British Medical Association publishes paper on prescription drug dependence and withdrawal

[Altostrata]

Full text PDF http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a21_1/apache_media/H6IB5G1BL8SX1KJ7VY4MCRCXVG6EV7.pdf
 
As described by the Council for Evidence-based Psychiatry at http://cepuk.org/2015/10/13/cep-welcomes-report-bma-prescribed-drug-dependence/

CEP welcomes report by the BMA on prescribed drug dependence

The Council for Evidence-based Psychiatry welcomes the publication of the analysis report by the BMA’s Board of Science, titled ‘Prescribed drugs associated with dependence and withdrawal – building a consensus for action’, which can be viewed here.

 

The report analyses evidence submissions from a variety of stakeholders, including CEP, patient groups and medical bodies such as the Royal College of General Practitioners and the Royal College of Psychiatrists.

 

CEP agrees with opinion of the Board of Science that ‘too little is known about prescribing patterns, the levels of dependence and withdrawal, and the level of harm that is being caused. There is also too little research about the long-term effects of these drugs.’

 

CEP is pleased to note there is consensus among stakeholders regarding the inadequate current provision of specialised support services, as well the need for improved doctor training and more funding for non-pharmacological treatments.

 

In addition, CEP agrees with the Royal College of Psychiatrists’ view (expressed in the report) that traditional addiction services are not appropriate for patients dependent on prescribed drugs, and supports its call for a review of the evidence and clinical guidelines in this area, including optimal methods of withdrawal.

 

We hope that the BMA will use this consensus as the starting point for a series of initiatives to tackle this issue.  As a priority, this must include the provision of appropriate support services for patients who have become dependent upon prescribed drugs, and we support the All Party Parliamentary Group for Prescribed Drug Dependence in their call for a national telephone helpline.

[nz11]

Theme 7: Antidepressants

 Antidepressant prescribing
 Safety of antidepressants
 Approaches to antidepressant withdrawal

 

Points relating to antidepressant prescribing, safety and withdrawal emerged as a distinct theme
across response submissions. There was a consistent view that antidepressant prescribing is
increasing, and some consistency that antidepressants can be prescribed without a clear clinical
need.

 

For example, the RCPsych noted that “...there is potentially overprescribing of these
medications, particularly SSRIs, where there is no particularly strong clinical indication…”; and CEP
noted that “[a]ntidepressants are currently indicated in the BNF only for patients with moderate to
severe depression. Yet withdrawal charities report numerous examples of inappropriate prescribing of
antidepressants for mild depression.”

 

The latter also highlighted research that in their view does not
support the use of these drugs for moderate depression, and that the benefits are unclear even in
cases of severe depression. CITA reported that “[t]here is an increasing use of antidepressants for
non-depression diagnoses, the prescribing several antidepressants simultaneously within the same
patient for no apparent sensible reason other than to mask the side effects of each other.”
There was disagreement between responses on the overall safety of antidepressants, particularly in
regards to their abuse and dependence potential.

 

Charity and support groups reported that the harm
associated with antidepressants – including severe mood disturbances, suicidal intention and
dependence potential – is not generally recognised, or is underestimated, by GPs and psychiatrists.

 

In contrast, the RCGP reported that there is “…evidence of the long term benefits of antidepressants
and the relative safety of their use. Most side-effects and problems occur earlier in treatment and
there is generally a delay in therapeutic response. Compared to the other medications considered
[opioids and benzodiazepines] there appears to be a very low prevalence of misuse and addiction.”

 

The RCPsych did note that antidepressants carry the risk of a discontinuation syndrome that can be
unpleasant for the individual, but added that this is not prolonged.

 

CEP highlighted their view that the increasing antidepressant prescribing rates reflected the fact that patients are unable to
discontinue their use due to the onset of withdrawal symptoms, going as far as saying that “…for a
proportion of patients, BNF prescribing guidelines [of at least 6 months or more, and for at least two
years for patients with a history of recurrent depression] are leading to involuntary dependence upon
these drugs. There is no safeguard here; it is a direct consequence of the manner in which these drugs
have been approved for use.”

 

Charity and support groups also felt that antidepressants pose similar levels of harm as
benzodiazepines, in regards to the severity of side effects and withdrawal, whereas the RCGP and the
RCPsych reported that antidepressants are safe relative to benzodiazepines and opioids.

For example, CITA and Recovery Road noted that they have seen a rise in the number of individuals
contacting them for support for antidepressant withdrawal, which, in their experience, can be as
severe as benzodiazepine withdrawal. Recovery Road specifically highlighted that “…many doctors
refuse to acknowledge it [antidepressant withdrawal] exists or even that there is a discontinuation syndrome. This results in patients taking antidepressants being left to self-diagnose and use the
Internet for support.”

