Times: NHS plan to help millions stop using antidepressants and painkillers

https://archive.ph/oBHQQ

Millions of patients will be offered help to come off antidepressants and painkillers under an NHS drive to tackle addiction to prescription pills.

New national guidance urges GPs to stop writing repeat prescriptions for those who have become dependent on common medications.

The NHS England plan, which aims to avoid a US-style opioid crisis, recommends that patients be sent to art, music or gardening classes instead of being prescribed painkillers such as tramadol or codeine.

Ugh. I use codeine and naproxen to counter muscle pain in PEM. Can’t see my GP sending me to a life drawing class instead, but still very irked by this creeping narrative that patients who claim to be in pain just need a distraction.

 

Heh?

 

Aaaah, you just have to breathe more, or breathe less possibly. If you do that, if you find that perfect spot not only will your pain go away, you'll also be able to change the channels without touching the remote and make your summer-plants bloom midwinter.

 

Don't know about naproxen... but I've never had any trouble just buying codeine in a pharmacy without a prescription...

 

But only 8mg with 500mg of paracetemol. Any stronger mix, or unadulterated codeine, is prescription only.

 

Aaaah you're probably right. I've never looked that closely

 

Which is still better than being fobbed off with piano tuition or a topiary course.

 

I don't think you even get that. It's group choirs and doing the alottments etc. I guess social prescription type stuff and combining 'other local groups' into the 'ICB' thing - which in theory for some things might make sense but I'm unaware that it is co-ordinated to make sure it isn't 20 choirs and no CAB?

It also is very different to actual psychology of someone's social network being supportive and providing proper help to those poor souls if they were 'victims' of having opiates pushed (what is the situation in the UK with that vs USA?) or dumped on antidepressans in place of fixing their injury in good time or whatnot

I'm pretty ashamed of those in charge that/if instead of saying mea culpa said people need to get the treatment they should have at first, and proper support for harm caused by inappropriate waits and medications we have the fob off and twist it stuff.

And opportunistically using it to then cause the same damage for those who actually did/do need such medications

 

1. Applies in England only, not UK wide

2. This is the briefing: https://www.england.nhs.uk/2023/03/...ion-in-four-years-as-nhs-continues-crackdown/

3. This is the document: https://www.england.nhs.uk/publicat...iated-with-dependence-or-withdrawal-symptoms/

Note contents of 2. and 3. may not reflect the priorities of The Times newspaper !

 

Some antidepressants are prescribed for issues other than depression, so hopefully GPs are allowed discretion in how to respond to this.

Unless it is also assumed to be a good thing to get someone off using a drug to help with such as sleep that could in different circumstances be used as an antidepressant.

 

Thanks, well sourced. Obviously the primary source is greatly preferable to splash copy in the Thunderer (which under Tony Gallagher is increasingly indistinguishable from the Daily Rothermere). There is much more content and much more nuance.

But I don’t see anything that particularly contradicts the Times interpretation: social prescribing alternatives should always be considered for long-term users of opioids and antidepressants. Is there anything specific that you thought was more important?

 

They have been tightening up prescribing limits for GP's in my country over the last decades or so, with respect to the off label use of antidepressants, unevidenced use etc as well as benzodiazepines and opiates (but also paracetamol and non-steroidal anti-inflammatories)

Many GP's had to go through MH to get a psychiatrist to review their diagnosis and be "allowed" to go above prescribing guidelines. Often people (generally and not specific to ME) had a diagnosable and treatable MH condition and once treated were successfully, able to come off opiates and benzodiazepines and wrongly prescribed antidepressants.

There is a lot more public health messaging on mental health prevention and management of mild disorders and self care within communities using cultural based practices and connecting people with mental health NGO's for addiction and pain rather than the public health service, here and seems to be echoed in this article.

Generally people find this less stigmatising than being referred to mental health services and the services are more accessible for rural dwellers and can be delivered online, which is useful for everyone. (also there is not enough formal MH staff or workforce to cover the major increase in some MH conditions and substance abuse/addiction in the general population).

Unfortunately there are lots of dodgy apps say they can cure your pain (and your CFS...) but not sure the positive thinking and wellness brigade will ever be overcome.

