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16 Jun 2009 : Column 26WH—continued
The all-party group on drugs misuse decided to launch an inquiry in the 2007-08 parliamentary Session into physical dependence on and addiction to prescription and over-the-counter medication. We published our report in January and it has attracted a lot of media attention. During our research we came across two other reports, one published in the state of Victoria, in
Australia, and another in Scotland, whose findings are very similar to ours. Our inquiry was carried out along the lines of a parliamentary Select Committee inquiry. We issued a call for evidence, using a press release, and then on the basis of the more than 100 pieces of written evidence that we received we invited two groups of witnesses to give oral evidence. One group represented organisations such as the royal colleges, trade associations and regulators, such as the Medicines and Healthcare products Regulatory Agency, as well as the pharmaceutical companies, of course. The other group was of patients who had been affected, or organisations representing them. My researcher, Gemma Reay, organised the inquiry and wrote the final report, which can be accessed through a link from my website at www.brianiddon.org.uk, or through the DrugScope website.
The evidence that we received suggests that there are two main groups of legal substances that are causing significant problems: the benzodiazepine tranquillisers and their successor drugs, the so-called zed drugs, and products containing codeine. Nevertheless, we recognise that millions of people have benefited worldwide from the use of those drugs.
Mr. John Grogan (Selby) (Lab): Will my hon. Friend say more about benzodiazepines? Is there a further case for getting more statistical information about addiction levels, across PCTs? Is that a possible role for Government? Also, does my hon. Friend recognise that where there have been specialist clinics those have made quite a difference in dealing with addiction?
Dr. Iddon: I shall say more about benzodiazepines in a moment, but yes: I cite the clinic run in Oldham by the well known Barry Haslam—or rather it is not run by him, as it is run by the PCT, but he was instrumental in persuading it to set up the clinic. It is a very useful one, doing excellent work for benzodiazepine addicts.
Benzodiazepines, of course, are class C drugs under the Misuse of Drugs Act 1971. They are popularly known as “benzos” and are used as downers by those who use stimulant street drugs or uppers such as cocaine and crack cocaine. Evidence available from the NHS suggests that there about 200,000 illicit users of benzodiazepines in the UK. The drugs are being smuggled into the UK now in considerable quantities. The ready availability of drugs on the largely unregulated internet has exacerbated drug abuse problems, in my opinion. The Royal Pharmaceutical Society of Great Britain has estimated that about 2 million Britons now get access to medicines through online pharmacies. The Society has devised a logo scheme for online pharmacies that follow its code of conduct for use. However, there are lots of websites on the internet that allow the purchase of prescription medicines without a prescription.
Bob Spink (Castle Point) (Ind): Does the hon. Gentleman think that there is a role for Government in restricting the quantity that can be supplied? For instance, in the press pack provided by the Library the example is given of 60 Solpadeine Plus tablets being made available for a low price from a pharmacy website, with “fast and discreet delivery”. Is the hon. Gentleman concerned about that, and does he think that perhaps the quantity should be controlled?
Dr. Iddon: I do, and shall refer to that issue later, but of course the internet is a very difficult animal to control. We rely on international agreements. We can regulate it domestically, but not as well as we should want to internationally, at the moment.
At least 10 per cent. of the drugs sold on the internet are counterfeit, which adds to the complexity of the problem. An article from the university of Edinburgh published in the British Journal of Clinical Pharmacology reported the discovery of 35 websites from which prescription-only pain relief medicines, some containing codeine, could be purchased without a prescription. The all-party group came across the case of a Welsh woman who had died of an overdose caused by self-medication using medicines available online. Other legal drugs, such as laxatives and antihistamines, are also misused, but we received no individual accounts of misuse of those medicines during our inquiry.
