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Independents' Day

One in four adults prescribed addictive medicines, says PHE review

Over 11 million adults in England were prescribed addictive drugs between 2017 and 2018, according to a major new review by public health officials who said they recognised the 'great pressure' GPs are under to provide access to medication.

The Public Health England review, which looked at data for five commonly prescribed medicines - antidepressants, opioids, gabapentinoids, benzodiazepines and z-drugs - found that 26% of adults in England received a prescription for one or more of these drugs in the 12 months prior to March 2018.

GP leaders have said it is 'encouraging' the review shows a decline in opioid prescriptions for chronic pain, and also welcomed the report's call for more support services to help GPs and patients manage withdrawal in the community.

The PHE review said it was 'difficult to determine' the prevalence of dependence on, or withdrawal from, the medicines covered in the review.

However, it concluded the data on the duration of prescribing suggests that dependence and withdrawal are 'likely to be significant issues, particularly when seen together with the significant concerns raised by some patients, campaigners and others'.

The data showed that in March 2018, among all those people in receipt of a prescription, around half of patients for each medicine type were estimated to have been receiving a prescription continuously for at least 12 months.

While long-term prescribing may be clinically appropriate for some patients, the review stressed the importance of regular reviews to avoid people developing dependence or experiencing withdrawal.

'Patients may come to medical appointments with a clear expectation that medicines will meet their needs, and some will assertively make a case to receive a prescription. Increased awareness among the public and clinicians of treatments that are alternative, or supplementary, to medicines, and of the risks and benefits of medicines, is vital,' said the report.

The data analysed for the review also showed prescribing rates and the length of prescriptions were higher in more deprived areas of the country. 

PHE admitted that GPs in these regions were under ‘great pressure’ to prescribe drugs, and said alternative treatments needed to be considered.

Rosanna O’Connor, director of alcohol, drugs, tobacco and justice at PHE, said: ‘We know that GPs in some of the more deprived areas are under great pressure but, as this review highlights, more needs to be done to educate and support patients, as well as looking closely at prescribing practice and what alternative treatments are available locally.

‘While the scale and nature of opioid prescribing does not reflect the so-called crisis in North America, the NHS needs to take action now to protect patients.’

Commenting on today's findings, Dr Andrew Green, who represented the BMA during PHE's drug review, said: 'Doctors in the UK are of course concerned at the number of patients being prescribed these medicines, and the length of time they are taking them for.

'While there isn’t a single cause for high prescription rates, social deprivation, an increased prevalence of mental health problems and poor access to mental health care, a rise in the demand for GP services and a growing, aging population, are likely to be significant contributing factors.'

He added: '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 NICE is in the process of developing this.'

Professor Helen Stokes-Lampard, chair of the RCGP, said: ‘This report analyses prescribing data for medications that when prescribed appropriately can be effective and beneficial for many patients – and it shows that the vast majority of prescriptions issued are short term, and that we are seeing a decline in opioid prescriptions for chronic pain, both of which are encouraging trends.

‘What it also indicates is the severe lack of alternatives to drug therapies for many conditions – and where effective alternatives are known and exist, inadequate and unequal access to them across the country.'

GPs previously urged the Government to increase funding for pain services, as often a lack of specialist services often leaves them with no option but to prescribe addictive medication.

The review was announced in January in response to NHS Digital data which showed an increase in the number of patients prescribed an addictive medicine in the previous five years.

Key recommendations from PHE's review of addictive medications 

  • Doctors and commissioners should be given better access to data to improve prescribing behaviour;
  • Updates to clinical guidance for medicines which can cause problems with dependence and withdrawal – and the safe management of this;
  • Better information for patients about benefits and risks of medicines
  • More discussions between doctors and patients, and more alternatives offered including social prescribing;
  • A national helpline for patients and local support;
  • More research around dependence and withdrawal.

Readers' comments (30)

  • Vinci Ho

    (1) The reality of these patients who are heavily dependent on opiates(Co-codamol, Dihydrocodeine , Tramadol ( I called it CDT and etc ) and lately , gabapentinoids, are no different from those on methadone blue prescriptions . Even reducing the latter from 50 mls to 45 mls a day was confronted by strong objection from patients , for instance. And GPs have 10 minutes to complete this debate with a patient! Seriously?
    (2) The recommendations from PHE are sound but was quintessentially written in a bookworm fashion , ideological and intangible. Somebody needs to get real and mobilise resources to help the frontline.
    (3) Pain clinics need to take more responsibilities in monitoring the patient being initiated and maintained on all kinds of complex pain medications, rather than throwing them back to GPs to ‘continue’ .

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  • It is so easy to criticize for people who do not deal with patients face to face.
    Has PHE offered any workable realistic solution? As usual no. The recommendations are laughable. The next thing a GP gets if they follow the suggestions are a complaint for not caring and leaving the patient in pain.

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  • If you don't give out opioids, you can be subject to investigations by GMC, PAG, NHSE and the Ombudsman to name but a few. This crisis is was promoted by the medical regulators. I suspect extra NICE guidelines will only make this worse - breach them at your peril.

