RCGP and NICE respond to PHE prescription medications review

PHE has published the first-ever evidence review of dependence and withdrawal problems associated with 5 commonly prescribed classes of medicines in England.

The Prescribed medicines review assesses the scale and distribution of prescribed medicines – and makes recommendations for better monitoring, treatment and support for patients.

It uses available prescriptions data, a literature review and reports of patients’ experiences.

A total of 5 classes of medicines were included in the review:

  • benzodiazepines (mainly prescribed for anxiety and insomnia)
  • Z-drugs (insomnia)
  • gabapentinoids (neuropathic pain)
  • opioid pain medications (for chronic non-cancer pain such as low back pain and injury-related and degenerative joint disease)
  • antidepressants (depression)

The main findings include:

  • 1 in 4 adults had been prescribed at least one of these classes of medicines in the year ending March 2018
  • in March 2018 half of those receiving a prescription (of these classes of medicine) had been continuously prescribed for at least the previous 12 months. Between 22% and 32% (depending on the medicine class) had received a prescription for at least the previous 3 years
  • long-term prescribing of opioid pain medicines and benzodiazepines is falling but still occurs frequently – which is not in line with the guidelines or evidence on effectiveness

Trends in prescribing include:

  • the number of prescriptions for antidepressants and gabapentinoids are rising
  • following years of increase prior to 2016, prescriptions for opioid pain medicines and z-drugs are now falling
  • prescriptions for benzodiazepines continue to fall, as they were prior to 2016
  • women and older adults (particularly over-75s) are prescribed to at the highest rates

The review makes a number of recommendations focusing on education and treatment, including:

  • giving NHS commissioners and doctors better access to data, improving insight of prescribing behaviour in their local area and enabling GPs to follow best practice
  • updating clinical guidance for medicines which can cause problems with dependence and withdrawal, and improving training for clinicians to ensure their prescribing adheres to best practice
  • to develop new clinical guidance on the safe management of dependence and withdrawal problems
  • giving better information to patients about the benefits and risks with these medicines
  • doctors should have clear discussions with patients – and where appropriate offer alternatives, such as social prescribing
  • commissioners ensure appropriate support is available locally for patients experiencing problems
  • a national helpline for patients to be set up
  • ensuring high-quality research around dependence and withdrawal is undertaken

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs has responded to the report:

She 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.

“There are wide-ranging and complex issues surrounding the prescribing of opioids and antidepressants. GPs don’t want to prescribe medication long-term unless it is essential and most patients don’t want to be taking medication long-term, but there will always be some patients for whom medication is the only thing that helps with distressing conditions such as chronic pain, or depression and anxiety.

“When prescribing any of the medications considered in this report, the mantra for prescribers will be to prescribe the lowest possible dose for the shortest possible time – and to offer regular medication reviews. But the decision to prescribe will also be made taking into account the physical, psychological and social factors affecting a patient’s health, as well as clinical guidelines – and in conversation with the patient about the risks and benefits of taking the medication.

“Whilst 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.”

Responding to Public Health England (PHE) first ever evidence review of dependence and withdrawal problems associated with five commonly prescribed classes of medicines in England,

Dr Paul Chrisp, director of the Centre for Guidelines at NICE, said: “We welcome this important work from Public Health England.

“NICE is developing a guideline on the safe prescribing and withdrawal of prescribed drugs. The proposed scope of this guideline should complement the evidence review. We are consulting on the proposed scope until the end of the month.

“Antidepressants are one of the groups of medicines included in the PHE evidence review. Ensuring patients are able to safely discontinue using antidepressants, when they are no longer clinically required, is a topic which requires careful investigation because there is limited high quality data in this area.

“We are currently updating our guideline on the diagnosis and management of depression in adults. As part of that work and following public consultation on an initial draft guideline last year, the independent guideline committee has now looked at the most up-to-date evidence on managing the symptoms that can occur when people stop taking their antidepressant medication.

“The recommendation on this aspect of care aligns with the evidence review. We hope the guideline will allow people with depression to be offered the best care, and when to safely stop or change their treatment, in accordance with their preferences and values.”