John Perrott kindly shared the following account of a survey he undertook between June and July 2023 on the provision in NHS England of support and withdrawal services for patients dependent on prescription drugs. John Perrott has been able to compare the results with a survey that he did in 2011. John Perrott concluded: "In summary, we are no further forward than we were in 2011 when told by the Health minister that local areas would be responsible for commissioning services."
Hundreds of thousands, if not millions, of NHS patients have become dependent on drugs prescribed by their doctors since the 1960s. There have never been appropriate withdrawal services to help patients discontinue these drugs. Many have been left on them for years and even decades by their doctors.
This issue has been brought to the attention of health ministers, health departments and doctors’ professional organisations for decades with no effective action. Many promises have been made and broken including those from Health ministers. Many reviews have been whitewashes written by academics with pharma interests, downplaying symptoms and ignoring evidence of harms, resulting in no effective action.
The issue of harms caused by benzodiazepines alone has generated over a thousand Parliamentary written questions and debates. The resilience of the Department of Health and other organisations such as the Royal Colleges in resisting acknowledging the problem or taking effective action has been staggering.
The latest PHE review Prescribed medicines review: report – GOV.UK (www.gov.uk) focused on benzodiazepines, z drugs, antidepressants, opioids, pregabalin and gabapentin. This review has resulted in no effective action yet and one of the review’s recommendations for a 24 hour helpline was refused funding by the Department of Health. Health departments and doctors have blamed patients for their predicament and misrepresented the issue as substance misuse.
Dependence on drugs is an iatrogenic illness caused by mis-prescribing and over-prescribing. Support and withdrawal requires specialist advice. The effects of these drugs is still not fully understood. Some patients require extremely slow tapering when withdrawing to mitigate severe withdrawal symptoms. Withdrawal symptoms are often misdiagnosed as a relapse or a new illness.
Substance misuse services are therefore highly inappropriate for treating these patients. A few charities such as the Bristol and District Tranquilliser Project (BTP) have, in the absence of NHS services, provided help and support for many decades now. NHS Bristol and North Somerset is withdrawing funding for BTP this year forcing its closure, seemingly in contradiction to the recently published NHS England framework.
Studies have shown that these drugs, especially benzodiazepines, z drugs and antidepressants can have particularly severe and lasting effects, contrary to the narrative of health departments and both Royal Colleges.
Many patients have long-term or permanent damage, even after discontinuing. Symptoms include a much higher risk of developing dementia and cancer, cognitive problems, a shortened life, sexual dysfunction, unexplained headaches and nerve pain to mention a few. Also, these drugs have resulted in many suicides, social decline and other debilitating and detrimental effects.
Many academics and health professionals and their organisations, such as the Royal College of Psychiatrists, many of whose members have links to the pharmaceutical industry, deny the harmful effects caused and blame the patients.
The Department of Health refused to fund a helpline ‘Deep disappointment’ as government rules out proposals for a national prescribed drug dependence helpline – The Pharmaceutical Journal (pharmaceutical-journal.com)
The Department and NHS England now claim that a new framework issued to Integrated Care Boards published at the beginning of March, NHS England » Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care will result in effective action and support and help for those affected, appropriate withdrawal services and better prescribing practice. However, this relies on local ICBs following the framework and commissioning services.
This survey intends to investigate the validity of this claim or whether ICBs continue to treat the issue as substance misuse and fail to provide appropriate withdrawal and support services. There is a current trend to focus on opioids and ignore the other drugs such as benzodiazepines, z drugs and antidepressants, which can have more severe and lasting withdrawal symptoms, with local areas failing to understand the issue or take effective action.
I have listed each ICB response below and written in bold type besides each ICB a summary of their response. This is my subjective summary based on the ICB FOI response. If they have mentioned support/withdrawal services I have indicated next to each if they are inappropriate substance misuse services.
