Public Health England has published its updated (Sep 2019) Prescribed medicines review to identify the scale, distribution and causes of prescription drug dependence, and what might be done to address it, covering adults 18 and over and drug classes including benzodiazepines (previously called hypnotics often used for sleep and anxiety), z-drugs (sleeping tablets much like benzodiazepines), gabapentin and pregabalin (used for nerve or neuropathic pain and sometimes anxiety), opioids for chronic non-cancer pain, and antidepressants.
Slightly worrying is that they found in 2017-2018, 26% of the adult population in the UK received one of the drugs studied. These consisted of antidepressants (17%), opioids (13%),Gabapentin and pregabalin (3%), benzodiazepines (3%), and z-drugs (2%).
In their evidence-based review, they found that Benzodiazepines, Z-drugs, Opioid pain medicines, Gabapentin and Pregabalin were associated with a risk of dependence and withdrawal. The withdrawal symptoms included insomnia, depression, suicidal ideation, and physical symptoms.
It was found that higher initial doses of opioids and prescribing them for more than 90 days was associated with more dependence. Also, it was found that low income was associated with longer term benzodiazepine use.
The views of patients was interesting, they felt that there was not enough information regarding the risks of the medication. Some also felt that doctors didn’t recognise or acknowledge withdrawal symptoms.
Very interestingly, they described not being offered any non-medicinal alternatives. They believed their treatment was not being reviewed sufficiently, and that there was not enough access to NHS drugs management and support services for these drugs.
Patients described not being offered any non-medicinal treatment options, their treatment not being reviewed sufficiently and a lack of access to effective management and NHS support services.
The Recommendations were rather vague, suggest increasing awareness of dependence and withdrawal, and guidelines that will be followed, improving support for dependence or withdrawal, and prevention of dependence or withdrawal.
As a GP, I feel these recommendations fall short of what actually needs to be done. Perhaps this is an opportunity to listen to the patient experience and provide them with the non-medicinal treatment options they desire, and the only way to do this is to be aware of the other treatments and methods out there. Therapies such as mindfulness, yoga, and talking therapies are effective for mental health problems, as well as many physical problems. It is strange that nowhere is mentioned the first line for all treatments should be simple Lifestyle changes.
Optimistically the report shows that the prescription of opioids is already starting to show a decline and the UK is nowhere close to the 4x higher rate of prescribing in the US, and nowhere close to the overdose death rates from opioid use. The future is bright and it could be brighter if we embrace the opportunity as to dealing with the underlying factors which make chronic pain, mental health problems, and insomnia worse which are often lifestyle related and likely have social factors contributing to them.
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