Debate on the Petitions Committee Report: Petition P-05-784 Prescription drug dependence and withdrawal—recognition and support

Janet, Chair of Petitions Committee:

Thank you. Diolch, Deputy Presiding Officer. I'm delighted to open my first debate as Chairman of the Petitions Committee. I'd like to thank the clerking team, the legal team, and my fantastic committee members for all the support and assistance that I've received in my position as Chairman. I'd also like to thank those who continually send in fantastic petitions to this committee.

Today’s debate is about a petition submitted by Stevie Lewis, which calls for better recognition and improved support for people adversely affected by dependence on prescription medication. I would like to personally thank Stevie Lewis for bringing the petition forward. She provided powerful—and often highly personal—evidence in support of the petition, and we are very grateful. I would also like to thank everyone who provided evidence to us. These included our health boards, professional bodies such as the Royal Pharmaceutical Society Wales and a number of people with personal experiences of prescription drug dependence and withdrawal. All of this evidence was invaluable to the Committee and has influenced a rather promising Government response.

The petition calls for greater action to be taken to recognise the issues relating to prescription drug dependence and for improved support services to be available to people adversely affected by dependence on and withdrawal of prescription medications, especially antidepressants. This is when people who take prescription medication become dependent upon those very same medications, even when they have used that medication exactly as prescribed. Most concerning is that patients can also experience symptoms when they seek to reduce their dosage or stop taking medications entirely. These symptoms can sometimes be severe and debilitating. Indeed, the petition highlights specific concerns relating to antidepressants and benzodiazepines. Stevie Lewis has highlighted her own personal experience of being prescribed an SSRI antidepressant. After several unsuccessful attempts to stop taking the drug, she discovered she was physically dependent upon it. In her own words, she experienced a 'long and crippling withdrawal' before eventually stopping the medication after 17 years. Stevie Lewis’s testimony is not unique. It is echoed by many people who responded to an invitation by the Petitions Committee for people affected to share their experiences with us.

I want to state at this point that these medications can have a positive impact for many people who are prescribed them. The committee is not suggesting that all prescribing of these medications is problematic—far from it. Rather, it is vitally important that patients have access to the right information and support, certainly at the beginning of their treatment, and also when they want to reduce or stop taking this medication. Also, medical professionals need to ensure that they sufficiently discuss approaches and therapies with patients that are considering an SSRI and are trying to manage their difficulties with mental health. I echo the aspirations of the Royal Pharmaceutical Society that patients should feel empowered when making decisions regarding their care.

Now, I would like to focus on the committee's findings and recommendations for the remainder of this contribution. Recognition of prescription drug dependence. Firstly, the petition calls for greater recognition of the issue of prescription drug dependence, particularly amongst policy makers and health professionals. This includes acknowledgement of the scale and impact of this issue and acceptance of the types of medications that can cause dependence and withdrawal issues. The committee was aware that it is not universally accepted that antidepressants are one of these medications. However, the experiences of the petitioner and others are evidence that dependence does exist and that many people do face difficulties in stopping their use of antidepressants.

We welcome the Welsh Government’s positive responses to our report, and I would like to thank the Minister for his recognition in doing that, and especially the recognition that antidepressants are associated with withdrawal symptoms in some cases. The petitioner has described this and other acknowledgements in the Minister’s response as an enormous step forward.

The petitioner also expressed concern that policy and treatment for prescription drug dependence is placed under the umbrella of substance misuse. We agree that this is not appropriate, and services designed for treating drug and alcohol addiction are unlikely to be the best place to support people dependent upon prescription medication. We recommended that the Welsh Government should clearly distinguish between such issues in the future and should also identify specific actions to prevent and support those affected by prescription drug dependence. We welcome the Minister’s acceptance of this recommendation.

Guidance. The committee also considered the professional guidance covering antidepressant prescribing. Concerns were raised with us about the potential of overprescribing and a lack of advice for people seeking to reduce their dosage. We recommended that the Welsh Government should further emphasise guidance about these matters, including that antidepressants should not be routinely prescribed for mild depression. In response, we note that the Minister has committed to ensure that NICE guidelines, which are currently under review, will be circulated widely within Wales. However, I am slightly concerned that this does not go far enough. We believe that the Welsh Government has a role in ensuring that health professionals adopt a more consistent approach to prescribing antidepressants and providing advice to patients. The petitioner has also proposed that further training materials may be required if the NICE guidelines are substantially revised.

There are two other recommendations that I want to address this afternoon in terms of monitoring. The Petitions Committee has called on the Welsh Government to introduce a national prescribing indicator for antidepressants. This would improve the information about prescribing patterns available to health boards and the Welsh Government. We also believe that this information would enable the Government to better understand the scale of any problems and would support improved targeting of other types of treatments for depression, such as psychological therapies. We are disappointed that the Government has rejected this recommendation. In his response, the Minister recognises the importance of improving prescribing patterns. Therefore, given he does not consider a national prescribing indicator to be the correct approach, we would welcome his clarification as to how the Government intends to monitor this.

