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

Public Health England Recommendations and SLWG Recommendations for Scotland

Recommendation 1

“Increasing the availability and use of data on the prescribing of medicines that can cause dependence or withdrawal to support greater transparency and accountability and help ensure practice is consistent and in line with guidance.”

Current Landscape in Scotland

A dedicated team in Public Health Scotland already make available a wide range of data and analysis on prescribing patterns in Scotland. Scottish Government commissioned visualisations on a suite of National Therapeutics Indicators (NTIs) which are displayed as a dashboard. Scottish Government has also commissioned the Atlas of Variation maps which aim to highlight geographical variation that exists in the provision of health services and associated health outcomes, this information is available to all to enable comparisons. Prescribing data is also made available in a range of formats including monthly prescribing activity data and dedicated focus on medicines used in mental health. In addition to undertaking analysis of the data themselves, which is made available on their website, PHS also make the raw data available to enable independent analysis.

As a result of the pro-active work undertaken by Public Health Scotland and Scottish Government, Scotland is already in a strong position in relation to the use of data on the prescribing of medicines. A screen shot showing an example from the National Therapeutics Indicators page is shown in Annex C.

The Scottish Government has commissioned the development of the Scottish Therapeutics Utility (STU) which is a computer program that interrogates data from GP IT systems with a focus on repeat prescribing and, more recently, high risk prescribing. It is available license-free to all NHS Boards and GP Practices in Scotland. It generates a suite of standardised reports to facilitate targeted medicine management activity.

Work already taken as a result of the SLWG

The team in Public Health Scotland with officials considered the analysis produced as part of the Public Health England review and then replicated for Scotland, together with an update to include the most recent years’ figures. This enabled the SLWG to consider differences between England and Scotland and how recommendations in Scotland needed to be adjusted. A summary of the analysis by Public Health Scotland is included within this consultation at Annex A. The time series in the analysis will continue to be updated so that change can be seen.

Work to be taken forward/recommendations

In line with National Statistics protocol, composition, and publication of statistics by Public Health Scotland will continue to be reviewed with consideration to user need. This will mean that clinical professionals and researchers can use the breadth of data and data indicators to improve patient care and treatment by evaluating interventions, measuring long-term outcomes in clinical trials, assessing the safety of new medical interventions and supporting the understanding of patterns of health and illness across the whole population. The suite of indicators and reports will be developed within STU to support front line practitioners identify patients that need review of their treatment.

Recommendation 2

“Enhanced clinical guidance and the likelihood that it will be followed”

Current landscape in Scotland

There are multiple sources of clinical guidance. The Scottish Intercollegiate Guidance Network (SIGN) produces guidelines that contain recommendations for effective practice based on current evidence. SIGN aim to improve the quality of health care for patients in Scotland. Membership includes medical specialists, nursing, pharmacy, dentistry, professions allied to medicine, patients, managers, social services, and researchers. Guidelines are developed by a multidisciplinary working group with representation from across Scotland and each guideline is subject to comprehensive review The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care

Scottish Government’s Effective Prescribing and Therapeutics Branch has also produced Quality Prescribing Guides on Chronic Pain, Diabetes and Respiratory. The strategies were developed in partnership with clinicians from across NHS Scotland and compliment the relevant SIGN guidance and aide implementation.

Work already taken as a result of the SLWG

In order to keep pace with up-to-date evidence and best practice, the Quality Prescribing Guides are subject to periodic review and update. The opioid guide is currently in the final stages of this revision process, has been shared with the SLWG and will be published shortly. The SLWG, including the Patient Group, approved of the way in which production of these guides is approached. Scoping of a Quality Prescribing Guide on antidepressants, benzodiazepines and hypnotics has already been developed with the scoping document shared with the SLWG. Scoping work on a gabapentinoid strategy has also began and has been shared with the SLWG.

Work to be taken forward/recommendations

A high priority recommendation of the SLWG is to take the antidepressant and gabapentinoid guides to conclusion, this will involve establishing expert groups, including patient representatives, and building upon the scoping document.

SLWG are also recommending that Quality Prescribing Guides are developed for the remaining classes of drugs covered by the SLWG, Z-drugs, and benzodiazepines.