The benzodiazepine class of drugs—Valium and Librium came first—was introduced in the 1960s, and was welcomed by clinicians as a way to treat anxiety and insomnia, in place of the much more toxic barbiturate drugs that had resulted in far too many overdose deaths. At first they were seen to be quite safe, and their addictive properties were overlooked for a number of years. By the 1970s, benzodiazepines were the most widely prescribed of all prescription medicines. They are still widely prescribed: 11.7 million prescriptions were issued for them in 2007. However, many who have tried to stop taking them have experienced severe withdrawal symptoms as a result of their involuntary addiction. I remember Esther Rantzen and her “That’s Life” team highlighting these problems in the early 1980s, and a book was published in 1984 as a result of her campaign. I note that the authors are Ron Lacey and a certain Shaun Woodward—someone who has gone on to other things.
In 1988, the Committee on Safety of Medicines issued clinical guidelines, recommending that the drugs should not be used for more than four weeks at a time and that patients on those drugs should be closely monitored. Sadly, many of our general practitioners have ignored that advice and, as a result, an estimated 1.5 million to 2 million of our citizens are now addicted to the drugs. The all-party group came across patients who have been prescribed benzodiazepines for more than 30 years. Evidence suggests that repeat prescriptions being handed out without the doctors monitoring their patients is a common cause of such involuntary addiction.
Mark Simmonds (Boston and Skegness) (Con): Is the hon. Gentleman of the view that GPs do not have enough information to discern whether any of their patients may be addicted in the way that he describes?
Dr. Iddon: There is a bit of that, but if a GP knows the patient well, he should be able to diagnose the problem. The trouble is that many patients who are refused the drugs by the doctor will revert to the internet for supplies. One cannot blame the GPs for that.
Just as ceasing to use controlled drugs such as heroin and cocaine results in severe withdrawal symptoms, the same symptoms will be felt by patients who cease to take benzodiazepines if they have become dependent on them. Professor Heather Ashton of Newcastle university has developed a withdrawal protocol for such patients. Many of them have struggled to cease their dependence
on benzodiazepines for many years, often without knowing about the withdrawal protocol. Patients are commonly incapacitated through their dependence on or addiction to benzodiazepines, or through their self-withdrawal from these medicines. Some are left with long-term health problems, even after withdrawal. Many would say that their lives have been wrecked as a result of being introduced to these drugs.
Many patients, who have not been supported by their doctors and who have become addicted to benzodiazepines, have turned to voluntary organisations for help. I praise the work of groups such as Benzodiazepines: Co-operation not Confrontation, Battle Against Tranquillisers and CITA—the Council for Information on Tranquillisers and Antidepressants. They have worked extremely hard over many years to support benzodiazepine addicts.
It is more difficult to estimate the number of people addicted to over-the-counter products containing codeine, but estimates suggest that the figure is at least 20,000 or 30,000 and that it may be as high as 150,000 or 200,000. The products that cause the most problems contain higher than usual doses of codeine, at 12.5 mg per tablet, and usually the codeine is admixed with another drug, such as ibuprofen or paracetamol. The most common of these products are household brand names.
Bob Spink: Is it not a paradox that the manufacturers of brand names such as Solpadiene and Nurofen Plus should be criticised for pushing the analgesic uses of their drugs and for giving insufficient information about the down-side, the risks? They are criticised for not telling us of the alternative and more recreational uses of their drugs, but if they were to warn people they would draw attention to them. That might put ideas into immature heads, which could increase addiction and the abuse of those drugs. Is that a factor, or do people know about it anyway and I am simply being naive?
Dr. Iddon: It is a factor, and I shall comment on what the hon. Gentleman said later in my speech.
Codeine is more abundant in the latex obtained from the poppy papaver somniferum than from its most desirable constituent, morphine, which is turned into heroin using acetic anhydride. The all-party group received evidence to suggest that those addicted to codeine-containing products are taking between 30 and, amazingly, as many as 70 tablets every day. One woman who gave evidence to our inquiry described how the 48 to 60 tablets she was taking every day gave her a “lift” and “helped her along”, and a male respondent told us how much he enjoyed the feeling of “calmness, happiness and control” that his 32 tablets brought him.
Unless the codeine is separated from co-medications such as ibuprofen, those dose levels can cause medical complications such as serious internal bleeding, which often results in death. The codeine can be easily separated from the co-medication, and the methods to achieve this separation can be obtained from the chatrooms regularly used by young people.
