Prescribing addictive medicines

When prescribing addictive medicines be sure to discuss fully the risks and benefits with patients.

EARLIER this month the RCGP and the Royal College of Psychiatrists published a consensus statement aimed at reducing patient addiction to prescription medicines such as tranquilisers and painkillers.

It advised: “Longer term prescribing can increase the risk of dependence, and with some medicines, such as tranquilisers like benzodiazepines, should only be considered under exceptional circumstances and with regular review by practitioners with suitable expertise and understanding of the risks.”

This statement might seem blindingly obvious yet a recent search of MDDUS files revealed dozens of cases where members have been the subject of complaints and claims involving alleged negligence in the prescription of addictive medicines such as dihydrocodeine, diazepam, temazepam, ativan, sevredol and others. The narrative is very similar in most of these cases with improper monitoring of repeat prescribing and lack of regular reviews often involving a number of GPs within a single practice.

The serious risks involved in the use of tranquilisers like benzodiazepine have been well known since the 1960s and 1970s when overuse led to many patients becoming dependent. Over the last decade there has been a steady drop in the use of hypnotic and anxiolytic medicines.

A 2011 study on Addiction to Medicine by The National Treatment Agency for Substance Misuse reported that in 1991 a total of 878.7 million items were prescribed in England compared to 550.4 million items in 2009. This was accompanied by a drop in patients being referred to drug treatment services with problems relating to benzodiazepines. The report attributes this reduction in part to increased vigilance over the prescribing of these medicines.

In the same period the prescription of opioid analgesics, such as tramadol, codeine or morphine, increased from 228 million items in 1991 to 1,384 million items in 2009. Referrals to drug treatment services in patients reporting problems with prescribed opiates have fluctuated but problems with over-the-counter opiates have increased.

Even with the drop in the use of hypnotics and anxiolytics, addictive medicines still account for a large number of prescription items and there is also huge variation in the patterns of prescribing among different regions of the UK. No doubt these drugs can offer comfort to patients in a range of distressing and debilitating diseases but overdependence can be devastating to those affected and their families (as demonstrated in this 2012 Guardian profile).

The authors of the Addiction to Medicines Consensus Statement urge practitioners to provide adequate information such that patients can make informed decisions on treatment. “This should include information both about the risk of dependence, and about how this can be reduced by taking medicines as prescribed and in ways that are consistent with the information supplied with the medicines.”

It encourages practitioners to reach agreement with patients on the duration and review of any proposed course of medication or treatment. Non‐pharmacological options should also be considered, such as physical rehabilitation advice for pain conditions, lifestyle advice, psychological and social therapies and support interventions for anxiety and depression. Any prescribing of potentially addictive medicines should be informed by current guidance from NICE and supported by evidence provided by NHS Evidence (www.evidence.nhs.uk) and the British National Formulary.

Care must be taken when reducing and stopping addictive medications as this can cause serious withdrawal symptoms in some patients. The authors advise: “Very many of those individuals affected by dependence on prescription or over‐the‐counter medicines require expert treatment and support to reduce their medication. Withdrawal symptoms for some medicines can be prolonged and some individuals require a gradual reduction to achieve success. The recovery pathway for an individual needs to take account of the medicine(s) to which a patient is addicted, any ongoing physical or psychological health needs, the period of addiction and the wider support needs of the patient.”

Consultant psychiatrist Dr Emma Whicher, of the Royal College of Psychiatrists, said: “Addiction psychiatrists are increasingly working with people who have developed dependence problems with prescribed or over the counter medication. Although these medications are beneficial to many people, awareness of the alternatives and risks is also important. This statement recognises the problem and supports people in their recovery. In addition treatment is available and effective for people who develop addiction to prescribed or over the counter medication.”

The RCGP has developed factsheets for GPs and their teams which will be available shortly and followed by an online learning module for GPs to inform their own continuing professional development to ensure they keep abreast of the latest treatments and developments in this area.

ACTION: Discuss fully with patients the risk/benefits of addictive medicines such as tranquilisers or painkillers and ensure that repeat prescribing is subject to regular review to prevent dependence