Health: Addiction to Prescribed Drugs
(13 years, 7 months ago)
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The Earl of Sandwich
To ask Her Majesty’s Government what progress they have made with their review of dependence on, and withdrawal from, benzodiazepines and other prescribed drugs.
The Earl of Sandwich
My Lords, this dinner hour debate is about the damaging effects of drugs that are legally prescribed. It is a sad story that has been told in the media for decades, but it needs retelling today because there is some chance that the Government are now listening. I declare a personal interest, since a member of my family continues to suffer after 19 months of painful withdrawal from benzodiazepines. He seems a little better and has contributed to this debate, but he still has to endure dreadful withdrawal symptoms, which prevent him from working or leading an active life.
I warmly thank all those who have come to contribute to this debate. I speak as vice-chair of the All-Party Parliamentary Group on Involuntary Tranquilliser Addiction and am grateful to Jim Dobbin MP and Michael Behan, among others, for their research on and knowledge of this issue. The authorities were first alerted to it by research by Professors Tyrer and Lader in the 1970s and Heather Ashton in the early 1980s, but manufacturers were already doing clinical trials identifying problems as far back as the 1950s. Benzodiazepines such as Valium, Librium, Ativan and Mogadon were first touted as miracle cures because of their immediate benefits following prescription, but the benefits are often short-lived. Tolerance develops and the drugs then turn and cause symptoms often much worse than the original problem and even worse than those of illegal drugs. Patients enter a vicious cycle in which more drugs may be prescribed to combat the side effects and withdrawal symptoms, and so the process goes on. This is at great cost to the health of the individual and, of course, to the health service.
According to the current Association of the British Pharmaceutical Industry website:
“Benzodiazepines … have a potential for addiction, but are considered acceptably safe for short-term use”.
Huge overprescribing continues by doctors who are ignoring the British National Formulary guidelines. While drug labels contain warnings for patients, those warnings are inadequate and need to be much more prominent, like cigarette warnings. Current NHS recommendations state that the drugs should not be given for more than two weeks, yet people suffer withdrawal effects even within this short time period. Professor Steve Field, chair of the Royal College of General Practitioners, said in March 2009:
“We now try to prescribe”—
benzodiazepines—
“only for a few days because we know that it’s very difficult to get people off these drugs ... in some people, it can be three or four days of the drug before they get hooked”.
These drugs are dangerous. Why do doctors prescribe them so freely if they provide temporary relief for so little time and never cure the original problem? I wonder whether this category of drug should be prescribed by doctors at all, considering the uneven benefits and the tremendous risks. There should be stricter controls and these drugs should be rescheduled and reclassified as class A. There are many proven non-drug alternatives for anxiety and sleep disorders, such as CBT, but these are subject to long waiting periods. They should become the first available line of treatment if we are to avoid the devastation that these drugs cause.
Psychological symptoms that persist after sudden withdrawal include anxiety, agoraphobia, panic attacks, depression, fatigue and lack of concentration. Common physical symptoms are muscle pain, insomnia, dizziness, blurred vision, tinnitus, sweating and nausea. These symptoms often last for months and years after withdrawal. For some people, the damage may even be permanent. In one support group, several members have had debilitating symptoms for over five years. Often these are physical symptoms and cannot be considered a resurfacing of the original psychological issue. Yet, perhaps because pharmaceutical research is inevitably profit-led, no research has been funded into long-term or permanent damage. This leads most doctors to believe erroneously that such damage does not exist. This research is essential if patients are to be rehabilitated and their condition properly managed during and after withdrawal.
It is pitiful that a problem of this severity, and on this scale, has been allowed to get worse over so many years when so much has been known empirically for so long. Back in April 1984, Professor Heather Ashton of Newcastle University published an article in the BMJ entitled Benzodiazepine Withdrawal: An Unfinished Story, which summarised the problem. As a result of this and other reports, GPs and NHS staff became more aware of the dangers, clinics were opened and prescriptions fell from about 32 million to 18 million per year—a significant fall. However, by November 2000—16 years later—Heather Ashton, who was in regular contact with patients, noted that things had not really changed. In many ways they had got worse. A “Panorama” survey at that time estimated that there were as many as 1.25 million long-term benzodiazepine users in the country, an average of over 180 for every GP.
We need to act urgently to ensure that these accidental addicts are provided with appropriate support from the NHS to help them to withdraw, yet today there is only one NHS-funded support centre—in Oldham—despite the fact that all these patients have become addicted as a result of drugs prescribed via the NHS. That brings me to the Labour Government’s welcome, if belated, review. I believe that the new Government are equally sincere, but I wonder whether they will now seriously consider the true costs of doing too little, too slowly. At a time of cuts and savings, have they estimated the social costs—the loss of earnings and tax, the cost of benefits and the drain on the NHS—incurred by these prescribed drugs if they do nothing? Do they even know how many people are long-term users?
