The medicines prescribed by doctors can help people cope with all sorts of conditions, but when misused, can lead to dependence and other difficulties, writes journalist John Windell.
The harm that dependence on illegal drugs can cause people has been documented at length, but less widely acknowledged is the problem of dependence on legal drugs, which are prescribed every day all over the country by healthcare professionals to help people.
Recent solid figures are hard to come by. However, in 2019, Public Health England (PHE) carried out a review into the extent and causes of prescription drug dependence (Taylor et al, 2019). It looked at five classes of drug: benzodiazepines, mostly prescribed for anxiety; z-drugs (zolpidem and zopiclone) for insomnia; gabapentin and pregabalin (known as gabapentinoids) for epilepsy, neuropathic pain and anxiety; opioids for chronic non-cancer pain; and antidepressants.
It found that between 2017 and 2018, 11.5 million adults in England were given prescriptions for one or more of the medicines covered. Antidepressants were the most common (7.3 million), followed by opioid pain medicines (5.6 million). The rates of prescribing were 1.5 times higher for women than men and generally increased with age.
Among patients with a prescription in March 2018, around half were estimated to have been on it continuously for at least 12 months. The proportion of those on a prescription for at least a year also increased with higher deprivation.
Benzodiazepines, z-drugs, gabapentinoids and opioids carry a risk of dependence, and all the medicines in the PHE review were associated with withdrawal, the common symptoms being depression, insomnia, anxiety and suicidal thoughts, and physical effects such as nausea, headaches, sweating and heart palpitations.
For some patients, withdrawal affected not just their personal wellbeing but also their ability to function socially and at work for many months. Opioid pain medicine prescribed for more than three months was associated with overdose.
Despite the findings of the review, it remains unclear just how much of this prescribing has become problematic for the recipients. Dr Rachel Britton, director of pharmacy at the drug, alcohol and mental health charity With You, says there are key reasons why it’s difficult to get a clear picture of the issue: ‘It’s because a lot of people who are dependent are not necessarily coming forward for help, or even realise that help is available. They’re largely a hidden group of people.’
Regional variations are also a factor. ‘Data shows that prescribing for drugs such as codeine and morphine is higher in the north-east of England than other parts of the country. We can perhaps surmise that the higher the rate of prescribing, the higher the rate of dependence. The drugs we find most problematic are the opioids that treat pain, sleeping pills, and medicines such as diazepam for anxiety.’
Owen Bowden-Jones, consultant in addiction psychiatry, Central North West London (CNWL) NHS Foundation Trust, says it’s also hard to gain a national view of this type of drug use because it too goes mostly unreported and unrecorded. ‘But in drug treatment clinics such as ours, we are seeing greater numbers of patients asking for help with problems related to prescription medication.’
At the Club Drug Clinic, run by the CNWL Trust, these patients can be divided into two broad groups. The first are users in a category known as non-medical prescription drug use (NMPDU).
‘They are typically using a range of recreational drugs and have increasingly started to add prescription medications to that repertoire,’ says Owen. ‘For example, they may regularly use a stimulant drug such as cocaine or MDMA but are now turning to a sedative prescription medication, for example, diazepam, to help the comedown. As a general rule, the more drugs you consume, the greater the risk of harm. This pattern of polydrug use can have serious acute and chronic health consequences.’
‘some are using a range of recreational drugs and have increasingly started to add prescription medications to that repertoire’
The second group are those who were legitimately prescribed a medication for conditions such as anxiety or pain. ‘The prescriber has reduced and stopped the medication, usually in line with national protocols, and the patient has decided to buy it from an online vendor or found a supply from another source,’ explains Owen. ‘These people often say they cannot function without this medicine and feel they have little choice.’
‘Purchasing prescription medication illegally is dangerous,’ he says. ‘The prescriptions have usually been stopped for a reason, such as risk of dependence, and continued illegal use will put that person at increased risk. Another risk is that many illegally purchased prescription medications are counterfeit, either containing variable quantities of the medication or harmful substitutes that often are unlicensed.’
