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(Round Table Discussion)

Professor C Heather Ashton, DM, FRCP,
BMA Meeting, January 22, 2013

In 2009 the Department of Health commissioned reports on addiction to prescribed drugs and over-the-counter medicines from the National Treatment Agency and the National Addiction Centre.

In introducing these reports when they appeared in 2011, the then Public Health Minister, Anne Milton, stated [I quote]: "For the first time we have a national picture of what is happening in the community and how we can address pain-killers and tranquillisers". She added [I quote again]: "Most areas of the country have services in place to support people who have problems".

How wrong she was! How complacent and short-sighted! Both these Ministerial statements were and are quite untrue!

The commissioned reports for some reason conflated prescription and other data from totally different populations of dependent (addicted) drug users - (1) those who had misused psychotropic drugs intentionally or recreationally and were taking prescribed opioids or benzodiazepines as part of a detox program, and (2) those who had been prescribed such drugs by their doctors for anxiety or pain, did not misuse other drugs, but had unknowingly become iatrogenically dependent because of long-term misprescriptions. This group were also stigmatised as misusers although they were simply compliant with their doctor's advice. Somehow the existence of this group was overlooked, but these different populations of addicted users clearly require different consideration and separate management. Services for illegal or recreational users are inappropriate for the second group.

The DOH organised several roundtable discussions but failed to obtain a consensus on what should be done about this problem. An all-party parliamentary group (APPGITA) made frequent representations to the DOH but these were ignored and no action was taken.

The BMA may be falling into the same trap if we are to consider at this meeting addiction to all the "abused classes of prescription drugs" [as my invitation letter puts it], including "opioids (for pain), CNS depressants (for anxiety and sleep disorders) and stimulants (for ADHD and narcolepsy)". One simply cannot lump together all people addicted to these drugs, nor describe all people addicted to prescribed drugs as abusers or misusers. Addiction is an exceedingly complex condition - it depends not just on the drugs but also on the motivation for taking them, the dose taken, the duration and frequency of use, the personality of the user, and many other factors.

We don't even know how many people are addicted to prescribed drugs. The National Addiction Centre produced some data on benzodiazepine prescribing using the Prescription Cost Analysis system. But on this system 10 prescription items may represent 10 repeated prescriptions for one patient or 10 single prescriptions for 10 different patients. Nor does the system record the indication for the script (benzos are often prescribed for non-psychological conditions such as sports injuries, backache, etc) or whether the patient becomes dependent. Thus it gives no information, either on the extent of harm or the number of patients involved.

The DOH often states that there are over 1 million long-term prescribed benzodiazepine users in the UK. This number is a rough estimate based on a few surveys and a small number of computerised GP records (We did one study in Newcastle on 7 typical GP practices and found an average of 185 long-term [over 6 months] benzodiazepine users in each practice). This number does extrapolate to over a million such patients in the UK, but there was no way of measuring how many of these were dependent.

However, more accurate information on benzodiazepines and other drugs, including the indications for scripts, dosages, frequency, length of use, symptoms and other data, is available from the GP research data base (GPRD) which has 3 million patient records from 400 primary care UK practices. Some of us applied to the DOH for funding to obtain this data for benzodiazepines but were not supported. So we still don't know the size of the problem in relation to benzodiazepines, let alone for opioids prescribed for pain or stimulants prescribed for ADHD. Maybe the BMA can help us here - we really need this information.

It is often believed that subjects treated with opioids for pain have no trouble in withdrawing the drug once the cause of the pain has been removed, but subjects treated with opioids, especially tramadol, often prescribed by GPs for minor injuries, not infrequently develop an addiction problem, and a significant number of people have an addiction to over-the counter codeine preparations. Similarly, methylphenidate (Ritalin), widely used for ADHD, is a highly addictive drug, closely related to cocaine and amphetamine. It is commonly abused and has a market value in school playgrounds. We have no evidence on the extent of this problem in the UK, yet it is important for adult psychiatrists who have to decide whether to continue or withdraw the treatment when the patients reach adolescence and early adulthood - the peak age for the onset of schizophrenia and bipolar disorder, and Ritalin also carries a risk for pregnancy.

