Short Life Working Group On Prescription Medicine Dependence And Withdrawal: consultation

Annex E - Recommendations for further Research

Background

The recommendations for the Public Health England study fell into 5 broad categories. The final category was to consider “Further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines.”

This paper draws out of the report, details on research that is currently being undertaken or recently published together with the specific areas of research that the report recommended. Do these themes fit in a Scottish context, or are there other areas for research? An indication of priority would also be useful.

Research Being Undertaken/recently published

• Keele University has been awarded an National Institute for Health Research (NIHR) programme grant to investigate ways to reduce inappropriate opioid prescribing in primary care by working with clinical pharmacists who will be trained to offer alternative pain management strategies.
• The University of Warwick has a randomised control trial of a self-management intervention to improve the wellbeing of people with opioid-treated chronic pain and a Health Foundation-funded project testing an electronic intervention with prescribers to improve medication selection and dispensing, to reduce costs and polypharmacy – the latter project is not targeted at specific medicines but opioids are expected to be a cost-priority for some organisations.
• The Royal College of Psychiatrists published a position paper statement on antidepressants and depression, setting out “the College’s view on promoting optimal use and management of antidepressants. It discusses the challenges with prescribing antidepressants, including considering the evidence around efficacy, benefits and harms, ensuring they are used when clinically indicated and managing withdrawal. The statement includes (a) range and recommendations aimed at the UK Health Departments, national bodies and commissioners. https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/position-statements/position-statements-2019

Areas Recommended for further research

1. Isolating withdrawal effects (especially of antidepressants) from the original disorder and its return.

2. Better understanding the incidence, duration, nature and severity of withdrawal from antidepressants, including long-term and enduring side effects.

3. Optimal recommended withdrawal regimes for each of the classes of medicines covered in the review, while recognising the importance of individualised care.

4. Determinants that result in a higher risk of dependence or of experiencing withdrawal: systemic failures, prescriber behaviour and individual (patient) factors.

5. Harms or dependence or withdrawal from prescription medicines, including impact of dose and duration of treatment, particularly for people who are already dependent.

6. Prevention or treatment of dependence or withdrawal caused by prescription medicines.

7. Patients’ experiences (from qualitative studies) of harms or dependence or withdrawal associated with prescription gabapentinoid use.

8. Published service evaluations of existing services including service level outcomes, patient outcomes and cost effectiveness. Following on from this, practice standards and model service specifications could potentially be developed to support local areas.

In addition, there were a number of recommendations contained within the revised SIGN Guideline Management of Chronic Pain. This focused on opioids and was published in August 2019.

1. Studies of interventions to support reduction or cessation of prescription opioids.

2. Studies of efficacy and harms beyond three months’ use. Harms potentially include (but are not restricted to) problematic use, mortality, impact on endocrine and/or immune function, GI effects.

3. Studies of factors affecting individual response to opioid therapy.

4. Studies of harm reduction strategies for patients on continued opioid use for chronic pain.

There is cross-over between the recommendations – recommendation 3 from PHE is similar to recommendation 1 in SIGN and recommendation 5 from PHE is similar to recommendation 2 in SIGN

Additional request from the Patient Group:

Establish recovery results of taking an antidepressant route verses a non-antidepressant approach.

Action

Taking on board the additional request from the Patient Group, Working Group members are requested to consider these recommendations in a Scottish Context. In addition, we would like members to consider and suggest other areas for potential research.

Traditionally, such pieces of research are considered by the academic community and undertaken in partnership with medical practitioners. An endorsement from the Working Group, as part of its final recommendations, would potentially increase a projects likelihood of being picked up and undertaken.

Scottish Government
March 2020 Amended May to include request from Patient Group