Finally, the committee received a number of positive references to the prescribed medication support service run by Betsi Cadwaladr health board. Through this, therapists work with GPs and pharmacists to carry out face-to-face assessments of patients and they produce personal programmes. These will sometimes include tapering advice and withdrawal support. Within Wales, this targeted support is unique and appears to be a low-cost intervention. Therefore, we recommended that the Welsh Government should explore the potential of a national roll-out of this service. The Minister’s response indicates that he considers this to be the responsibility of local health boards to take forward. However, several health boards expressed to us that they would welcome greater opportunities to learn from best practice in relation to how they can best support patients. I continue to believe that the Government should take a greater leadership role in this regard. So, as is envisioned by the Royal Pharmaceutical Society, individuals that have inadvertently become dependent on prescribed medications—that they then have access to timely and appropriate support to clinical and psychological therapies in their own areas without fear of judgment and conflation of prescribed dependence and substance misuse.

In conclusion, Llywydd, it was clear to the Petitions Committee that prescribed drug dependence is a serious issue and one that has not always received the attention or recognition that it deserves. I certainly hope that this is a starting point for change and I certainly look forward to listening to the the other comments made by Members of the Senedd here today in this afternoon’s debate. Diolch yn fawr.

 

Helen Mary Jones AM:

May I thank Janet Finch-Saunders and her committee for this very impressive and important piece of work? I have to say that it's often my experience that the work in the Petitions Committee is amongst some of the most important things that this Assembly does—the way in which our system empowers the voice of citizens to be heard directly. One of the most positive things I think I've heard today is what Janet Finch-Saunders has just told us about the petitioner's response to the whole of this process, because that multiplied many times, of course, grows a faith in this as a democracy that really listens to people and takes their concerns on board.

Reading the report was a very personal experience for me, because many years ago, we had an experience in my own family of a family member who became dependent on medicine that had been prescribed because of mental health issues. We went through a process that felt like taking a family member through the horrible cold turkey that you see of heroin withdrawal. Now, this was back in the very early 1980s and what disturbed me, I think, was to read in the report that some of these problems still persist—that there are still some issues about the appropriateness of providing, that there are some issues about the understanding around the potential of some of these medications to develop a dependency. And it is really important that these issues are addressed. I'm very grateful to the petitioner for her individual courage in bringing these issues to the Assembly's attention, and I'm sure that all of us, including the Minister, appreciate the courage that it must have taken to speak so openly.

I'd just like to respond to a couple of particular points. One is a very important need, which obviously the committee Chair has already touched on, about making a difference between the right sort of services to support somebody who has developed an addiction either to illegal drugs or to alcohol and people who have become dependent on prescribed medications. The paths that people will have taken that have got them into those unfortunate situations will be very, very different and the help that they need and the support that they need will also therefore be different. And I think the important points that are made about not conflating the language—these are things that we all need to take on board. I feel I need to think about that in terms of my own personal discourse and the way I might talk about some of these issues.

Like Janet Finch-Saunders, I want to come to recommendation 6, which the Welsh Government has rejected. I appreciate the reasons that the Minister has given, but I'd appreciate it if he could inform us today about how the concerns that lie behind that recommendation are to be addressed if they're not to be put on the list of drugs targeted for drug reduction. It is really, really important that we do acknowledge that these medications, as Janet Finch-Saunders has said, can make a huge positive difference for people, but they can also, of course, create difficulties, and people must know, when they are having those medications prescribed, what the options are and potentially what the risks are, and they must have support to manage those risks.

I also wanted to make a reference to recommendation 7, which the Minister has accepted in principle, but has said that it should be a matter for local health boards. I think what I would put to the Minister—and it's a point that was raised by Members across this Chamber—is that we're not always very good in Wales about seeing something that works well in one place and replicating it and learning from it elsewhere. Now, I can't claim, as an individual, to be sufficiently familiar with this particular model, though I've obviously read what the report has had to say and I've heard what Janet Finch-Saunders has had to say. But given that the health boards are asking for some strong national leadership on this, I wonder if the Minister can say a little bit more—having accepted in principle, which I take to read that he's accepting in principle that there is a need for some more national guidance—whether he would ask his officials to look again at that model and see if it could be effectively replicated elsewhere. It may be that it isn't suitable. It may be that, for geographical reasons or whatever, it wouldn't work particularly well perhaps in more urban environments, but when we have this level of knowledge, I think it's a good idea to pick up and run with it. And that approach, of course, fits with some of the work that the Minister himself is trying to achieve through the transformation fund, which is all about developing good models that can then be effectively delivered elsewhere.

