DEPARTMENT OF HEALTH SUBMISSION
AND CORRESPONDENCE 2003-2004
Professor C Heather Ashton, DM, FRCP
October 14, 2003
School of Neurosciences
Division of Psychiatry
The Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne NE1 4LP
The Ashton Manual · Professor Ashton's Main Page
Meeting attended by Rosie Winterton MP, Minister of State, DOH, Phil Woolas MP, John Grogan MP, Jim Dobbin MP
There are still about 1 million long-term, prescribed benzodiazepine users in the UK. Our own survey in Newcastle found an average of 186 such patients in every GP practice. Similar figures have been obtained in surveys in Gateshead, Liverpool and other UK general practices.
These patients, taking prescribed benzodiazepines regularly for 6 months, a year, often many years, have become dependent on the drugs through no fault of their own, yet they receive little medical help or advice. Almost daily I receive letters, phone calls and emails from such people who claim that they get scant support from their doctors and almost none if they wish to withdraw their medication.
In fact benzodiazepines are still affecting people at all stages of life, from the elderly who take them chronically as sleeping pills or are given them to keep them quiet in retirement homes, to young and middle-aged patients still being prescribed potent benzodiazepines such as Ativan for long periods, to psychiatric patients discharged into the community, still taking benzodiazepines started in hospital, to women prescribed during pregnancy and thus to their developing foetuses and newborn infants. And finally this overprescription has led to benzodiazepines leaking into the illicit drug scene - there are about 100,000 so-called "recreational" benzodiazepine abusers in the UK who take the drugs illegally, (with all the health and social risks of polydrug abuse, including hepatitis and HIV) and this number is growing rapidly.
I ran an NHS benzodiazepine withdrawal clinic in Newcastle for 12 years from 1982-1994. The success rate for withdrawal was nearly 90% and the patients' physical and mental health improved. But when I retired this clinic closed, along with other dedicated NHS withdrawal clinics throughout the UK. As far as I know, there are none left now. Some benzodiazepine dependent subjects have been diverted to "detox" units designed for alcoholics and users of hard drugs, but such clinics are highly unsuitable for benzodiazepine patients. Other patients are simply left to fend for themselves or to attend charities and self-help groups which receive little public funding.
It is a well-established fact that long-term benzodiazepine use leads to physical and mental health problems. In addition there were 1810 deaths from benzodiazepine overdose 1990-1996 according to Home Office Statistics and there are an estimated 1600 benzodiazepine-related traffic accidents with 110 deaths each year in the UK.
There is a regrettable paucity of available treatments for such patients. This is partly because many doctors have not heeded the advice of the Committee on Safety of Medicines, circulated to all doctors in 1988, that prescriptions should be short-term only (2-4 weeks) and that benzodiazepines should not be prescribed to patients with depression, and partly because doctors are unsure how to handle benzodiazepine withdrawal, despite the sound advice available in the British National Formulary that all doctors receive.
The only contributions I have been able to make since having by law to retire from NHS practice at the age of 65 is to write the booklet "Benzodiazepines: How They Work and How to Withdraw" (available free on the Internet), to give advice to local support groups and charities such as the North East Council for Addictions (NECA) in Newcastle, and to answer several hundreds of personal requests for advice.
I submit that there are some minimum immediate requirements for action that the Government could and should take now:
The CSM should issue repeat guidelines on benzodiazepine prescription and withdrawal methods to all doctors, and the Chief Medical Officer should also issue a statement to all doctors outlining the problem and providing guidelines for prescription and withdrawal. I would be happy to assist in the drafting of such documents.
The Government should provide finance for health workers, such as community nurses and pharmacists and counsellors, to attend GP practices to support patients withdrawing from benzodiazepines. They can supply the much needed regular patient contact that GPs don't have sufficient time for. This approach has already proved successful in some centres but needs to be extended nationwide.
The Government should provide grants to support groups such as Council for Involuntary Tranquilliser Addiction (CITA), Bristol & District Tranquilliser Project, North East Council for Addictions (NECA), the Oldham Group and others to set up and run benzodiazepine support and withdrawal centres. Many of these groups have more knowledge and experience of benzodiazepine problems than doctors.
