The NHS needs to take action to protect patients as the number of prescriptions for antidepressants and pain medications are rising, according to a Public Health England report.

The first-ever evidence review of dependence and withdrawal problems associated with five commonly prescribed classes of medicines in England assessed the scale and distribution of prescribed medicines and makes recommendations for better monitoring, treatment and support for patients. 

The five classes of drugs included in the review are 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) and antidepressants (depression).

It found that one in four adults had been prescribed at least one of these classes of medicines in the year ending March 2018 and half of those receiving a prescription 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 three years.

In addition, 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. The number of prescriptions for antidepressants and gabapentinoids are also rising.

Dependence on prescription medicines linked to deprivation

The prescribing rates and duration of prescription are higher in some of the most deprived areas of England. For opioids and gabapentinoids, the prescribing rate in the most deprived quintile was 1.6 times the rate in the least deprived quintile.

Opioids for chronic non-cancer pain are known to be ineffective for most people when used long-term (over three months), while benzodiazepines are not recommended to be used for longer than 28 days. The review identified that when first used these medicines are prescribed for short term use. However, some patients do still end up being prescribed these medicines for longer periods.

Long-term prescribing is likely to result in dependence or withdrawal problems, but it is not possible to put an exact figure on the prevalence of dependence and withdrawal from current data.

Should patients on prescription drugs just stop?

People who have been on these drugs for longer time periods should not stop taking their medication suddenly. If they are concerned, they should seek the support of their GP.

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

PHE has also published a detailed geographical breakdown by clinical commissioning groups of prescribing rates for 2017 to 2018 and the proportion of people that had been receiving a prescription for at least 12 months prior to March 2018.

Rosanna O’Connor, Director of Alcohol, Drugs, Tobacco and Justice at PHEsaid: "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.

"While the scale and nature of opioid prescribing does not reflect the so-called crisis in North America, the NHS needs to take action now to protect patients.

"Our recommendations have been developed with expert medical royal colleges, the NHS and patients that have experienced long-term problems. The practical package of measures will make a difference to help prevent problems arising and support those that are struggling on these medications."

More high-quality research into alternatives to drug therapies needed

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs said that the report shows that the vast majority of prescriptions issued are short term, and that there is a decline in opioid prescriptions for chronic pain, both of which are encouraging trends.

She added: "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."

She added that while the vast majority of prescriptions will be appropriate, if GPs are to reverse the prescribing trends outlined in this report, they need better access for their patients to alternative therapies in the community. They 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 their practice.