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GPs buried under trusts' workload dump

Prescription drug addiction review must boost funding for pain services, say GPs

GPs have warned a severe lack of specialist services is often leaving them with no option but to prescribe addictive medication, ahead of a key government review on prescription drug dependency. 

They have called for specialist services, including those for pain management and providing therapy, to be a 'focus for investment' if efforts to cut patient dependency on prescription drugs are to succeed. 

Public Health England is due to publish its 18-month review into prescription drug addiction and dependence this summer. It was announced by the Government in response to NHS Digital data which showed an increase in the number of patients prescribed an addictive medicine in the past five years.

At the same time NICE is also working on new guidance for GPs and other health professionals on how to manage prescription drug dependence and withdrawal.

And the MHRA is undertaking a major review of opioid medicines to cut overprescribing and the numbers of patients becoming addicted.

But GPs have warned that while the focus on the issue is welcome, in many areas services such as pain clinics are being cut leaving them with few options to help their patients.

BMA GP Committee chair Dr Richard Vautrey said: 'There is a serious lack of capacity, and in places availability, of specialist services to help patients with problems of addiction to prescribed drugs.  All too often this can leave GPs with limited options to refer to.

'Some drug and alcohol services will not accept referrals for such patients and many patients would be reluctant to attend such services as they may not think think they were appropriate for them.'

He added: 'What’s really needed is not just access to services to help patients with addiction but also better pain management services and access to psychological therapy options, both of which are sadly lacking in many areas.

'This must be a focus for investment if this issue is to be properly and effectively addressed.'

Birmingham LMC secretary Dr Robert Morley said: 'Worsening deficiencies and cuts in specialist services across a whole range of areas are a massively increasing problems that GPs are having to deal with. With drug and alcohol services this is particularly problematic as their commissioning has been removed from the NHS and is now subject to local authority budget cuts.'

The PHE review will cover benzodiazepines, Z-drugs, GABA-ergic medicines, opioid pain medications for non-cancer pain, and antidepressants.

Data is being collected on GP prescribing of the addictive medicines, including the number of patients taking the drugs for more than a year.

Minutes from meetings of the expert group undertaking the review suggest the data shows wide variation in prescribing between CCGs.

Notes from a meeting in January said while more work on the data was being carried out ‘there seemed to be a sizeable problem with the numbers of patients being prescribed these drugs and the duration for which they were receiving them’.

It was pointed out at the meeting that only practice audit could determine whether prescribing was ‘appropriate’ or not.

The committee said it was considering evidence on what interventions would be useful although there is limited evidence on the best approaches for prevention and dealing with dependence.

Professor Azeem Majeed, head of primary care and public health at Imperial College London said a key issue was having ‘suitable local services to support people to reduce their use of medication’.

‘In many areas, these kind of services are being cut and there are long waiting lists for services such as pain clinics.

‘CCGs need to consider how they support these patients and provide easily accessible and high-quality services to help patients reduce their use of these drugs.’

He added that prevention would also be important in reducing dependency on these prescribed medicines including wider issues around education, employment and housing.

Dr Shaba Nabi, a GP in Bristol, said: ’There are no specialist services for these patients and therefore it lands on the laps of GPs.

'The fundamental issue is that physical and mental health are viewed as two separate entities but it is way more complex and integrated than that.'

She added: 'Mental health or drug addiction specialists are completely incapable of addressing anyone’s underlying physical problems - such as back pain - and physical health specialists have a poor working knowledge of psychological issues impacting on and maintaining physical issues. The only speciality which is dual trained is general practice and there aren’t enough of us.’

'If we were really serious about addressing prescription drug dependence we would either put way more money into the core general practice contract - to attract more GPs and develop a GPSI role - or we would spend even more money offering dual training for psychiatrists so they were both psychiatry and general practice trained.'

 

Readers' comments (5)

  • David Banner

    I get the sinking feeling that this report will be splashed across the news with the usual GP scapegoating, and league tables to name and shame beleaguered practices.

    Increasing Pain Clinic provision will only lead to more opiate prescribing dumped on GPs after single consultation and discharge.

    The ship has sailed for those patients already consuming/selling their gabbies and opiates, trying to wean them off is maddeningly futile.

    The real toughening up should be on new patients. Ban primary care initiation of CDs for chronic pain, if initiated in secondary care then keep on a “shared care” basis rather than discharging back to GP. That will focus the minds of our hospital colleagues, who will drown in follow up patients if they don’t drastically cut prescribing.

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  • Took Early Retirement

    Good point David B. I'd just say that for a lot of patients, say with chronic MSK pain, nothing much works except something like a small dose of S/R morphine. I never found anyone whose life was transformed by the "Pentin" drugs. I did have a small number helped by low dose MST or even a low dose Fentanyl patch plus top ups with other things.
    Oddly, an awful lot of people (purely personal observation) found Co-Proxamol helpful and it was as cheap as chips, despite all the evidence that it was not better than paracetamol.

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  • David Banner

    Great point, TER!
    The banning of co-proxamol , the demonisation of NSAIDs, the stripping away of weaker opiates to treat back pain (with no reasonable alternatives) have all contributed to the strong opiate/gabapentinoid tsunami.
    With firm advice to avoid prescribing to those at risk from deliberate overdose , co-proxamol could make a welcome (if unlikely) comeback.

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  • A few points come to mind. Oramorph and tramadol should only be prescribed in the context of cancer care of by those who are willing and able to follow up and take ongoing responsibility. All others should issue sustained release preps.
    GABA should be banned bar definite neuropathic pain eg post zoster pains.
    Pain consultants need access to inpatient beds as the hardcore need admitting and almost intensive care to get them off this stuff.
    GP s need protecting from complaints when they are trying to control drug use by addicted patients.
    New docs need better training as a lot of my trainees seem unable to spot the type of individual that are at risk of dependence.
    Community support workers needed to provide brief interventions for the army of codeine addicts.

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  • Vinci Ho

    (1) Agreed that there should be more precise understanding (hence, training ) in the physiological as well as psychosomatic characteristics of pain . Pain is a complex syndrome entity . The treatment approaches( including pharmacological) we have adopted traditionally could have been ‘wrong’ entirely. The ‘’analgesics ladder’’ could be subjected to falsifiability (or even refutability) ? Recent new evidences suggesting our traditional approach of cutting off all saturated fat without looking into the type of food sources in preventing cardiovascular morbidities and more importantly, mortalities , could be a slippery slope . As Sir Karl Popper advocated , we must have the courage to admit that we could be wrong with our present knowledge in science and be ready to prove ourselves wrong everyday .
    (2) I prefer more GPs with better communication and decision-sharing skills preserving continuity of care, to pain specialists who ,in all due respect, could have been one of the sources of the problems we are facing right now . The heavy emphasis (arguably , easy access) on seeing specialists in America, for instance, could also be a precipitating factor of an even bigger problem of prescription drug addiction over there . Premature deaths in high-profile , relatively young , celebrities told only part of the story.
    (3) Then it leads to one of my recent , favourite subjects ; Internet-smartphone-AI driven private GP services. I would love to see some statements from these providers who had taken on so many relatively younger patients , about how they would like to manage these prescription drug addiction problems. If these providers are to stay in NHS , they clearly have a responsibility of , at least , NOT to pose additional risks to an already precarious and vulnerable situation .

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