Another concern is that the National Treatment Agency may be given responsibility for treating these addictions. The NTA has no expertise in this field. I understand that tranquilliser addicts whom it has treated in the past have been withdrawn abruptly over three weeks as if they were illegal drug users. This is wholly inappropriate and dangerous, as successful and safe tranquilliser withdrawal requires a timescale of between six months and two years.
What is the timetable for this review? Will the department move swiftly to encourage the many voluntary initiatives that already exist in the absence of any NHS programme? We are dealing with a daily emergency in the lives of many patients. Instead of further consultation within the institutions, why not immediately set up a working party to develop best practice and to set up pilot projects, using the expertise already in place in many areas? When, for example, will the Government support the largely voluntary services in Liverpool, Bristol, Newcastle, Belfast and elsewhere that are already helping victims of these drugs and bring them within the range of the NHS? Some services depend entirely on heroic individuals such as Pam Armstrong, director of CITA in Liverpool. David McKeown in Belfast, a NHS prescribed medication nurse, is another professional who not only understands the needs of these patients and the properties of these drugs but actually leaves people drug-free.
The answer that I and others have received to these questions so far—that nothing can be done this year—is simply not satisfactory when you think of the scale of the emergency and the silent suffering of so many people. I hope that the coalition will come up with some more urgent interim solutions pending the outcome of the review. As to the pharmaceutical companies and the regulators—I have not had time to cover them today—will the Government revisit and if possible implement the conclusions of the 2005 Health Select Committee report, volume I, which recommended a review of the activities of the Medicines and Healthcare Products Regulatory Agency? These are serious and urgent matters and I hope that the department and the Minister will give them their fullest attention.
Baroness Bottomley of Nettlestone
My Lords, I warmly congratulate the noble Earl, Lord Sandwich, on raising this matter of great importance. I think that all of us greatly respect his commitment to and interest in this issue and the depth of his research and investigations. My earliest involvement in this subject was in the early 1970s when I worked in child guidance clinics in Brixton and Peckham. I was all too aware of the number of mothers whom I met who had been prescribed Valium or Librium for their problems, which did not seem to help them one little bit. In some cases, it seemed to remove the inhibitions that they might otherwise have had and their family situation deteriorated faster.
I can understand what it is like to be a general practitioner in an impoverished area where a great number of people come into the practice with insoluble social, psychological and economic problems. The requirement of a patient for a pill for every ill must have been irresistible. One of the great strengths of GP fundholding was forcing and enabling general practitioners to look at the opportunity cost of pharmaceutical routes. Some of them could prescribe more cautiously and employ a counsellor or a more appropriate resource to help these patients, the problems of many of whom were highly complex and difficult—even intractable. For some of them, with the best will in the world, the general practitioner was very poorly equipped. However, once a benzodiazepine is prescribed, addiction can easily develop.
I am aware that all medication has side effects. For every physician and clinician who prescribes any product, there is a risk-benefit analysis. Many of those who visit a physician in these circumstances are in a deeply troubled and disturbed state. I also accept that when you look at the detail, for example, of the Royal College of Psychiatrists’ 1997 report, or at the NHS South Essex Partnership’s All About Benzodiazepines: Treatment for Anxiety and Psychosis, you see that best practice now advocates that,
“this should be no longer than about one month to help you get over your problems”,
and that there should be short-term prescribing and much lower doses.
In days gone by, particularly when benzos were still within patent, it may have been that pharmaceutical companies oversold their benefits and the drugs were overpushed as a solution to too many problems. That is no longer the case, because the drugs are now into the generic space and there is not the same advantage to the pharmaceutical companies of overpushing these products. Neither are we a nation of great pill pushers.
However, a great number of people suffer from anxiety and mental health conditions and we have been all too slow at making talking therapies as available as a pharmaceutical outcome. We need to consider all those contributing elements as we look at our problems today. I very much hope that, with the review that the Government have in hand, they will look again at the pathway of care for many of those who have ended up addicted. It of course starts with the general practitioner and with looking to all community resources, as well as with perhaps looking at the acute sector. I hope that they will reissue guidance and that, given this new start with general practitioners in a much more powerful position in commissioning care and planning care pathways, they will be absolutely certain that the real facts, and the issues and concerns over benzodiazepines, are properly understood.
The noble Earl referred to Professor Heather Ashton at Newcastle University. She and others have taken care, time and trouble to look at ways in which addiction can be tackled. But, once addicted, all will be aware that the withdrawal of the product is extraordinarily difficult. Debate has been mentioned about the National Treatment Agency possibly taking over this field. This is not a preference for the All-Party Parliamentary Group on Involuntary Tranquiliser Addiction. There is real anxiety that, instead of getting better, things will somehow get worse and fall between the cracks. The Government will make their decisions, but I think that all of us would ask that if this is a step forward it must be taken from first principles. The arguments, issues, dangers and risks must be properly addressed if the agency takes on that additional responsibility.
