There was an APPGITA meeting with Jane Ellison MP, Public Health Minister, arising from David Cameron’s answer in Prime Minister’s Question Time to a question on involuntary tranquilliser addiction by Jim Dobbin MP. The meeting took place at Richmond House on Tuesday 17 December 2013.
Attending were Jane Ellison MP, Public Health Minister, Yemi Fagun, Department of Health, Jim Dobbin MP, Chair APPGITA, Emily Pignon, Office of Jim Dobbin MP, Lady Rhona Bradley, CEO Addiction Dependency Solutions, John Perrott and the Earl of Sandwich. Apologies from Eric Ollerenshaw MP and Baroness Hollins.
The Minister was presented with the following briefing in advance of the meeting and will be responding to this and issues raised in the meeting in the New Year:
Briefing for APPGITA meeting with Public Health Minister Tuesday 17 December 2013
The Prime Minister said “this [ITA] is a terrible affliction; these people are not drug addicts but they have become hooked on repeat prescriptions of tranquillisers. The Minister for public health is very happy to discuss this issue with him and, as he says, make sure that the relevant guidance can be issued.” (HC Deb 23 Oct 2013 c 296)
- David Cameron said clearly it is not substance misuse and directed that the correct guidance be issued.
Thus, the question for the Minister is – What are the Minister’s plans to stop future addiction and treat those already addicted?
Immediate urgent action needed:
1. A guide for commissioners on involuntary tranquilliser addiction is needed immediately. The PHE guide for commissioners written by Steve Taylor, Programme Manager, Drugs and Alcohol, PHE, is not fit for purpose because it mainly deals with illicit drug use interwoven with brief mentions of ITA to give the appearance of addressing the issue. The proposed guide will direct commissioners to identify patients, assess the true scale of the problem and to provide appropriate treatment with drug free goals based on the Ashton manual and the recently amended BNF guidelines on benzo withdrawal. ITAs need to be treated as a separate population from substance misusers because substance misuse treatment, including abrupt withdrawals, is dangerous for this cohort. Also, ITA’s may be unable to attend drug centres due to debilitating withdrawal symptoms.
APPGITA and Professor Ashton strongly advise that the guidance be amended accordingly and that PHE distribute it under PHE banner and publish it on the DH and PHE website. A detailed list of criticisms and recommendations is provided at the end of this briefing.
2. Enforcement of existing guidelines (ignored by doctors using “clinical judgement”) is required for NEW patients. Doctors continue to prescribe beyond the 2 – 4 week guidelines, subject patients to rapid tapers, abrupt withdrawals, forcing patients to discontinue the drug without support, telling patients that withdrawal does not last longer than a few weeks or months which poses major problems including polypharmacy i.e. additional medication including SSRIs to treat withdrawal symptoms misdiagnosed as new illness or a return of original one.
- Estimated 1.5 million people have been prescribed tranquillisers long-term by their doctors (Survey of GP surgeries by Professor Ashton, survey conducted by BBC Panarama “The Tranquilliser Trap” 2001, figure also stated in paper co-written by Clare Gerada “Benzodiazepines addiction and abuse, Ashworth, Gerada, Dallmeyer 2002). A figure of over 1 million is also corroborated by initial findings of a recent survey of GP surgeries by John Perrott. Most are likely to be addicted and will suffer withdrawal symptoms, five times as many people as there are in treatment for illegal drugs.
- Professor Steve Field, when Chair of RCGP, said on ITV West interview, March 09:
“… there are still a lot of people on benzodiazepines and tranquilisers that have been on for many years…..the patient doesn’t want to come off the drug because they’ve tried before and they get all of these horrible withdrawal side effects which are very similar to coming off heroin or cocaine and indeed in my experience it can be more difficult to get people off benzodiazepines….the best thing to do is to not prescribe them in the first place…..some of the drugs, in some people, it can be three or four days of the drug before they get hooked”.
- Last year’s DH poisoning statistics show there were sixteen times more hospital poisoning admissions for tranquillisers and antidepressants than for the illegal drugs added together (Tranquillisers 14,192, Antidepressants 16,055, Heroin and Cocaine together 1813) showing which drugs cause the most problems. Source, Drug poisoning Finished Admission Episodes 2011 -2012
- Over 1000 Parliamentary Questions on ITA since 1970 from MPs have expressed concerns about widespread addiction to prescribed tranquillisers. Many promises from Ministers in the past have all led to inevitable inaction.
- All the sourced evidence has been based on biased reporting as a misuse issue.
Commissioning Guide – Criticisms and Recommendations by APPGITA and Professor Ashton
1. The first paragraph entitled “What is the issue” incorrectly refers to two substance misuse documents. The 2010 Drug Strategy”, a Home Office document on substance misuse and the JSNA support pack for commissioners, which is also a substance misuse document. Both have had only a single sentence added mentioning addiction to prescription medicine. ITA is an urgent medical issue and is not a Home Office issue; neither is it a substance misuse issue.