These are modest short-term aims. Long-term, research and development of non-drug treatments for anxiety and insomnia is needed, as well as better education of doctors on long-term drug effects. Already there are problems arising with non-benzodiazepine hypnotics such as the "Z-drugs" (zopiclone, zolpidem and zaleplon) which are being prescribed instead of benzodiazepines but are causing the same problems including dependence and abuse.
It is a tragedy that these steps are needed 50 years after benzodiazepines were first introduced. They could have been foreseen and prevented but instead the skeleton was locked in the cupboard for many years. Now we are faced with worms that are crawling out of the woodwork including not only the problems of long-term prescribed users but also the increasing spectre of illicit benzodiazepine abuse.
REPLY BY ROSIE WINTERTON MP,
MINISTER OF STATE,
DEPARTMENT OF HEALTH
TO JOHN GROGAN MP AND OTHERS
January 11, 2004
Dear John,
Thank you for a very helpful meeting in October to discuss the issues associated with benzodiazepine prescribing and the problems experienced by those who are now dependent. Thank you also for the documents you have supplied.
First of all let me say that the Department of Health, the NHS and the various professional groups regard involuntary addiction upon benzodiazepine drugs as a very important issue. We have taken a number of steps to tackle the problem, and we are encouraged that the number of prescriptions is now falling.
As you know, the main focus of the Department of Health's action in this area has been to try and prevent addiction/dependence occurring in the first place by warning GPs and other prescribers of the potential side-effects of prescribed medicines and the dangers of involuntary addiction. I know you are aware of the advice issued in the British National Formulary (BNF), updated twice yearly and issued free to all doctors, and the advice issued by the Committee on Safety of Medicines (CSM).
In addition, we have commissioned the National Institute of Clinical Excellence to develop a guideline on the management of anxiety. This will include recommendations about drug treatments. I believe we can remind GPs of how important this is by publishing a short note in the Chief Medical Officer's Update and I will ensure that this is done.
At the meeting the dangers of illicit drug taking and of the operation of a black market in tranquillisers was mentioned. I understand that a common means of obtaining diverted drugs is by deception of the general practitioners either through plausible exaggerations of daily consumption or multiple registration with different GPs, commonly as a temporary resident.
As you know, responsibility for prescribing, including the issue of repeat prescribing of tranquillisers, rests with the doctor who has an ethical responsibility to inform patients about the treatment proposed, including any possible side-effects of prescribed medicines. It is the responsibility of the PCT to ensure that adequate controls of prescribing are in place. Conspicuous poor prescribing would result in disciplinary action, either from the PCT or from the General Medical Council. The use of clinical audit and peer review has also provided a powerful incentive for local clinicians to study their patterns of care and improve prescribing standards.
It is the responsibility of the prescribing doctor to try to ensure that any drugs issued are not diverted onto the illicit market. The Misuse of Drugs Act 1971 makes it illegal to supply benzodiazepines to someone else. Provisions contained in the Criminal justice Bill that comes into force on 29th January this year mean that the maximum penalty will be changed from 5 years in prison and a fine to 14 years. I understand you have concerns about how to change the controls in place relating to these drugs. Of course this is a matter for the Home Office, but I suspect the more promising approach for people who suffer dependence is to ensure there is good awareness among patients, the public and the NHS, and an adequate range of services.
For those who have developed dependence upon tranquillisers, treatment is available in primary and/or secondary care settings. Anxiety management which may be on an individual or group basis, often includes some focus on reduction or cessation of tranquillisers. Such therapy may be available in Clinical Psychology Departments, via a Day Hospital or from a Community Health Team.
I realize that waiting lists for 'talking treatments' can sometimes be too long. This is why we set out standards for access to treatment in the National Service Framework for mental health and issued guidance to help GPs and service users and carers know more about the effective treatments in 2001. Copies of this guidance are available on our website at http://www.dh.gov.uk.