I, too, ask the Government for the timetable of the review. I would like to know more about the review. Who is chairing it? Who is being consulted and what are the real objectives? I ask the Minister to assure us that the result will be not only a review but guidelines for best practice. As the noble Earl said, all too many people at this moment are involuntary addicts of benzodiazepines. The danger, the damage, the hurt and the pain, not only for those individuals but for their families, are almost without cost. I very much support the noble Earl.
Baroness Masham of Ilton
My Lords, I thank my noble friend the Lord Sandwich for this short but important debate. His close association with this difficult problem makes this debate more pertinent. The All-Party Parliamentary Drug Misuse Group undertook an inquiry into physical dependence and addiction to prescription and over-the-counter medication in the parliamentary Session 2007-08. I found the inquiry most interesting but of great concern. I hope that the inquiry will be helpful to the people taking part in the Government’s review and that some of our recommendations will be adhered to.
An estimated 1.5 million people are addicted to benzodiazepine drugs in the UK. Many of these people will have been addicted for long periods. There is a common pattern to their submissions. First, there is a visit to their GP and a prescription for a particular benzodiazepine, followed by years of repeat prescriptions, often without review. For many patients, the drug initially alleviates their symptoms, but for others the symptoms continue and their general health deteriorates.
The British National Formulary states that benzodiazepines are indicted for short-term relief—two to four weeks only—of anxiety that is severe and disabling or which subjects the individual to unacceptable distress. It states that the use of benzodiazepines for short-term “mild” anxiety is inappropriate and unsuitable and advocates that withdrawal from benzodiazepines should be gradual, as abrupt withdrawal may produce confusion, toxic psychosis, convulsions or a condition resembling delirium tremens.
Your Lordships might be interested to hear a case study from the inquiry:
“Ms R was prescribed benzodiazepines following treatment for alcohol addiction. For the next 28 years her doctor allowed her repeat prescriptions of the drug despite the fact that she continued to experience feelings of anxiety and ill health. More recently she has attempted withdrawal but failed on a number of occasions. Her GP told her his medical training did not equip him with the skills to help her withdraw, so she approached her local Drug and Alcohol Action Team (DAAT) who refused to help her as she was ‘only a prescription drugs addict.’ She was told that, as her GP had created the problem, it was up to him to solve it. Her DAAT told her that, if she had become addicted to benzodiazepines through illicit use, they would have been able to help her”.
Clearly, there must be a more joined-up approach to educating all health professionals, from pharmacists to nurses and doctors, to ensure that they are able to help vulnerable patients. Despite the fact that the guidelines have been made quite clear about prescribing benzodiazepines, repeat prescriptions for longer than two-week to four-week periods continue to be allowed. Conversely, some GPs continue to try to reduce the benzodiazepine usage of their patients too fast, which is most dangerous. What can be done about this?
The drugs, which contain codeine and include brand names such as Nurofen Plus and Solpadeine Plus, are sold over the counter and are routinely used to ease headaches, back pain and period pains. Official figures show that tens of thousands of people have become dependent on them, many accidentally, with women at the most risk of developing an addiction. Warning that addiction can begin after just three days, the Medicines and Healthcare Products Regulatory Agency has said that, from this year, all packets of painkillers will carry a prominent warning label that will read, “Can cause addiction after only three days’ use”. Also, the pills will be available at a maximum of 32 per packet instead of 100. That is good news, but has this already happened?
With so many problems in the training of junior doctors and student nurses, it is important that the British Medical Association, the General Medical Council and the Royal College of Nursing should ensure that all medical students and nurses are trained to recognise the symptoms of physical dependence and addiction to drugs, including over-the-counter and prescription medications, and that voluntary groups working in this field should be supported. There is the added problem of people ordering drugs such as anabolic steroids over the internet, despite the potential health risks. Does not the Minister agree that the safety of all drugs should be made a priority?
Lord Mancroft
My Lords, your Lordships will be grateful to the noble Earl, Lord Sandwich, for initiating this important debate. I commend the noble Earl on his courage in describing through the example of his own family the particular and peculiar degree of suffering as the result of addiction to benzodiazepines and other prescription drugs. I declare an interest as chairman of the All-Party Group on the Misuse of Drugs. My predecessor, Dr Brian Iddon, who retired at the last election and to whom I pay tribute for his commitment to and tireless work for the group, set up an inquiry and produced in January 2009 a report on addiction to prescription and over the counter medication. I would suggest that the report is required reading for anyone with an interest in this subject. It is by no means perfect, and I am aware that the All-Party Group on Involuntary Tranquilliser Addiction did not agree with all the recommendations, and consequently produced its own report. Having read both reports, I see little of substance to separate them. More important is that it appears that there has been little reaction to either report from those responsible for this appalling situation.