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  • David Banner

    Solicitors are already all over this like a cheap suit. Soon, patients (who badgered us for years to obtain ever more powerful analgesia) will be queuing up at their nearest “No Win, No Fee” outlet to blame ‘n’ claim their way to a few grand whilst trashing our reputations in the media. (“My prescription drugs hell”/ “My GP never bothered to review me” Panorama special coming to a TV near you soon).

    So now we have to drag them all in to non-existent appointments to document that they refuse any withdrawal attempt just to cover our massively exposed behinds. The benzo claims were merely an hors d’oeuvre, the coming codeine main course will be a bean feast.

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  • This year's qof requires we audit and take people off nsaids so with this, that leaves us with .. Paracetamol .. To offer. Easy for the pen pushers to say what we must not do .. What alternatives do they advise ?

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  • Refer them all to secondary care,see how they like that.

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  • Agree with all of above. I've tried this before including patient contract but it just takes time. We are already running at 11.5min/consultation (from BMA study good few years ago, so prob longer now). We can't then add extra 5min every time medication is prescribed.

    I'm happy to do this if government can fund 20min GP appointment. Over to you DoH

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  • Whystayagp?---Unfortunately the CCG says anything that can be bought OTC cannot be prescribed so we do not even have paracetamol! We should be assessed on what most doctors do and not these political or career boosting guidelines.

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  • GPs responsible for mortality and real fact people suffer sadly from numerous forms of chronic pain. Considering 6 months plus to pain clinic or 12 months to get OPA and almost no available talking therapies etc
    "I am in agonising chronic pain - want to talk about it? - I'd rather have some respite to function please"
    WHAT EXACTLY DO WE DO IN THE REAL WORLD? Can someone please answer from NHSE who actually works day to day seeing real patients in pain.

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  • Really angry that antidepressants are placed in the same category when they are not addictive and for recurrent severe depression patients need to be on them long term and there is no problem with that.

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  • The usual BS from PHE
    (one of many agencies that dabble in healthcare provision and is only relevant for the irritation it causes)

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  • Oh dear, oh dear, oh dear. I think I need a few of my diazepam to cope with all this.

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  • This review from P.H.E concludes with:

    "Further Research" -

    5.1 "Isolating withdrawal effects (especially of antidepressants) from the original disorder and its return.

    Surely this will require greater awareness and understanding of SSRI/SNRI and "Atypical"antidepressant induced akathisia and its potentially fatal sequelae?

    Induction, dose increase, A.D. change all can trigger akathisia and the akathisic patient is then at risk of misdiagnosis of this condition, and its overwhelming suffering, as emergent serious mental illness.

    Akathisia is also a life-threatening component of AD withdrawal syndromes and carries the same risk of misdiagnosis and exacerbation by increasing the dose or by "augmented" psychotropic medication.

    Agitation is mentioned in the summary of clinical features of AD withdrawal syndromes, but agitation is a key indicator of akathisia.

    (Alongside adverse changes in feelings, emotions, behaviour, ceaseless pacing, bizarre abnormal movement (dyskinesia) - in addition to overwhelming agitation).

    5.2 "Better understanding the incidence, duration, nature and severity of withdrawal from antidepressants, including long-term and enduring side effects".

    A commitment to address the long term and life changing syndrome of post SSRI sexual dysfunction - (as an ADR and not a feature of
    "the underlying disorder") - might restore some hope to those in despair.

    For a class of drugs advocated as a component of chemical castration, denial of PSSD seems a remarkable response to a common outcome of taking, and for some, long after ceasing antidepressant Rx.

    AD/SSRI induced akathisia has been described in published scientific literature for some thirty years, some would state 40 years.
    Terms such as "hyperkinesis" and "emotional lability" have decreased the visibility of akathisia in sponsored clinical trials.

    "Depressive psychosis is vanishingly rare compared to treatment induced akathisia".

    Sad indeed to see the latter misdiagnosed as the former.

    Sad indeed that committed G.P.s feel the discomfort induced by this P.H.E. Report.

    Prescribers can only follow the evidence base available to them via CME.
    The same, industry funded C.M.E evidence base used by Regulators and promoted by Key Opinion Leaders.

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  • I work as a GPSI addiction. Remember that the evidence base for OST (methadone and buprenorphine) advises doses 60mg and not to detox unless the patient wants to / or there are safety issues. Under treating opiate dependency & inappropriate detoxes contribute to the escalating DRDs.(This is in response to the first comment)

    A big issue with iatrogenic opiate dependency, is that often the patient doesn't understand / admit that they have an addiction issue. Many would benefit from conversion to OST but decline this intervention. The stigma associated with methadone /addiction exacerbates this problem further.

    Primary care isn't in a position to deal with this massive issue. From experience our local specialist addiction service don't have the capacity either, even if this group of patients was willing to attend a service mainly catering for street drug users.

    Addiction to heroin or prescribed meds is a response to stress/ trauma / poverty / our culture and society. There needs to be more focus on the root of the problem.

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  • To The cavary isnt coming.
    Anti depressants are addictive!

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  • Vinci Ho

    Thank you for the insight on OST to clarify my usual ignorant rantings . 😄😇

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  • I have complete faith in the Chain of Command.

