We may not have reached US-levels of prescription-drug dependency, but there is no room for complacency.
Public Health England has concluded its long-awaited 18-month review into the effects of five types of commonly prescribed drugs that can lead to problems with addiction or withdrawal.1
The results were concerning. Between 2017 and 2018, 11.5 million adults in England – 26% of the population – were dispensed a prescription for one or more of the five classes of drugs assessed (see graph below for number of drugs prescribed in 2016, 2017 and 2018).
It concluded that, while it was ‘difficult to determine’ the prevalence of addiction, around half of patients for each of the five medicine types were estimated to have been receiving a prescription continuously for at least 12 months. As such, dependence and withdrawal were ‘likely to be significant issues’.
The report’s main recommendations to counter these problems were fairly general: better access to data, better information for patients, updated clinical guidance, a national helpline and local support for patients, and more research around dependence and withdrawal.
However, the document contains some suggestions that could have a real impact on GPs: more regular reviews to prevent patients developing dependency, clearer guidance and greater support services.
Any improvement in clinical guidance would be welcomed by GPs. Professor Tony Avery, professor of primary care at the University of Nottingham, says: ‘Opioids are a significant problem, particularly if they have been prescribed at a high dose. Despite the evidence that they are not effective in many forms of chronic pain, there has been little guidance thus far in terms of how long they should be used for.
‘So the default for many patients is for them to remain on the opioids because most patients say they think they are getting some benefit and are usually reluctant to come off the medication, especially when they are still in pain.’
Gabapentinoids were “sold” as wonder drugs for managing chronic pain 10 years ago
Dr Louise Warburton
For GPs, it hasn’t just been a case of unclear guidance. In some cases, addictive medications were actually being promoted in guidance only a few years ago.
Dr Louise Warburton, a GP with special interest in musculoskeletal health in Shropshire and a researcher at Keele University, points out that gabapentinoids were seen as the go-to drugs for managing chronic pain only a decade ago.
She says: ‘Gabapentinoids were “sold” as wonder drugs for managing chronic pain 10 years ago and GPs encouraged to prescribe them by guidelines from organisations such as the British Pain Society, the RCGP and pain clinics.’
Dr Andrew Green, East Yorkshire GP and the BMA’s representative on the PHE review, points out that GPs have led the move away from the culture of long-term prescribing. He says: ‘The figures suggest most people who are started on them [now] come off within a few months.’ The high number of prescriptions, he says, are for patients who were on them before prescribing habits changed.
Lack of support and guidance
Clear advice for GPs on managing addiction and withdrawal is still needed, however. Dr Alun George, a Leeds-based GP with a special interest in substance misuse, says: ‘GPs definitely need awareness of boundary setting when managing this group – for example, lost prescription policies, named prescribers for reductions, limiting input from locums regarding reductions, avoiding prescribing for those with illicit drug/alcohol problems and involving substance misuse services when necessary.
‘But mainly more time and interpersonal support for prescribers is needed. Drug reductions are usually uncomfortable for patients and bring up many unpleasant feelings, which are often directed at the prescriber making the reductions. This can be draining for the prescribers who need robust and compassionate support to enable them to manage the difficult feelings raised.’
This is especially true in deprived areas. The PHE report concluded that more deprived regions of England were likely to have higher prescribing – and co-prescribing – rates, with patients on the drugs for longer.
The report says: ‘For all medicine classes the proportion of individuals who had been in receipt of a prescription for 12 months or more increases in line with deprivation, with those people living in the most deprived areas more likely to have been in receipt of a prescription for a year or more.’
Chronic pain disproportionately strikes our most deprived patients
Dr Jonathan Tomlinson
It later adds: ‘There is a clear relationship between increasing deprivation and increasing co-prescribing rates, with the co-prescribing rate in the most deprived quintile 1.4 times higher than in the least deprived quintile (30% compared to 21%)’.
Public health officials acknowledged GPs in these regions are ‘under great pressure’ to provide access to medication.
East London GP Dr Jonathan Tomlinson says: ‘This is not about lazy GPs or naughty patients. Chronic pain disproportionately strikes our most materially and socially deprived patients; those who are poor and socially isolated.’
Dr Warburton agrees: ‘The people in the most deprived sections of society do not cope with pain well because they often have co-existing anxiety, depression and/or difficult life situations. They consult more and are bound to get more prescriptions for opioids and pain medication.’
GPs have knowledge of non-pharmacological approaches, but delivering this is often too time-consuming
Professor Tony Avery
Even more than advice, GPs need alternatives to the prescribing of addictive medicines, especially in deprived areas. The report acknowledges as much and PHE has previously recommended that the NHS work with local authorities to commission tiered support. It states: ‘Depending on local needs and circumstances, the response should be developed by local primary care services, involving pain and addiction specialists, and peer-support groups.’
A BMA report in 20162 reached similar conclusions. It made the case for better guidance, alternatives such as pain clinics, mental health services and physiotherapy, dedicated withdrawal services, and a patient helpline.
The absence of such options remains a problem for GPs. Professor Avery says: ‘There is lots of talk about non-pharmacological approaches to managing chronic pain, but there seems to be very little available to patients.’
The ongoing dearth of alternatives leaves GPs in a difficult position, and it is similar for other conditions, says Professor Avery. ‘GPs have knowledge and experience of non-pharmacological approaches, but delivering this properly is often too time-consuming. I might talk to a patient for five minutes about how to manage their insomnia and give them an advice leaflet or a link to a website, but it would help if we had access to more dedicated support for these patients.’
Dr Green says he is pleased that PHE is thinking along the lines set out by the BMA three years ago. However, he adds: ‘The challenge now is getting those thoughts translated into actions.’
• NHS England and Improvement should look at the potential for the new service specification on structured medication review, which forms part of primary care network arrangements through the GP contract, to address medicines that can cause dependence or withdrawal.
• The NHS should work with local authorities to commission the tiered support previously recommended by PHE. Depending on local needs and circumstances, the response should be developed by local primary care services, involving pain and addiction specialists, and peer support groups.
• Primary care services, clinical and community pharmacists and GPs should develop their knowledge of, and competence to identify, assess and respond to, dependence or withdrawal associated with some medicines and the support needs of people experiencing related problems.
• It is recommended that NICE enhance its focus on medicines that can cause dependence or withdrawal when developing or reviewing relevant prescribing recommendations. It should also undertake a targeted review of all output including commissioned products, guidelines and technology appraisals that recommend the prescribing of opioid pain medicines.