And this is an appalling situation. It is now pretty clear that a very large group of patients, through no fault of their own, are suffering debilitating physical and psychological symptoms to the point where many are incapable of leading remotely normal or happy lives. It is not clear exactly how many people are in this position, but it seems likely to be well over 1 million. That is significantly more than the 350,000 chronic and chaotic illegal drug addicts who clog up our criminal justice system and take up so much of our time and money.
Interestingly, I have had more briefing for this debate than for almost any other that I have taken part in. For example, I was intrigued to learn from Professor Hamid Ghodse’s recent annual report on drug related deaths in the UK that out of a total 2,182 deaths last year, 20 per cent were caused by heroin or opiates, which is perhaps not particularly surprising. However, 10 per cent were as a result of prescription drug overdose. More significant is the number where a mixture of illegal, prescription, over the counter drugs and alcohol are the cause of death. I shall return to this point at the end of my remarks. Whichever way you look at it, this is an unacceptable situation. What is clear is that responsibility for researching it in order to fill the very real gaps in our knowledge, and for producing a plan to tackle the problem, lies fair and square with the Department of Health, the royal colleges—in particular those for general practitioners and psychiatrists—and the pharmaceutical industry, which produces and profits from these drugs. It is clear that all three have been guilty of a quite staggering degree of complacency, which amounts to a gross dereliction of duty.
The problems we are discussing have been known about since the 1980s, if not earlier. I wonder, too, how much of this is the result of the cosy relationship between doctors, the drug companies and the department. The previous Government are to be congratulated on setting up last year the review which is the subject of this evening’s debate. From correspondence I have seen, it appears that the terms of that review may have been amended and reduced by officials—quietly, I suspect, while one Government went and another came. I hope, when he comes to reply, that my noble friend will be able to reassure the House that the review will be thorough, all-encompassing, and that it will be completed in a reasonable time. I hope, too, that this Government will publish the report, that it will include recommendations—a point made by another speaker earlier in the debate—and that those recommendations will be subject to consultation among the relevant stakeholders. We should also remember that the Government are currently reviewing their drug and alcohol strategy, for which the consultation period will shortly draw to a close, but I hope that my noble friend will be able to reassure the House that the issue of addiction to prescription drugs that we are discussing tonight will form a significant part of the review and be included in the Government’s proposals when the strategy comes out.
In respect of this, I should like to make two final points. I referred earlier to the number of deaths caused by a mixture of different drugs and alcohol. Increasingly, whether we like it or not, we live in the age of the poly-addict—the addict who will take any or all sorts of drugs. I know that some seek to differentiate between involuntary addiction to prescription drugs and the use of illegal or street drugs. Having said that, I have never met a voluntary drug addict, whatever drug they were taking. But the resulting health problem is that of addiction. It does not much matter whether you break your leg ballroom dancing, playing cricket or falling over outside the pub, having had a glass too many. What matters is that you have a broken leg and it needs to be fixed. That is the key point.
The noble Earl said clearly that he does not believe that the National Treatment Agency has the expertise to provide the specialist withdrawal services that benzodiazepine addicts need. He is certainly correct in that, and indeed I wonder who does have that expertise. I could argue that the National Treatment Agency’s main area of expertise lies in prescribing drugs such as methadone rather than in helping patients off drugs altogether, which could suggest that it is part of the problem rather than part of the solution. What matters is that the solution is one of appropriate healthcare, which currently is not being provided either for involuntary tranquilliser addicts or voluntary street drug addicts. Both need to be provided with appropriate care, and ultimately the NHS must provide that care, whether via the National Treatment Agency or any new body to be set up as part of the public health reforms.
That brings me to my last point. Whatever happens, the solution to this problem lies in proper regulation of prescribing, better training of doctors and other healthcare professionals, the provision of high quality detoxification and treatment for all addicts that gets them off rather than keeps them on drugs, and assistance back into the work place. In other words, it is a health solution, not a criminal justice one, and that is why it is so welcome that the Minister responding to tonight’s debate is a Minister from the Department of Health, not one from the Home Office. That, at least, is progress.
Baroness Meacher
My Lords, I thank the noble Earl, Lord Sandwich, for creating the opportunity to raise important issues relating to the over prescribing of benzodiazepines and other prescribed drugs. The noble Earl referred to the huge numbers of patients who remain addicted to these hypnotic drugs for decades, and set out graphically the side-effects and symptoms of withdrawal. It will not surprise some noble Lords, least of all the Minister, that for me this debate raises the possibility that regulating rather than criminalising medical marijuana use might help to reduce the pressure on GPs to prescribe benzodiazepines. Has the Government’s review of dependence on and withdrawal from benzodiazepines considered this possibility? If not, will the Minister extend the review to assess the possible benefits and savings from a medical marijuana use policy in terms of the reduced use of costly and dangerous prescribed drugs?
