A practical summary for GPs of the NICE guidelines on prescribing drugs associated with dependence or withdrawal symptoms
The guideline
New NICE guidelines published earlier this year recommend a cautious approach to prescribing, increasing, reducing or stopping medicines that have the potential to lead to dependence or withdrawal symptoms.
The guidance groups together benzodiazepines, Z-drugs (non-benzo hypnotics like zopiclone and zolpidem), opioids, gabapentin and pregabalin as drugs ‘associated with dependence’. It also covers antidepressants, which it states are ‘historically not classified as dependence-forming… [but can] cause withdrawal symptoms when they are stopped’.
It encompasses safe prescribing of these medications and withdrawal management for adults, whether or not they are at increased risk of developing problems associated with drug dependence. Excluded are gabapentinoids to treat epilepsy, opioids for acute cancer pain or end-of-life care, and illicit drug dependence.
Key points for GPs
- When considering prescribing drugs that can cause dependence or withdrawal, GPs should counsel patients on those risks and offer non-pharmacological alternatives, including ‘watchful waiting’.
- They should assess the patient’s individual risk of developing dependence or withdrawal, but not withhold the medicine on that basis. Factors that might increase risk include:
- a comorbid mental health diagnosis
- a history of drug or alcohol misuse
- not having a clear, defined diagnosis to support the prescription
- taking an opioid together with a benzodiazepine.
- On starting one of these medications, GPs should provide the patient with verbal and written information about the drug, risks and benefits, and draw up a management plan together with the patient.
- The patient should be offered regular reviews, based on their preference, the exact drug prescribed, factors that might heighten patient risk, and whether the patient is undergoing a dose adjustment.
- If a secondary care clinician recommends a drug associated with dependence or withdrawal to be started or continued in primary care, they should explain to the person that that drug will need to be prescribed by the GP practice and that it will need to be reviewed first by the GP team. GPs can decline or delay the prescription, in which case, NICE suggests, ‘the secondary and primary care teams [should] discuss the medicine and involve the person in these discussions, explaining the reasons for any delay’.
- When considering stopping or reducing the dose of the medication, discuss with the patient the risks of abrupt discontinuation. Agree a suitable rate of reduction and where appropriate, give patients autonomy over their tapered dosing.
Practical issues
One key issue is scheduling regular reviews with patients who are starting on these classes of drugs, or when adjusting a dose up or down. No specific review interval is proposed; rather, frequency should be based on several considerations including patient preference, and ‘factors that indicate a need for frequent reviews’.
This leaves room for confusion, and in many cases, relies upon patients notifying GPs of such factors – deciding to plan a pregnancy or experiencing some unwanted adverse effects, for instance. Patients might not be forthcoming, especially if they are concerned their medication will be stopped.
The guidance also suggests a single clinician should, where possible, oversee prescribing and management. While beneficial for most patients in this complex cohort, it will often be difficult to achieve in practice.
GPs will usually be best placed to assess whether a dependence-forming drug is suitable for an individual patient, based on their history, comorbidities, social circumstances, access to support and other factors that might increase risk of dependence or withdrawal – context that secondary care clinicians may lack.
However, transferring prescribing responsibility from secondary to primary care entails some potentially time-consuming back-and-forth if GPs aren’t happy to prescribe or wish to consider other options. There may be delays in sharing records and letters secondary care and general practice. It is then left to GPs to field demands from distressed and unwell patients wondering why they cannot get the medication their specialist has told them they should be taking.
Nonetheless, the guidance offers some useful advice on avoiding dependence and managing withdrawal, and recommends areas for further research, including psychological and other interventions to support withdrawal.
Expert comment
Dr Tim Lyttle, GP and clinical director of North Shropshire PCN, says: ‘A big problem here is that GPs often feel they don’t have adequate alternatives. Take gabapentinoids for patients with chronic pain, for example. If there was a better pain management service where the patient could have more comprehensive assessment and support, then GPs may feel less pressure to prescribe. These are patients with complex problems who need a holistic approach.’
Dr Lyttle added: ‘It’s easy for pressurised staff in hospitals to say to patients, “get your GP to sort out your medication”. The patient then comes in and tells you, “the specialist says you’ve got to prescribe a different drug” or “I need stronger medication”. But the specialist may not know the wider context, such as a patient who’s had a problem with dependence previously, or other aspects of the patient’s health that put them at higher risk.
‘And it’s very difficult to balance those risks with the benefits of a drug – especially if you don’t have continuity of care.
‘It’s critical that health service policymakers recognise that continuity of care at GP level, which has been shown to improve patient outcomes and well-being and lead to patients living longer, has been reduced because of the pressures we’re under and the push to increase patient access.
‘The people agreeing our contracts must provide the resources for GPs to give patient groups who need it more continuity and, therefore, more time. Those resources are essential if we’re to have any hope of implementing this type of guidance.’
Source
NICE. Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. 2022. NG215 https://www.nice.org.uk/guidance/NG215