The survey was conducted between June and July 2023. The following FOI request was sent on 5 June 2023 to all 42 Integrated Care Boards:
Dear Sir/Madam, I would like to request the following information please: Is your Integrated Care Board aware of the recently published NHS England publication titled "Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care"? NHS England » Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care If so, what action will your Board take to:  Provide appropriate withdrawal services (not inappropriate substance misuse services) for patients who have become dependent, through no fault of their own, to prescribed drugs identified in the recent PHE review, such as benzodiazepines, z drugs, opioid containing drugs, antidepressants and pregabalin and gabapentin? Develop local policies for the above  Implement in prescribing practice when prescribing the drugs mentioned above? These were three key objectives in the NHS England publication. Please respond by email, including any relevant attachments or documents. Kind regards, John Perrott
- Only two ICBs had specialist services, BOWS focusing on benzodiazepines and opiates and REST focusing on benzodiazepines and z drugs , both in Camden and Postscript360 (used to be BAT) in Bristol which does not provide support for antidepressants = 6% of total
- Ten ICBs are still considering and reviewing – 29% of total
- Two ICBs have some unspecified action planned = 6% of total
- Nine ICBs have no action planned as yet – 26% of total
- Four ICBs quoted substance misuse services – 12% of total
- Eighteen ICBs are focusing mainly on opioids, with some ICBs also including gabapentinoids – 53% of total
This is disappointing. It appears that this is still being treated as a substance misuse issue by some and although the framework lists benzodiazepines, z drugs, antidepressants, gabapentin, pregabalin and opiates over half the ICBs are focusing on opioids.
It appears despite other drugs being the subject matter of the framework many ICBs are taking it to mean opioids.
The real need for support is for benzodiazepines, z drugs and antidepressants, and for these drugs support may be required for years. Opiate physical dependence is largely resolved in a couple of weeks.
In my survey of Primary Care Trusts in 2011, the results were:
- 83% had no specialist withdrawal services
- 11% had very limited services
- 6% had specialist services
So, in summary, we are no further forward than we were in 2011 when told by the Health minister that local areas would be responsible for commissioning services.
Details of FOI returns for 2023: 35 out of 42 ICBs have so far responded as follows:
NHS Devon – No action planned
Yes, NHS Devon is aware of the report. But does not hold the information requested in the remaining parts of your request.
NHS Staffordshire and Stoke-on-Trent – No action planned
The ICB has no plans around the publication at this present time.
NHS Lancashire and South Cumbria – Predominantly pain management
ICB is aware of this guidance. Primary care health care professionals are appropriately placed to facilitate reviews as per the national DES indicators in 2022/23, this approach will be taken again in 2023/24. Within our ICB we endeavour to support the patients holistically by ensuring that locally services such as Escape pain programmes are utilised by the local population.
If a gap or need is identified in terms of a service this would be explored.
Locally resource packs are being sourced and reviewed and ICB education sessions are planned.
An ICB “controlled drug medicines use group” has be set up to explore this document and ensure there are systems and pathways to support both prescribers and patients. There will be a set of quality improvement indicators that will be monitored during 2023/24 and performance will be fed back to practices on a monthly basis.
NHS Hertfordshire and West Essex – Predominantly opioids and pain management with mention of benzodiazepines and z drugs but not withdrawal or support services
In 22/23 HWE ICB GP practices have undertaken targeted work to review patients who are taking high dose opioid analgesics for chronic non-malignant pain. At the same time practices in Hertfordshire have worked to reduce inappropriate prescribing of opioid analgesics and promote alternative pain management strategies. Practices in West Essex in 22/23 started to work with
patients to reduce co-prescribing of dependence forming medicines. This piece of work has been expanded to include all of the HWE ICB GP practices in 23/24. All HWE ICB GP practices are working towards reducing the number of patients who are co-prescribed an opioid analgesic with either a z-drug, benzodiazepine or gabapentinoid. This is part of the HWE ICB GP Enhanced Care Framework for 23/24. Also included in the HWE ICB GP ECF for 23/24 is a target to increase the number of patients taking dependence forming medicines who are reviewed by a multi-disciplinary team to support with reducing DFM medicines doses/stopping.
In addition, we have mapped out and shared with GP practices the support available and referral options in each Place within Herts and West Essex. This includes hospital outpatient chronic pain services, physiotherapists, occupational therapists and talking therapy services (IAPT) which includes CBT, educational workshops/webinars and wellbeing classes.
As above. Supporting tools and guidance documents have been published to support practices with this system wide priority. Practices have all been offered PrescQIPP training on reducing opioid prescribing and medicines associated with dependence will be incorporated into junior doctor training and mandatory training in the acute hospitals in HWE.
NHS Dorset – Reviewing, no action yet
Yes, NHS Dorset is aware of this NHS England publication.
