Dependence on prescription medicines linked to deprivation
PHE has published the first-ever evidence review of dependence and withdrawal problems associated with 5 commonly prescribed classes of medicines in England.
The Prescribed medicines review assesses the scale and distribution of prescribed medicines – and makes recommendations for better monitoring, treatment and support for patients.
It uses available prescriptions data, a literature review and reports of patients’ experiences.
A total of 5 classes of medicines were included in the review:
- benzodiazepines (mainly prescribed for anxiety and insomnia)
- Z-drugs (insomnia)
- gabapentinoids (neuropathic pain)
- opioid pain medications (for chronic non-cancer pain such as low back pain and injury-related and degenerative joint disease)
- antidepressants (depression)
The main findings include:
- 1 in 4 adults had been prescribed at least one of these classes of medicines in the year ending March 2018
- in March 2018 half of those receiving a prescription (of these classes of medicine) had been continuously prescribed for at least the previous 12 months. Between 22% and 32% (depending on the medicine class) had received a prescription for at least the previous 3 years
- long-term prescribing of opioid pain medicines and benzodiazepines is falling but still occurs frequently – which is not in line with the guidelines or evidence on effectiveness
Trends in prescribing include:
- the number of prescriptions for antidepressants and gabapentinoids are rising
- following years of increase prior to 2016, prescriptions for opioid pain medicines and z-drugs are now falling
- prescriptions for benzodiazepines continue to fall, as they were prior to 2016
- women and older adults (particularly over-75s) are prescribed to at the highest rates
Links to deprivation include:
- prescribing rates and duration of prescription are higher in some of the most deprived areas of England
- a similar pattern is also seen for the number of medicines co-prescribed (for example, at least 2 of the drugs)
- for opioids and gabapentinoids, the prescribing rate in the most deprived quintile was 1.6 times the rate in the least deprived quintile
- the co-prescribing rate in the most deprived quintile was 1.4 times higher than in the least deprived quintile (30% compared to 21%)
Opioids for chronic non-cancer pain are known to be ineffective for most people when used long-term (over 3 months), while benzodiazepines are not recommended to be used for longer than 28 days. The review identified that when first used these medicines are prescribed for short term use. However, some patients do still end up being prescribed these medicines for longer periods.
Long-term prescribing is likely to result in dependence or withdrawal problems, but it is not possible to put an exact figure on the prevalence of dependence and withdrawal from current data.
People who have been on these drugs for longer time periods should not stop taking their medication suddenly. If they are concerned, they should seek the support of their GP.
People who had experienced problems from prescription medicines also reported that they felt uninformed before they started them, and unsupported when they experienced problems.
The drugs in this review are vitally important (when prescribed properly) for the health and wellbeing of many patients. It is important that doctors follow the clinical guidelines and do not put inappropriate limits on prescribing that could cause patients’ harm or drive them to seek drugs from illicit sources.
The review makes a number of recommendations focusing on education and treatment, including:
- giving NHS commissioners and doctors better access to data, improving insight of prescribing behaviour in their local area and enabling GPs to follow best practice
- updating clinical guidance for medicines which can cause problems with dependence and withdrawal, and improving training for clinicians to ensure their prescribing adheres to best practice
- to develop new clinical guidance on the safe management of dependence and withdrawal problems
- giving better information to patients about the benefits and risks with these medicines
- doctors should have clear discussions with patients - and where appropriate offer alternatives, such as social prescribing
- commissioners ensure appropriate support is available locally for patients experiencing problems
- a national helpline for patients to be set up
- ensuring high-quality research around dependence and withdrawal is undertaken
PHE has also published a detailed geographical breakdown by clinical commissioning groups of prescribing rates for 2017 to 2018 and the proportion of people that had been receiving a prescription for at least 12 months prior to March 2018.
Rosanna O’Connor, Director of Alcohol, Drugs, Tobacco and Justice at PHE said:
We know that GPs in some of the more deprived areas are under great pressure but, as this review highlights, more needs to be done to educate and support patients, as well as looking closely at prescribing practice, and what alternative treatments are available locally.
While the scale and nature of opioid prescribing does not reflect the so-called crisis in North America, the NHS needs to take action now to protect patients.
Our recommendations have been developed with expert medical royal colleges, the NHS and patients that have experienced long-term problems. The practical package of measures will make a difference to help prevent problems arising and support those that are struggling on these medications.
Professor Paul Cosford, Emeritus Medical Director at PHE said:
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, particularly antidepressants, which can take longer to have their full effect.
This report shows that while the vast 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. It is vital that clinical guidelines for prescribing are followed and regular reviews with patients take place to address this.
We also know how difficult it is for some people to come off these medicines and more research is needed for us to understand better how we help people to stop using them when they are no longer clinically helpful.
Keith Ridge, Chief Pharmaceutical Officer at NHS England, said:
As PHE rightly say, 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, particularly antidepressants, which can take longer to have their full effect.
But for many patients they may not be the best option - with talking therapies and social prescribing often more appropriate.
Arabella Tresilian, a patient who has experienced problems associated with withdrawal, said:
I was on and off anti-depressants for over twenty years, juggling work and family life at the same time. I really struggled to come off them and in 2015 I was diagnosed with post-traumatic stress disorder and chronic fatigue. Day to day activities became overwhelming and I quickly began to feel isolated.
I was very lucky that my doctor’s surgery offered social prescribing which made all the difference. They referred me to a local choir which helped me with my recovery and gave me back my confidence.
I know first-hand that dependence and withdrawal from prescription medicines can be extremely difficult to cope with. It is reassuring that this review recognises that more needs to be done and I am hopeful that social prescribing will now be offered more widely.
Background
The review analysed available NHS prescriptions data from community pharmacies from April 2015 to March 2018 on 5 classes of prescribed medicines:
- antidepressants
- opioids
- gabapentinoids (gabapentin and pregabalin)
- benzodiazepines
- z-drugs
It also included a rapid evidence assessment of literature on the harms caused by dependence or withdrawal, risk factors, treatment and prevention interventions and the support patients receive.
An expert reference group, made up of a broad range of specialists and experts by experience, was recruited to provide advice and support for the project.
The Prescribed Medicines Review (PMR) brought together the best available evidence, following PRISMA guidelines, on:
- prevalence and prescribing patterns in adults
- the nature and risk factors of dependence and withdrawal symptoms associated with prescribed medicines among some adults who take these medicines
- effective prevention and treatment of dependence and withdrawal for each drug category Supportive statements
Dr Norma O’Flynn, Chief Operating Officer of the National Guideline Centre at the Royal College of Physicians said:
We’re pleased to be able to support the work of PHE on their prescriptions medicines review by conducting systematic reviews of the research evidence.
The reviews and report recommendations are important steps in promoting a focus on managing prescription and withdrawal and highlighting areas where more research is required to inform practice.
Professor John Read from University of East London, speaking on behalf of the British Psychological Society’s representative on the PHE review’s Expert Reference Group said:
We thank Public Health England for all its work on this hugely important report.
We especially welcome the thorough research review documenting the alarming numbers of people experiencing withdrawal effects from prescribed medicines, and the recommendations for urgently needed services and a phone line to support people struggling to come off these drugs, including antidepressants.
We also value the emphasis placed on increasing accessibility to talking therapies for the problems that the drugs are currently prescribed for.
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