There are some replacement medications for "psychiatric medications like antidepressants" for pain and neuralgia (but some are no worse/better with respect to side effects) -eg. pregabalin, gabapentin. But that is an individual thing due to many factors, often genetic and related to drug metabolism and complex medical histories and diagnoses.

Our country doesn't have enough free professional addiction services - inpatient detox and community treatment centres so many people get no formal treatment. I gather that is worldwide from what I have read about downsizing services in the UK and elsewhere. It is very hard to get into a pain clinic to get a review of pain meds and authorisation to continue usual dose.

I don't know anyone who abused their antidepressants but many have taken too many with alcohol but that is a big concern as it can be lethal and a leading cause of death by suicide here. Lots of OD's on paracetamol and major liver complications with liver transplantation required or it is sadly lethal. NSAIDS can cause gastric bleeding and ulcers.

So getting people off medication and learning new skills is good overall for the health services and the people who overuse or abuse prescribed medication, their families, friends and communities.

Of course, people who have addiction problems will then just go into the black market and start using other even more hazardous substances depending on where they live. Sigh

Legal free cannibinoid products for pain are still hard to get here and strict criteria for GP and pain specialists to prescribe.

 

No, not that I recall. The recommended one here is ibuprofen as has less gastric involvement. Voltaren can cause a lot of problems even with food.

Unfortunately people also take them with alcohol to numb the pain and compounds the problem

 

I posted for thoroughness - a possible resource for others, and I've still only skim read. However, I think The Times article is wrong in its presentation of document being a guidance to GPs - the sub head: "GPs urged to prescribe art classes instead of codeine in drive to avoid US-style opioid crisis" is particularly egregious.

What the actual result of the document will be is open to question - I'm cynical in the extreme as to what valuable change can be achieved in the NHS under the current resourcing arrangements. But the document seems reasonable and is far more about structural change in primary care services for certain classes of patient, than about any direction to GPs. Much of the guidance is for ICBs in terms of service provision while the desired outcomes all seem appropriately couched in properly conducted studies, appropriate data and NICE Guidance.

I may be missing something but I can't see any proposals that would make social prescribing a mandated alternative, indeed I can't see how that would work in the face of disease specific NICE Guidance, which is where GPs would look first. The thrust of the document seems mainly to be about building service provision so that new patients would have ready access to alternatives and GPs could prescribe accordingly. The seven case studies deal with various aspects of use reduction - interestingly for a NHS England doc, the first example is a Welsh Health Board, which makes no mention at all about art classes, although inclusion of "auricular acupuncture" is a touch alarming.

 

I was looking at the detail behind Action 2, concerning the alternatives to be considered (this looks to me as if consideration is mandatory, although whether that has any practical effect is moot):

That section references case study six, from Gloucestershire, on “living well with pain”, which includes this gem:

So if you are a bit rubbish at art, you can swap your Penguin for Nigel’s Trio, and the pain just goes away.

 

All that stuff fills me with horror - but it does have a role for some people, clearly pain isn't removed but for those who may have problems avoiding unwanted rumination on their discomfort, having someone else go through the process of introducing them to a new, and supported activity seems to offer a way out of the self involvement.

In terms of how likely it is that existing patients are going to get a medicine review (COVID put paid to that in many practices) where the GP says "it's either life drawing or felting" for you, I think we need to look at the numbers - in 2020 (before COVID really bit) there were an estimated 1.85mn on 12 month prescriptions of the medicines of concern. How many art therapists or OC diverted from elsewhere are going to be needed to actually impact 2 million+ long term ill patients ? How much cash are the new ICBs (commissioners) going to commit to providing new speculative services (no guarantees of cost reductions elsewhere) to meet the demand beyond diverting new patients to the alternatives ?

I suspect the ICBs will act conservatively and apart from some local headline grabbers in reality not much will change. The real danger will come if the Secretary of State decides to require arbitrary prescription reduction targets and/or targets for referrals to the alternative services.

 

And now there is going to be so much more of that with the restrictions that in many cases will cut millions of people from pain medication. Gotta love unintended consequences that are entirely predictable and therefore not quite unintended so much as not bothered with. As long as it happens to other people, it's always OK.