SUMMARY OF CHANGES REQUIRED BY THE WELSH ASSEMBLY GOVERNMENT TO APPROPRIATELY RECOGNISE AND SUPPORT PEOPLE WITH PRESCRIBED DRUG DEPENDENCE
Wales is in the enviable position of being ahead of the game as far as recognition and support for people with PDD is concerned. The All Wales Medicines Strategy Group (AWMSG) has already recognised the danger for dependency on certain drugs, namely benzodiazepines, anxiolytics, hypnotics and opioids and targeted these for reduction in prescribing. The dangers of pregabalin and gabapentin have also more recently been highlighted to prescribers. Wales already has a 24/7 Mental Health helpline (CALL) and a 24/7 drugs and alcohol helpline (DAN). Wales already has a Prescribed Medication Support Service covering 701,000 people in North Wales. England, Scotland and Northern Ireland do not have any of this in place. England agreed a review of PDD which will take at least a year to report. Scotland has a petition which has reached the point where the Committee are thinking about a review. N Ireland doesn’t have a parliament and no campaigning is taking place. Southern Ireland is just about to submit a formal petition, to which I was invited to contribute.
WHAT WALES CAN DO NOW
A. Recognition: with specific reference to SSRI and SNRI antidepressants
Antidepressants to be targeted for reduction in prescribing
As of today, it has not been formally recognised that antidepressants cause dependence to a level equal to the benzodiazepines, anxiolytics, hypnotics and opioids. Many medical experts deny the possibility. A recent report published by the All Party Parliamentary Group (APPG) for PDD prepared for the Public Health England (PHE) review of PDD and published in the Journal for Addictive Behaviours1 has concluded that:
“• More than half (56%) of people who attempt to come off antidepressants experience withdrawal effects.
• Nearly half (46%) of people experiencing withdrawal effects describe them as severe.
• It is not uncommon for the withdrawal effects to last for several weeks or months.”
The findings were inevitably challenged by other medical experts2. In response, the authors, Professor John Read and Dr James Davies publicly stated:
“We readily concede, as we did in the review, that our estimates are indeed estimates, based on the best available evidence. They may be off by 5% or even perhaps as much as 10%, lower or higher.
Nevertheless, even the most conservative estimate of 46% experiencing withdrawal, and 36% of those at the severe level, would represent a public health issue of significant proportions.”3
In order for change to occur in Wales so fewer people are affected by PDD, the AWMSG must add SSRI and SNRI antidepressants to the list of drugs that are targeted for reduction, as benzodiazepines, anxiolytics, hypnotics and opioids currently are.
New guidelines for antidepressant prescribing required
Three different reports produced by the APPG for the PHE review have concluded that one of the main reasons that patients become dependent on antidepressants is that the NICE guidelines, followed by doctors UK-wide, are inaccurate and inadequate. The guidelines have been quoted widely in the media, stating that antidepressant discontinuation is mild and self-limiting. This leads to lack of informed consent and inappropriate prescribing. The APPG reports state:
“Current UK and USA Guidelines underestimate the severity and duration of antidepressant withdrawal, with significant clinical implications.”4
“Clinical guidelines must also be updated to reflect the actual incidence, severity and duration of antidepressant withdrawal, and to enable doctors, psychiatrists and other practitioners to provide appropriate care, including slow tapering protocols.”5
“Possible additional preventative actions include:
• Update NICE guidelines covering the prescription of psychoactive drugs to include the requirement to warn the patient about possible issues of dependence and associated withdrawal effects (in addition to side effects)
• Implement a method of ensuring warnings are given to enable patients to give informed consent to treatment”6
Current NICE guidelines for depression are under review, but there is no confirmation at this point that antidepressant guidelines will change. The AMSG must give all prescribers in Wales new guidelines for antidepressants which accurately demonstrate the risks and benefits of the drugs and allow true informed consent. The Welsh Government can assist by lobbying NICE to update the current antidepressant prescribing guidelines.
Training and Education throughout the NHS
Making the changes above will lead towards all Welsh NHS employees being made aware of the symptoms of antidepressant dependence and withdrawal. Without the clear recognition and acceptance of PDD, GPs and A&E departments erroneously diagnose Medically Unexplained Symptoms (MUS) and refer patients on needlessly to Consultants, Specialists and Psychiatrists. This has huge cost implications for the NHS in Wales.
B. Effectively support patients with Prescribed Drug Dependence and Withdrawal: for all dependency forming drugs
Provision of a Wales-wide Prescribed Medication Support Service
The Assembly Government must give all of Wales access to an NHS funded Prescribed Medication Support Service to match that currently provided across part of North Wales7. A service specifically targeted for patients with PDD is required because the promoted alternative is the Substance Misuse Services which treat PDD the same as street drug and alcohol withdrawal. A short withdrawal for patients with PDD is dangerous and potentially life-threatening. Dr Anne Guy recently visited the PMSS in N Wales on behalf of the APPG. She is the co-author of a report8 on the PMSS and 3 other services in the UK which provide support for patients with PDD. This is for submission to the PHE review with a view to taking the best from the services currently available as a template to roll out across the UK. The PMSS is the only NHS funded service in the UK. Highlights on the PMSS from her report are:
“Costs and outcomes :
• Population of 701,000 across six counties
• Cost per annum £179K
• Cost per population head £0.26 a year
• Cost per person helped: £272
• Outcomes – in the 6 months Apr-Sep 2018
• A total of 329 people used the service (260 new referrals)
• 62% people were reducing prescribed medications
• 33% ceased taking prescribed medications”
Extrapolated to whole population of Wales of 3,125,000 people (as at 30/06/17 according to the ONS) at £0.26 pppa = £812,500. Therefore, for less than £1m, the whole of Wales could have a service which has been tried and tested over a period of 20 years, and which clearly produces excellent results. Seeing as c £50m pa is provided for substance misuse, this hardly seems to be an excessive request.
Training and Education throughout the NHS
Training and education will then be required in order to signpost people to the Wales-wide PMSS. All prescribers will need to know of its existence. The 24/7 helplines (CALL and DAN), which are manned by the same team, are already on board as they currently refer callers from N Wales. A dedicated section of the NHS Wales website is necessary, together with an on-line chat section for those who don’t wish to make a phone call.
Tapering Advice and Tapering Strips
Tapering advice and tapering plans are needed for each drug, and to be made available widely for all prescribers, mental health workers, and patients. These resources already exist within the PMSS and other charitable support services. The Welsh Government should look seriously at the introduction of tapering strips9 – tablets in reducing potencies to enable a patient to taper slowly from their drug. These are currently only available in the Netherlands.
References
1. http://prescribeddrug.org/wp-content/uploads/2018/10/Davies-Read.pdf
4. http://prescribeddrug.org/wp-content/uploads/2018/10/Davies-Read.pdf
7. http://www.nhsdirect.wales.nhs.uk/localservices/ViewLocalService.aspx?id=2556&s=Health
8. http://prescribeddrug.org/wp-content/uploads/2018/11/APPG-Service-Model-Report.pdf
9. http://www.taperingstrip.org/