We know that benzodiazepines prescribed for anxiety can, over time, exacerbate anxiety rather than alleviate it. We also know that elderly people on benzodiazepines are more likely to suffer falls and broken hips than other elderly people. Would cannabis be a safer option for people in constant pain or other discomfort who have difficulty sleeping? No GP should recommend cannabis for people with anxiety—I wish to be quite clear about that. They should be recommended for cognitive behavioural therapy, a well-tried and highly successful treatment.
International research, however, shows the considerable medical benefits of cannabis for a wide range of ailments and I shall mention a few. I could go on and on about this but I will not, your Lordships will be glad to hear. Benzodiazepines have no such benefits. Patients with respiratory complaints, for example, who are prescribed cannabis in other countries to help them sleep, and who use a vaporiser for the smokeless delivery of cannabis, show meaningful improvements in respiratory function; not only do they sleep better but they recover, at least to some degree, from their respiratory disease. Cannabinoids, a key ingredient of cannabis, which would be enhanced in a regulated system of MMU, can grow new brain cells, researchers tell us, fight brain cancer, aid mental health and reduce inflammation. Again these matters need elaboration but there is no time tonight.
So what is the international experience of medical marijuana use? In at least 14 US states and Washington DC, covering more than 20 per cent of the population, the law stipulates that individuals who receive a recommendation from a medical doctor for marijuana use for medical purposes are allowed, in most cases to grow, and in all cases to possess and use, limited amounts of the drug. The law also protects caregivers who are involved in those activities.
In Canada, the medical marijuana access programme was established after a ruling by the Ontario Superior Court concluded that the blanket prohibition of cannabis use violated constitutional rights for individuals who could derive medical benefits from marijuana use. In 2003, another ruling of a higher court required the Government to establish a government-sponsored supply of marijuana for medical use. This is crucial. It has been estimated that 40 per cent of patients in these other countries prescribed marijuana suffer from serious illnesses such as cancer, AIDS, glaucoma, epilepsy and multiple sclerosis. The remainder have ailments such as anxiety, sleeplessness, ADHD and assorted pains. How many of such patients in this country, where cannabis is illegal even for medical use, are prescribed benzodiazepines or equally dangerous prescribed drugs? Will the Minister include an exploration of this issue within the review?
The Minister may think that such a step would run counter to the UN conventions and the United Nations Office on Drugs and Crime. I can reassure the Minister that every step away from the criminalising of drug use towards a health-based approach is in line with UNODC policy. That august body, which is responsible for the UN drugs conventions, issued a ground-breaking discussion paper in March arguing for the first time that UN conventions need to be reinterpreted, leaving behind the criminalising policies in relation to drug use of the past 50 years. The new executive director of the UNODC, none other than a Russian, Mr Fedotov, in his first statement on taking office, reaffirmed the commitment of his organisation to promoting a health-based focus on drug use policy across the world.
Many patients are suffering unnecessarily because of the misguided drug use policies of the past 50 years in this country. The coalition Government are looking for significant opportunities for public sector cost savings which deliver improvements in public experience. The drugs policy is probably the most fruitful candidate for making a major contribution to public sector savings in a constructive way which will benefit our communities. The introduction of a medical marijuana use policy would be a valuable start. I hope the Minister will agree.
Lord Alderdice
My Lords, I am grateful to the noble Earl, Lord Sandwich, for the opportunity to explore this complicated issue in a larger way than with a simple question and answer.
I have never taken diazepam but it did help me sleep on one occasion. I had just qualified as a junior doctor and, on my first night on call, I got to my bed shortly after 12 o’clock. I was suddenly seized with the anxious thought that I could not think of a single medical emergency that I could treat on my own. Eventually it came to my mind that if a patient came into the casualty department with status epilepticus, I could simply inject diazepam until they stopped fitting and that would resolve the problem. It was not a dangerous procedure—in fact it was much the best way of dealing with the situation; it was not a toxic drug—and I was able to sleep with the knowledge that I could possibly treat it. My last words were a prayer that any patient who came in that night would have status epilepticus. I woke up at half-past seven the next morning but there had been no patients, with or without the condition, and so the diazepam, in my thinking, had helped me to get to sleep.
As a young doctor—particularly as a young psychiatrist and one who specialised in psychotherapy and worked in an addictions department—I became familiar with the whole question of benzodiazepines. The first thing to say is that although this is a group of drugs, they are not identical by any means. I remember that in those early days, diazepam and a number of other drugs of that kind had been used and it was beginning to become apparent that for many people they had addictive qualities, and a new drug, lorazepam, was sold under the drug name Ativan. We were recommended this drug because it was believed that it was much less addictive. As it turned out, it was much more difficult to get patients off it. It had a very unusual profile: you could reduce the dose of the medication by a half, even by three-quarters, without any terribly serious effect, but getting them off that last bit was extremely difficult.