2. The guide conflates the two populations of ITAs and drug misusers which Professor Ashton advised against as the treatments are entirely different.
3.This is a hidden problem and a new issue for commissioners and as such there is no local expertise. Commissioners need to be directed to GPs’ surgeries to assess the scale of the problem and how to provide appropriate treatment. Addiction Dependency Solutions (ADS) provide dedicated withdrawal services for ITAs via local CCGs and such services should be duplicated on a national scale, as an example of best practice.
4. “Sources of data”. None of these sources will provide meaningful data on ITAs. The NTA, now PHE, only had a remit to treat ITA from April 2013 and prior to this did not collect data on it. ITAs prior to April 2013 were routinely turned away from Drug and Alcohol Treatment Centres. To include NDTMS data in the guide gives the wrong impression that the problem is small, approximately 20 ITAs per CCG instead of over 7000. The only way to assess the true scale of the problem is to audit GP surgeries.
5. “Who and where”. Referring ITAs back to their GPs is not the answer. It was “clinical judgement” which caused ITA; GPs do not have the time, resources or knowledge to treat ITA.
6. “If patients are uncomfortable returning to their GP…” Patients who complain have been abruptly deregistered, with other practices reluctant to register patients who have complained about benzodiazepines.
7. “Patients may feel uncomfortable sharing space with those using illicit drugs”. The main reasons are that substance misuse treatment is dangerous and inappropriate and that ITAs are unable to attend Drug and Alcohol Centres due to debilitating withdrawal symptoms which often render them housebound.
8. “References and further reading”.
Home Office (2010) Drug Strategy 2010 – ITA is an urgent medical issue, not a Home Office issue.
NTA (2011) Addiction to medicine – This report was on substance misuse and does not contain data on ITA and as such is not an appropriate evidence base. It contained inaccurate claims including the assertion that 94% of local areas have withdrawal services for ITA whereas a survey of PCTs by John Perrott proved that 83% do not.
The NTA (2012) JSNA support pack is a substance misuse document and irrelevant to ITA.
The RCGP (2011) Safer prescribing in prisons: guidance for clinicians is irrelevant to ITA
NAC report (2011) “The changing use of prescribed benzodiazepines and z drugs and over-the-counter codeine containing products in England: a structured review of published English and international evidence and available data to inform consideration of the extent of dependence and harm.
One of the authors, Professor Strang, had undeclared financial interests with tranquilliser manufacturers. The report was biased, understated/ignored known risks associated with tranquilliser use and “missed” 130 papers and articles referenced by Dr Reg Peart easily available on www.benzo.org.uk, but instead selected papers biased towards benefits and not stating risks such as benzo babies “floppy infant syndrome”, protracted withdrawal, post-benzo withdrawal symptoms, long-term damage, pseudo-dementia caused by long-term use to name but a few.
9. The DH Drug Misuse and Dependence: UK Guidelines on Clinical Management is a substance misuse document and irrelevant. Also, it contains dangerous and out of date withdrawal guidance not consistent with the recently revised BNF guidelines on benzo withdrawal.
10. Appendix A – Antidepressants including SSRIs have demonstrably been shown to produce severe withdrawal reactions similar to tranquillisers. There is enormous evidence of dependence and also of death, birth defects and suicide from these drugs in the scientific and medical literature, in testimony from withdrawal charities and patients, in litigation and in the media. SSRIs and all anti-depressants have been airbrushed out of the policy review at the last minute by this paragraph, despite assurances from Anne Milton MP in answer to the Parliamentary Question by Jim Dobbin MP:
“Anne Milton: The Government’s Drugs Strategy seeks to tackle dependence on all drugs, including prescription and over-the-counter drugs. We are leading work to prevent and tackle addiction to prescribed and over-the-counter medicine, including anti-depressants.” HC Deb 19 Dec 2011 c 1037
11. The guide does not acknowledge the concept of drug free goals.
12. The guide does not address doctors’ refusal to comply with the 1988 CSM 2 – 4 week guidelines which is the main cause of involuntary tranquilliser addiction and PHE has not confronted this issue or provided any advice to commissioners on how to control GP prescribing.
13. Any services that may emerge from the new commissioning arrangements are directed by Steve Taylor’s commissioning guide into the inappropriate and failed substance misuse treatment models previously promoted by the National Treatment Agency.
14. Steve Taylor has not implemented Anna Soubry’s policy declared in her keynote address at the NTA conference on Addiction to Medicines in February 2013.
15. Steve Taylor was warned by APPGITA and Professor Ashton regarding all the above concerns and refused to change it.