I acknowledge the point made that advice and guidance on prevention is not always enough, but we have to work with the levers that are available to us. This is why, to strengthen the performance management arrangements in place to support best practice, we recently asked the Commission for Health Improvement (CHI) to consider including waiting times for psychological therapies as one of the Performance indicators for mental health trusts, which is still under discussion.
In addition to this, since our meeting, there has been extensive discussion with CHI about the PCT Performance indicators relating to prescribing. Although I understand you may be disappointed at the outcome, we were persuaded by the arguments made by the CHI and others that we should not restrict our attention to the Benzodiazepine group of drugs alone. We have therefore agreed to broaden the focus and extend this PI to include other drugs such as ant-depressants and anti-psychotics as well. Information about this has been placed recently on the CHI website www.chi.nhs.uk.
Last but by no means least, I would urge you to contact the National Institute for Mental Health's (NIMHE) Expert by Experience Programme. I would like to see better information available for benzodiazepine users about the scope for supported self help, and about best practice. NIMH(E) is supporting dissemination of information for service users and carers and I believe there may be an opportunity for you to strengthen this.
I am copying this letter to Jim Dobbin MP and Phil Woolas MP and I assume you will share this letter with those who accompanied you to the meeting.
Best wishes,
Rosie Winterton
REPLY BY PROFESSOR C H ASHTON
TO ROSIE WINTERTON MP,
MINISTER OF STATE,
DEPARTMENT OF HEALTH
Ms. R. Winterton,
Department of Health,
Richmond House,
79 Whitehall,
LONDON SW1A 2NS
30th January 2004
Dear Ms. Winterton,
Thank you for your letter about the meeting with John Grogan and others last October 14th, which has now been passed on to me. We appreciate your having given thought to many of the points we raised about involuntary dependence on prescribed benzodiazepines. However, I would like to raise some further issues.
(1) You say in your letter that you are encouraged that the number of prescriptions for benzodiazepines is now falling. Unfortunately, as we pointed out at the meeting, this fall is largely due to prescriptions being shifted to the "Z-drugs" (zopiclone, zolpidem and zaleplon) which have all the same disadvantages of the benzodiazepines including drug dependence (addiction) and are more expensive. There were 3.57 million prescriptions for these drugs in England in 2001-2 and 3.99 million in 2002-3 (Prescription Pricing Authority - PPP). The National Institute for Clinical Excellence (NICE) is looking into these "Z-drugs" at present and is not likely to recommend them over benzodiazepines, indicating that, unless steps are taken, benzodiazepine prescriptions are likely to rise again.
Some of the fall in benzodiazepine prescriptions is also due to a shift towards antidepressants which are more toxic than benzodiazepines and also produce withdrawal ("discontinuation") effects. Thus the fall in benzodiazepine prescriptions does not necessarily signify a benefit to patients and is not necessarily a basis for encouragement.
(2) We are aware of the excellent advice about benzodiazepines in the British National Formulary (BNF) and that of the Committee on Safety of Medicines (CSM). Unfortunately, doctors are not heeding this advice and, as I mentioned at the meeting, surveys in Newcastle, Gateshead, Sunderland, Liverpool and other parts of the country show that there are on average over 180 long-term (6 months to many years) prescribed benzodiazepine users in every general practice despite the guidelines that prescriptions should be limited to 2-4 weeks only. Prescribing is no higher in the North of England than elsewhere and there are over 1 million long-term prescribed benzodiazepine users in the UK.
For this reason, we welcome your assurance that the Chief Medical Officer will publish a "short note" (though why is "short" specified?) to remind GPs with advice on benzodiazepine prescribing, and that you have commissioned NICE to develop a guideline on the management of anxiety.
(3) However, the management of anxiety, though it may possibly help to limit future anxiolytic benzodiazepine prescriptions, does not address the root of the problem that we hoped to draw to your attention at the meeting. It should not be assumed that all benzodiazepines are prescribed for anxiety. In fact almost twice as many benzodiazepines are prescribed as hypnotics. In 2002-3 there were 5.67 million prescriptions for benzodiazepine anxiolytics in England but 10.45 million for benzodiazepine hypnotics (PPP). In addition, many benzodiazepines were prescribed for conditions unrelated to anxiety e.g. as muscle relaxants in orthopaedics, for post-flu depression, menstrual problems and home difficulties (Ashton 1987). Many of these people have become benzodiazepine-dependent after prolonged use.