The point is that benzodiazepines as a group are not all identical with each other—they have different components—and they are addictive because they are effective for many people in relieving them of their anxiety and helping them, for example, to get to sleep because some are used as hypnotics rather than anxiolytics. That is not to take away from the tragic stories which have been recounted in the debate, which are also absolutely true and the case. Many people suffer because they become dependent but we must remember that many people function and get on with their lives, get to sleep at night and operate the next day. They are able to manage with their anxieties and difficulties precisely because they have access to these medications. Therefore the idea that this is a kind of modified cocaine or something like that is to not understand the need for some of these medications.
The noble Baroness, Lady Meacher, referred to the medical use of marijuana. Given all the indications, it was interesting for how long we knew problems were arising with the use of marijuana that people refused to accept. It is only in the past few years that people have been prepared to point up the increase in psychosis among young people who use marijuana and the increase in suicidal behaviour. The idea that we should shove aside benzodiazepines and introduce medical marijuana would need a great deal more exploration. There are major problems with even medically-used marijuana and we need to be very careful about it.
My preference is to move to psychological methods of treatment and I wish to say two or three things about that. First, many patients do not want to adopt a psychological approach to treatment; they very much want a pill that will take away the unpleasantness of the difficulties of the moment. I suspect there may be some, not in your Lordships’ House this evening but perhaps at other times, who might use other ways of putting a problem to the side rather than confronting it—perhaps in the Bishops’ Bar, for example. Whatever the problems of benzodiazepines, they are generally less than the problems of alcohol addiction in various ways. We need to steady ourselves and realise there are many problems with these drugs but there are also certain benefits to a substantial number of people. That is what makes it difficult. If they were only problematic it would be easy; it is because they are helpful to some people that we have a big problem.
But there is a further component. We began to notice in Northern Ireland in the late 1960s and the early 1970s a major increase in the prescription of benzodiazepines in the areas around where there had been street trouble and riots. It was not in the areas where they were happening, but in the areas around—the penumbra, as it were—where people as a whole community were terrified about what might happen to them and their families. In other words, you were not dealing with a mental illness; you were not dealing with a personal problem; you were dealing with a societal problem of anxiety on a large scale. In the end, the only way to deal with that was to deal with things at a social level and to try to remove the fundamental problem.
Here we have a problem of the moment. The serious economic crisis that we face, the austerity that all of us experience and will experience, is going to make life more difficult for people to manage. That is just a piece of reality. So, in looking at the individual question of how we deal with the withdrawal of dependent people from drugs, there is a particular approach—a psychological approach, a medical approach and the provision of talking therapies—that we can take. However, let us not imagine that if we go down that road it will be cheaper than the prescription of medication, because it will not be. It will be more expensive to pay for the time of people. Cognitive behavioural therapy is very helpful, but it is very rarely a short-term resolution for all problems.
But one opportunity is opened up for us in the proposals of the Government for reform of the health service; that is, by devolving more control and more decision-making to a local level, particularly in relation to local councils, which also have responsibility for the provision of social care. It may, I hope, be possible for general practitioners and others in acute primary care to see the resolution of a lot of the anxieties that were raised, for example, by the noble Baroness, Lady Bottomley, whose experience as a social worker let her see how the prescription of medication was used to deal with social problems. If social services departments can co-ordinate much better with primary care, it becomes possible for general practitioners not to prescribe medications of any kind but more to relate to those whose responsibility it is to deal with social service and social care problems.
I therefore hope that the Minister will be able to tell us something about dealing with benzodiazepines, but I trust also that he will be able to fold that into the opportunities for better co-ordination between the different components of care that we need to provide for our citizens.
Baroness Thornton
My Lords, I am very pleased that the noble Earl, Lord Sandwich, has succeeded in securing this debate. His persistence in raising this important issue is to be commended.
Last November, the noble Earl pressed me as the then Minister about this important matter and I assured him that the promised review would report this year, 2010. I understand that this has now been extended to next year. I join the noble Earl in his disappointment, given that we know the scale of the problem. I also join the noble Baroness, Lady Bottomley, in saying that this issue should not fall between the cracks of reorganisation.
I understand that the extended review includes a literature review, an audit of selected PCT prescribing data and a survey of the withdrawal assistance that is available from the voluntary sector. However, many believe the review to be a case of too little, too late. The terms of reference have been shrunk; the completion date is repeatedly extended; and patients have been excluded from the process. This is a far from satisfactory situation and I hope that the Minister will be able to give us more comfort than seems apparent. It is simply not acceptable in these days of sophisticated medication that people should take prescribed drugs in good faith and then find themselves incapacitated when they try to stop taking them.