The extent to which, of course, some of these antidepressants do cause dependency is still a matter of debate, but I think it's very important that we create a culture of honesty around this, and the fact that a medication can create a dependency is not a reason not to use it, it's a reason to use it with care. We use morphine to manage extreme pain relief in hospitals all the time, but when that is being prescribed, the people prescribing it know the potential risks, the people taking it know the potential risks, and the management system around it is there to prevent danger. I really think that we need, with these substances, which were, of course, sold to us as safe antidepressants—well, I think we know that there cannot be a medication that affects one's emotional well-being that is entirely safe, and we need to ensure that when people are making decisions about treatment, they are making them effectively.

I will end, Llywydd, as I can see my time is running out, just by saying that this is in some way reflective to me of the problems we have with our mental health services—that we know that many of the people who are being treated with these medications are being treated with these medications because there are no suitable talking therapies that might actually be much better. I'd urge, therefore, the Minister to look at dealing with this particular issue in that wider context, of which I know he is aware. We know that mental health services across Wales are not consistent; we know that talking therapies are available to some and not to others. Many of the people perhaps facing this difficult situation should never have had to take this medication in the first place if better alternatives had been available. I look forward hearing the Minister's response and to Janet Finch-Saunders's summing up of the debate and others' contributions. Diolch yn fawr.

 

Vaughan Gething AM, Minister for Health and Social Services:

Diolch, Llywydd. I'm very happy to take the opportunity to respond to the Petitions Committee's report and the debate today. Tackling dependence on prescription-only and over-the-counter medicines remains a priority for this Government. The budget for substance misuse has increased to almost £53 million a year to provide a range of services and actions to respond to all forms of drug use, including prescription and over-the-counter medicines. We've also ensured prescribers across Wales have comprehensive guidance and advice in this area, so we are happy to note the motion today and we accept or accept in principle all but one of the recommendations, as Janet Finch-Saunders has set out.

The committee's recommendations are very much in line with the work already under way, which is led by both the Welsh Government and our partners across the national health service and area planning boards, bringing in a wider range of partners, including members of the third sector and the police.

Recommendation 1, which seeks recognition around prescription drug dependence in both national policy and strategy, I'm pleased to give that recognition and outline the support that is already in place and work under way. I agree with the need to distinguish between substance misuse and dependence. So, our 2019-22 substance misuse delivery plan, which we'll be consulting upon in the coming months, will make that distinction clear. In recognition of this, our work in responding to the issues of prescription drug dependence going forward will be overseen jointly by our pharmacy and prescribing as well as our substance misuse teams within the Government. Research is being undertaken at the University of South Wales, and the Welsh Government aims to gain a better understanding of the causes, characteristics and consequences of prescription and over-the-counter medications. That work will inform policy and identify best practice for us in the delivery of treatment and, hopefully, we expect this should lead to the development of a treatment framework on this issue.

Turning to recommendation 2, the Government recognises SSRI and SNRI antidepressants are in some cases of discontinuation associated with withdrawal symptoms, and they can be consistent with symptoms of inadvertent dependence. We also know that some antidepressants are more likely to cause symptoms than others, but this is a complex issue where caution should be exercised so we don't conflate the problems of dependence with those of discontinuation. Our position reflects the evidence that indicates discontinuation effects can be minimised through the structured tapering of those medicines, overseen with the support of the prescribing clinician. 

In recommendations 3 and 4, I know clarity is sought on the guidance on not routinely prescribed medication and on the tapering of prescription medicines. As Janet Finch-Saunders set out, current guidance from NICE advises prescriptions and antidepressants are generally not recommended for mild depression, but they're more likely to be effective for moderate to severe cases of depression. And those guidelines are, of course, being reviewed, and we will ensure those guidelines, which are expected in February next year, 2020, are circulated widely to clinicians in Wales for their adoption. I understand that the Royal College of Psychiatrists are planning to issue a new position statement on antidepressants and depression, including specific reference to how best to manage discontinuation. We will, of course, work with the Royal College of Psychiatrists in Wales, which will be making recommendations specific to Wales.

Recommendation 5 requested an update on our actions in responding to recommendation 8 of the Health and Social Care Committee's inquiry into alcohol and substance misuse, which was published in August 2015. I can confirm that the All Wales Therapeutics and Toxicology Centre has produced or contributed to a range of relevant guidance and good practice on prescription-only and over-the-counter medicines since that inquiry. I provided a list of that comprehensive work to the committee. I can also confirm specific action relating to the recommendations of the former advisory panel on substance misuse were included in the substance misuse delivery plan that just ended last year. The recommendations made in the advisory panel's 'A report on: Harms Relating to Prescription Only Analgesics', published in December last year, are being taken into account in the drafting of the new delivery plan for 2019-22.

