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A sea of troubles – prescription drug dependency

Illustration for a sea of troubles feature about drug dependence

Patients who become dependent on prescription drugs often lack the support and information they need. Following years of work by the BMA and campaigners, they are being promised new services and clinical guidelines. Peter Blackburn reports

A long-awaited study into prescription drug dependence has revealed a host of fundamental problems in care and communication.

The Public Health England review into the experiences of patients prescribed, and becoming dependent on, benzodiazepines, z-drugs, opioids and antidepressants found ‘barriers to accessing and engaging in treatment services’, a ‘lack of information on the risks of medication’, a ‘lack of access to effective management and NHS support services’ and a host of other problems in the area.

It follows years of pressure from the BMA and other campaigning groups.

‘After it happened to me it took me three or four years before I could function’

The review says 11.5 million adults in England, 26 per cent of the adult population, received and had dispensed one or more prescriptions for the drugs considered.

While this does not itself give evidence of dependency, the conditions are there in which dependency might develop.

There were almost a million patients receiving prescriptions for antidepressants, and more than half a million for opioid pain medicines, continuously between April 2015 and March 2018.

 

Lack of support

Luke Montagu (pictured below) spent 20 years taking sleeping pills and anti-depressants he says he did not need, before finally ‘entering hell’ while attempting to stop taking them.

11th earl of sandwich Luke Montagu

After turning to the internet for help, he found scores of people who had also struggled with a lack of support, or the offer of alternative therapeutic approaches, and decided to campaign for change.

‘After it happened to me it took me three or four years before I could function and leave the house. But I realised I was in a very good position to try to help and try to do something about it,’ Mr Montagu, the son of the 11th Earl of Sandwich and a campaigner at the Council for Evidence-based Psychiatry, says.

‘It was a moment in one’s life where you stumble across an injustice and you have a choice as to whether to help out. I feel very lucky that I was in that position.’

Portrait of Baroness Sheila Hollins

Mr Montagu’s experiences kick-started the campaign for change. He describes how he made contact with the former BMA president and board of science chair Baroness Hollins (pictured above), who spoke on the issue in Parliament before helping to set up an APPG (all-party parliamentary group) to look at prescription drug dependency and campaign for better care and support.

 

Safe prescribing

Sir Oliver Letwin, the West Dorset MP who later chaired the group, says he was convinced by Mr Montagu’s ‘remarkable story’, combined with a natural interest in mental health provision.

The BMA’s voice was to be an important partner in the process. In 2016 the BMA board of science, having gathered evidence on improving the prevention and management of prescribed drug dependence, recommended:

  • A national helpline for prescribed drug dependence
  • An increase in provision of specialist services
  • Revised guidance for doctors on safe prescribing, management and withdrawal of prescription drugs.

The pressure for change began to grow. ‘We felt that the first step to tackle the problem would be a national NHS-funded helpline and website,’ says Mr Montagu.

‘We asked for support from the BMA and the [medical] royal colleges to sign up to that and that was tremendously helpful.’

A systematic review was undertaken on behalf of the APPG and published last year. It indicated that an average of 56 per cent of patients who stopped or reduced their antidepressants experienced withdrawal symptoms, with almost half of those reporting symptoms as severe. It was not uncommon for patients to experience symptoms for weeks, months or longer.

Public Health England’s report supports all three of the BMA’s recommendations from three years ago and urges more action including ramping up collection of, and use of, data in the area as well as a much-increased focus on research.

It is, doubtless, a win for campaigners and health leaders who have fought tirelessly on this issue.

 

GP support

BMA GPs committee prescribing lead Andrew Green says: ‘The BMA has been working for some years with patients and health organisations to understand and address the causes behind high prescription rates, and we were pleased to engage with this review and welcome its recommendations.’

Sir Oliver (pictured below) tells The Doctor: ‘It’s very good that there is now a properly established evidence base which had previously been lacking, so we are all now operating on a much better platform of understanding and information which is very constructive.

oliver letwin

‘The report makes some very sensible reflections about how to proceed and improve this situation – we don’t just want to know how bad it is, we want to make it better. There is all the difference in the world between a good set of recommendations in a report, and actually making them happen.

‘The next stage is to make this happen in the real world. I’m optimistic that given the high degree of consensus between the professional bodies and the report about the steps that are necessary that we can get them to happen. That’s the work we are now engaged in and will have considerable conversations with all the interested parties and hopefully shortly with the health secretary to make sure the recommendations are implemented, and in particular that the quick wins are won.

‘The helpline and the support for GPs and the improvement in the ways that GPs are informed are the kinds of things we can do pretty much immediately if there is a will.’

 

Investment

For GPs, new clinical guidance and a strong evidence base should help – and data shows prescription rates for some drugs, including opioid painkillers, are already falling so doctors are taking action.

But, crucially, it’s important to understand the complex causes of a problem if a solution is to be found.

Andrew Green, General practitioners committee 2017

Dr Green (pictured above) says: ‘While there isn’t a single cause for high prescription rates, social deprivation, an increased prevalence of mental health problems and poor access to mental healthcare, a rise in the demand for GP services and a growing, ageing population, are likely to be significant contributing factors.

‘It is positive that this report recognises that, to reduce prescription levels, we need significant investment in support services; this will enable patients and GPs to manage dependencies together in the community.

‘GPs will often be the sole clinicians who are managing a patient’s withdrawal, and there is a real need for better clinical guidance in this respect. We are glad that [the National Institute for Health and Care Excellence] is in the process of developing this.

‘And while there remains a place for prescribing the kinds of drugs this report covers – including, in some circumstances, for long-term use – we need many more alternatives to medication, such as pain clinics, improved access to mental health services, and physiotherapy – the universal provision of which are all lacking.’

‘If you’re a GP and you know the referral will not be immediate you could feel you are bound to do something for your patient’

Sir Oliver echoes the point that GPs having ready access to non-pharmaceutical alternatives, such as CBT (cognitive behavioural therapy), is essential.

‘CBT is entirely evidenced already, it is entirely accepted as a powerful tool for addressing anxiety and depression and there’s lots of it but not nearly as much as there is demand for it and the result is that people have to wait.

‘That’s often a very, very serious problem. First of all, if [patients] have to wait, things get worse, and secondly if you’re a GP and you know the referral will not be immediate you could feel you are bound to do something for your patient.’

 

Social prescribing

The timing of this report could hardly be more prescient. The NHS is working to establish primary care networks across England.

These new structures in primary care, negotiated by the BMA in the GP contract, will allow GPs to work at scale and provide access to increased funding for social prescribing and support services.

This could be a major opportunity in the area of prescribed drug dependence.

As Mr Montagu says: ‘Social prescribing plays a really important role in all of this. It is completely understandable and right that a doctor should be able to give their patients a way forward other than a traditional prescription.’

Clearly, there needs to be an effort across the health, social care sectors and beyond to tackle the problem. For some conditions, doctors are left wishing, ‘if only there was a pill for that’. Here they are wishing for readily accessible alternatives.

Find out how the BMA is supporting people in difficulty with dependency


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