Prescribing of psychoactive drugs is a major clinical activity and a key therapeutic tool for influencing the health of patients. But often their use can lead to a patient becoming dependent or suffering withdrawal symptoms.
In the absence of robust data, we do not know the true scale and extent of the problem across the UK. However the evidence and insight presented to us by many charity and support groups shows that it is substantial.
It shows us that the 'lived experience' of patients using these medications is too often associated with devastating health and social harms.
Data on UK prescribing patterns
Data on UK prescribing patterns of drugs associated with dependence (antidepressants, benzodiazepines, Z-drugs and opioids) show that:
- antidepressant prescribing more than doubled over the last decade, and over 75 million prescriptions were dispensed in 2016 at a cost of over £340 million
- there were 12 million benzodiazepine prescriptions in 2015, costing over £50 million
- there were 28 million opioid prescriptions in 2016, costing over £340 million.
There are limited data on the number of people affected by dependence and withdrawal. Data published by NatCen (National Centre for Social Research) in September 2017 show that potentially dependence forming medicines (benzodiazepines, opioids, Z-drugs and GABAergic medicines) are widely prescribed in primary care.
The study of 50,000 patients on the CPRD (clinical practice research datalink) show that:
- opioids were prescribed to 5% of all patients on the CPRD, while benzodiazepines and z-drugs were prescribed to around 2%
- there has been an upward trend in the length of continuous prescribing, especially for opioids which increased from 64 days in 2000, to a peak of 102 days in 2014
- there has been an increase in very long-term (over 100 days) benzodiazepine prescribing, but no change (or a slight decline) in the proportion of benzodiazepine prescribing periods that were just over 30 days.
There are some data projecting the level of dependence from specific drug groups (benzodiazepines and Z-drugs). A recent survey of 100,000 patients registered in Bradford, UK, show that:
- the number of 16-80 year olds patients taking benzodiazepines and Z-drugs over the long-term (more than one year) is 0.69% - when applied to nationwide patient numbers this projects that there are between 265,000 and 295,000 patients taking benzodiazepines and Z-drugs over the long-term in the UK
- 35% of all patients taking benzodiazepines or Z-drugs are taking these drugs long term – at least 12 times longer than the BNF (British National Formulary) recommendation of 2-4 weeks.
Source
NHS Digital (2017) Prescriptions dispensed in the community, statistics for England – 2006-2016. Leeds: NHS Digital;
NHS National Services Scotland (2017) Prescription Cost Analysis 2017. Edinburgh: NHS National Services Scotland;
NHS Wales Shared Services Partnership (2017) Prescriptions dispensed in the community – Wales. Cardiff: NHS Wales Shared Services Partnership.
Cartagena Farias J, Porter L, McManus S et al (2017) Prescribing patterns in dependence forming medicines. London: NatCen.
Davies J, Rae T C and Montagu L (2017) Long-term benzodiazepine and Z-drugs use in the UK: a survey of general research. British Journal of General Practice 67(662): e:609-e613.
This represents a significant public health issue, one that is central to doctors' clinical role, and one that the medical profession has a clear responsibility to help address.
That is why we have undertaken a project working collaboratively with key stakeholders to start to identify what positive action can be taken for the future benefit of patients. This has had a particular focus on the prescribed use of benzodiazepines, z-drugs, opioids and antidepressants.
While there is a wide range of actions needed to address this issue comprehensively, the following sets out key policy calls identified through our ongoing programme of work.
Working collaboratively with key stakeholders
In March 2014, the BMA board of science sent out a call for evidence to gather the views of stakeholders on ways to improve the prevention and management of prescribed drug dependence.
We received a wide range of responses from professional organisations and charity and patient groups. This evidence was set out in an analysis report published in October 2015, bringing together the views of all the organisations who made representations.
We invited all the stakeholders to discuss what collaborative actions can be taken in light of the issues identified in the analysis report.
These actions focused on four key policy calls:
- the creation of a national helpline for prescribed drug dependence;
- an increase in provision of specialist support services;
- revised guidance for doctors on safe prescribing, management and withdrawal of prescription drugs;
- and better education and training for healthcare professionals.
How do we better support patients?
By listening to and working with a range of professional and governing bodies, charities and support organisations, it is clear that there is an urgent need for better support systems for patients suffering because of dependence or withdrawal.
Too often they feel there is no support, and no one to talk to, when they encounter problems with these psychoactive drugs.
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Recommendation 1
The UK government, working with the devolved nations, should introduce a national, 24 hour helpline for prescribed drug dependence
There is a strong view among stakeholders that this should be the top priority action for providing better support to individuals affected by prescribed drug dependence. The evidence submitted to the BMA sets out a compelling case for a helpline which would provide vital, real time support, and could be implemented in a relatively short time frame.
While there are a limited number of existing helplines run by small charities and support groups, these only cover a small proportion of the UK, and report significant demand. Too many patients do not therefore have access to this critical support.
A national helpline would sit alongside a website and act as a single trusted resource for patients on managing prescribed drugs dependence, coping strategies and support for carers and family members. It would also provide a service that doctors could signpost patients to when they need support.
This would follow a similar model to the FRANK service that provides advice on illicit drugs.
