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NICE: GPs should regularly review patients withdrawing from addictive medication


antidepressant withdrawal


GPs should provide regular reviews for patients on antidepressants and drugs for chronic pain that may be addictive, NICE has recommended in draft guidance on managing withdrawal.

The frequency of reviews should increase once a patient has decided to stop taking a medicine and the process could take several months, NICE said in its new guidance now out for consultation.

Extra reviews – which can be done face to face, by phone or online – should be offered to anyone reporting adverse effects, pregnant women or those planning a pregnancy, or those who have reported a change in their condition or psychosocial circumstances, the guidelines state.

Decisions to stop a medicine and how to do so should be done in consultation with the patient, taking into account signs they may be developing problems with dependence such as running out of medicine or reporting it no longer works.

Patients should get an updated management plan after every review and any decision to withdraw a medicine should be done in a ‘shared decision making approach’.

The guidance, which does not include opioids for acute pain, cancer pain or at the end of life,  follows a report from Public Health England that warned that one in four patients had been given a prescription for a potentially addictive medicine.

In 2019, NICE revised its depression guidelines to warn of ‘severe’ and lengthy antidepressant withdrawal symptoms, having originally said such symptoms were ‘mild’. 

The recommendations also note that all other relevant management options should have been discussed and offered before potentially addictive drugs are prescribed in the first place and patients should be made aware of the potential long-term consequences, the NICE committee said.

Discussions around withdrawing an opioid, benzodiazepine, gabapentinoid, Z-drug or antidepressant should happen when the medicine is no longer benefiting the patient, problems of dependency have developed or the harms outweigh the benefits.

But a medicine should not be stopped suddenly unless there are exceptional circumstances such as serious side effects.

Withdrawal should be a planned process with medicines that are no longer effective or necessary reduced gradually over time.

For some a dose reduction rather than complete withdrawal may be a more realistic approach, NICE said. If there is more than one medicine, this should be done in stages.

Healthcare professionals will need to consider whether symptoms that appear during withdrawal are symptoms of coming off the medicine or a sign of a new problem.

For those withdrawing from benzodiazepines, group cognitive behavioural therapy should be considered.

And if a withdrawal has not been successful, healthcare professionals should aim to stop any further dose increases and make a plan to try again at a later date.

But NICE concluded more research is needed on interventions to support dose reductions of opioids, psychological interventions to support those coming off addictive medicines and which support services are most effective for patients.

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘Many people continue to be prescribed these dependence forming medicines despite evidence that the risks associated with adverse advents of taking them outweigh their benefits. People are being harmed and we cannot ignore it.

‘Although these medicines can provide lasting symptom management for a proportion of people taking them, they do not work for everyone.

‘Having the right strategy for withdrawing safely from these medicines is key and that is why these evidence-based guideline recommendations are required to support healthcare professionals and patients.’

READERS' COMMENTS [10]

Decorum Est 22 October, 2021 1:29 am

NICE persist with their pre-adolescent philosophies of necessity and excellence – they ‘walk-the-walk’ of the ‘idiot savant’ on the ‘crazy-paving’ of their childish understanding of medical science……

Decorum Est 22 October, 2021 1:56 am

…suspect that we can all talk a lot of shxte….

Kevlar Cardie 22 October, 2021 9:17 am

Broom and KY gel please.

David Jarvis 22 October, 2021 9:50 am

So withdrawing needs more work than continuing. Hmmmm???

Turn out The Lights 22 October, 2021 10:22 am

Sound like an addiction service needs to be commissioned?Good louke with getting medics for that.GP to do doubt it(two fingers rampant).

Mark Cathcart 22 October, 2021 10:29 am

So here in Northern Ireland our gp service is drowning and yet, in the midst of a global pandemic DoH removes pregabalin from the NI formulary and instructs all gps to stop this medicine ASAP!
No consideration of the workload issues and safety concerns re withdrawal or extra resources to facilitate this new task,
And…..
Flu jabs
Covid jabs
Staff isolating
Massive demand
Minimal workforce
How can primary care do everything asked of it with little investment in people or resources?

The Prime Minister 22 October, 2021 10:38 am

The NICE panel don’t actually see patients, they are “theoreticians”-really they should be disciplined for making recommendations without recommending resources……

Patrufini Duffy 22 October, 2021 1:28 pm

What this country is yet to understand – is that scientists don’t like being told what to do anymore. They trust no one but their own instincts. And institutions smell off currently. Take a backseat for a decade or so.

David Banner 22 October, 2021 5:12 pm

How fortunate we are to be awash with empty GP appointments and incredibly short waits for CBT. As usual, NICE have looked carefully at service availability before foisting their plan of action on the profession. Bravo!
NICE keep churning out their ill- thought through diktats with no care about the utter chaos Primary Care is in, then wonder why we simply ignore them.
Either come up with real world solutions or go away and stop annoying us with your irrelevant drivel.

David Jarvis 22 October, 2021 5:15 pm

Regular could be once a year. So that’s OK I suppose. Of course if they actually meant frequent then not so good.