The recent report from the All Party Parliamentary Group for Prescribed Drug Dependence (APPG) which was published on 2 October 2018 served to highlight what many patients on long term medication already knew – withdrawing from the treatment itself can be as difficult as living with the condition that it was meant to treat.
The review can be accessed by clicking here.
Whilst the review highlighted specific concerns in relation to the long term effects of withdrawing from antidepressants with nearly 1.8 million patients suffering severe withdrawal symptoms, the wider picture is that any long term medication must be carefully managed.
I can recall being involved with a group of claimants who had been dependant upon opiates or benzodiazepines for many years and after being imprisoned underwent enforced withdrawals which were, in theory, meant to reflect NHS practice. Withdrawal methods varied throughout the country – some involved instant cessation of medication and enforced withdrawal whereas in others there was a graduated titrated reduction in the medication with substitute medication introduced to counter side effects. Those who had the titrated reduction faired better, suffering minimal withdrawal symptoms and crucially being able to avoid relapse. However, this approach required constant medical input and was the more costly of the two. Whilst all were in theory treated under NHS guidelines, local PCT treatment policies influenced the approach and the position is likely to be similar with medications prescribed and managed in a primary healthcare (i.e. GP) setting.
From the cases that we see within our department it is clear that general practices vary throughout the country. Concerns arise where patients are placed on long term medication without adequate or sufficiently frequent medication reviews. Over time, side effects or complications can develop without recognition and present at a later date with an acute onset of symptoms. For example, long term management of pain using steroids such as prednisolone can be associated with gastric ulcer formation and potential rupture. If there are no regular reviews then subtle clinical signs of an evolving ulcer can be missed and only recognised after it has perforated resulting in more significant and potentially life threatening complications.
Some of these issues were highlighted in the APPG review which noted that there was a lack of understanding of the seriousness of antidepressant withdrawal symptoms by prescribers because there was a general gap in the evidence base surrounding the effect of withdrawal.
Effective medication management requires:
– Regular review
– Discussion with the patient and an understanding of side effects
– A careful consideration of interactions with other medications
– A controlled and well managed withdrawal where appropriate
– Post withdrawal planning and relapse prevention.
This is a time consuming process. With the increasing concerns relating to GP consultation times and accessibility, we have to ask whether we will see the improvements that have been recommended?