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THE IMPOSSIBILITY OF DIALOGUE WITH
THE DEPARTMENT OF HEALTH
March 10, 2009
Ms Dora East
Department of Health
79 Whitehall London
10 March 2009
Dear Ms East,
"There's no scientific evidence to indicate that one particular tranquilliser is worse than another ... To act just against one would he wrong because there is a problem with the whole group."
Professor Michael Rawlins, member of the Committee on the Safety of Medicines and chair of its Subcommittee on Safety, Efficacy and Adverse Reactions, Vice-chairman and chairman of the Committee on Safety of Medicines, Chairman of the National Institute of Health & Clinical Excellence (NICE), Chairman of the Advisory Council on the Misuse of Drugs, Professor of Clinical Pharmacology at the University of Newcastle.
"It is difficult to defend that we have such a huge problem of benzodiazepine prescription and long-term use and therefore dependence. – Professor Louis Appleby, National Director for Mental Health
"There's still a significant continuing problem with benzodiazepines in this country. We would have liked if it was solved 20 years ago, but it still exists. We continue to work as a College with prescribing groups around the country to try and continue to raise awareness of this issue and reduce the prescribing of these drugs to appropriate use, but it is a very long struggle. ..."– Dr Jim Kennedy, Royal College of General Practitioners
"I am passing your letter to Paul Boateng who, as legal affairs spokesman, has specific responsibility for the litigation side of what is a national scandal." Rt. Hon. David Blunkett MP.
"Clearly, the aim of all involved in this sorry affair is the provision of justice for the victims of these drugs [tranquillisers]." Paul Boeteng MP
"The Medical profession, I think, is fairly ashamed of what has happened..." Professor Malcolm H Lader
"Well I think that you'll know that this is nothing short of a national scandal that many practitioners know about..." Professor Robert Kerwin
"Increasing numbers of people have been turned into drug addicts through legal prescriptions..." Dr Vernon Coleman
Reading your reply to me again this morning (3 March 2009), I have a suspicion that you have sent an omnibus 'reply' to my reply to you and to my Illegal v Legal paper with accompanying letter. If so, the Department has risen to new heights of contempt for the predicament of patients and completely ignored the entire document which is 12 pages long and which was described by benzodiazepine expert Professor C. H. Ashton as an important document.
The document entitled Illegal v. Legal Benzodiazepine Addiction was an attempt to provide an explanation to your department that there are clear differences between the two populations and you cannot treat them in the same way – something which common sense would tell most people. But it seems from your reply that the department intends to regard them as one.
Over the years, the department has shifted its argument several times. In essence the DoH has moved from an official recognition that iatrogenic addiction was something prescribers inflicted on patients to a position where patients are seen as having inflicted addiction on themselves, just like people who use them on the street illegally. Fifty years of iatrogenic addiction and more than a million existing addicts would have merited a dedicated support service wouldn't you think and not statements about how drug treatment services have been developed in a way that allows the service to meet the needs of individuals irrespective of their dependency? There is no treatment in Primary or Secondary 'care settings'. There is no treatment in a bottle or pack for those permanently injured by iatrogenic benzodiazepine addiction. GPs have no knowledge of benzodiazepine withdrawal procedure (but carry on addicting patients anyway) and Drug Misuse centres and psychiatric hospitals are inappropriate as the department has been often told before. All the consequences of prescribed addiction are borne by the patient, not by prescribers, not by illegal drug use services which patients cannot access and certainly not by government.
You answered not a single point made about the position of injured patients – neither in your first letter nor the second. Instead, following the new DoH line (which no evidence in this world supports) of patients being drug misusers and abusers, you set out a positive picture of what was being done for illegal users and how successful it is.
