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Supporting individuals affected by prescribed drugs associated with dependence and withdrawal

pharmacist holding prescription drugs

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.

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.

 

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.

Following this we've hosted a series of roundtable meetings with stakeholders to discuss what collaborative actions can be taken in light of the issues identified in the analysis report.

These actions focused on key policy recommendations:

  1. the creation of a national helpline for prescribed drug dependence;
  2. an increase in provision of specialist support services;
  3. revised guidance for doctors on safe prescribing, management and withdrawal of prescription drugs;

We launched these policy calls in October 2016, accompanied by appearances on BBC Breakfast, BBC5 Live Investigates and national newspaper coverage. You can find links to the various media items at the bottom of this page in the Media coverage tab.

While there is a wide range of actions needed to address this issue comprehensively, the following recommendations set out key policy calls identified through our ongoing programme of work.

Since October 2016 we continue to work with stakeholders to lobby on our key policy calls.

Read more about what the BMA is doing

 

  • 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.

  • 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.

  • Recommendation 3

    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 Royal Pharmaceutical Society publish a competency framework for all prescribers in collaboration with patients and other prescribing professions. The framework published in July 2016 is endorsed by a number of professional bodies and is next due to be updated in July 2020.

  • 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 wrote to the then Public Health Minister, Nicola Blackwood MP in October 2016, highlighting the devastating health problems caused by dependence on prescribed drugs. We subsequently met with the government to discuss our policy calls in more detail.

    We wrote to Sarah Wollaston MP, Health Select Committee chair in April 2017 to highlight our policy calls and ask her committee to consider an inquiry into prescribed drugs associated with dependence and withdrawal.

    We have submitted written evidence to inquiries taking place in the Scottish Parliament and Welsh Assembly following public petitions.

    With support from the Faculty of Pain Medicine, we’ve produced a briefing paper on Chronic pain: Supporting safer prescribing of analgesics.

     

    Public Health England Review

    Following lobbying from the BMA and others, in January 2018 the government announced that Public Health England had been commissioned to undertake an evidence review to assess the scale of the problem the harms caused by dependence and withdrawal and how they may be prevented and the best way to respond.

    Read the review

    Read the press release

  • 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. Opioids were prescribed to 5% of all patients on the CPRD, while benzodiazepines and z-drugs were prescribed to around 2%.

    The study of 50,000 patients on the CPRD (clinical practice research datalink) show that:

    - 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.

     
  • 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
  • Media coverage

    Read our news story 

    Read the blog from Dr Andrew Green

     

    External media coverage (October 2016)

    Dr Andrew Green was interviewed on Radio 5-live Investigates

    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