Is it time to slash psychoactive drug prescribing?
Dr Des Spence argues for a 50% cut in prescribing but Dr Michael Banna says that we need to address mental health stigma first
GPs are expected to defer to specialists, whose slick presentations of pristine research show us where we are going all wrong. But in the dirty real world, this evidence sinks into the quagmire of uncertainty that is general practice. This is a particular problem with psychoactive medication, with specialists accusing GPs of ‘under-diagnosis’ and ‘under-treatment’. So we have witnessed a doubling and even a tripling of the use of opioids, sedatives, antidepressants and gabapentinoids within a decade.¹ But after the ‘experts’ are gone, GPs are knee deep in the unforeseen and disastrous consequences. Supposedly concrete evidence is now being exposed as flimsy, prefabricated pharma research junk.²
For example, the definition that ‘pain is what the patient says it is’ is impossibly broad and wrongly marks out large swathes of the population for potential treatment with opioids. But opioids bring escalating dependence, are ineffective over time and are causing an epidemic of prescription drug deaths internationally.4 As for benzodiazepines, all GPs know the decades of harm they have done. Research now even links them to dementia.5
The gabapentinoids are a disaster in waiting, with a two- to three-fold increase in prescribing over the past five years. These are widely abused and also implicated in drug deaths.6 In the US, gabapentinoids are being rescheduled as controlled drugs.7
As for antidepressants, these have been shown to be little better than placebo in GP populations.8,9,10 With scant evidence of long-term benefits, they are associated with withdrawal syndromes and patients struggle to stop them.11,12
Antidepressants also medicalise normality, create doctor dependence and deny people the chance to develop their own coping strategies. And why weren’t intuitive and effective talk-based interventions promoted in the 1990s rather than medication? All these psychoactive medications are doing real and lasting harm.
Lastly, how much of our time is wasted reviewing psychoactive prescriptions, fretting about diversion and dependence? It’s time to ignore those Big Pharma mafioso medical experts with their financial conflicts of interest. Less medicine is almost always better medicine. We could (and should) halve the levels of prescribing. General practice needs to seize this agenda.
Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow
Psychoactive drugs make up a massive range of medications that are used successfully for a wide variety of conditions. Restricting them could be hugely detrimental.
Rather than trying to avoid or cut back on certain treatments, we should simply ensure we use them appropriately. I am totally against frivolous over-medication of any patient, but attempting to avoid prescribing psychoactive drugs because we sometimes overuse them puts us on a slippery slope to denying patients treatment they will benefit from.
If we are using these medications inappropriately, we should educate ourselves and change our practice, but we should not need any arbitrary constraints.
One of the biggest obstacles we face in the treatment of mental health problems is stigma. While patients are happy to accept that their blood pressure needs controlling, being medicated for mental health problems can often be seen as a sign of failure. Any attempt to reduce our prescribing of these drugs risks appearing to be an endorsement of this damaging view.
It would be more helpful to find a way to spend more time discussing management choices with patients. For example, when treating mood disorders, there seems to be an assumption that GPs just ‘hand out antidepressants’ rather than considering other diagnoses and options. Longer appointments would give doctors and patients time to discuss and agree on a management plan that could involve more than medication - as well as help to counter the suggestion that GPs are simply thrusting a green slip at the patient and shoving them out of the door.
Increased availability of talking therapies, in-house mental health practitioners and multidisciplinary pain clinics might also reduce reliance on psychoactive prescribing. This would of course be hugely dependent on the commissioning of local services, but where education is concerned, we can all improve our skills as part of our continuing professional development.
At the end of the day, though, some patients want - and need - medication.
No drug should ever be prescribed without clinical justification, but neither should there be a blanket reduction of a whole range of drugs that are helping many people.
Dr Michael Banna is a GP in Bognor Regis, West Sussex
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3 Chou R et al The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention workshop. Ann Intern Med. 2015;162:276-86.
4 Lyapustina T. The prescription opioid addiction and abuse epidemic: how it happened and what we can do about it. Pharm J, 11 JUN 2015.
5 Billioti de Gage S. Benzodiazepine use and risk of Alzheimer’s disease: case-control study. BMJ 2014;349.
6 Public Health England. Advice for prescribers on the risk of the misuse of pregabalin and gabapentin. December 2014.
7 Spence D. Bad medicine: gabapentin and pregabalin. BMJ 2013; 347.
8 Fournier JC, DeRubeis RJ, Hollon SD et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47-53
9 Kirsch I, Deacon BJ, Huedo-Medina TB et al. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med20085:e45.
10 Arroll B, Elley CR, Fishman T et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009;3:CD007954.
11 Geddes JR, Carney SM, Davies C et al. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet 2003;361:653-61
12 Haddad PM, Anderson IM. Recognising and managing antidepressant discontinuation symptoms. Adv Psychiatr Treat 2007;13:447-57.