Really the refusal of the department to engage with what some people in it know to be reality is grossly despicable. And the department has the nerve to maintain a pretence that it is there to protect public health? It would be obvious to anyone other than a DoH bureaucrat that the quotes at the top of this page demonstrate unarguably that patients have been abused by prescribed drugs for half a century and not the other way round. But you simply will not recognise truth and reality in case it sets a precedent to do so, preferring instead what Professor Ashton described as 'weasel words'. How you sleep at night is beyond me. The DoH is indeed the Circumlocution Office:
'Regard our place [The Circumlocution Office] from the point of view that we only ask you to leave us alone and we are as capital a Department as you will find anywhere...It's like a limited game of cricket. A field of outsiders are always going to bowl in at the Public Service, and we block the balls...Clennam asked what became of the bowlers? The airy young Barnacle replied, that they grew tired, got dead beat, got lamed, got their backs broken, died off, gave it up, went in for other games.' Charles Dickens, Little Dorrit, pp 736, 737
Our ref: 7000000391079
Department of Health
3 March 2009
Dear Mr Downes-Grainger,
Thank you for your further letters of 13 February to Dawn Primarolo and the Customer Service Centre about benzodiazepines and the appointment of David Nutt to the Advisory Council on the Misuse of Drugs (ACMD). I have been asked to reply.
I was sorry to read that you were dissatisfied with my previous reply (our ref: 7000000378848).
Drug treatment services have been developed in a way that allows the service to meet the needs of individuals irrespective of their dependency, rather than the development of drug specific services. One of the reasons for this that a large number of those taking drugs are not using one substance alone, and need a range of interventions to reflect this when undergoing treatment. Data on the number of people accessing, and being retained in, these services are all positive, which indicates that this type of approach meets the needs of individuals.
The Department expects that those with a dependency on any drug should have access to a range of services both in primary and secondary care settings to meet their needs. As you may be aware it is the responsibility of local drug action teams (DATs) to meet the specific treatment need of their locality. This is why Primary Care Trust allocations for the pooled drug treatment budget for substance misuse, which DATs received to use as appropriate for their area, increased by 28 per cent in 2005/6.
With regard to your ongoing concerns about David Nutt, there is little I can add to the information previously given to you. You may wish to write directly to the ACMD at the following address:
c/o The Home Office
3rd Floor Seacole Building 2 Marsham Street London SW1 P 4DF
Tel: 020 7035 0454
I appreciate that you may find this reply disappointing, but I hope I have been able to clarify the Department's position.
Customer Service Centre
Department of Health
10 February 2009
Your ref; 7000000378848
Dear Customer Service Department,
You may be surprised to learn that your hope that I would find your reply helpful regarding my concerns about Professor David Nutt, has not been fulfilled. Much of what I take to be reassurance has been ineffective and some of the assertions are untrue.
Your letter to me consists of 27 lines and of those only 5 are in any way to do with the question. The first four paragraphs out of a total of five are a description of what the DoH has done in the area of tranquilliser addiction. I have read those paragraphs so many times over the years that I can almost repeat them word for word. It is as though the department has an addiction to irrelevance rather than patient protection.
If the DoH, its agencies and local health authorities had taken effective action on the benzodiazepine scandal, statements of continuing tranquilliser damage and the unavailability of help for those affected historically and today would not continue to be made by Health Select committees, APPGs, individual MPs, campaigners and patients.
As you must be aware, not only does David Nutt conflict with DoH policy on tranquilliser prescribing but he also conflicts with Home Office policy on cannabis and ecstasy. The Home Office has at least been forced by the media into 'having words' with its own top expert and we are told that he has apologised to the Home Secretary. As reported last night however, it seems likely that the 'apology' was something less than that and Nutt's self belief remains undiminished. But as a comparison, the best the DoH can do over the crucial area of legal tranquilliser injury and addiction is to state in essence that as a doctor and in his professional capacity, David Nutt can influence as many medics as he likes into over-prescribing in direct contravention of government advice.
The idea that medics who listen to his views in lectures or read his papers are unaware of who he is in public life is a nonsense but that is not the problem. The real problem is that for years health ministers have maintained that the priority of the DoH is to prevent addiction occurring in the first place (this after 50 years of continuing harm to patients). The Department of Health can never in truth make this statement again. The department's priority it seems is not to prevent patients becoming addicted leading to health and socio-economic injury, but to maintain the freedom of doctors to flout mainstream medical opinion and increase the scale of the addiction.
