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HOUSE OF COMMONS OFFICIAL REPORT
PARLIAMENTARY DEBATES (HANSARD)
Tuesday, 7 December 1999, 11.30 am
Mr. Phil Woolas (Oldham, East and Saddleworth) : Thank you, Madam Deputy Speaker, for the privilege of opening this debate. This is the first time that I have spoken in the new Chamber. Westminster Hall is not bad as lean-tos go. I shall be grateful for your guidance.
The debate has been given weight by the recent report of the Select Committee on Health on procedures related to adverse clinical incidence and outcomes in medical care. I draw that report and the evidence gathered by the Committee to the attention of hon. Members.
The story of benzodiazepines is of awesome proportions and has been described as a national scandal. The impact is so large that it is too big for Governments, regulatory authorities and the pharmaceutical industry to address head on, so the scandal has been swept under the carpet. My reasons for bringing the debate to the Chamber are numerous and reflect the many strands that weave through the issue.
I was first alerted to the matter when a constituent, Mr. Barry Haslam, wrote to me describing the nightmare in which he has lived as a result of having taken benzodiazepines. He was prescribed Ativan - one of the family of benzodiazepine drugs - for 10 years. As a result, he suffered permanent brain damage, hearing and thyroid problems, fatigue and mood swings, bad circulation, pains in his limbs, slurred speech and memory loss so severe that he cannot remember the past 10 years of his two daughters' growing up: he has lost 10 years of his life. He and other members of the Oldham Tranx support group would have been here today had that been possible.
There are good days between the bad days for the victims of tranquilliser addiction. Like many others of the Victims of Tranquillisers group, Barry is a campaigner. My first impression was that he was a member of the green spidery ink brigade - he bombarded me with letters, documents, quotations and research that he and others had painstakingly eked out of officialdom. However, my constituent is not an obsessive, but a highly intelligent and articulate man with enormous courage and a loving wife who has supported him throughout his campaign. He is a victim of damage to his brain caused by years of heavy dosages of benzodiazepines. There are in this country many thousands of similar cases in which harm has been done, not only to individuals who take the drugs, but to the children of mothers addicted to benzodiazepines while pregnant.
I have permission to cite the case of Mrs. Jackie Gillard, a constituent of my hon. Friend the Member for Basildon (Angela Smith). Mrs. Gillard wrote to me:
"My life is in the pits. I am unable to go out. I get panic attacks. I go to bed and ask God to let me die in my sleep."
Mrs. Gillard's is an especially difficult situation, as her two sons also appear to be victims of the addiction.
Angela Smith (Basildon) : I am grateful to my hon. Friend for having given way; I want not to detract from his excellent comments, but to place on record my gratitude that he has mentioned my constituent.
I have been distressed by the letters that I have received from my constituent on the matter, in which she details not only the impact of the drugs on her, but the effect on her family. She could not even attend her father when he died in hospital, because she could not go out. I ask my hon. Friend for his comments on something else that she has said:
"Life just frightens me every day."
Mr. Woolas : I have received correspondence from hon. Members on both sides of the House describing awful and heart-rending cases such as Mrs. Gillard's from round the country. Recent media interest includes documentaries by the respected "You and Yours" programme on Radio 4 and Tyne Tees Television, and numerous television and radio news reports supported by press reports.
Evidence submitted to the Select Committee by Dr. Peart, national co-ordinator of Victims of Tranquillisers, details the story of benzodiazepines for the past 40 years. In his introduction to that evidence, he says:
"the catalogue of misprescribing, misdiagnosis and mistreatment . . . has cost this country billions of pounds."
The side effects of benzodiazepines are not widely known, despite publicity. Patients are not given the full information about the side effects and are, therefore, unable to make an informed choice. My constituent, Mr. Haslam, would never have taken the drugs had he known the problems that they cause, despite the difficulties that they were originally intended to cure.