NHS Dorset is reviewing the framework and preparing future commissioning options for discussion with executives.
NHS Dorset review the framework at the local network and develop a systemwide policy.
The local network is already considering prescribing practices.
NHS Sussex – Some action planned
The ICB Integrated Pharmacy and Medicines Optimisation plan is being refreshed (Oct 23) and plans for reducing inappropriate prescribing of all dependence forming medicines are a key priority area. This includes working with our partner organisations to develop holistic services to support patients through dose reductions and/or stopping medication, as appropriate.
As above, and all prescribing is expected to adhere to the national NICE guidance.
The ICB are promoting the adherence to national NICE guidelines for the use of dependence forming medications. The annual Medicines Optimisation Incentive Scheme for general practice includes a specific focus on dependence forming medicines and practices are provided tools to support identification and individual review of appropriate patients prescribed these medicines.
NHS Bristol and North Somerset – Predominantly substance misuse and pain management – not renewing BTP contract forcing closure
The ICB is currently reviewing the framework and the services currently available in BNSSG include: Breaking free is an online resource for patients with alcohol and drug problems, including prescribed medications, which is available for patients registered with a GP in Bristol and South Gloucestershire.
Bristol ROADS (Recovery Orientated Alcohol &Drugs Service) provides free and confidential advice, support and treatment for adults with problematic alcohol and drug use. ROADS do not delineate in their support offer between someone who has been prescribed a dependency forming medication and someone who has obtained a dependency forming medication illegally.
We Are With You – provide drug and alcohol services for North Somerset, including a programme of treatment for prescription only medication
Developing Health & Independence (https://www.dhi-online.org.uk/get-help/pain-management-and-wellbeing-project) – an integrated Drug and Alcohol service providing support to people in South Gloucestershire.
Also see information on the local BNSSG Remedy Webpage
The ICB continues to review service provision on an ongoing basis and will try to address gaps as part of the review of recommendations.
- Individual providers have their own internal prescribing policies. The ICB has overarching guidance in relation to prescribing benzodiazepines and medications in chronic pain, which highlight the risks associated with dependence forming medicines and the importance of monitoring. The need for local guidance and their updates is ongoing.
- Local webinars have taken place to support clinicians in relation to shared decision making, pain management and deprescribing dependence forming medicines. Information relating to services available via our local BNSSG Remedy website. Awareness of potential harms of these medications is shared via learnings from audits, working with local secondary care colleagues and by reviewing benchmarking data.
NHS North East and North Cumbria – Predominantly pain management, no other plans at present
NENC ICB can confirm that it is aware of that publication.
- Commissioning of services is under constant review and the development of an ICB clinical strategy will inform this in future. The information in this review is a consideration in the development of that clinical strategy
- As above
- There are a number of initiatives in place to support prescribers with the
information in the report and according to best evidence. These include a public facing campaign; along with various locally commissioned prescribing quality schemes. A new pain clinical network has been established to support development of evidence and commissioning direction in relation to dependence forming medicines used in that clinical condition.
NHS South Yorkshire – Focusing on opioids and gabapentinoids. No mention of benzos, z drugs or antidepressants
This publication is currently being considered with the Medicines Optimisation Team compared to existing services to identify gaps and produce a plan to remove those gaps. SYICB set up a task and finish group currently discussing how to take things forward as an organisation.
Services are being delivered by/within individual GP practices in Barnsley,
Doncaster and Sheffield. Doncaster Place Medicines Optimisation Team has a workstream for the current financial year which involves reviewing patients co-prescribed opioids and gabapentinoids with a view to deprescribe if appropriate (please see attached ‘Doncaster CCG Position Statement on Opioid
Prescribing 2021 and ‘SYICB Doncaster Place: Position Statement on the Prescribing of Gabapentinoids’). Case study 5 of the NHS England publication outlines a pilot programme currently being undertaken in Rotherham Place. This publication is currently being considered with the Medicines
Optimisation Team compared to existing services to identify gaps and produce a plan to remove those gaps. Barnsley and Sheffield Place have issued guidance and shared resources to support clinicians within primary care and GP practices. Doncaster Place has issued guidance, shared resources, and developed position statements for opioids and gabapentinoids to support clinicians within GP practices (please see attached ‘Doncaster CCG Position
In Rotherham Place future policies will be considered in light of the results of the pilot.