In relation to this, the RCPsych submitted the 2004 CSM (Committee on Safety of Medicines) review
on the safety of SSRI antidepressants submitted which provides an overview of research (up to 2004)
on the relationship between SSRI antidepressants and dependence potential and withdrawal
reactions. The report concluded that SSRI’s have low abuse liability but that they can cause
unpleasant withdrawal reactions that should be managed through tapering over a period of several
weeks. A research recommendation to study the most effective methods for SSRI withdrawal was
also documented in the report. The RCPsych commented that to their knowledge this research has
not yet been conducted.
Where there was agreement that antidepressants are associated with a withdrawal (or
discontinuation) syndrome, it was also agreed that there is no recognised approach for managing this
type of withdrawal (discontinuation) syndrome. For example, CITA reported that their experience
accrued over the years suggests “…that there is no consistent model being applied across and within
practices…” with regard to antidepressant withdrawal management. CEP specifically noted that BNF
and NICE guidance are in urgent need of revision as they have conflicting advice on antidepressant
withdrawal that may contribute towards this inconsistency, which is out of step with the charities’
experience working with sufferers. The BNF advises that the dose should be reduced gradually over
about four weeks, or longer (up to 6 months) for patients on long-term maintenance treatment;
while NICE advise that antidepressant use can be stopped over a four week period.

 

CEP stated that “[t]he experience of the withdrawal charities suggests that antidepressants should be tapered very slowly at a rate of no more than 10% of the previous dose every four to six weeks, at a pace guided by
the patient. A four-week taper is therefore much too fast, and this guidance should be changed.”

 

In consideration of the RCPsych’s comment on the CSM recommendation for research into SSRI
withdrawal methods, it may be the case that research clarifying what is the best practice to withdraw
from antidepressants has not been conducted.

Concluding remarks

This report identifies various themes relevant to preventing and managing the potential harms
associated with the prescribed use of benzodiazepines, Z-drugs, opioids and antidepressants. It does
not provide a detailed examination of every issue highlighted to us, but aims to identify areas of
agreement and difference, with a view to supporting change. As the majority of submissions focused
extensively on benzodiazepines, our analysis has a particular emphasis on this drug group; however,
many of the issues highlighted are relevant across the other drug types. For example, a common
thread among responses was the need for better training on the safe prescribing and withdrawal of
these psychoactive medications (including the importance of adherence to prescribing guidelines;
safe tapering protocols; the risks of long-term use; and providing appropriate support and advice
before, during and after prescribed use). This is likely to be an important area for action.
Looking to the future, this analysis identifies areas where there is some common ground among
stakeholders, such as the need for gradual tapering during withdrawal, the under-funding and poor
availability of non-pharmacological and psychological treatments, inadequate provision and funding
of specialised services, and the need for more research. In other areas, however, there are significant
differences that need to be considered further.

 

For example, a clear view emerged that some prescribing guidelines, as well as the views and understanding of medical professionals, do not
correlate well with the lived experience of patients. This is typified with the differing views on types
and magnitude of harms associated with prescribed drug dependence and withdrawal, as well as
attitudes towards the causes of dependence and withdrawal problems. While some of these
differences may be resolved or reduced through research, changing attitudes and mindsets will
require a more collaborative approach.
One example of the need for collaboration is illustrated by how medical organisations have called for
better guidelines on tapering and withdrawal management for benzodiazepines, while charities and
supporting groups were broadly of the view that these exist and should already be in use. This
difference may be explained by the fact that the existing guidelines are expert-based rather than
having a strong scientific evidence base, and medical professionals may not therefore feel confident
in using them. Only by working together will such differences in opinion be resolved.
A further consideration from this analysis is how responses from support groups, charities and
individuals included an element of 'blame' on doctors (eg for prescribing beyond guidelines or not
providing adequate information or support), while submissions from medical organisations reflected
elements of patients being at fault (eg for demanding a 'prescription'), or that some patients may
become addicted because of particular personal and social factors. It is vital that these perspectives
do not prevent positive action moving forward.

 

 

 

.......................................//.............................................

 

There is some excellent stuff here and what a wonderful voice is CEP. Cant speak more highly of them.

But also what a lot of nonsense some people are talking . 'may become addicted because of personal and social factors '...what a joke to say that!!

 

And who are these RCGP clowns clearly none there has ever taken these drugs.

Later ...did a google ...

"The RCGP is the professional membership body for family doctors in the UK and overseas. We are committed to improving patient care, clinical standards and GP training."

Right so who is training the RCGP....pharma?

[indigo]

Thanks for posting Altostrata. It's a beginning.