The clinicians involved in the development of the Quality Prescribing Guides will use their networks to help ensure that the guides are used in practice and we will take their advice on what additional steps need to be taken to aid implementation of each guide.

Recommendation 3

“Improving information for patients and carers on prescribed medicines and other treatments, and increasing informed choice and shared decision making between clinicians and patients”

Current landscape in Scotland

Under Realistic Medicine, Scottish Government and NHS Scotland are committed to Shared Decision Making (SDM) to ensure that people are supported to make decisions about their health and care that are right for them. Collectively, we promote the 7-step approach to medication review, this has been developed with patient groups and doctors and pharmacists in primary and secondary care. The 7-step process has what matters to the patient as the number one priority and embedded in the process, it is a collaborative process, through which a health or care professional supports an individual to reach the right decision for their needs. The 7-step process is shown in Annex D. Shared Decision Making is a multi-stranded, transformational process involving patients and medical professionals and is about establishing a different relationship and culture shift. Scottish Government funding supported Pain Concern to develop the ‘Navigator Tool’ which supports a Shared Decision Making approach for people with chronic pain. There are existing decision aids in place already that work towards this aim, such as the Scottish Government’s Polypharmacy App that takes a patient and healthcare professional jointly through a medicine review where a patient is prescribed multiple medications. This App includes the Chronic Pain Shared Decision Aid which supports patients to explore both pharmacological and non-pharmacological approaches. A strength of this approach is that it enables the patient to be walked through the process prior to meeting with the healthcare professional and helps them focus on what matters to them and prompts questions for the patient to pose to their healthcare professional.

Work already taken as a result of the SLWG

In terms of Prescription Medicine Dependence and Withdrawal, the SLWG agreed that further focused information should be produced and made available in an accessible format for patients, including through digital shared decision aids within the Polypharmacy App for the five classes identified. The SLWG considered how existing assets and platforms could be best used to develop this information quickly and make available to patients. in addition, it was agreed that development of existing resources on NHS Inform represented the best way forward. We have established an NHS24 synergies sub-group that will take this forward jointly with recommendation 4.

Work to be taken forward/recommendations

Work with NHS Inform and NHS 24 to develop on-line guides and resources to support patients suffering from withdrawal from the 5 classes of medication covered by the review. This will involve considering existing material produced for recreational drug use and put a team together to produce tailored guidance for each of the 5 classes of medication. The teams will include patient representation. Additional shared decision aids will be developed for the medicines covered by the SLWG and included within the polypharmacy app.

Recommendation 4

“Improving the support available from the healthcare system for patients experiencing dependence on, or withdrawal from prescribed medicines”

Current landscape in Scotland

Patients experiencing withdrawal from prescription medicine need tailored support as side effects take many forms and can occur at any time of the day. The reassurance of being able to access support any time is important so services beyond their GP surgery are required.

NHS Scotland provides a range of services to support unscheduled care. One of these services is NHS 24 111 which provides urgent health advice, by telephone, when GP or dental practices are closed. Most calls are handled between 6pm and 8am Monday to Thursday and 6pm Friday to 8am Monday. People across Scotland can access the service, on landlines and mobile phones free of charge, using a number that is short and easy to remember.

During the COVID period, Scottish Government made available £3.8 million to increase the capacity of NHS 24s telephone and online service. This included £2.6 million to expand the NHS 24 Mental Health Hub and Breathing Space telephone helpline and web services and £1.2 million to provide the extra capacity for Computerised Cognitive Behavioural Therapy (CCBT).

Work to be taken forward/recommendations

The SLWG agree that an out-of-hours helpline is required to help patients suffering from dependence and withdrawal from prescribed medicines as it is often out-of-hours when symptoms are most acute. Further scoping work should be undertaken on how the existing service provision can be boosted to take this requirement on board, this would include training for those staff who answer calls on behalf of the service. We have established an NHS24 synergies sub-group that will take this forward jointly with recommendation 3.

Recommendation 5

“Further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines”

The Public Health England group came up with some proposals for further research. The SLWG considered these in a Scottish context and added some additional project proposals. It is hoped that some of these proposals will be adopted by academia and while Scottish Government will not commission these directly, we will consult with the Chief Scientist’s Office on how these can best be promoted to relevant academic and other bodies. The proposal for further research can be found in Annex E.