What is needed are dedicated clinics or other arrangements to help people already dependent on benzodiazepines to withdraw. You state that "treatment is available in primary and/or secondary care settings" for those who have developed dependence on tranquillisers. This is simply not the case. I and many others in the field get daily telephone calls/letters/e-mails from benzodiazepine-dependent people who are desperate because they are receiving no help or advice from their doctors and cannot find any support groups or benzodiazepine withdrawal clinics. I also mentioned this point at the meeting.
"Talking treatments" by psychologists, for which you rightly say there are long waiting times, are not always appropriate for benzodiazepine-dependent patients. Clinical psychologists are very rarely aware of the special problems, withdrawal effects, or withdrawal methods for benzodiazepine users. Anxiety management is not always indicated for users of benzodiazepine hypnotics or anxiolytics. The patients need specific information about benzodiazepine-related problems including withdrawal symptoms and personalised withdrawal schedules. Such expertise is usually in the remit, training or experience of clinical psychologists, as I know from my own experience in my benzodiazepine withdrawal clinic. (Addiction clinics for alcohol and illicit drug abuse are clearly inappropriate for these patients.)
Much more beneficial would be the setting up of support groups in the community dedicated to benzodiazepine-dependent clients. These could be staffed by counsellors who are ex-benzodiazepine users trained by a similar scheme which has been set up for ex-heroin users to become drug counsellors. In addition, the participation of trained community nurses, community pharmacists and counsellors in GP surgeries should be encouraged. This approach has already worked well in some areas including Liverpool (as mentioned by Pam Armstrong at the meeting) and Newcastle where the North East Council for Addictions (NECA) and community pharmacists have provided counsellors and pharmacists to GP surgeries. Perhaps the CMO could write not only to doctors but also to pharmacists' and nurses' organisations to encourage this approach.
(4) You mention that the maximum penalty for supply of benzodiazepines to the illicit market will be increased from 5-14 years in prison and a fine. At the meeting, it was pointed out that much of these supplies come from elderly ladies on repeat prescriptions of the hypnotic temazepam (who have taken them for years) who pass on all or part of their prescriptions to their younger relatives. Imprisoning little old ladies will hardly solve this problem! Helping these elderly ladies to stop taking benzodiazepines would be much more to The point and is sometimes feasible with minimal intervention (Heather et al. 2004; Cormack et al. 1994; Bashir et al. 1994). Other users may require more prolonged, experienced and dedicated support in support groups and GP surgeries as detailed above.
(5) There is no mention in your letter, or in the minutes, of the plight of many exbenzodiazepine users who have been left with apparently permanent cognitive and physical damage as a result of long-term prescribed benzodiazepine use. This problem was cogently illustrated at our meeting by a carer of such a patient. Many of these people have difficulty in obtaining DSS benefits because their disability is not recognised. Prolonged and sometimes irreversible sequelae of chronic, often high dose, prescribed benzodiazepine use has been well documented (Ashton 1995). This point should be mentioned in the CMO's "short note" and sent to the DSS so that those affected receive more sympathetic treatment.
(6) I regret to say that the minutes fail to record many of the issues discussed at our meeting. Some of the points may therefore be missed if the minutes are viewed as the "official record". However, a list of follow-up actions is mentioned at the end of the minutes. We have received no feedback on some of these and are not clear whether the suggested actions have been taken.
(7) Finally, we are, as you expected, "disappointed by the outcome" of our meeting, especially for the lack of financial help to set up dedicated benzodiazepine withdrawal clinics. We note that you feel constrained by "the levers that are available" to you, but surely it is the Department of Health that should lead in pressing those levers. For your information, a meeting has been arranged in Bristol on February 4th, 2004 with the European Commissioner for Health and Consumer Protection, Mr. David Byrne, and reports on UK and European drug issues, written by Barry Haslam, will be handed over at the meeting.
