The Medicines Safety Clinic (MSC) has been set up at the Lawson practice to ensure safe prescribing for our patients. As good practice, we carry out ongoing medication reviews for patients. However, we prioritise addressing prescriptions that could be harmful to patients and are no longer in line with recommended guidelines.

We know that there is overwhelming evidence to show that high-risk drugs (such as the ones listed below) are causing more harm than good to our patients. Many recognised bodies such as NICE (National Institute for Health and Care Excellence) and Public Health England have highlighted this over the last few years.

Evidence-based medicine: Opioids have a very limited role in the management of chronic pain. The harms of opioids are well documented and include tolerance and dependence. People taking prescribed opioids are at risk of increased mortality from all causes.

A review undertaken by Public Health England found that opioids for chronic non-cancer pain are known to be ineffective for most people when used long-term (over 3 months), while benzodiazepines are not recommended to be used for longer than 28 days. People who had experienced problems with prescription medicines also reported that they felt uninformed before they started them and unsupported when they experienced problems (1).

Gabapentinoid prescribing prevalence has increased from 0.21 to 2.1% of the UK population between 2000 and 2017. 50% of new prescribing is now off-label for which there is no evidence of benefit. There is evidence of harm (respiratory depression and death) caused gabapentinoids- on their own and more so in combination with opioids. The exact mechanism of increase in death rate is thought to be more than simple synergy. Similar arguments exist for benzodiazepines and z drugs. With chronic use, they are limited in how much they help, and they do more harm than good. For a long time, we have relied on medicines being the answer in the absence of alternative or better options. They are not the solutions they promised to be.

Over the past 10-15 years it has become clear that many drugs we have used previously such as opiates and gabapentinoids are not the safe and effective treatment for chronic non-cancer pain that was first thought. The message in the 1990s was that any pain could be treated with opioids, provided the dose was high enough and the presence of pain protected against the development of addiction. Conversely, there is now a better appreciation of the risks, including dependence and opioid-related mortality.

• Constipation

• Nausea

• Daytime somnolence

• Poor concentration and memory loss

• Increased risk of falls

• Opioid-induced ventilatory insufficiency: the respiratory effects of opioids are more pronounced during sleep. Fatalities have been reported in patients with obstructive sleep apnoea who are prescribed opioids, and sleep apnoea may be a relative contraindication to opioid therapy. This is particularly important if patients are taking other central respiratory depressants such as benzodiazepines or gabapentinoids.

• Effects on hormones, notably reduced testosterone levels (in men and women), leading to infertility, reduced libido, amenorrhoea, sexual dysfunction, fatigue, hot flushes, depression and osteoporosis.

• Effects on the immune system: Both animal and human studies have demonstrated that opioids have an immunomodulating effect.

• Opioid-induced hyperalgesia (OIH) OIH may be diagnosed if a patient on long-term opioid therapy presents with increased pain. Pain associated with hyperalgesia tends to be more diffuse than the pre-existing pain and less defined in quality. Stopping opioids completely will reverse OIH.

• Problem opioid use, or opioid dependence

• Increased mortality: prescription of long-acting opioids for chronic non-cancer pain, compared with anticonvulsants or tricyclic antidepressants, is associated with a significantly increased risk of all-cause mortality. Research from the USA shows that patients who take more than 100mg of morphine equivalent per day have a 7 times increased risk of death compared to patients who take 20mg per day or less, such as codeine 30mg four times a day.

Benzodiazepines are a group of medicines prescribed for anxiety, sleeping problems (insomnia) and other disorders. Z-drugs act in a similar way to benzodiazepines and are sometimes prescribed for short term insomnia. Benzodiazepines and Z-drugs should only be taken for a short period of time (2 to 4 weeks maximum). If taken for longer than a few weeks problems and side effects can occur. 

Such side effects include:

• Tolerance: the medicine then gradually loses its effect and you need a higher dose for it to work. In time, the higher dose does not work and you need an even higher dose and so on, until the risks outweigh the benefit of taking the medicine.

• Dependence (addiction) – there is a good chance that patients become dependent on a benzodiazepine or Zdrug if taken for more than four weeks.

• Other side effects: drowsiness and light-headedness the next day; confusion; accidents and falls; memory loss; low mood; muscle weakness; constipation; slurred speech; nausea (feeling sick); dry mouth and blurred vision.

• Increased energy

• Improved mood and less anxiety

• Being able to think more clearly

• Feeling less drowsy

• Improved libido

• Decreased risk of falls

• Decreased risk of infections

• May even experience less pain (majority find the pain is unchanged)

• May be able to gradually increase activity and exercise, which can help to reduce pain levels

• Reduced risk of serious harm and death