In this case-based CPD module, GP specialist in substance misuse Dr Alun George offers guidance on how to manage four scenarios involving prescription drugs associated with dependence or withdrawal symptoms
Key points:
- Commonly prescribed drugs in primary care with potential for dependence include opioids, Z-drugs and gabanergic drugs. Antidepressants while not known to be dependence forming are often associated with withdrawal syndrome
- It is important to document any history of previous possible dependency issues with medications, alcohol or recreational drugs. Other risk factors include family upbringing linked with cultural and social influences, mental health problems, neurodiversity and deprivation
- Signs of dependence include anger if prescriptions delayed, requests for dose increases, asking to see locums or different doctors and requesting medication from out of hours or walk-in services.
- Drugs for non-cancer pain are of limited use long term and should be restricted to management of acute pain, for example post-surgery
- Approach patients who have developed dependency in a non-judgemental but firm way. Explain the benefits of managed tapering and withdrawal of a drug, such as improved mental health, sleep and day-to-day function
- Have several clinicians oversee a medication reduction plan, and include a warning in notes that other clinicians should not alter the plan without their approval
The cases in this module are not based on real people and are for illustrative purposes only
Case 1. A 36-year-old woman attends complaining of low mood and poor sleep for some months. She has tried some self-help measures without any real improvement. She has a friend who is taking an antidepressant and sleeping pills and wonders if this might be the right course of action for her. ‘But,’ she says, ‘I’m worried I might get hooked on them.’
1. Which drugs prescribed in primary care are most likely to cause dependence?
The commonly prescribed drugs in primary care with the potential to lead to dependence are the opioids (codeine, buprenorphine, fentanyl or morphine preparations), the Z-drugs (eg, zopiclone, zolpidem) and the gabanergic drugs (pregabalin and gabapentin). Antidepressants are not known to be dependence forming, although they are often associated with a withdrawal syndrome.
2. Terminology can be confusing and GPs sometimes struggle to explain the issue to patients – what exactly are the key differences between withdrawal syndromes, dependence and addiction?
Withdrawal is the term used to describe the negative symptoms experienced when a CNS acting drug is discontinued, especially if in an abrupt manner. These are mainly mental health symptoms such as increased anxiety, insomnia, altered sensations (eg, ‘brain zaps’) and GI upset. Withdrawal symptoms are usually associated with stopping drugs of dependence but they also occur when stopping antidepressant medications. Patients started on these medications should be counselled that withdrawal symptoms may occur when the time comes to discontinue treatment and to seek expert guidance before stopping so support and monitoring can be put in place. Antidepressants do not have any potential for dependence formation, as their onset of action for mind altering effects is very slow. Patients may be anxious that the possibility of withdrawal effects on cessation means they are dependent on the drug and an ‘addict’.
Dependence is a cluster of behavioural changes that can begin to develop and progress during prolonged exposure to a substance resulting in loss of control over use of the drug. A central feature of dependence is craving for and loss of control over the use of the substance (eg, using more than intended or at times or events when it is not appropriate to use it, such as before driving a car). Before prescribing drugs with dependence potential the patient must be informed that this is a possibility, particularly if the drug may be prescribed long term as the progression to dependence requires regular repeated exposure to the drug over a period, usually more than three months. While withdrawal upon discontinuation is often a feature of dependence its presence alone does not indicate someone is dependent on their prescribed drug.
Addiction (from the Latin addicere meaning ‘enslaved’ or ‘bound to’) is a lay person term used to describe the loss of control over the use of a substance or behaviour with negative effects. The label ‘addict’ to describe a person conjures up unhelpful stereotypes and it is not helpful to use the term with patients, although ‘addictive’ may help patients understand the risks associated with the medications.
3. How should we document these discussions? And are there resources of value for explaining dependence risks and providing self-help?
Prior to prescribing drugs with withdrawal or dependence potential other non-pharmacological options should be considered and exhausted, such as self-help, exercise or psychological interventions.
If a decision is made to prescribe, the patient should be informed of the potential for these medications to cause a withdrawal syndrome or dependence if taken long term. This should be balanced against the hoped for benefits and the discussion documented in the clinical record. History of previous possible dependency issues with medications, or alcohol or recreational drugs should be asked about and documented – their presence would indicate a higher risk of dependency with further similar drugs.
Advise the patient prior to initiating prescribing that they will be required to attend regular medication reviews to assess benefit and to screen for any potential dependence problems that may be arising. If there is little benefit the treatment should be stopped.
There is NICE guidance with specific recommendations on what to advise patients when starting, reviewing and withdrawing drugs associated with dependence or withdrawal symptoms.3 NHS England has produced resources for patients undergoing medication review.4
Click here to complete the full module on Pulse 365 and download your certificate worth 2 CPD hours
Dr Alun George is a GPwSI in substance misuse and addiction lead at NHS Practitioner Health
READERS' COMMENTS [1]
Please note, only GPs are permitted to add comments to articles
Useful to know that all my Type 1 diabetics are now formally classified as dependent addicts who will maliciously increase their insulin doses.