Given the limitation in the time that we have this evening, I wish to address two areas. The first is in the context of the treatment of depression. As the Minister will know, NICE guidance on the treatment of mild to moderate depression and anxiety disorders recommends cognitive behavioural therapy as the treatment with the strongest evidence base for efficacy. For this reason, the Labour Government invested £173 million in the Improving Access to Psychological Therapies programme to train a new workforce of 3,600 people in cognitive behavioural therapy in the three years to 2010-11. Will the Minister explain what the future holds for psychological therapies? With GP commissioning coming down the track, this seems to be yet another matter that is riven with uncertainties.
I raise, secondly, SSRI antidepressants, which I discussed with the noble Earl before our debate. I think that we agree that this is also a matter that is linked to this discussion. We know that they are effective treatments which have benefited millions of people. Since completion of the review by the expert working group in 2004, every effort has been made to issue updated advice as appropriate, and communications are issued to healthcare professionals via the central alerting system, the MHRA website and the Drug Safety Update. What is the current position on the usage and ongoing reviews of SSRIs? Can we be sure, for example, that no person under 18 is prescribed a drug such as Seroxat? I feel strongly about this issue, because a relative of mine has never recovered from having been prescribed Seroxat when he was 15 years old, many years ago. All companies have a responsibility to patients and should report any adverse data signals to us as soon as they discover them. The investigation into GlaxoSmithKline and the use of Seroxat revealed important weaknesses in the drug safety legislation in force at the time. Can the Minister assure the House that steps being taken to strengthen the law will ensure that there can be no doubt as to companies' obligations to report safety issues?
I urge the Minister to take up this important issue of dependence on benzodiazepines and to ensure that a co-ordinated action plan results from the review now being undertaken.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I join other speakers in thanking the noble Earl for having called this debate, which has prompted some excellent contributions from all speakers. This is an issue of considerable importance and I am well aware that it is of great concern to the noble Earl’s own family. I know that he made a moving statement on this question to the All-Party Parliamentary Group on Drug Misuse last December. I commend the all-party group for its report on dependence on prescribed and over-the-counter medicine.
When most people consider the harmful effects of drugs and drug addiction, they will tend to think of illegal drugs such as cocaine and heroin. They will be less likely to think of the drugs that are available perfectly legally from their GP or over the counter at their local pharmacy. The harmful effects of addiction to medicines for pain relief, anxiety or insomnia do not make for lurid headlines. People assume that if your doctor has prescribed a drug, or if you can buy it at the local chemist, it must be safe. In most cases, it is, but this is not the whole story. Unfortunately, some people suffer the consequences of dependence on medicine. At the Department of Health, we receive a steady stream of letters from people whose lives, or the lives of their loved ones, have been badly affected by addiction to tranquillisers or other prescribed medicines. To them, I say that we acknowledge the problems that they face and are working systematically to understand how services can be improved.
I should also like to pay tribute to the NHS and voluntary organisations that are already doing so much to help people withdraw from prescribed and over-the-counter drugs, but we need to know more about how well placed these services are to meet the needs that exist and what support might improve them.
To tackle this problem properly, we must first understand it. The Department of Health has asked the National Addiction Centre to conduct a literature review to identify and assess the existing medical and scientific evidence about the scale and nature of the problem and how it can be treated. We also need reliable information about how many people are dependent on medicine and how many need help to withdraw.
The true scale of the problem is hard to quantify. I will say a little more about that in a minute, although I recognise that the APPG offered an estimate. To a large extent, the misuse of prescribed and over-the-counter drugs is a hidden problem. Some people do not realise that they need help, so do not ask for it; others do not know where to go for advice and support; some will not admit that they have a problem and need help, and as a result are simply not counted. We need to gauge the true extent of clinical dependence and the need for help in withdrawing from dependence on legal medicine. The Department of Health has asked the National Treatment Agency for Substance Misuse to conduct an audit of GP prescribing which, I can tell my noble friend Lord Mancroft, will indeed be thorough.
The department has also asked the NTASM to map the extent of current service provision to help people withdraw from dependence on legal medicine. We have asked to see the results of this work by the end of this year. After Ministers have had an opportunity to consider the findings, we will share them with interested individuals and organisations to inform a debate about where we go from here. In advance of their publication, I shall set out how the initiatives already announced will help to improve services for this group of people. The Secretary of State for Health plans to create a new, integrated public health service to promote public health and encourage behaviour change to help people live healthier lives. The treatment of dependency will be a priority of a public health service. The public health White Paper, due for publication later this year, will set out the service’s role in the rehabilitation of people whether they are dependent on illicit drugs, alcohol or legal medicines.
Later this year, we will publish a new drugs strategy; the consultation on that closed last week. We are now looking at the responses received to inform the development of that strategy, but we are clear that we want to achieve a closer integration of services to help people, regardless of the substances on which they are dependent, to live full lives, participating actively in society. I mention those forthcoming policy statements because they will set the context for our future work.