As early as 1980, a report in this country on the use of benzodiazepine-based drugs suggested that they were effective for only 10 days, after which they were no longer effective against the wide variety of problems for which they were originally prescribed. It is now an established fact in the medical profession that it takes only seven to 14 days for addiction to take hold of someone taking benzodiazepines. The problem is twofold: the addiction and the paradoxical side effects.
Guidelines on the prescription of benzo-based drugs suggest that patients should be closely monitored while using them, but that does not happen in practice. Patients are able to obtain repeat prescriptions of the medicine without seeing a health care professional, which can lead to patients being prescribed benzos for many years without being offered an opportunity to lower the dosage or try alternative treatments.
There are many problems related to the drugs beyond addiction and side effects. They can have catastrophic effects on children born to women prescribed them, such as congenital defects, and physical and mental handicaps; there is evidence that they can cause attention deficit disorder and autism. Increasing problems related to the black market and street use of benzodiazepines are emerging. In 1991, the previous Government made the benzodiazepine Halcion illegal. However, there is an increasing street market in other benzodiazepines: Rohypnol - the date rape drug - is a benzodiazepine. Benzodiazepines are increasingly used and abused with alcohol and opiate-based drugs.
The group that campaigns for action on the issue claims that there has been a contravention of the Medicines Act 1968 by drug companies producing these pharmaceuticals. It is claimed that they knew about the cases of addiction, toxicity and side effects before the drugs were even licensed. The Journal of the American Medical Associations reported the problems as early as 1969. The Department of Health must increase its funding of research into the after effects and consequences of the drugs.
My constituent, Barry Haslam, has permanent neurological damage and other disabling conditions, yet he has recently been refused disability living allowance, which he had received for many years. On most days, he would fail all seven tests for mobility allowance and all four tests for care allowance, but on other days he is perfectly articulate and able to look after himself, get about and hold down part-time work, were any available.
The issue also concerns the Department of Social Security, which must urgently improve the disability benefits handbook on the matter. I remind hon. Members that MIND estimates that 1.2 million people are affected by addiction to benzodiazepines. For 20 years or so, benzos, including Valium, Ativan and Librium, were fashionable drugs. They were prescribed in abundance on both sides of the Atlantic and considered to be the cure-all for depression, sleepless nights and a range of problems thought to be associated with the modern world. However, it took more than 25 years for United Kingdom medical authorities to issue guidelines, and it was not until 1988 that the committee on review of medicines toughened up the prescription guidelines for general practitioners.
In 1979, some 30 million prescriptions for benzos were issued in this country. Drug manufacturers, led by the company Roche Products Ltd., launched an onslaught on the medical profession, including 1,000 visits a week made by company representatives to general practitioners. Despite the 1980 review, prescriptions continued to be issued at similar levels throughout the 1980s. Even today, on the latest figures available, MIND estimates that 16 million prescriptions are issued each year. The drugs are being prescribed to one in four adults, to women more commonly than to men - indeed, twice as often. More than 1 million pensioners take benzodiazepines every night, supposedly to help them sleep. Despite the weight of evidence from both sides of the Atlantic and the current guidelines on prescriptions, no victim from those 20 to 30 years has ever been compensated. All collective legal actions have been withdrawn as legal aid licences have ended. A solicitor of Drummond Miller of Edinburgh, a well-known law firm in Edinburgh city, described as impossible the fight that the campaign has waged against the "might of the multinational drug companies". Indeed, in the United Kingdom, only one individual's legal case remains outstanding - and all power to his elbow.
I have no doubt that controlled and time-limited use of benzodiazepines can bring enormous relief to some patients. However, 40 years after their introduction, 30 years after the first warnings, and 10 years after the UK authorities put on the brakes, they remain commonplace and are still prescribed above the recommended level. The blight on our streets is getting worse. Home Office statistics show that such class C drugs are now a commonplace commodity in the street market. In the past three months in my constituency, benzos have been the target in two burglaries of pharmacies, and there are hundreds of such cases throughout the country. The 1998 Home Office statistical bulletin shows that, from 1990 to 1995, 1,602 deaths were directly related to benzodiazepines, including 683 suicides. In the same period, 218 deaths were linked to heroin, and 483 to methadone. That is the scale of the problem.