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Recommendation 2
Each of the UK governments, relevant health departments and local authorities should establish, adequately resourced specialist support services for prescribed drug dependence
Our analysis highlighted a gap in the provision of appropriate and specialised services for those suffering with dependence to prescribed drugs. There are limited examples of support services in some local areas where a concerted lobbying effort has resulted in an effective local response; for example the Bridge Project based in Bradford and Oldham Tranx. However, these services are isolated examples of good practice and provision is inconsistent across the country.
In the absence of specialist services, patients are often referred to general drugs services, which do not have the resource, training or skills to manage prescription dependence. Patients may also not access these services because of the stigma around illicit drug use. To overcome the inconsistent provision of support across the UK, a national approach should be adopted in order to allow doctors to refer patients who require support in their local area.
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Recommendation 3
How do we reduce the risk of patients becoming dependent and suffering withdrawal?
Clear guidance on tapering and withdrawal management should be developed collaboratively with input from professional groups and patients
Prescribing of psychoactive medications should be informed by good quality guidance. Our analysis found that doctors do not feel there is adequate guidance on tapering and withdrawal management, particularly in relation to benzodiazepines. In contrast, charity and support groups are broadly of the view that these exist and should already be in use. This difference can be attributed to the existing guidelines on benzodiazepines being expert-based rather than having a strong scientific evidence base, and medical professionals therefore not feeling confident in using them. Our analysis also found that there is an inconsistent approach to managing withdrawal from antidepressants, and that existing guidance was in urgent need of revision.
The adverse consequence of these issues is patients suffering significant harm as a result of rapid and poorly managed tapering protocols. Action is therefore needed to develop robust guidance on tapering and withdrawal management for psychoactive medications. NICE (National Institute for Health and Care Excellence) have recognised that this is an issue and is considering the development of guidance on managing prescription medicines associated with dependence and withdrawal. As is their standard approach, such a review would include actively seeking input from a wide range of stakeholders including practitioners and those who use services and family members or carers.
To complement these measures, it is important to promote best practice through the development of a readily accessible, practical and compact resource for prescribers and other clinicians. The RCGP (Royal College of General Practitioners) has been working with the RCN (Royal College of Nursing), Royal Pharmaceutical Society, the BMA, and patient groups to develop this.
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What the BMA is doing
We are working with key stakeholders to look at ways of ensuring doctors and medical students are adequately trained in managing the risks associated with prescribing psychoactive medications.
We are also working to encourage the various UK research councils to prioritise research in a range of areas, including:
- the harms and benefits of long term use of antidepressants
- the optimal withdrawal and tapering protocols for benzodiazepines, z-drugs, antidepressants and opiate analgesics
- the withdrawal syndrome which is reported to be associated with benzodiazepines, z-drugs and antidepressants
- the prevalence of antidepressant use in the UK, showing patterns of prescribing among different patient groups, for example by gender and location
- the use of non-medical alternatives, such as psychosocial interventions and the effectiveness of these methods.
With support from the Faculty of Pain Medicine, we’ve produced a briefing paper on Chronic pain: Supporting safer prescribing of analgesics.
Lobbying Parliament
We have written to Nicola Blackwood MP highlighting the devastating health problems caused by dependence on prescribed drugs.
Read the letter (PDF)
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Key stakeholders
We are extremely grateful to the following organisations and individuals who have been directly or indirectly involved in supporting this work.
Organisations
- Academy of Medical Royal Colleges
- Addiction Dependency Solutions
- All Party Parliamentary Group for Prescribed Drug Dependence
- Battle Against Tranquillisers
- BenzoBuddies
- Bristol and District Tranquilliser Project
- British Dental Association
- British Pharmacological Society
- British Psychological Society
- Council for Evidence-based Psychiatry
- Council for Information on Tranquillisers, Antidepressants, and Painkillers
- Critical Psychiatry Network
- Faculty of Pain Medicine of the Royal College of Anaesthetists
- General Medical Council
- Health Education England
- Medical Schools Council
- National Institute for Health and Care Excellence
- NHS Greater Glasgow & Clyde Managed Clinical Network for chronic pain
- NHS Greater Glasgow & Clyde Management Addiction Services
- Opioid Painkiller Dependence Alliance
- Prescribing Observatory for Mental Health
- Public Health England
- Recovery and Renewal
- Recovery Road
- REST (Mind in Camden)
- Royal College of General Practitioners
- Royal College of Nursing
- Royal College of Physicians
- Royal College of Psychiatrists
- Royal Pharmaceutical Society
- The Bridge Project
Individuals
- Professor Heather Ashton
- David Dicks
- Catherine Pittman
- Jill Williams
- Howard Wingfield
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Media coverage
Read our news story
Read our latest press release
Read the blog from Dr Andrew Green
External media coverage
Dr Andrew Green was interviewed on Radio 5-live Investigates (available until 22 November 2016)
Listen to the interview
BBC Online published an article supporting the radio programme.
Read the BBC news story
The Guardian published an article on our review and calls for more support.
Read the Guardian news story
The Daily Mail published an article to highlight our call for support helpline.
Read the Daily Mail news story