1 in 4 people take 'addictive' medicines, finds review

Mail Online and The Guardian report that a staggering 1 in 4 people in England – nearly 12 million people – are taking "addictive" prescription medicines such as antidepressants, sleeping pills and opioid painkillers. They say: "the NHS must take action".

The news reports follow a review by Public Health England that assessed the number of prescriptions issued for 5 common medicines in England used to treat depression and anxiety, insomnia and chronic pain.

The main findings of the review were:

• 1 in 4 adults have been prescribed these medicines, and half of them have been taking these medicines for at least 12 months
• the number of prescriptions for antidepressants is rising, particularly among women and older adults
• the highest prescribing rates are in areas with greatest social deprivation

There were also some encouraging findings, such as a recent fall in the number of prescriptions being given for opioid painkillers and tranquillisers, but dependence and withdrawal symptoms can be a problem with these drugs.

The review recommends better monitoring and support of patients taking prescribed medicines. It also calls for a national patient helpline to be set up.

Who conducted the review?

The review was conducted by Public Health England (PHE), an organisation that works with the Department of Health & Social Care.

PHE aims to protect and improve the nation's health, support people in leading healthy lifestyles, help the NHS and local authorities to plan care services, and reduce inequalities. As part of this role, PHE provides the government and NHS with evidence-based information and recommendations.

In 2017 PHE was commissioned by the Department of Health & Social Care to assess the scale of prescription drug dependence in England and how it might be addressed. The review, titled "Dependence and withdrawal associated with some prescribed medicines", involved a literature search to look at evidence on the effectiveness and harms of 5 broad classes of drug treatment used in the management of mental health and chronic pain:

• antidepressants
• benzodiazepines – tranquillisers mainly prescribed for anxiety
• z-drugs – such as zolpidem, zopiclone and zaleplon for insomnia
• opioid pain medicines – used to relieve severe and chronic pain
• gabapentinoids – used to treat epilepsy, but also to treat nerve pain and to prevent migraines

In addition to the literature search, PHE researchers looked at data from NHS Business Authority, which collects dispensing information from community pharmacies and other data sources.

What were the main findings?

1 in 4 adults in England is taking these medicines

Between 2017 and 2018, 11.5 million adults in England received a prescription for 1 or more of these medicines. The rate was highest for antidepressants, taken by 7.3 million people (17% of the population), followed by opioids, which were taken by 5.6 million (13% of the population). The number of people prescribed gabapentinoids was 1.5 million, while 1.4 million were prescribed benzodiazepines (around 3% of the population each). Z-drugs were taken by 1 million (2% of the population).

Antidepressant prescription rates are increasing, but others are decreasing

The rate of antidepressant prescriptions increased from 15.8% of the population in 2015-16 to 16.6% in 2017-18. Gabapentinoids prescriptions also increased, but only marginally, from 2.9% to 3.3%.

There were small decreases in prescription rates for the other 3 groups in the review.

Prescriptions for benzodiazepines and z-drugs had already been decreasing. However, opioid medications showed a downward trend following progressively increasing use rates until 2016.

People are taking medicines for longer

In 2017-18, around half of people prescribed these medicines had been taking them for at least 1 year.

Some patients need long-term prescribing of antidepressants to maintain benefit and prevent relapse. However, apart from antidepressants, the other medicines are all licensed and indicated for (usually) short-term treatment of acute conditions.

Clinical guidelines specify that benzodiazepines should not usually be prescribed for longer than 2 to 4 weeks. Long-term prescribing of opioids for chronic, non-cancer pain is not beneficial for most patients.

Researchers estimated that around 500,000 were taking opioids and 120,000 taking benzodiazepines continuously for at least 3 years (from 2015 to 2018).

There are inequalities in medicine use

Prescription rates for women are about 1.5 times higher than for men. Prescription rates also increase with age.

Nationally, prescriptions of opioids and gabapentinoids was 1.6 times higher in areas with greater poverty. People in deprived areas are also more likely to be taking medicines for longer and taking more than 1 of these drugs.

The medicines were linked with dependence and withdrawal symptoms

There was evidence that stopping antidepressants can be linked with potentially severe and prolonged withdrawal symptoms such as insomnia, depression, physical symptoms and suicidal thoughts.

The other 4 drugs are also linked with risk of dependence and withdrawal symptoms when stopping.

In particular, higher opioid doses and other mental health problems were linked with greater dependence on opioids, while low income was associated with greater dependence on benzodiazepines.

Some patients reported lack of support from the NHS

Some patients felt that a doctor had not given them enough information on the risks of medicines or withdrawal symptoms.

Some described not being offered any alternative care approaches from drug treatment and felt they did not get sufficient review of their treatment.

What does PHE recommend?

PHE made 5 main recommendations for the NHS to ensure there is increased awareness and better shared decision-making and patient support:

1. make prescribing data on medicines that can cause dependence or withdrawal more transparent and accessible
2. improve treatment information for patients and carers to support shared decision-making
3. improve the support available from the NHS for patients getting dependence or withdrawal symptoms
4. do further research on the prevention and treatment of dependence and withdrawal from prescribed medicines
5. set up a national helpline for patients who are experiencing drug dependence

For patients who are taking any of these medicines and who are worried by the report, PHE advises not to stop taking them on your own, but to make an appointment with your doctor to talk about your concerns.

Stopping or limiting the use of medicines could cause harm, including increasing the risk of suicide or making people try to get medicines or illegal alternatives from less safe sources, such as illegal websites or drug dealers.

PHE also highlights that these drugs are proven to be effective and when they're used as recommended, they can help people manage their symptoms. Not prescribing them at all could increase the risk of suicide or make people seek illegal and unsafe alternatives.

What do experts say?

Experts highlight the importance of these medicines, but balance this against the difficulties of withdrawal and the need to find alternatives. They also note the importance of addressing inequality.

The Chief Pharmaceutical Officer at NHS England said: "As PHE rightly say, these medicines have many vital clinical uses and can make a big difference to people's quality of life. For some, their long-term use is clinically necessary, particularly antidepressants, which can take longer to have their full effect. But for many patients they may not be the best option, with talking therapies and social prescribing often more appropriate."

Meanwhile the Director of Alcohol, Drugs, Tobacco and Justice at PHE said: "We know that GPs in some of the more deprived areas are under great pressure but, as this review highlights, more needs to be done to educate and support patients, as well as looking closely at prescribing practice and what alternative treatments are available locally."