Finally can I say that I find it hard to accept that Dawn Primarolo came anywhere near these concerns. To believe that, I would have to also accept that now she is in government she has somehow come to believe something different from what she believed in opposition. Perhaps she has, but when those who know nothing about the tranquilliser scandal reply on behalf of those who do, ignoring the points being made in the process, it is hard to know where truth lies.
Our ref; 7000000378848
23 January 2009
Dear Mr Downes-Grainger,
Thank you for your letter of 19 December to Dawn Primarolo about Professor David Nutt, the newly appointed Chairman of the Advisory Council on the Misuse of Drugs (ACMD). As you will appreciate, Ms Primarolo receives a large amount of correspondence and is unable to respond to every letter personally. I have been asked to reply on her behalf.
The Department of Health regards involuntary addiction as a very important issue. As you may be aware, the main focus of the Department'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 to benzodiazepines.
I can assure you that the safety of the use of benzodiazepines in routine clinical practice is closely monitored by the Medicines and Healthcare products Regulatory Agency (MHRA). Any possible new safety issue to emerge is evaluated and, if necessary, appropriate action will be taken and the product information for prescribers and patients updated.
As you are aware, concerns about the safety of benzodiazepines, especially in relation to the risk of involuntary addiction, has led to action being taken by the Department, the MHRA and other professional bodies to limit prescribing, provide extensive warnings about the risks of dependence and advice about gradual withdrawal. Health professionals were informed of these changes and various reminders have been distributed by the MHRA and the Department of Health since 1980.
The Department is aware of recent comments made by Professor Nutt. However, the Department understands that said comments were made in a professional capacity and not as part of his role of Chairman of the ACMD, I would like to clarify that Professor Nutt's views on benzodiazepine do not reflect the ACMD's views on this matter as a whole.
I hope this reply is helpful.
Customer Service Centre Department of Health
Dawn Primarolo MP
Minister of State
Department of Health
19 December 2008
Dear Ms Primarolo,
I am writing to you on the subject of Professor David Nutt, recently appointed chairman of the ACMD for two reasons –
I know that as far back as the 1980s you were seriously concerned about the impact on patients of these drugs as were David Blunkett and Paul Boeteng, and asked a series of questions in the Commons.
I know that you will therefore be aware that what David Blunkett referred to as a 'national scandal' has still not been resolved.
In 1980 the Committee on the Review of Medicines, in its 'Systematic Review of the Benzodiazepines' concluded that:
"The number dependent on benzodiazepines in the UK from 1960 to 1977 has been estimated at twenty-eight persons. This is equivalent to a dependence rate of 5–10 cases per million patient months."
By that time there had been hundreds of millions of prescriptions and the conclusions, as they were simplistically based on the number of Yellow Cards received were as you know nonsense.
In 1988, based presumably on a more accurate assessment of the facts and available research, the Committee on the Safety of Medicines issued Current Problems 1988; Number 21: 1-2.which said among other things that:
'Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.'
In January 2004, with an understanding that benzodiazepines were still being over-prescribed and doctors were ignoring the advice in the British National Formulary, the Chief Medical Officer Sir Liam Donaldson wrote in 'A communication to all doctors from the Chief Medical Officer CMO's Update 37.'
"Doctors are being reminded that benzodiazepines should only be prescribed for short-term treatment, in light of continued reports about problems with long-term use. Clear guidance for appropriate use was published in 1988 by the Committee on Safety in Medicines (CSM)."
This advice from government coincides with and reflects accurately the position of a large number of authorities and agencies around the world but now it is clear that a senior government adviser in the Home Office does not agree with this position and is actively seeking to overturn it in this country.