I referred to the letters we received from those affected by addiction to medicines. The letters are often heartbreaking. If there are more people affected in the same way, we need to know and to act. Equally, if we are to intervene and make this a priority for the health service, we need to ensure that we provide the right help in the right way. We all know that funding is extraordinarily tight; there will be difficult choices to make. Before local commissioners commit resources to dedicated medicine addiction services, they need the evidence that that spending will be effective.
There are good examples of areas where local commissioners have recognised a need in the area and have commissioned dedicated services. Bristol's Battle Against Tranquillisers, or BAT, is working with primary care trusts and mental health trusts across the West Country to provide dedicated counselling group therapy and telephone advice for people dependent on medicines. It is also educating GPs about the risks of tranquillisers and safe and effective methods of withdrawal. BAT also provides advice and counselling sessions at a number of prisons where benzodiazepine use is particularly high among older inmates. I commend the hard work of local NHS and third-sector organisations like BAT, and similar organisations across the country, in helping to deliver these vital services.
There may be a greater role for chemists and practice nurses to help in planning and delivering withdrawal programmes. There was already a great deal of advice available to GPs about the risk of addiction in prescribing benzodiazepines, sleeping pills and painkillers. Advice is also available to help clinicians manage patients’ safe withdrawal, and is set out in the British National Formulary, in clinical knowledge summaries and on the Patient UK website.
I was asked by more than one noble Lord about the scale of the problem of people addicted to benzodiazepines. Evidence to the All-Party Group on Drug Misuse estimated that 1.5 million people were so addicted. However, further work is needed to reach a more statistically reliable estimate of the scale of dependence on these medicines. That estimate was worked out by researchers for a television programme broadcast 10 years ago using prescribing figures for one primary care trust, which were then extrapolated to arrive at a national estimate. It can easily be seen that we need to revisit this question.
In any event, overall numbers of prescriptions do not by themselves show the scale of the dependence. Many prescriptions, including long-term prescripts, are clinically appropriate: that is, they are based on the doctor’s full knowledge of their patient’s condition and deemed by the doctor to be beneficial. In some cases, tranquillisers are prescribed as part of a full package of medication for conditions such as epilepsy or multiple sclerosis. It is also important to note that prescription numbers overstate the true numbers of patients, as those figures will include repeat prescriptions for the same patients.
A number of noble Lords questioned whether the NTASM was the appropriate body to be commissioning the services for people who become addicted. In fact, as I am sure your Lordships will know, the NTASM does not directly provide treatment services. NHS drug and alcohol services are there to do that job. I do not agree that drug and alcohol action teams are not best placed to help people addicted to drugs. DAATs commission to provide help for a wide range of drug users, including people dependent on medicines such as tranquillisers. In many cases, services for people hooked on such drugs are provided at different sites than those for people hooked on illicit drugs. Case workers are fully qualified to advise people who need advice on withdrawing from prescribed and over-the-counter drugs. Services for people trying to withdraw from benzodiazepines are offered in a sympathetic way, with sessions held at separate sites or at different times by some PCTs to make users feel more comfortable. When I asked about this, the advice was that treatment providers would typically treat each case on its individual clinical merits, both psychosocially and pharmacologically. Examples of these services are established in specialist clinics to treat those with addiction to medicines such as benzodiazepines.
Mention was also made of the 2004 Health Select Committee report. The previous Government published a response to that report in 2005, replying to all the recommendations in it. As a result, the MHRA has made a number of improvements given the concerns in the report. Time prevents me from reading them out, but they are significant. Noble Lords also asked me what the timetable for this review was. I have already indicated when Ministers have asked for the report to be on their desks. The review is considering services across the board, both in the NHS and the third sector. As regards the latter, the Government will allocate funding centrally for third-sector organisations only from the third-sector investment programme.
The noble Baroness, Lady Thornton, criticised the Government for not involving people directly affected by dependence on benzodiazepines. In fact, the review under the previous Government, which as she knows was not a formal public consultation—there was therefore no formal requirement to consult external stakeholders—nevertheless included a programme in which officials contacted most of the main patients’ organisations and obtained their views on the way forward. That was very helpful background to the work that we are now doing.
The noble Earl asked about support for the voluntary services in Liverpool, Oldham, Bristol, Belfast and elsewhere. He will know that decisions about funding of local services for people dependent on medicine are based on local needs. We are aware of several PCTs that fund withdrawal counselling.
Time prevents me from going further, although I do have further information and will write to noble Lords whose questions remain unanswered. I apologise for not being able to do so now. Contributions made in today’s debate illustrate graphically the concern felt by this House on the issue, which I and my ministerial colleagues take extremely seriously. I look forward to sharing the results of our reviews with noble Lords as we develop policies and services in the light of evidence.