The latest view on opioids and other dependent drug use
News article published on: 1st October 2019
Following on from my last few blogs on the opioid crisis. The eagerly awaited report ‘Dependence and withdrawal associated with some prescribed medicines’ has been released.
The report was commissioned to look at the scale, distribution and causes of prescription drug dependence and what may be done to address this. The report suggests that more people are being prescribed benzodiazepines (originally used in the 1950’s, 60’s and 7-‘s to treat anxiety and insomnia); z drugs, gabapentin, pregabalin, antidepressants and opioid medicines. Further, since at least 10 years more people are being prescribed these drugs and are taking them sometimes, for longer than they should. Some of these drugs may not work after a while and therefore, it is imperative for prescribing doctors to review a patient’s prescription on a regular basis to ensure that the medication prescribed is, if you like, fit for purpose and doing what it should for the length of time it should.
Public Health England (PHE)’s analysis of the data revealed that in ‘2017 to 2018, 11.5 million adults in England (26% of the adult population) received, and had dispensed, one or more prescriptions for any of the medicines within the scope of the review. The totals for each medicine were:
- antidepressants 7.3 million people (17% of the adult population)
- opioid pain medicines 5.6 million (13%)
- gabapentinoids 1.5 million (3%)
- benzodiazepines 1.4 million (3%)
- z-drugs 1.0 million (2%)
The rate of antidepressant and gabapentinoids had increased from 2015/2016 but the other three types of drug had decreased marginally. Women were prescribed more medication than men and opioid and gabapentinoids were prescribed more often in areas of England where there was deprivation.
Statistically speaking, that is 1 in 4 people in England were prescribed benzodiazepines, z-drugs, gabapentinoids, opioids for chronic non-cancer pain, or antidepressants.
The report suggests ‘that Clinical guidelines specify that benzodiazepines should not usually be prescribed for longer than 2 to 4 weeks. Long-term prescribing of opioids for chronic, non-cancer pain is not effective for most patients. And some patients need long-term prescribing of antidepressants to maintain benefit and prevent relapse’.
Also that :
‘Inappropriate limiting of medicines may increase harm, including the risk of suicide, and lead some people to seek medicines from illicit or less-regulated sources, such as online pharmacies. There needs to be increased public and clinical awareness of other interventions, such as cognitive behavioural therapy’.
These are effective in treating acute anxiety and insomnia but they need to be carefully monitored by GPs who prescribe them or other prescribers. They are addictive and the withdrawal effects of coming off of a drug like this can create further problems for the person taking the medication.
Similarly, z drugs (zopiclone, zaleplon and zolpidem) are also often prescribed for longer than they should.
Clinical guidelines state that:
‘In 2014, the European Medicines Agency advised that the recommended dose for zolpidem should be a single dose before sleep, and driving should be avoided for the next 8 hours.41 Z-drugs have the potential to lose any therapeutic effect over time and cause tolerance and a risk of dependence, so the summary of product characteristics (SmPC) advises against long-term use: prescription should be for as short a time as possible and not exceed 2 weeks, including a taper, for zolpidem, not more than 2 to 5 days for transient insomnia, and 2 to 3 weeks for short-term insomnia using zopiclone’.
The report suggests that these are not addictive but there are likely to be issues with sudden withdrawal in so far as the person who stops taking their antidepressant medication abruptly may suffer:
‘F: flu-like symptoms – lethargy, fatigue, headache, achiness, sweating
I: insomnia – and including vivid dreams or nightmares
N: nausea – and sometimes vomiting
I: imbalance – dizziness, vertigo, light-headedness
S: sensory disturbances – ‘burning’, ‘tingling’, ‘electric-like’ or ‘shock-like’ sensations
H: hyperarousal – anxiety, irritability, agitation, aggression, mania, jerkiness’
Therefore, it is sensible to ensure that the medication is gradually reduced over a period of time and then discontinued. Medical supervision is probably the safest way to do this.
The report suggests that in a lot of patients opioids are taken to combat chronic pain especially back pain and that some manufacturers of such medication suggest that the condition is under treated and that opioids are required.
It is stated that in the USA ‘from the mid-1990s to the end of the decade there was a four-fold increase in new users of opioids (from 628,000 to 2.4 million), and an increase of 135% (from 1995 to 2002) in emergency hospital admissions involving opioids’.
Here in England, there has been a steep rise in opioid prescriptions being dispensed to patients within the last 10 years. We are behind the USA as far as statistics go but we are moving in the same direction. Opioids have their place for short term pain relief but long term prescribing of such medication, places patients at risk of addiction.
The recommendations of the PHE report are concise:
- ‘Increasing the availability and use of data on the prescribing of medicines that can cause dependence or withdrawal to support greater transparency and accountability and help ensure practice is consistent and in line with guidance.
- Enhancing clinical guidance and the likelihood it will be followed.
- Improving information for patients and carers on prescribed medicines and other treatments, and increasing informed choice and shared decision making between clinicians and patients.
- Improving the support available from the healthcare system for patients experiencing dependence on, or withdrawal from, prescribed medicines.
- Further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines’.
Suitable medication for the right time period
A multidisciplinary approach is required to ensure that patients are prescribed the medication that they require for the requisite time. Some patients will want an instant cure for a long term condition and others may want short term relief for an acute condition. Ensuring that the combination of medication prescribed to a patient is suitable and will do the trick is key.
Health practitioners must review prescriptions regularly, this will reduce the risk of long term dependence on drugs, other options should be explored such as therapy albeit CBT for depression or physiotherapy for long term pain. Long term repeat prescriptions may be required for some patients but not others. The long term cost for the patient in terms of health and the NHS in terms of financial burden can be improved if a sensible approach to prescribed medication is instituted.
Stephanie Prior:– Head of the Medical Negliglence department