Prescription for change?
With addiction to prescription and over-the-counter drugs at epidemic proportions in the US, GPs here are being warned to take care when prescribing any drugs that could lead to dependence
‘Prescription drug abuse’ is classified as an epidemic by America’s Centers for Disease Control and Prevention,
prompting the Obama administration to issue a specific prevention plan to expand on its 2010 National Drug Control Strategy (DDN, May 2010, page 5). As former White House drugs advisor Keith Humphreys told DDN last year, legal pharmaceutical drugs are the leading cause of overdose in the US, and one in eight American teenagers have taken potentially addictive legal drugs like Vicodin and OxyContin (June, page 16).
Now UK doctors and psychiatrists are warning that care must be taken ‘in the initiation of any drugs that can lead to dependence’. A consensus statement issued by the Royal College of General Practitioners (RCGP) and Royal College of Psychiatrists (RCPsych), and supported by 17 other organisations, says that medicines such as tranquilisers and painkillers should not be prescribed for long periods ‘except in exceptional circumstances’ (see news story, page 5), and that patients need to understand the risks involved in order to make informed choices.
‘Addiction psychiatrists are increasingly working with people who have developed dependence problems with prescribed or over-the-counter medication,’ said RCPsych consultant psychiatrist, Dr Emma Whicher. ‘Although these medications are beneficial to many people, awareness of the alternatives and risks is also important.’ Prescribing must be informed by the very latest guidance – such as that from NICE – says the statement, and patients should also be offered appropriate non-pharmacological options as adjuncts, or alternatives, to their prescription.
‘We talk about addiction to prescription-only medicines, but we’re not talking about one group – we’re talking about a range of medications, from laxative abuse right through to serious opioid misuse,’ RCGP substance misuse lead Dr Linda Harris tells DDN. ‘That means that the complexity of these presentations can vary enormously.’
While the statement was welcomed by the NTA, the agency stated that much of what it called for was already being done. ‘I think that’s a fair assessment,’ says Harris. ‘This is an area where I don’t think one agency or college is going to be in a position to take all the responsibility – there’s a firm platform of activity that we’re developing and building on. Where I might disagree is that there are some gaps around options in primary care. I get doctors saying to me, “yes, we’d clearly like to do less prescribing but we need more options”. That means more access to counselling, psychotherapy, psychosocial and the like.’
Isn’t it the case that there can sometimes be long waiting times for NHS mental health services, though? ‘I don’t know the full national picture but for me locally I can draw on my IAPT [Improving Access to Psychological Therapies] services – our substance services are well joined up to IAPT, and our waiting times are within national targets. But I suspect that it might be patchy. It’s down to localities now to identify if there are gaps, and there are things that GPs can take more control over if they think that locally they haven’t got those resources.’
According to the statement, the issue is best addressed through collaborative action – is there enough joined-up working going on around this? ‘I think we’re poised – we should be able to do it,’ she says. ‘And the clinical commissioning groups are commissioning more assertively to meet local need.’
Does she feel that drug treatment services generally give enough consideration or priority to prescription and over-the-counter drugs? ‘I think they’re beginning to. The 2010 drug strategy firmly identifies this as an area that substance misuse services should be responding to, and they certainly have the skills, but many services have been commissioned with a focus and emphasis on illicit drug misuse – they might not be seen by the general population, or even GPs, as the place where you’d refer. So we want to do a lot of work to raise awareness, that absolutely there are skills, and particularly with shared care.’
What about people who say that there are some GPs who are quite happy to just sign prescriptions, as it’s the easiest thing to do? ‘I would challenge that position,’ she states. ‘We have to understand that the GP cohort is mixed – there’s a mixture of ages, and people at different stages of their careers, where experience of education and training may be different. With our younger GPs, the modern curriculum equips them with the full competencies around safe and effective prescribing, and obviously if GP training were to be extended – as the Royal College would love to see – that would give us more opportunities for young GPs in training to be exposed to services and wraparound care.
“They’d be even better placed – when faced with those decisions, when they’ve got the pressure of day-in, day-out consultation in primary care – to really do the right thing. My feeling is that we’re really getting on top of this.’ DDN
Consensus statement at www.rcgp.org.uk