This publication is currently being considered with the Medicines Optimisation Team compared to existing services to identify gaps and produce a plan to remove those gaps.
Currently, prescribing patterns for dependence forming medicines are monitored across South Yorkshire and support is provided to practitioners to reduce and prevent prescribing where this is taking place. Pilots of alternative interventions to medicines have been taking place within the ICB eg: exercise therapy. Acupuncture is available for certain groups of patients and the ICB is looking as a proposal to expand the provision of acupuncture in line with NICE guidance.
Barnsley Place is undertaking local audit against guidance issued.
Doncaster Place has agreements in place with secondary care regarding initiating opioids on discharge, has delivered educational training on opioid prescibing to support clinicians and has developed a chronic pain pathway to support implementation (see attached ‘Doncaster Chronic Pain Pathway’).
In Rotherham Place future policies will be considered in light of the results of the pilot.
Sheffield Place will look to monitor via prescribing data.
NHS Kent and Medway – Predominantly opioids. Benzodiazepine and Z-drug prescribing guidance is being planned but no mention of withdrawal services.
NHS Kent and Medway ICB Medicines Optimisation Team (MOT) have reviewed the framework actions and undertaken an initial gap analysis to help inform future ICB commissioning strategy discussions/planning. Also, related MOT clinical workstream leads have created a joint working group to bring together ongoing and planned worked from the separate workstreams to inform this work.
NHS Kent and Medway ICB can confirm that some local prescribing policies are already in place, please see the links below to formulary website. Benzodiazepine and Z-drug prescribing guidance is being planned.
Please click on the below link:
Opioid Tapering Resource Pack
KMCCG Opioid Position Statement on Opioid Prescribing
KM Controlled Drugs Benzo Treatment Agreement
Kent and Medway Guidance to Support the Safe and Effective,
Initiation and Review of Opioids
Information leaflet – 10 opioid safety messages
Practices are directed to above resources. Prescribing of Dependence Forming Medicines forms part of the ICB medicines optimisation scheme for 2022-24 to drive improvements in prescribing in primary care.
NHS Lincolnshire – Predominantly opioids and pain management
Current pilots underway which will be evaluated, and actions will be taken based on their outcomes. We have guidelines and resources in place for opioids that are in use, likewise for the other areas which will be updated accordingly. This is currently in development – the clinical reference group are doing a high dose opioid pilot, which needs to be evaluated and then rolled out depending on the outcomes. Upskilling is ongoing for prescribers and healthcare staff to support patients on all opioid doses and we are developing gabapentinoids tapering guidelines.
NHS Coventry and Warwickshire – Considering
Since publication of this NHSE framework earlier this year, the ICB is currently considering actions.
Question 2: Please see response to 
Question 3: Please see response to 
NHS Gloucestershire – Opioids and pain management only
Reducing pain medicines that are harmful has been at the heart of the purpose of the NHS Gloucestershire Living Well with Pain Programme (LWwPP) for the last 6 years. At the start of the programme, everyone who was identified at being at risk from their pain medicines was reviewed in primary care. We collated records of around 900 clinical encounters and 40% of patients were able to reduce or stop their medicines and dose escalation was stopped in 50%. Barriers to dose reduction were identified and these have informed the further work of the programme (see below). We ran an initiative in which an experienced addiction worker, trained in psychodynamic counselling, met with individuals on high doses of pain medicines. Some of these people were able to reduce the doses of their medicine but many complexities were identified as a barrier to tapering doses. many complexities were identified as a barrier to tapering doses.
From both initiatives we identified that barriers to dose reduction included
- lack of time for holistic assessment of broader mental health and social needs
- lack of time to build appropriate empathic relationships
- undiagnosed mental health needs
- lack of evidence based alternative treatments
Our main focus is to reduce prescribing of dependence forming medicines by improving understanding of complexity of persistent pain and promoting holistic assessment so that the social and emotional factors contributing to the pain experience can be identified and addressed. We have also offered educational initiatives to around 800 health care professionals in both primary and secondary care with focus on the role of medicines in persistent pain.
Within Gloucestershire we have developed a countywide pain formulary and the work of the LWwPP is shared across the system including with partners in the voluntary sector and social care.