The stereotypical addict of codeine-containing products is a middle-aged female. However, more and more people are becoming addicted to them as a result of treating of chronic pain by using codeine-containing drugs and in the absence of an adequate pain management strategy by local clinicians. It would seem that a significant
number of codeine addicts also have a co-morbid mental health problem. Some addicts also have a poly-drug problem, involving, for instance, alcohol or other prescription drugs.
Mark Edwards became addicted to codeine following complications arising from an operation that left him with chronic pain. If he had received help to manage his pain, he would probably not have become an addict. Following his experience, he established “codeinefree.me”, an online site to support those who have problems with over-the-counter medicines, especially those that contain codeine products.
People who regularly suffer headaches and who self-medicate with codeine-containing products may develop a symptom that has been termed medication overuse headache. When they are enabled to give up the products, the headaches disappear. The overuse of codeine, of course, desensitises the pain receptors, particularly those in the brain.
People who become addicted to over-the-counter medicines believe that the products that they are buying without prescription are safe and therefore that they cannot become addicted to them. Similarly, patients who receive prescriptions from their doctors believe that they will be protected from serious side-effects, and they too cannot believe that they might become addicted or at least physically dependent on a product prescribed by their GP.
With both tranquilliser and codeine addiction, we found that most GPs either do not recognise the problem that their patients have or are at a loss to know how to deal with them. The plain fact is that it is probably easier today for an illegal drug user to get a referral to a drug and alcohol action team—a DAAT—than it is for those having problems with legal drugs, other than alcohol, to get treatment for their condition.
Our report contains 24 recommendations. They include the adequate training of medical professionals; raising awareness of the problem; proper prescribing and the monitoring of patients; more research to establish the scale of the problem; and, most important, recognition of those patients with problems and the ability to refer them to an appropriate treatment centre.
It is vital that all who work in the health care field, especially nurses, doctors and pharmacists, receive training in substance misuse as well as good prescribing practice. We live in an era of a pill for every ill, yet many patients require only to be listened to and perhaps referred on; for example, to a cognitive behavioural therapist.
The pharmaceutical industry and the patient both have responsibilities, the former to make patients aware of potential problems such as physical dependence or addiction—for instance, in the patient information leaflet or PIL—and the latter to ensure that they read the PIL or listen to the advice given by their doctor or pharmacist. Trade organisations, such as the Association of the British Pharmaceutical Industry and the Proprietary Association of Great Britain, also have responsibilities to ensure that the products produced by their member companies are safe at the point of sale, as does the MHRA, which licenses and monitors the sale of medicines in the UK.
All those bodies should raise awareness of the dangers of buying products on the internet. The MHRA works with internet service providers to close down websites
found to be operating illegally, but it has jurisdiction only in the UK. In the past five years, however, it has been successful in 18 prosecutions of operators of websites trading medicines illegally in the UK. Primary care trusts also have a responsibility to ensure that benzodiazepines and zed drugs are prescribed responsibly, that general practitioners who prescribe outside the guidelines justify that behaviour to them and that the patients affected are monitored adequately so that the problems described this morning do not develop.
Our all-party group believes that codeine-containing packs should contain no more than 18 tablets and that all sales should be accompanied by appropriate advice on the addictive potential of these medicines. In some countries, the advertising of codeine-containing products has been banned and, in others, such as the USA, they have been made prescription-only medicines—POMs. However, we would not wish to burden doctors any more than they are already, and, in any case, there is a move in this country towards self-medication, with a greater role for pharmacists in advising patients. I welcome that. A 2006 study conducted in Northern Ireland concluded that, on average, a pharmacist would see about two over-the-counter medicine misusers a week, but a 2001 study conducted in Scotland put the figure a little higher—at an average of five per pharmacy per week. So the problem is not unknown in pharmacy shops.
The National Treatment Agency was set up in 2000 and has been very successful in treating those referred to it who are addicted to controlled—or street—drugs. However, we believe that it is not geared up to treating those with the problems that I have been describing. The stigma associated with controlled drug addiction, and the shame associated with those who have become involuntarily addicted to prescription and over-the-counter medicines, means that such patients are hardly likely to volunteer for referral to the facilities provided by DAATs. In our report, therefore, we have recommended that the Department of Health provide centres for treatment within the NHS, but separate from those provided by DAATs. Throughout our report, we stress the importance of voluntary organisations in helping patients, but their resources have become extremely stretched in recent years. I plead with the Government to support them more.