In a recent Home Office pilot project undertaken in five locations throughout England, 61 per cent. of people arrested tested positive for drugs, one fifth of whom - 12 per cent of the total - tested positive for benzodiazepines, compared with only 10 per cent for crack and cocaine combined and 8 per cent for methadone. The Advisory Council on the Misuse of Drugs has recommended the introduction of additional controls on the import, export and possession of benzodiazepines, which, according to parliamentary written answer No. 93720, the Home Office is "actively considering". I believe that, in the lexicon of Sir Humphrey, "actively considering" means "probably". Let us hope that the Home Office acts forcefully and quickly.
We need joined-up policy. Leading academics on the subject have presented evidence to the drugs tsar, Mr. Keith Hellawell. We need recognition of the harm done to thousands of people, robust guidelines that are forcefully promoted and a review of the classification of benzodiazepines. We need stringent support for addicts in the NHS, social services and the voluntary sector, to ensure that the withdrawal from such drugs is beneficial and does not increase the pain and suffering of many addicts. The problem of benzodiazepines is an iceberg, involving, according to accepted figures, 1.2 millon people addicted as a result of over-long prescription of the drugs. It involves an increasingly dangerous street trade and a level of ignorance and lack of awareness that is perpetuating the problem rather than solving it, 40 years after the first warnings of the effects of Valium.
The Minister of State, Department of Health (Mr. John Hutton) : I congratulate my hon. Friend the Member for Oldham, East and Saddleworth (Mr. Woolas) on having raised this important issue. I assure him and my hon. Friends the Members for Basildon (Angela Smith) and for Newport, West (Mr. Flynn) - he takes a close interest in such matters - that we treat the issues raised extremely seriously, and have no intention of sweeping them under the carpet.
As my hon. Friend the Member for Oldham, East and Saddleworth said, a great deal of research has been conducted and much has been written on the topic over the past 25 years or so. In the past three years, the Medical Research Council has commissioned more than £1.5 million-worth of research into benzodiazepine use. The largest project, which is worth more than £1 million, deals specifically with benzodiazepine addiction.
Based on the findings of existing research, current advice from the Committee on Safety of Medicines is in the British National Formulary, which as my hon. Friend will know, is distributed regularly to all doctors.
It states clearly that benzodiazepines are indicated for the short-term relief 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. The use of benzodiazepines to treat short-term mild anxiety is now considered inappropriate and unsuitable. The Committee on Safety of Medicines advises that benzodiazepines should be used to treat insomnia only when it is severe, disabling or subjecting the individual to extreme distress.
My Department has taken several measures to support the appropriate use of such drugs, a matter to which my hon. Friend the Member for Oldham, East and Saddleworth referred in his thoughtful and well-constructed remarks. We recently published a new national service framework for mental health services, in which we spell out national standards for mental health, taking into account mental health promotion, primary care, access to services, effective services for people with severe mental illness, and other issues. Of particular relevance to this debate is that primary care services in the national service framework are required to work with specialist care providers to develop and implement assessment and management protocols for several mental health problems, including anxiety disorders, for which benzodiazepine is prescribed. Those protocols will draw on the best available evidence and will help to establish proper consistency in managing such conditions throughout the country.
My Department has also been focusing on preventing addiction or dependence from ever occurring, by warning GPs and other prescribers of the potential side effects of prescribed medicines and in particular of the dangers of addiction to benzodiazepines.
My hon. Friend raised the issue of the side effects of pregnant women using benzodiazepine. I understand and am currently advised, that there is no proven link between benzodiazepine use and damage to developing foetuses. Current advice is that all drugs should be avoided in pregnancy if at all possible. The Government keep the issue of benzodiazepine use in pregnancy under close review, as we do the use of other drugs, through organisations such as the Advisory Council on Drug Misuse.
Doctors have an ethical responsibility to inform patients about any treatment proposed, including possible side effects of prescribed medicines. It is the responsibility of health authorities to ensure that adequate prescribing controls are in place. Conspicuous poor prescribing would result in disciplinary action from either the health authority or 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, which is now part of the Government's clinical governance agenda.
