found.

Paul Cosford, emeritus medical director at PHE, said, “Clearly we have a problem with opioids that we need to deal with, but we are at about a quarter of the prescribing level (defined daily dose per one million of the population) of the US, about half the level of Germany, and about two thirds of the levels seen in places like Austria and Switzerland.”

The report outlined 41 recommendations, including setting up a national helpline and website to provide expert advice to patients.

It said that GPs need to ensure they have clear discussions with patients about the risks and benefits of the drugs, but to do this they need to be supported through improved training and updated guidelines. Patients should also be told about alternatives to drugs such as social prescribing.

Andrew Green, who represented the BMA during the review process, said: “It is positive that this report recognises that to reduce prescription levels, we need significant investment in support services; this will enable patients and GPs to manage dependencies together in the community. GPs will often be the sole clinicians who are managing a patient’s withdrawal, and there is a real need for better clinical guidance in this respect. We are glad that the National Institute for Health and Care Excellence is in the process of developing this.”

He said that while there was a place for long term use of some of the drugs reviewed many more alternatives to medication was needed, such as pain clinics, improved access to mental health services, and physiotherapy.

He welcomed a national helpline for patients and said that people who are dependent on prescription drugs need separate services to those addicted to illicit drugs. “These are different problems, with their own causes, effects, and solutions, and they require different approaches,” said Green.

Patients who contributed to the report said that “harmful effects and withdrawal symptoms on stopping benzodiazepines, z drugs, opioids and antidepressants affected their wellbeing, personal, social, and occupational functioning” that could last many months.

Others said that they had problems finding any information about the drugs they were taking and the risks associated with them and that doctors did not acknowledge or recognise withdrawal symptoms they reported.

An update to NICE guidelines on depression has been delayed by nearly two years after a group of experts called the draft “not fit for purpose” and raised concerns about the evidence being out of date.2 They also questioned the lack of evidence for NICE’s current depression guidelines,3 which state that withdrawal symptoms linked to antidepressants are “usually mild and self limiting over about one week.”4

The NICE website does not say when the guidance will be published.

Number of prescription items for each class of drug

  • Antidepressants increased from 64 703 568 in 2016 to 70 873 824 in 2018

  • Opioid pain medicines (excluding for treatment of cancer pain) decreased from 41 916 273 in 2016 to 40 497 419 in 2018

  • Gabapentinoids increased from 12 014 067 in 2016 to 14 360 117 in 2018

  • Benzodiazepines decreased from 8 417 874 in 2016 to 7 711 783 in 2018

  • Z drugs decreased from 6 351 983 in 2016 to 5 966 051 in 2018

References

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