NHS Cornwall and Isles and Scilly – Considering
We are aware of NHS England publication titled “Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care”, and an initial discussion has taken place at Cornwall Area Prescribing Committee (CAPC) on 10 May 2023. We are still in the process of considering possible actions however these medicines continue to be a focus of the primary care incentive scheme.
NHS Buckinghamshire, Oxfordshire and Berkshire West – No action and do not understand commissioning
In terms of the drugs mentioned, some could be dealt with by the addiction service. Public Health England (PHE) may commission the service.
PHE can be contacted via the following link
Others could be dealt with in a variety of ways either through reviews in Secondary Care trying to reduce the dosages in an effort to wean them off or by Primary Care doing the same in conjunction with the patient. It also depends on who started the medication initially and why it was started.
There are resources available to support deprescribing and many of the clinical pharmacists attached to practices will be aware of these and they are encouraged to do structured medication reviews on patients, although they are no longer in the Primary Care Network Directed Enhanced Services (PCN DES) and Investment and Impact Fund (IIF).
NHS Humber and North Yorkshire – Considering
NHS Humber and North Yorkshire Integrated Care Board (ICB) can confirm the
publication has not been discussed in detail at the ICB Board. However, it has been considered as part of the Integrated Medicines Optimisation and Pharmacy Committee, Medicines Quality and Safety Group, which is looking at a system-wide approach in addressing inappropriate prescribing of dependence-forming medicines. As part of this approach points B and C are being progressed whilst point A requires further consideration to ensure any service developed and commissioned is appropriate, meets the identified need and provides value for money.
North Central London – 7 out of 9 examples are for substance misuse services, future planning mentioned focusing on opioids, apart from BOWS and REST
NHS North Central London ICB does not hold this information. Please contact the providers of withdrawal services, which includes Local Authority Public health teams and NHS Trusts. Please refer to the table below.
Barnet Public health – Drug and Alcohol misuse
Barnet – Change, Grow, Live
Camden Council – Public health
Camden – Change, Grow, Live
Enfield – UK Rehab
Haringey Public health – Alcohol and drugs misuse
Islington Council – Public health
Enfield Alcohol and Drug service
Camden and Islington NHS Foundation Trust: The Benzodiazepine and Opiate Withdrawal Service (BOWS)
Better Lives, 99-101 Seven Sisters Road, London N7 7QP. The service offers support with prescribed pregabalin and gabapentin as well as prescribed opiates and benzos but not anti-depressants.
The drugs mentioned above would be prescribed by provider NHS Trusts and organisations e.g. GP practices rather than the ICB. Prescribing support information for GP practices regarding opioids and dependence forming medicines has been made available. The ICB Integrated Medicines
Optimisation Committee and North Central London Medicines Safety groups will be considering the guidance, alongside a North Central London Academic Health Science Network (AHSN) system wide Opioids group.
NHS West Yorkshire – Considering
We can confirm that West Yorkshire ICB is aware of the recently published
document you refer to in your FOI request. At the current time colleagues from the ICB are working through the framework for action to understand how it might be implemented across West Yorkshire.
NHS Somerset – Predominantly focusing on opioids and pain management – no action yet
The Somerset ICS is considering the recommendations. We are working with our Primary Care Networks, Clinical Directors and our GP Provider Board, to identify work that is planned or underway, and identify opportunities for the recommendations to be worked into new service development.
Please see the pain management prescribing guidelines on our website.
NHS Black Country – Considering, no action yet
Yes, the ICB is currently reviewing this framework. The ICB cannot comment on any actions because the framework is currently being reviewed
NHS Surrey Heartlands (Durham) – Considering, no action yet
NHS Surrey Heartlands ICB are aware of this guidance and it has been noted at the Surrey Heartlands Medicines Safety Committee. A briefing paper is being written by the Surrey Heartlands Head of Medicines Safety for consideration by the Surrey Heartlands Executive Leadership team. Next steps and any appropriate actions will be taken as an outcome of that meeting.
NHS Frimley – Considering, no action yet
The ICB is aware of the recently published Framework. As a result, a gap analysis has been undertaken to determine what services/initiatives are currently in place across the integrated care system, where there are current gaps in provision of services and what the next steps are to commission and implement suggestions from the Framework as well as acknowledgement of national services.
The ICB will use the gap analysis, prescribing data and population health data to identify and prioritise the development of local policies and services.