The Department funds a number of publications that provide up-to-date information on a variety of treatments. Those are made readily available to GPs, pharmacists and other health professionals. As my hon. Friend will know, the British National Formulary is published by the British Medical Association and the Royal Society of Great Britain and is issued every six months, free of charge to all GPs, pharmacists and other health professionals. The medicines resource centre publishes a monthly bulletin giving up-to-date information on the treatment of various conditions and the drugs involved in such treatment.
Mr. Paul Flynn (Newport, West) : Does my hon. Friend agree that our knowledge of the chemistry of the brain is in its infancy, and that the rash, vast over-prescribing of benzodiazepines has done damage that dwarfs all that done by illegal drugs, as my hon. Friend the Member for Oldham, East and Saddleworth (Mr. Woolas) made clear? We are repeating those experiments now with the prescription of Prozac and Ritalin. Ritalin is prescribed to 2 million children in America. Should we not tell pharmaceutical companies that they should not be allowed to use dangerous drugs with unknown consequences in an experiment that serves not the public's need, but companies' profits?
Mr. Hutton : I am grateful to my hon. Friend for that intervention. Of course, the subject of the debate is benzodiazepines, but he raises the subject of Prozac. I am quite happy to correspond with him about his concerns, or he could come into the Department and discuss them with officials and with me. If possible, I would like to confine my remarks today to the issue of benzodiazepines.
Madam Deputy Speaker (Mrs. Gwyneth Dunwoody) : Order. That is indeed the subject to which the Minister must confine his remarks.
Mr. Hutton : Thank you, Madam Deputy Speaker. I am trying hard to do so, tempting though my hon. Friend's intervention is.
In addition to the literature available to GPs, most health authorities employ professional advisers, both medical and pharmaceutical, whose role is to provide another source of advice and information on medical and prescribing issues to GPs in the area. Those arrangements have had tangible success in the sense that the number of prescriptions for tranquillisers continues to fall. That focus on preventing people from becoming dependent on these drugs has resulted in the number of prescriptions of benzodiazepines dispensed in the community falling steadily from more than 20 million in 1985 to a little more than 13 million in 1998, which is lower than the figure quoted by my hon. Friend the Member for Oldham, East and Saddleworth.
The volume of benzodiazepine prescribing in the community is monitored and has this year been included as a national indicator of performance of the national health service through the performance assessment framework. That should allow health authorities to compare how they perform against national averages, and to benchmark themselves against similar organisations within the NHS, so as to identify where they can improve their performance. The monitoring of prescriptions of benzodiazepines is further developed in our recently published national service framework. Local clinical audit programmes are being asked to focus on prescribing rates for a range of drugs, including the benzodiazepines. As the mental health minimum dataset, which is being piloted, is rolled out across the country, the prescription of benzodiazepines will be monitored in relation to hospital, as well as community, prescribing. I hope that my hon. Friend welcomes that.
What have we been able to do to tackle dependence on these drugs? Treatment may be offered in primary care or in more specialised settings. Clear advice is given in the British National Formulary that withdrawal of benzodiazepines from patients who have developed dependence problems must be gradual. In some cases, a withdrawal programme may extend over many weeks. It is important that people are well supported during the process and helped to develop other ways of coping with their anxiety, sleeplessness and other symptoms.
For those who have developed dependence on tranquillisers, treatment may be offered in primary or secondary care settings. Anxiety management, which may be provided on an individual or group basis, often includes a focus on cessation of usage of tranquillisers. Therapy in secondary care may be made available in clinical psychology departments by way of a day hospital or community mental health team. Counselling and psychotherapy are available on the NHS and form an important part of the range of medical and non-medical provision for people with mental health problems. All such issues are covered by the national service framework. We know that such treatments can be effective. They are increasingly popular and are in great demand. That is why we are committed to ensuring that the right treatments are delivered where they are needed most.