Euphoria to depression
Problems with prescription medicine can affect anyone, says Rachel. Opioids prescribed for pain relief pose a particular risk. ‘One of the effects of opioids is that they are euphoric, they make you feel good, especially if there are underlying mental health issues, such as anxiety or depression or some kind of trauma. But they do nothing to help long-term pain. NICE guidelines tell us this [NICE, 2021]. They just kind of make you feel better about it.’
Opioid usage becomes problematic when people continue to take the medication simply to get that feeling, and as their tolerance build they need to escalate their dose. ‘People can develop a problem such as severe tolerance or withdrawals symptoms when trying to stop,’ says Owen. ‘They are often dependent and are taking the medication in much higher than recommended doses.’
When it reaches this point, it can also impact the immediate and wider family. ‘Confronting a spouse with a problem is a difficult conversation for a partner to have, because often there is a degree of denial and justification,’ says Rachel. ‘They will argue that the GP has prescribed the medicine, so it must be okay. Children are especially sensitive to the tensions this can create within a family.’
Spotting the problem
Despite the stress that problematic prescription drug use can cause within a home, it can be hard for an outsider such as a community practitioner to spot it.
Owen suggests expanding a routine assessment for alcohol and drug use to include questions about prescription medicine use: ‘When I ask people about their illicit drug use, I also ask them about their non-medical prescription use. They often view prescription medication, even if purchased illegally, as somehow safer than illegal drugs such as cocaine. If you don’t directly ask people, they tend not to mention it.’
Rachel agrees that being inquisitive is vital: ‘Try to read the unwritten signs, such as lots of packets of medication lying around or noticing that somebody seems more drowsy than usual.’ If those signs are evident, a useful next step might be to contact their GP. ‘They should be able to look at the patient’s medication history and see if somebody is potentially ordering too much.’
When misuse of or addiction to a prescription medicine is identified, treatment is always an option. ‘The NHS and charity sector are commissioned to provide care for people with problematic drug use and it doesn’t matter whether it’s illicit heroin or a codeine prescription,’ says Rachel. Some charities also provide anonymous telephone helplines and online chat services (see Resources).
‘In most cases, people can be referred to the local community drugs service,’ says Owen. ‘However, the experience of drug services in treating prescription medications can vary around the country. There are few specialist services.’
The treatment offered will depend on the medicine used. If physical dependence is a factor, as with opioids, detox may be required. This can take just a few days, although the follow-up rehab therapy and aftercare can take much longer. If physical dependence is not a factor, the first step is rehab therapy to address the underlying emotional and psychological issues. Further support is also available via counselling and peer support groups.
There can be hurdles. The PHE review found that patients felt GPs did not acknowledge or recognise withdrawal symptoms, and that people encountered barriers to accessing and engaging in treatment services. A key barrier is stigma. ‘Many people don’t want to disclose their prescription drug misuse,’ says Owen. ‘They worry they will be judged. A vital step for any healthcare professional is to reassure them that judgement gets put to one side and that we will support them to achieve the changes that the patient identifies.’
The NHS offers an overview of addiction and the various treatment options and services nhs.uk/live-well/addiction-support
Many charities also offer information, advice and support, such as Help Me Stop bit.ly/helpmestop_prescription_drugs
Addiction to Medication (AtoM) is a free app for healthcare professionals and others who want to learn more addiction-to-medication.org/atomic
With You has an anonymous online chat service where anybody worried about their prescription drug use can log on and talk with a trained adviser wearewithyou.org.uk
NICE. (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. See: https://www.nice.org.uk/guidance/ng193 (accessed 30 September 2022).
Taylor S, Annand F, Burkinshaw P et al. (2019) Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England: London. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/940255/PHE_PMR_report_Dec2020.pdf (accessed 30 September 2022).
Image Credit | Ikon