Email from Jim Dobbin, MP to Anne Milton, Parliamentary Under Secretary of State for Public Health (05 September 2011)

I am writing to you in advance of our meeting on the 6th September to give you time to consider the issues which will be raised by the APPGITA. I do not consider this to be a party political issue, we have had similar difficulty with previous administrations and I believe that the DOH has a long standing problem with the quality and independence of its advisors on this subject. I hope that our meeting can be the beginning of proper consultation.

1. The APPDMG meeting chaired by Lord Mancroft at which you launched the NAC and NTA reports was not jointly organised by the APPGITA as was subsequently claimed. The APPGITA does not support or endorse the two reports in any way, for the following reasons:

a) The NAC report claims to be a “comprehensive literature review” (p.87). Its terms of reference are ” to identify and collate all accessible published information from the English and international literature” but it is not a comprehensive review at all. Professor
Heather Ashton is a recognised world expert on tranquillisers and tranquilliser dependence and has published over fifty scientific papers on these subjects. Professor Ashton’s work only receives one brief mention in the 90-page NAC report.
A significant part of the literature has therefore been excluded from the review. Professor Strang is Head of the NAC and an author of the report. The excluded literature coincides with Professor Strang’s own opinions in that Professor Strang is a drug maintenance psychiatrist whereas Professor Ashton’s work is the basis of successful tranquilliser withdrawal and abstinence.
The APPGITA therefore considers the NAC report to be biased and unreliable. Bias in academic work can often be explained by conflicts of interest.
b) Professor Strang, Head of the National Addiction Centre, has a serious conflict of interest in that he is a consultant for Genus Pharmaceuticals a main manufacturer of the benzodiazepines lorazepam and oxazepam which are a subject of the report. This was reported in the Independent on 26 July 2011 . It has now also emerged that Genus
is a wholly owned subsiduary of Clonmel Healthcare (Attachment 1.). Clonmel Healthcare manufacture the benzodiazepine diazepam and the Z drugs Zolpidem and Zopiclone all of which are subject matter of the NAC report.
Professor Strang, with the other authors, “declared no conflicts of interest in their tender for the work commissioned by the Department”, according to your own answer on July 5th to a PQ by Eric Ollerenshaw M.P. This was a false declaration. The late declaration that was added to the report is still incomplete because Professor Strang has not
specified that Genus manufacture benzodiazepines, or that Clonmel manufacture a benzodiazepine and Z drugs.
Two other authors have not made proper declarations. Declarations are intended to mitigate conflicts of interest. Conflicts of interest are not mitigated by late declarations. In my view Professor Strang has been caught red handed and as a consequence the NAC report should be regarded as invalid.
The NTA say their report has a “corporate author”, the NTA itself, and
will not provide any declartions of interest.

c) The NAC reports conclusions will encourage tranquilliser use in several ways: the NAC report’s suggestion of reducing the tapering period to 6 months, whilst the BNF recommends up to 12 months or more, will result in more unsuccessful withdrawals; the report approves a study which finds some “users persist” in taking benzodizepines
because of anxiety, without mentioning that benzodiazepines cause anxiety as a side effect and a withdrawal symptom; the NAC under reports the literature on long term and permanent damage and the post withdrawal syndrome, Dr Reg Peart collated 28 papers on this subject and 72 papers on physical, psychological and social decline of benzodiazepine users (Attachment 2.); Professor Lader’s research evidence of brain abnormalities in 7/14 long term benzodiazepine users are dismissed as “some marginal findings” The NAC’s undereporting of the post withdrawal syndrome and of long term and permanent damage will encourage tranquilliser prescribing.

d) The reports are of no benefit to patients and contain no proposals for withdrawal services. Professor Ashton has written a commentary on the reports. (Attachment 3.)

