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GPs go forth

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)

  • 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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