Thank you again for meeting with us.
Yours sincerely,
References
Ashton H. Benzodiazepine withdrawal: outcome in 50 patients. British Journal of Addiction 1987; 82: 665-71.
Bashir K, King M, Ashworth M. Controlled evaluation of brief intervention by general practitioners to reduce chronic use of benzodiazepines. British Journal of General Practice 1994; 44: 408-412.
Cormack MA, Sweeney KG, Hughes-Jones H, Foot GA. Evaluation of an easy cost-effective strategy for cutting benzodiazepine use in General Practice. British Journal of General Practice 1994; 44: 15-8.
Ashton H. Protracted withdrawal from benzodiazepines: the post-withdrawal syndrome. Psychiatric Annals 1995; 25: 174-9.
Heather N, Bowie A, Ashton H, McAvoy B, Spencer I, Brodie J, Giddings D. Randomised controlled trial of two brief interventions against long-term benzodiazepine use: outcome of intervention. Addiction Research and Theory 2004 (in press).
REPLY BY PAM ARMSTRONG (CITA)
TO ROSIE WINTERTON MP,
MINISTER OF STATE,
DEPARTMENT OF HEALTH
R. Winterton,
Minister of Health
House of Commons
Westminster
London
SW1A 0AA
February 17, 2004
Dear Ms. Winterton,
Thank you for your letter following the meeting with yourself on 14th October 2003.
I feel that there appears to be some misunderstanding about what is actually available to dependent benzodiazepine users. In most areas the help available is non-existent. GPs greatly underestimate the seriousness of the problem and still start new people on these drugs without warning them of the consequences of long term use. The national helpline run by CITA every day takes calls from people desperate to find specialised help who have unwittingly taken benzodiazepines and realised they cannot stop them. Very often doctors try to stop them too quickly and may be unwilling to co-operate and help the patient to cut down slowly.
Services in secondary care simply do not exist for benzodiazepines as services are directed towards severe mental illness, so-called hard drug use or alcohol and expertise among health care professionals concerning benzodiazepines is virtually non-existent.
Reduction in prescribing has occurred for the most part because patients are transferred onto antidepressants, usually SSRIs many of which have their own problems and I have recently provided evidence to the CSM expert enquiry concerning SSRIs which details dependency problems with those drugs.
The other group of drugs onto which patients are switched are those known as 'Z' drugs (zopiclone, zolpidem and zaleplon). These are very expensive and are benzodiazepines by another name. I have recently been involved with NICE analysing the difference between benzodiazepines and the 'Z' drugs in both efficiency and cost and this report is due to be published in March 2004. The report is likely to suggest that these drugs are no better and a great deal more expensive. This is likely to result in a huge move in prescribing back to benzodiazepines.
I applaud the fact that the Chief Medical Officer is to warn doctors about benzodiazepines prescribing, as described in the article in The Guardian last week and other publicity. The difficultly is that doctors are now going to stop many patients' benzodiazepines abruptly without any clear guidance on how this should be done and many, many people will suffer. The publicity last week has led to enormous pressures on our organisation which has no real funding and exists largely on donations.
We run highly effective clinics in GP practices across the North West, in Wigan, Liverpool, Sefton, Ormskirk, Lytham St Annes and Salford. These are a very inexpensive and value for money way of dealing with the problem. Patients are able to withdraw effectively and GPs are made aware of the problem but even in the areas where we are involved we are not in all practices. Many other Primary Care Trusts have contacted us to discuss our work and they through lack of funds have not been able to go ahead with the work even though they have felt it was very much needed.
I cannot help but feel that the situation is not improving. I had great hopes of our meeting with you but proper clinics and training programmes need putting in place if benzodiazepine users are to be given the help to escape this precarious dependence and regain quality of life. Trying to restrict prescribing although needed also needs back up to help doctors and patients to cope.
Your sincerely,
Pam Armstrong
CITA Consultant and Advisor
CITA - COUNCIL FOR INVOLUNTARY TRANQUILLISER ADDICTION
JDI Centre
3-11 Mersey View
Waterloo
Liverpool L22 6QA