3.For the patients who have become dependent upon tranquillisers when seeking medical help from their doctor withdrawal has nothing to do with drug misuse, craving, addictive personalities, disorders of the mind or any other theory from the addiction psychiatrists. It is a physical addiction resulting from the properties of the drug.
Tranquillisers disrupt the normal mechanism in the brain that regulate calmness. This disruption leads to addiction, the nervous systems of many patients have great difficulty in readjusting to normal activity and during readjustment become hyper sensitive and hyper excited. This produces the painful, intense, and bizarre psychological and
physical symptoms of benzodiazepine withdrawal.
The severity of withdrawal can be reduced by the tapering method designed by Professor Ashton which allows the nervous system to adjust more gradually. Experience has shown that a tapering period of 12 months is often required and this should be used as a benchmark. A further period of post withdrawal healing and recovery is also
required which may last several months or several years. The authors of the NAC and NTA have not understood this basic information and have therefore been unable to distinguish involuntary prescribed tranquilliser dependency from the drug misuse in which they specialize.

4. The NTA and NAC were inappropriate choices for the commissioning of reports on this subject, they have no expertise on tranquillisers or tranquilliser withdrawal. The NTA commissioned services are well known for their dangerous and unsuccessful 3-week cold turkey approach to tranquilliser addiction.
Both organisations are involved in the methadone maintenance system which achieves an abstinence rate of less than 3% at enormous expense. They believe that “drug addiction is a chronic relapsing condition” and that abstinence is not achievable. In contrast tranquilliser withdrawal practitioners such as CITA, Belfast and Professor Heather
Ashton have achieved 80% abstinence rates using the tapering method developed by Professor Ashton. This method is safe, successful, very cost effective and used world wide yet Professor Ashton has been sidelined by the Department of Health during this policy review. The Department has preferred instead to consult addiction psychiatrists who specialize in drug maintenance with pharmaceutical products. Professor Strang is aware of the unanimously negative response to his report but he has attempted to shift responsibility for this onto the Department of Health.

5. Throughout the policy review the APPGITA has been excluded from the process but promised in correspondence, in answers to PQ’s and in debates that we would be consulted when the report stage was completed. You yourself gave me a personal assurance at our last meeting that we would be consulted. We now know that there is to be a “Roundtable meeting” on the 15th September at the Department to which
not one APPGITA supporter or expert patient has been invited. Professor Ashton is also uninvited. Will attendees at this meeting be required to make declarations of interest and will those declarations be made public?

6. The predicament of patients has been ignored throughout the policy review. The review has been secretive and excluding of any view outside of their very narrow parameters. We still do not know how many patients are affected because the most important statistic, the number of long term users has still not been calculated.
There is still no prospect of medical research into the damage patients have suffered, no recognition of the injuries suffered and no medical treatment for those injuries. There is no mention of tranquilliser related deaths calculated at 17,000 over 50 years. There
is no toxicology report as part of the review, although this is a drug toxicology issue, there is also no mention of “benzo babies”.
Tranquilliser dependence can lead to poor heath, unemployment, and decades on benefit but there has been no calculation of the social cost. No compensation scheme for drug injuries has been discussed. No one has been held responsible for the tranquilliser scandal.
Tranquillisers have limited long term use, their main use is to feed the addiction that they create, nevertheless it is a fundamental assumption of the review and of the reports that their can be no challenge to the product licences of the benzodiazepines and Z drugs.
Total tranquillisers prescriptions have increased by 200,000 scripts in the last year from 17.2 million 2009/10 (Hansard 31600) to 17.4 million 2010/11 ( Hansard 62809).

7. In summary the DOH has adopted a biased and unreliable evidence base for the review. That evidence base is to be discussed at the so called “Roundtable Meeting” on the 15th September by policy officials, GP’s and Psychiatrists. Two politically unaware addiction workers have been selected to attend to create a pretense of consultation. There is little prospect under these arrangements for policy change or proper
help for patients. In practice the policy review has been turned into an opportunity for consolidation of the existing policy of prescription addiction.