The Department issued "Drug Misuse and Dependence - Guidelines on Clinical Management" to all GPs in April. Those guidelines were written and peer-reviewed by experts. They give advice on treating misuse of a range of drugs, including benzodiazepines, and will reflect best evidence and knowledge of what works in treating drug misusers. For example, they contain advice on the best way to manage benzodiazepine withdrawal. Given that the only source of benzodiazepines is through diversion of prescribed medication, the guidelines stress to doctors and professionals the importance of appropriate and secure prescribing.
There are, of course, several organisations working to help people to overcome benzodiazepine addiction and that includes voluntary sector bodies. In 1994, the Mental Health Foundation produced an excellent publication entitled "Guidelines for the Prevention and Treatment of Benzodiazepine Dependence", which was aimed at general practice. It not only gives a summary of good practice in prescribing, but sets out a protocol in the management of benzodiazepine withdrawal. It remains as valid today as it was in 1994, and those working in general practice would be well advised to apply the principles that it sets out. The Mental Health Foundation also issued a booklet aimed at people who use tranquillisers, entitled "A Guide to Starting and Stopping Tranquillisers and Sleeping Tablets", which contains good, practical advice.
Apart from the Mental Health Foundation, I should like to mention the Council for Involuntary Tranquilliser Addiction. CITA aims to raise awareness of the problems of drug addiction and to support the withdrawal and rehabilitation of those addicted to tranquillisers. It helps to train doctors and other health workers in respect of benzodiazepine withdrawal, and provides support to a variety of health professionals. It does that by running 27 clinics in GP practices and by providing training through workshops, conferences and literature, as well as a helpline that is open five days a week. In addition, it provides a valuable resource for the media, fielding inquiries and providing information.
I mention that because my Department helped to maintain and consolidate CITA's helpline with funding of more than £30,000 over three years. In addition, earlier this year, my officials met representatives of CITA to discuss its current work programme and to see what further help we could give. I am pleased to say that CITA has now made an application for further assistance from next April to help to establish a number of clinics on Merseyside. That will build on its existing good work, most notably in Wigan and Bolton, and provide for face-to-face counselling coupled with the innovative use of natural therapies in helping patients to cope with withdrawal. I am not in a position to say today what the outcome of the application will be, but I hope that we will be able to include it in our wider programme of support for the voluntary sector.
I now want to concentrate on the concerns raised by my hon. Friend the Member for Oldham, East and Saddleworth about our part of the world, the north-west. He raised concern about the proportion of people attending drug misuse treatment in his constituency who report benzodiazepines as their main drug. Nationally, that proportion is relatively low - about 2 per cent. I understand that that figure is roughly the same in my hon. Friend's local health authority - the West Pennine health authority - and the north-west region as a whole.
Much more worrying is the proportion of people who report using benzodiazepines as a subsidiary or secondary drug. Nationally, that figure is about 16 per cent. I understand that the figure for the West Pennine authority is much higher, at about 40 per cent. That is also higher than figures for elsewhere in the north-west region.
I assure my hon. Friend that we are acting to reduce high levels of prescribing. For example, in the West Pennine authority, audits have been carried out of GP practices. In addition, the health authority intends to run a series of workshops aimed at primary care staff to inform the way in which they prescribe benzodiazepines. The West Pennine health authority plans to relaunch its guidelines for planned benzodiazepine withdrawal, and that will be fully audited to determine the success of GP withdrawal programmes. There will also be a review of the evidence for use of benzodiazepines by drug misusers to develop further guidance for GPs. As part of the Department of Health's north-west regional offices's performance review of its health authorities, benzodiazepine prescribing will be monitored very carefully.
I fully understand my hon. Friend's concerns about benzodiazepine prescribing in his constituency and I hope that he will be reassured about the action we are taking. The regional office and the health authority will continue to consider the issue closely in future. We are aware that, although a lot of good work is already under way, there is more to be done to ensure that everyone has access to the best possible services.
Although benzodiazepines will continue to have a place in treating short-term mental health problems, alongside counselling and other psychological interventions, I can assure my hon. Friend -
Madam Deputy Speaker : Order.