Finally, it is important that the Department of Health commissions research to measure the extent of these problems and monitor future prescribing and sales of the problem medicines. I hope that my hon. Friend the Minister—I am glad that he is answering this debate—can persuade the Minister of State, Department of Health, my hon. Friend the Member for Lincoln (Gillian Merron) to meet me with a small delegation to discuss these problems in more depth and to seek a sensible way forward.
11.23 am
Mr. Dai Davies (Blaenau Gwent) (Ind):
It is a pleasure to follow the hon. Member for Bolton, South-East (Dr. Iddon). His all-party group was the first that I joined when I entered this place; his leadership is exemplary and a fantastic example of how an all-party group
should be run. It is one of the most proactive groups in this place. He has done a fantastic job and will be a great loss to this House.
I joined the group owing to personal involvement: my mother was an addict. When she was originally diagnosed with alcoholism, in the 1970s and 1980s, the answer was to prescribe medication, which is what the GP did. But he did not stop at one prescription. After five or six years, she ended up taking about seven or eight types of medication. She would not stop taking one type, but simply start taking an extra one. At that time—this remains a huge problem—there was very little understanding of the interaction between all those types of drugs. But the situation gets even worse than that. Although the situation with prescription drugs has improved over the past 10 to 15 years, there remains a problem with their interaction with things that can be bought in the supermarket. For instance, cough mixtures contain morphine and codeine, which simply fuel past addictions. However, in my experience, assistance with, and understanding of, full-blown addiction to over-the-counter drugs is very limited.
There are huge differences between an illness, a condition and an addiction, and the treatments for all three have their own peculiarities. However, each one is also inter-linked, and treating an addiction, like treating an illness or condition, can actually make it worse, so education on those three terms is extremely important. I recently attended a seminar, in this place, run by Mind and spoke to some of those present. Until then I had never thought about the difference between mental health and mental illness, but the issues involved are quite different. Over-the-counter drugs have a hugely detrimental effect on people with mental illnesses. It is easy to overdose on these drugs, whether through, for example, paracetamol, codeine in tablets or Nurofen. It is extremely easy to get into that position. The problem affects all age groups, and is not confined to the old, the young or the middle-aged. One of the huge tasks before us is on education, not just of individuals, but of service providers.
Hon. Members should try this for themselves: enter a supermarket and try to buy three or four bottles of cough mixture. It will sell them. Then go to a pharmacist and ask for the same. It will say, “You can’t have them.” There is a huge imbalance in the controls for pharmacists and off-the-shelf buys, and obviously that is exacerbated by the internet.
The hon. Gentleman raised another huge concern about the support services. During a recession, budgets are always cut, whether through local health boards, PCTs or borough councils, and I am worried that the fringe element—as it is seen—of support will be the first to be hit, despite being the very services that support people with addictions. For example, the Drug and Family Support Group, in my constituency, relies on donations and funding from borough councils. It is one of the few organisations in my borough that deals with such problems, and the consequences of losing that support will be dire.
Counselling services—we have heard about some today, but there are many others—need to be core funded. Too many support groups have to go cap in hand for funding. We also need to consider how people are signposted to services in our local communities and constituencies. Through GP services, they tend to be signposted to the first support group in the book, but there are so many
groups helping so many different things. From personal experience, I know that it is very difficult to work through the minefield of support.
I urge the Minister and the Secretary of State to read the report, of which I had the privilege to be a part, and to consider its recommendations. They were made in the hope that we can improve the situation. The suffering of an addict spreads throughout their family; it affects not only the addict, but so many others within the family and the community. I fear that the problem is growing. People often turn to some form of medication during periods of recession, depression and anxiety, and before they know it, their drug taking can spin out of control.
It is a pleasure to take part in this debate. I urge everyone to read this excellent report—I was part of it, so I would say that, would I not?—and I hope that its recommendations will be taken forward.
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