Long-term prescribing of addictive medication 'widespread' in England

Hundreds of thousands of patients in England are being prescribed addictive medication over long periods, often in breach of clinical guidelines, a report suggests.

One in four adults in England were prescribed benzodiazepines, z-drugs, gabapentinoids, opioids for chronic non-cancer pain or antidepressants in 2017/18, according to a report by Public Health England (PHE).

Apart from antidepressants, all of these drugs are recommended for short-term prescribing only - but in March 2018 more than 1.1m patients had been receiving prescriptions for opioids for 12 months or more, the report shows.

A total of 455,000 patients had been receiving gabapentinoids for 12 months or more, around 200,000 patients z-drugs and a similar number benzodiazepines for a year or more. More than 2m patients had been prescribed antidepressants for a year or more as of March 2018.

Drug dependence

The PHE report warns that long-term prescribing of these drugs is 'likely to result in dependence or withdrawal problems', but found that dependence and withdrawal rates could not be accurately calculated based on existing data.

The report - the first evidence review of dependence and withdrawal problems linked to these five drug classes - found a strong link between deprivation and prescribing of both opioids and gabapentinoids, with a weaker association for antidepressants. For opioids and gabapentinoids, 'the prescribing rate in the most deprived quintile was 1.6 times the rate in the least deprived quintile', PHE found.

GP leaders said the majority of prescriptions for these drugs were still short-term, but warned that the prevalence of long-term prescribing reflected 'the severe lack of alternatives to drug therapies for many conditions'.

The report found that long-term prescribing of opioid pain medicines and benzodiazepines was falling 'but still occurs frequently' - a practice out of step with guidelines and evidence on effectiveness. Opioids for chronic non-cancer pain are 'ineffective' for most patients when used for more than three months and benzodiazepines are not recommended for more than 28 days, the report warns.

GP prescribing

Prescriptions for antidepressants and gabapentinoids are rising, it found, while prescriptions for opioid pain medicines and z-drugs are now in decline after years of increase. Benzodiazepine prescribing is also in decline.

The report calls for updated prescribing guidelines on drugs that can cause dependence and withdrawal problems, and better training for clinicians.

It calls for patients to be better informed about the benefits and risks of these classes of medication, and for alternatives to medication, such as social prescribing.

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.'

Long-term use

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.'

RCGP chair Professor Helen Stokes-Lampard said: 'This report analyses prescribing data for medications that when prescribed appropriately can be effective and beneficial for many patients – and it 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.

'While 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.'

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