Prescription drug dependence linked to deprivation
Author: Jo Carlowe
Prescription rates are higher in deprived areas of England, new data shows.
The figures come from Public Health England’s (PHE) first-ever review of dependence and withdrawal problems associated with the following five commonly prescribed classes of medicines:
- 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)
Published today, the main findings revealed that one in four adults had been prescribed at least one of these classes of medicines in the year ending March 2018. Half had remained on their prescribed drug for at least the previous 12 months, with between 22% and 32% (depending on the medicine class) receiving a prescription for at least the previous three years.
PHE warns that long-term prescribing is likely to result in dependence or withdrawal problems, and that opioids for chronic non-cancer pain are ineffective for most people when used long-term, while benzodiazepines are not recommended to be used for longer than 28 days.
The number of prescriptions for antidepressants and gabapentinoids are rising, although those for long-term prescribing of opioid pain medicines and benzodiazepines is falling. Nonetheless long-term prescribing still occurs frequently, which is not in line with guidelines or evidence.
For opioids and gabapentinoids, the prescribing rate in the most deprived quintile is 1.6 times the rate in the least deprived quintile, and the co-prescribing rate in the most deprived quintile is 1.4 times higher than in the least deprived quintile (30% compared to 21%).
The review makes a number of recommendations focusing on education and treatment. These include:
- 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
Commenting on today’s publication, Professor Helen Stokes-Lampard, chair of the Royal College of GPs said: "This report… shows that the vast majority of prescriptions issued are short-term, and that we are seeing a decline in opioid prescriptions for chronic pain, both of which are encouraging trends.
"What it also indicates is the severe lack of alternatives to drug therapies for many conditions – and where effective alternatives are known and exist, inadequate and unequal access to them across the country.”
She added: “Whilst the vast majority of prescriptions will be appropriate, if we are to reverse the prescribing trends outlined in this report, GPs need better access for our patients to alternative therapies in the community. We also need more high-quality research into alternatives to drug therapies in general – as well as around dependence and withdrawal - and for this to shape the clinical guidelines that GPs use to inform our practice.”
Dr Andrew Green, who represented the British Medical Association (BMA) during the review process, said: “We have seen the devastation that addiction to prescription drugs has had in the United States, and while the problem here is on a lesser scale, doctors in the UK are of course concerned at the number of patients being prescribed these medicines, and the length of time they are taking them for.
“The BMA has been working for some years with patients and health organisations to understand and address the causes behind high prescription rates, and we were pleased to engage with this review and welcome its recommendations.
“Indeed, today’s report shows that prescription rates for some drugs – including opioid painkillers – are beginning to fall thanks to doctors actively working with their patients to avoid inappropriate prescribing.
“While there isn’t a single cause for high prescription rates, social deprivation, an increased prevalence of mental health problems and poor access to mental health care, a rise in the demand for GP services and a growing, ageing population, are likely to be significant contributing factors.
“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. 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. We are glad that NICE is in the process of developing this.”
Echoing Professor Helen Stokes-Lampard’s comments, Dr Green added: “While there remains a place for prescribing the kinds of drugs this report covers – including, in some circumstances, for long-term use – we need many more alternatives to medication, such as pain clinics, improved access to mental health services, and physiotherapy – the universal provision of which are all lacking.”