Preventing and responding to dependence on prescribed and over-the-counter medicines: national policy, local action Steve Taylor, Programme Manager Alcohol, Drugs & Tobacco Division - Health & Wellbeing Directorate 15 May 2014
Brief recent history 2007 - All Party Group launches inquiry into the misuse of prescription-only and over-thecounter medicines 2009 - All Party Group publishes inquiry, concerns at: Availability by prescription and sale (POM/OTC medicines) Possible mis-prescribing of tranquillisers by GPs Possible shortage of services to help people addicted to medicines 2 Addiction to medicines policy May 2014
Brief recent history (continued) 2010 - DH commissioned two reports: Literature review published evidence on the extent of the problem and how best to respond to dependence (National Addictions Centre) Consultative review Investigate prescribing patterns and the services and support available to people who develop problems. 2011: NTA and NAC reports published Roundtable convened 2013: PHE responsible for programme delivery Products/activities: consensus, conference, commissioning guide, practice examples, pilots 3 Addiction to medicines policy May 2014
Service delivery Access Surveillance NTA report 2011 - findings 1. Over the last 19 years dispensing of benzodiazepines has decreased but there has been an increase in the prescribing of anxiolytic benzodiazepines and the sale and prescription of opioid painkillers 2. Long-term prescribing increases the likelihood of dependency but this is not inevitable 3. There are sub national and local variations in the level of prescribing 4. Local areas have access to the information needed to address any issues. 1. Most local areas offer treatment for people who develop problems in relation to medicines, but some provide very little 2. Those who do not have concurrent problems with illegal drug use are a distinct population within drug treatment services but may be under representative of the treatment need 3. There is sub national variation in the level of treatment reported 4. Trends in treatment presentation suggest that there could be an increase in need within this group, in relation to opioid painkillers 1. Local areas report commissioning of services that are flexible, in order to meet local need 2. Services report providing a wide range of interventions in a variety of settings 3. Performance data suggests that these services are meeting the needs of those reporting a problem with just POM/OTC 4. Services and local areas report that there is room for improving understanding and service delivery for addiction to medicine. 4 Addiction to medicines policy May 2014
Range of populations People who entirely inadvertently became dependent on prescribed medicines Damaged people who were always liable to become dependent on something as a way of coping with their problems People who self-medicate but get into problems People who start on prescription or OTC drugs because they re available/legal People who prefer illicit drugs but will top-up/substitute with medicines when they have to 5 Addiction to medicines policy May 2014
Benzodiazepine (and z-drug) px 6 Addiction to medicines policy May 2014
Regional variation 7 Addiction to medicines policy May 2014
Opioid pain medicines px Trends in the prescribing of opiates analgesics in general practice in England (National Treatment Agency May 2011) 8 Addiction to medicines policy May 2014
Number of patients (10 4 ) Mostly for non-cancer 6 50 5 4 3 2 1 Prescriptions- noncancer Prescriptions- cancer Patients- noncancer Patients- cancer 45 40 35 30 25 20 15 10 Number of prescriptions ( 10 4 ) 5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 0 Total number of prescriptions and number of patients stratified by non-cancer and cancer CPRD (England) 2000-2010 9 Addiction to medicines policy May 2014
Px opioid deaths mirror prescribing may signal an emerging problem in the UK similar to the issue that is now well established in the USA. Prescription opioid abuse in the UK, Giraudon I et al., British Journal of Clinical Pharmacology 2013 10 Addiction to medicines policy May 2014
Again, tremendous regional variation Variation between Strategic Health Authorities in prescribing of opioid analgesics (Quarter to March 2010) NHS prescribing services. 11 Addiction to medicines policy May 2014
Interesting but... Trend data tells us something about the use of these medicines Levels of prescribing can identify areas where there might need to be further focus (particularly at a practice level) But... Higher levels of prescribing do not necessarily mean that these medicines are not being used appropriately 12 Addiction to medicines policy May 2014
It s not just benzos and OPM Pregabalin and gabapentin Antidepressants Over-the-counter medicines 13 Addiction to medicines update February 2014
Pain in secure environments Concentration of risk factors for chronic pain and depression/anxiety Difficulty distinguishing genuine patients Opportunities for regular assessment Non-pharmacological interventions Bridges 14 Addiction to medicines policy May 2014
What do we do? 15 Addiction to medicines policy May 2014
Service delivery Access Surveillance NTA report 2011 - questions 1. How can we be better informed about the overall extent of the issue and what drives changes over time? 2. What information do local areas require to support them to better understanding need 3. What should be done to improve public understanding of treatments for anxiety, insomnia and pain? 4. What actions should be taken to prevent problems in relation to addiction to medicines from occurring in the first place? 1. How can we ensure that the availability of support reflects the local need and changes over time? 2. How can we make people more aware of the availability of services? 1. What training or guidance is needed to support clinicians and how can this best impact on their practice? 2. How should we measure the outcomes of treatment for this group? 3. How can we improve the coordination of care for patients across all health services (i.e. GP services, Talking therapies, mental health and pain services.) 16 Addiction to medicines policy May 2014
Assessing need Data NHS Px Services NDTMS (quarterly reports, JSNA) but dependence and tx services only Intelligence Medicines management Professionals: pharmacists, doctors, etc Patients/service users Audit 17 Addiction to medicines policy May 2014
Service responses Primary care Specialists: Support to GPs Specialist treatment Dedicated or integrated Other non-drug specialist responses: Access to psychological therapies Links to mental health and pain services 18 Addiction to medicines policy May 2014
What did NTA (and partners) do? Round table Consensus statement Conference NDTMS/JSNA Core medical competencies IAPT eligibility MHRA oversight MHRA e-learning CDAOs 19 Addiction to medicines policy May 2014
What is PHE (and partners) doing? Four areas in consensus: Support to GPs and other healthcare professionals Improve access to treatment and support Media and political Refresh JSNA data/guidance RCGP/CPPE e-learning SMMGP face-to-face training Improve the commissioning of services Highlight best practice to improve public and professional awareness RCGP factsheets Commissioners guide Secure environments guidance Practice examples OPM core resource BMA review 20 Addiction to medicines policy May 2014
Resources 21 Addiction to medicines update February 2014
How important? It s real Drug strategy s wider remit Public health Secure environments Future But keep it in proportion 22 Addiction to medicines policy May 2014
Summary of the policy position ATM is a multi-faceted and complex issue that government takes seriously From the centre we provide data and advice to support local areas to understand and respond to their local ATM problems Working with many stakeholders we have a wide-ranging programme of activity Like many other social and health issues, the problems and their solutions need to be owned jointly by the local authority, NHS England, CCGs and patients (likely through health and wellbeing boards) It is for them (you) to determine the most-effective shape of local responses and where they come from, not for us to dictate 23 Addiction to medicines policy May 2014