More guidance and training is needed for clinicians to ensure the safe prescribing of painkillers, antidepressants and sleeping pills that patients risk getting hooked on, according to a major review.
The review published by Public Health England looked at the use of five types of commonly prescribed medicines including opioid painkillers and drugs for depression, anxiety and insomnia.
“It is positive that this report recognises that to reduce prescription levels"
Andrew Green
It found one in four adults had been prescribed at least one of these classes of medicine in the past year.
At the end of March 2018, half of those on the drugs had been taking them for at least 12 months while many – up to 32% - had received a prescription for the past three years or more.
Officials from Public Health England said the findings raised concerns about the level of longer-term prescribing which can result in dependence and withdrawal problems.
“These medicines have many vital clinical uses and can make a big difference to people’s quality of life and for some their long-term use is clinically necessary,” said PHE medical director Paul Cosford.
“The report shows that while the majority of new prescriptions for these medicines are for short-term use, within clinical guidelines, it also highlights significant numbers have been taking these medicines for a long time.”
He said it was vital to ensure clinical guidelines for prescribing were followed and prescriptions were regularly reviewed.
The five classes of medicine looked at in the review were:
- Benzodiazepines, which are mainly prescribed for anxiety and insomnia
- Z-drugs used to treat insomnia
- Gabapentinoids used to treat neuropathic pain
- Opioid pain medications for chronic non-cancer related pain such as lower back pain and joint disease
- Antidepressants
While some drugs such as antidepressants may need to be taken over a period of time to have a full effect, others are not recommended for long-term use.
For example, opioid painkillers are known to be ineffective for most people when used for more than three months while benzodiazepines are not recommended for use for longer than 28 days.
However, the review found some patients do end up being prescribed these medicines for longer periods, which was not in line with the guidelines or evidence on what works.
It found the number of prescriptions for antidepressants and gabapentinoids were rising.
Meanwhile, prescriptions for opioid painkillers and z-drugs were now on the wane following years of increases prior to 2016. Prescriptions of benzodiazepines continue to fall.
The review found a higher rate of prescribing to women and older adults and large variations in prescribing rates between clinical commissioning group areas.
Significantly, the report identified a link between increased prescribing and deprivation with prescribing rates and length of prescriptions highest in some of the poorest areas of England.
There was a similar pattern when it came to co-prescribing – when people were taking at least two of the drug types.
For opioids and gabapentinoids the prescribing rate in the most deprived areas was 1.6 times higher than in the least deprived while the co-prescribing rate was 1.4 times higher.
As well as looking at prescribing data and research evidence, the review gathered the experiences of patients.
Those who had experienced problems with prescription medicines said there was a lack of information on the risks and said they felt uninformed before they started taking the drugs.
They also said there was a lack of support when they did experience problems such as withdrawal symptoms.
The review made a series of recommendations including the need to update clinical guidance for medicines that can cause problems with dependence and withdrawal and improve training for clinicians to ensure they stuck to best practice.
It said medical bodies should provide advice and support to ensure training for doctors “adequately address issues related to dependence on and withdrawal from prescribed medicines”.
Meanwhile, Health Education England should review the training and educational resources available to health practitioners including when it came to supporting people experiencing problems.
It said there was a need for new clinical guidance on the safe management of dependence and withdrawal issues.
“We hope the guideline will allow people with depression to be offered the best care"
Paul Chrisp
Other recommendations included the need to ensure patients received clear information on the risks and benefits of these medicines.
Where appropriate, doctors should offer alternatives such as talking therapies for depression and physiotherapy or tailored exercises programmes to tackle chronic pain.
Commissioners needed to ensure support was available locally for people experiencing problems with prescription medication and the review called for a national helpline to be set up.
The National Institute for Health and Care Excellence said it was working on guidance on the safe prescribing and withdrawal of prescribed drugs.
The body was also in the process of updating guidance on the diagnosis and management of depression in adults which had included looking at how best to manage symptoms when people came off medication, explained Dr Paul Chrisp, director of NICE’s Centre for Guidelines.
“We hope the guideline will allow people with depression to be offered the best care, and when to safely stop or change their treatment, in accordance with their preferences and values,” he said.
Clinicians were keen to stress that patients who were worried about taking any of the drugs covered by the review should not stop taking them but should speak to their GP.
The British Medical Association said doctors were concerned about prescribing rates and duration and had been actively trying to avoid inappropriate prescribing.
“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,” said Dr Andrew Green, who represented the BMA during the review process.
“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,” he added.
He also highlighted the need for “many more alternatives” to medication such as pain clinics and improved access to mental health, which were often lacking.
Meanwhile, he welcomed the recommendation for tailored services to support people with dependence to prescription drugs.
“Currently those who think they may have developed dependence on medication could have to use services developed to help people addicted to illicit drugs,” said Dr Green.
“These are very different problems, with their own causes, effects and solutions, and they require very different approaches,” he added.
Public Health England’s research and Report denies a voice to people who have benefitted from these drugs with no adverse effects whatsoever.
As one of the “silenced majority” who have benefitted greatly from benzodiazepines with no side effects at all, I tried to submit evidence to Public Health England’s investigation. They stated however that no individuals were allowed to do so and that patient experiences would only be accepted if they were experiences of dependence, withdrawal problems, or related treatments, which had been collated into an organisation’s report. (See appendix E of PHE’s Report).
Diazepam aided my recovery from severe anxiety, depression and phobias. I had no problem whatsoever stopping when I felt I no longer needed them. I also used benzodiazepine sleeping tablets for several years and simply stopped abruptly as I recovered. I still occasionally take a diazepam if I need to and also find mental health mutual support groups very helpful as part of my own mental health self-management strategy.
My personal evidence of the effectiveness of benzodiazepines, together with mutual support groups, is my numerous achievements including my science degree, world-wide independent travel, ongoing social activism and prior to my retirement, my profession as a Mental Health Outreach Worker