I have read papers from Professor Nutt in the past. Professor Nutt was still saying at the end of the 20th Century:
"The case for benzodiazepine dependence causing real damage has not been made."Recently I was made aware of a lecture he gave in Newcastle in November 2008. Presumably he will continue to make others in an attempt to disseminate his view of things as widely as possible. The lecture to around 100 psychiatrists, researchers, academics and medical students cited no plausible evidence for his position but nevertheless his expert opinion regarding benzodiazepines was
That tolerance does not develop to the anxiolytic effects of benzos.
It is possible to take them for as long as you like (many years) and problems will only occur in withdrawal.
He did not mention the effects of benzodiazepines on thinking processes, on human aspirations, relationships, economic activities and the many reported physical effects.
The crucial point about these views, which former patients who have experienced the injuries produced by benzodiazepine use find disgraceful, is that Professor Nutt is a very influential man with ready access to doctors in the NHS. As well as being the chairman of the ACMD, he is Professor of Psychopharmacology at Bristol, a Clinical Consultant in pharmacology and Editor of the Journal of Psychopharmacology. It is clearly not possible for the DoH to maintain that it is doing all it can to reduce the incidence of addiction when Professor Nutt, as a key government figure is on the ground, doing all he can to increase it.
According to the Medical Research Council website for 2008 he has the following major declarations of interest:
Personal Remuneration (employment, pensions, consultancies, directorships, honoraria etc) Consultancies/Advisory Boards – Pfizer, GSK, Novartis, Organon, Cypress, Lilly, Janssen, Lundbeck, BMA, Astra-Zeneca, Servier, Hythiam, Sepracor Speaking Honoraria – Wyeth, Reckitt-Benkiser, Cephalon Grants or clinical trial payments – MSD, GSK, Novartis, Servier, Janssen, Lundbeck, Pfizer, Wyeth, Organon
Professor Nutt is clearly seen by Pharmaceutical companies as an Opinion Leader and gave his lecture not only to present prescribers but to future prescribers as well. I am sure you will see the grave contradiction in all of this and the likely serious consequences for the health of NHS patients. Patients reporting to the Department of Health what has happened to them through tranquilliser prescribing are told that the department's priority is to prevent addiction occurring in the first place. They are told of the CSM Guidelines on prescribing, the CMO's reminder and the advice in the BNF. On the other hand we have a senior government adviser with a significant position now actively declaring that there is not much wrong with the drugs and they can be safely prescribed indefinitely.
I have no doubt you will agree that in disseminating such views, Professor Nutt cannot be seen as merely expressing an opinion, on a similar basis to individual doctors exercising clinical judgement. Professor Nutt holds an official government position and therefore his assertions will carry great weight with doctors. Patients and yourself in the 1980s and 90s, fought hard to ensure recognition of tranquilliser drugs as addictive and broadly deleterious to health. Indeed last year, reinforcing this truth, Dr John Marsden, himself a member of the ACMD said:
"If any drug over time is going to just rob you of your identity and be an ironic reaction to early effectiveness – [leading] to long, long term disaster, it has to be benzodiazepines."
If the DoH is to allow the views of David Nutt to be broadcast as though there is a possibility that they might become official pronouncements, or if it sees them as merely part of a debate, where does that leave all that has been said in the past by the department? The current CMO, all advisers past and present and researchers around the world would look foolish to say the least if Professor Nutt's views are allowed to gain wider acceptance in medical practice. Where does that leave the legal position of patients?
It is extremely difficult to gain legal redress for injury due to the over-prescribing of tranquillisers, not least because of the Bolam principle, but if that defence is strengthened because individual doctors can point to expert opinion they received in a lecture or through an article written by Professor Nutt, then it will become even more so.
Professor Nutt is reported to have said that he seeks to change DoH guidance. In doing so he is attempting to speak and write out of existence the very real experience of large numbers of people and one wonders why he is doing it. Is he misguided, blinded by the pursuit of academic medicine or his relationship with drug manufacturers? Whatever the reason, he is wrong in his conclusions. But the consequences of the influence of his views should not be under-estimated or dismissed.
I would very much appreciate your comments in due course.
December 19, 2008
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