With regard to treatment for people addicted to prescribed drugs, the DOH told us that this matter is always referred to the local PCTs, claiming that adequate services are freely available in most areas. But there is no evidence for this claim - they had not done their homework - (so much for evidence-based medicine!). It took an unpaid researcher for the all-party parliamentary group to send a questionnaire to the 149 UK PCTs inquiring whether they provided services for dependent prescribed benzodiazepine users who did not misuse other drugs. This was a result of many letters from prescribed addicted users saying that they were unable to obtain admission to local addiction centres or receive any treatment unless they also abused opioids or illegal drugs. The answer that the researcher received was that 84% of the PCTs had no services at all for these benzodiazepine dependent patients. Only 6 of the 149 PCTs had dedicated services, 11 had partial services, but the rest had no separate services or did not reply.

Yet long-term benzodiazepine use and addiction can cause a severe illness with many physical and psychological symptoms and considerable socio-economic consequences, including cognitive impairment, family break-up, loss of job, hospital investigations, traffic accidents, falls and fractures, withdrawal difficulties, and sometimes apparently permanent damage which has never been properly investigated.

It seems that the new Health Bill plans for "Integrated Services" for addictions this year will still be devolved to the local authorities. A major problem is that many GPs have no knowledge or experience of benzodiazepine withdrawal, and also claim that they have no time to devote to it. Many clinics that deal with drug addiction are similarly unskilled in benzodiazepine withdrawal for non-drug abusers. Clinics specialising in opioid withdrawal are only now beginning to contemplate methadone withdrawal after years of long-term "maintenance" prescribing, often with long-term benzodiazepines as well.

At present, services for long term prescribed benzodiazepine users are mainly provided by a handful of courageous charities. These services are excellent but are grossly inadequate compared to the size of the problem. Staffing levels are low across all the projects, with many using volunteers. They rely largely on small, insecure grants from a variety of private and statutory sources. It seems that some, such as CITA in Liverpool, are threatened with closure if they do not also treat opioid and other addictions (on which they naturally have little experience or training). What is needed is extended nationwide provision of specialised benzodiazepine (and other drug) support services, for the large population of iatrogenically dependent people. These services could be organised on an outreach principle within GP surgeries, as carried out successfully by CITA and the Bradford Bridge Project. All these projects are in need of many more field workers, and more projects are needed.

This issue has been raised regularly by individuals and through debates and questions in both Houses of Parliament, but has received only dusty answers. It seems that the least the DOH should do, if it persists in devolving such matters to the local authorities, is to convey to all 149 of them the urgency of the case and to provide ring-fenced funding for specialised benzodiazepine support and withdrawal services, along with appropriate staff training, and perhaps a series of pilot projects. Maybe the BMA could endorse such an approach.

Otherwise we will remain stuck in the present Slough of Inertia and Ignorance. The DOH will continue its consistent tactic - of giving the appearance of action but achieving nothing, backing non-unanimous consensuses consisting largely of empty words, and making policy decisions without first ascertaining the facts.

One of the most important things the BMA could do, as a start to break the deadlock, is to issue a statement recognising the illness of involuntary tranquilliser addiction - that is addiction to benzodiazepines, and sometimes other drugs such as SSRIs, caused by long term prescribing to compliant patients. The population involved - which is largely ignored by the DOH - accounts for far more addicted users than all the misusers/abusers of illegal drugs on which the DOH spends so much money. Surely the DOH has a responsibility to provide services for these people?

Finally, I would like to thank the BMA for lending a prestigious ear to our concerns.

C.H. Ashton
Emeritus Professor of Clinical Psychopharmacology
University of Newcastle upon Tyne
January 22, 2013

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