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  • I’m a psychiatrist and worked in general adult psychiatry for 15 years. They are not addictive. You do not need increasing doses for same effect. You do not get tolerance to them. They do not cause misery like codeine/ benzos/ heroin etc. This is unhelpful scaremongering.

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  • And that’s 15 years at Consultant level.

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  • @Cavalry
    All anti-depressants create withdrawal syndromes
    No antidepressants actually do what they say they are going to do better than placebo
    In the long run they do more harm than good in everyone
    At least opiates give you SOME happiness (Victory Gin?)

    (More Orwell)The higher you are in the Inner Party, the stronger your skills in double-think

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  • Inability of so many docs to say no is surprising, but perhaps the lawyers will change that.

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  • Holy smoke batman.
    I’m wondering exactly how much actual training you have had in psychiatry? I know that you can be a GP with precisely nil following medical school. Here in lies the problem. To say that antidepressants are no better than placebo proves that you don’t know the evidence and are treating the wrong population or using them in the wrong way- something I see all the time. Misinformation is appalling for patient where antidepressants are re absolutely life saving.

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  • It is beyond doubt that prescription of addictive drugs including opiates is driven by multiple factors well outside the control of general practice.
    However it is true that their is a difference in ability of individual GPs even within the same local systems to decline to prescribe.
    It is akin to antibiotic prescribing rates.
    Rather than just ranking and blaming we need to learn the consulting skills that the low prescribers have to lower overall rates.
    There are many good MSK courses that can help with this.

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  • I remember in the 1980s as a junior doc we were being berated for NOT TREATING PAIN PROPERLY. The analgesic ladder was published in 1986 and eventually anyone at A&E with a sprained ankle or even undiagnosed pain was sent away with some co-codamol 30/500 or similar. And the rest is history.

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  • But don't worry, the PCN-funded pharmacist will solve all these problems....

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  • "Patient education" Where have I heard that before?? Ah yes, antibiotics. Another success leading to increased patient complaints and more paperwork. "Just give me the painkillers and educate the next patient"

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  • Here is an idea

    How about PHE/NHSE/CCG/PCN or whichever else organisation with time on its hands knock up some posters for our surgeries..

    "this is a non-prescribing GP practice
    We are not allowed to prescribe anything, for the risk of harm
    We are however happy to do the jobs of others and talk to you about fixing you boiler, gambling problems, safeguarding issues or refer you to Prevent if you are a nutty terrorist, or listen to you moan about your terrible life.
    Hugs and kisses, your local friendly GP"

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  • "Psychiatric drugs and some general medications have effects that are not always the ones that are intended".

    "Reactions to different drugs and drug-drug combinations are governed by individual metabolising rates".

    "It is established (that) genetic polymorphisms in the CYP 450 and serotoninergic metabolising system cause higher drug levels which are associated with neuropsychiatric adverse drug reactions (ADRs) such as akathisia".

    "If not recognised, akathisia, which often precedes violence, suicidality, homicide, mania and psychosis, may be mistaken for new or emergent mental illness and treated with further ineffective, counter-productive psychiatric drugs".

    Reference: -

    Treatment Emergent Violence To Self And Others; A literature Review of Neuropsychiatric Adverse Reactions For Antidepressant And Neuroleptic Psychiatric Drugs And General Medications.

    Clarke C. Evans J. Brogan K. 2019.

    US National Library of Medicine. N.I.H. Adv Mind Body Med. 2019. Winter, 33(1): 4-21.

    (It is recognised that reports of akathisia as a precursor to harm against self and/or others are subject to widely different opinion and interpretation).

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  • And? Who made available these medications? Who requested, no, demanded them? Which Governance organism advocated the use of Gabapentinoids??? And don't get me started on trying to get patients to change their life style choices... Expectations are nearly impossible to fulfil, the culture of "I want it all and I want it now" has done no favours to anyone, even less people that needs help!

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  • Oh dear, it seems our foolish and uncaring actions have finally been revealed.
    I too remember the "Defeat Depression Campaign" and the other big cultural push to treat pain effectively.
    No data I have seen this week on how many patients are on analgaesia because:
    1. they are currently waiting for a long time for definitive treatment (eg joint replacement)
    2.they have been to clinic, "nothing more I can do for you, go back to your GP"
    3. anecdotally, outcome from Pain Clinic is not great "nice people but I still have a lot of pain, Dr" Some great individual results but not the norm.
    4. "If I take this painkiller I can sleep / move/ go to work and pay taxes/ look after my frail relative". (delete as applicable)
    Sorry to tell you that they help a lot of people to function.
    As soon as there is a well thought-out , accessible, effective pathway for patients who are taking opiates and antidepressants "wrongly", I'll gladly refer. I'm waiting, and waiting...
    Can't have opiates, can't have antidepressants, mustn't take NSAIDs, can't have "gabapentinoids" : we are entitled to some defence and clinical leadership here.
    I have just come back form visiting family in USA.. I was horrified to see complex and poweful meds being advertised to the public on TV: " if you have joint pain and your golf swing is worsening, go ask your Physician for Etanercept" WTF. We have a lot to be thankful and thanked for!

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