As you've heard, I don't accept recommendation 6. Depression is a common, recurrent and, in some cases, debilitating illness. For many people with depression, prescribing an antidepressant will be a safe and effective treatment option. We believe that a national prescribing indicator that intends to reduce prescribing could have the unintended consequence of discouraging the appropriate use of antidepressant medication and result in some patients not starting treatment and others stopping prematurely. We know that such medications can have an effective role to play in managing depression. Our interest is in the appropriate prescription and management of medication. I'd be concerned that targeting those for wholesale reduction would not lead to a positive outcome for the person. We remain of the view that improvements to prescribing practice, patient review and safe tapering will achieve the desired outcomes outlined by the committee that we share in terms of the outcome and the impact on the person. Alternative psychosocial treatment options, such as counselling, should of course be available and considered. Our investment to improve access to and the range of psychological therapies in Wales continues to increase. We are also testing new approaches to improve access to non-clinical support to improve mental health through, for example, our social prescribing projects.

And, as you know, I've agreed recommendation 7 in principle. I recognise and applaud the work of the Betsi Cadwaladr prescription medication support service, but I'm not convinced of the need for a national programme based upon that particular service. I continue to believe that that should be addressed at a local level in response to local needs as part of the needs assessments of area planning boards to ensure that the issue is considered including ensuring that local drug treatment services engage with general practice to provide additional support when needed. There are different but positive approaches across Wales—for example, in Aneurin Bevan on tramadol reduction. Rather than endorse one approach across the country, I expect that practice to be shared between different area planning boards to understand what further improvement can be made. Patients should of course in the first instance be supported by their clinician appropriately, whether that is by prescribing medication and indeed the regular monitoring of any side-effects and providing support for safe tapering of the medication.

We of course recognise that sharing information and best practice in relation to drug dependence will improve support for patients as proposed in recommendation 8, and our All Wales Medicines Strategy Group has a key role to play in this, and we'll continue to work with them to share best practice and drive improvements.

Recommendation 9 is for NHS Wales, but I very much support all opportunities for the NHS to benefit more from pharmacists' expertise. We'll have more to say on that in the coming weeks and months. I encourage health boards, trusts and primary care clusters to work more consistently with pharmacists to support patients. Our pharmacists have a vital role in providing medication reviews and professional advice, including crucially, in light of this report, helping patients end prescribed treatment.

In response to recommendation 10, my officials will work with DAN 24/7 to evaluate if further training on prescription-only medication is required for staff and to ensure the website includes content on dependence on these medicines.

I'd like to close by thanking both the Petitions Committee for their work and all those people who gave evidence, but most importantly to put on record my gratitude to Stevie Lewis, whose personal experience has brought to our attention the difficulties that can arise when withdrawing from prescribed medication.

 

Janet:

Diolch, Llywydd, and I would like to thank the Minister for what was actually a very detailed and quite a positive response, which is heartwarming for me as Chairman on our committee, but also for Stevie, who actually brought this petition forward because of their own experiences. I would also like to thank Members for their contributions and, in particular, Helen Mary Jones, who gave an excellent contribution as always. You spoke with much personal experience—your own life experiences with a member of your own family—and you also, very ably, provided us with recognition of the different approaches that are needed, and to avoid conflation between prescription drug dependence and substance abuse. I agree with you. I cannot see any earthly reason why, especially a health board that's been in special measures for four years, where they can be seen to have, and it's proven that they have a good model to be working, why the Minister actually leading those special measures isn't convinced that perhaps the roll-out of those to where there isn't this good practice in evidence, where that can't be provided at the moment, to certainly help other health boards and help other individuals like Stevie with their concerns. 

I would just—. In your response, though, you didn't touch on this, so I would like, even if you write to me at a later date on this, Minister, if you could give some further guidance that the Welsh Government could give to ensure that you will fulfill a leadership role and, by doing that, endorse the proposed model from the Royal Pharmaceutical Society that effective communication is now required between pharmacists and GPs, from the initial administering of medication to reduced dosages. How does your Government intend to monitor and vocalise the requirements of pharmacists and the pharmaceutical industry in ensuring the safe use of prescription drugs?  I'd also like to know a little bit more about what support services will be made available across Wales going forward, in this regard, so I would really like you to write to me on that.

In conclusion, though, Llywydd, I would like to thank Stevie Lewis and everyone who has worked very hard in bringing forward this very important issue to our attention. I do hope that this debate, and indeed the work of the petitions process as a whole, has been a positive experience, and I do hope that the Welsh Government will give further consideration to the additional points raised this afternoon and that action is taken to provide better advice and support to people affected by prescription drug dependence in the future.

As I mentioned, I am very pleased by the number of recommendations that you have agreed to in principle: a large number of those—only one, really, that we beg to differ on. But to me, recommendations in principle are only as good as the actual action that is carried out afterwards. So, thank you again, Minister, and thank you, Members. Diolch yn fawr.