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reviews for patients on antidepressants and drugs for chronic pain that may be addictive, NICE has recommended in draft guidance on managing withdrawal.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