Local policies on the prescribing of drugs associated with dependence and withdrawal symptoms are developed in conjunction with our local providers and the expertise of clinical specialists. All policies and guidelines where appropriate undergo our robust clinical governance process and are finally approved by our integrated care system Medicines Board.
As mentioned above, local prescribing guidelines are developed in conjunction with our local providers. Provider organisations such as acute, and mental health organisations are responsible for ensuring that they implement the agreed guidelines.
The ICB supports our General Practice clinical colleagues to implement prescribing guidelines via initiatives such as clinical decision-making software on GP clinical systems, provision of education and training to prescribers and other general practice staff, support with the identification of patients who would benefit from having regular structured medication reviews.
NHS North East London – Short reply, no action yet
Currently being scoped.
NHS Derby and Derbyshire – Focusing on opioids and pain management
Withdrawal services are within the scope of Public Health commissioning and not the ICB, though the ICB will support Local Authorities as system partners on future strategy. Through the ICB ‘Improving pain management & reducing harm from opioids in chronic non-cancer pain’ workstream, which forms part of the National Medicines Safety Improvement Programme, a number of the recommended actions of the report have been implemented, specifically regarding question B:
- Our formularies contain general prescribing advice Chapter 4 CNS
- Opioid resources
- Upskilling 34 colleagues to Live Well With Pain practitioners to support scale up and adoption of non-pharmacological approaches.
- Further to targeted quality improvement support to practices in deprived areas with high levels of prescribing, we have captured case studies that show the changes achieved.
- An electronic pain management plan based on the 10 footsteps programme and integrated into the clinical system as a template, is currently being developed.
- ICB- funded practice training sessions are also being utilised to share best practice to support practices to identify areas of improvement with chronic pain management and undertake QI projects using the toolkit provided.
- A local opioid tapering clinician support tool and Post Surgery Patient information leaflet have been developed and are currently going through local governance processes.
- A local “pain hub” was created on the JUCD website to host local and national resources to support management of chronic pain, which is accessible to both patients and healthcare professional across the system.
NHS Cheshire and Merseyside – Focusing mainly on opioids
NHS Cheshire and Merseyside ICB is aware of the recently published
NHS England publication titled “Optimising personalised care for adults prescribed medicines associated with dependence or withdrawal symptoms: Framework for action for integrated care boards (ICBs) and primary care”.
Work is currently underway to ensure that prescribers across Cheshire and Merseyside are supported with guidance such as that previously produced by
NHS Cheshire & Merseyside ICB’s Chief Pharmacist is having discussions with the Innovation Agency/Northwest Coast Patient Safety Collaborative, regarding their support in relation to a ‘Whole Systems Approach to High Risk Opioid Prescribing’ Framework and liaising with the National Patient Safety Specialist & Clinical Improvement Lead.
There will be consideration of ICB priorities, which may include liaising with stakeholders including local authority colleagues in relation to accessing appropriate withdrawal support for patients who have become dependent on prescribed medication.
NHS Norfolk and Waveney – Apparently no effective action
The questions set above are not seeking recorded information however please see our response to the whole request below.
The ICB is aware of the guidance published in March 2023. The ICB has conducted some engagement work and has been working with system partners and stakeholders locally to support primary care.
NHS Suffolk and North East Essex – Seem to be focusing on opioids and withdrawal services/support reliant on SMRs and educating GPs
SNEE ICB is committed to supporting the PrescQIPP East of England Opioid Awareness Campaign, which includes patient education on opioid harms and benefits, and support with reducing opioid use.
One of the SNEE Health and Wellbeing Alliances has recently completed a dependency forming medicines (including opioids) pilot, the findings of which will be shared, and will inform a service that will be provided to practices to support the review of patients prescribed DFM.
Peer to peer learning on practical ways to reduce the prescribing of DFMs is a planned training and education event for GPs and their practice staff.
Shared decision making and structured medication review (SMR) for patients using one or more potentially addictive medications from the following groups: opioids, gabapentinoids, benzodiazepines and z-drugs forms one of the PCN requirements in the 2023/24 Network Contract DES.
A practice support pack has been developed to support identification of patients for whom an SMR is required.
As each piece of work is developed and a policy produced, this is taken through the local governance process at both ICB and Trust/Mental Health Trust level as appropriate.
Monitoring of DFM prescribing will be undertaken at practice, Alliance, and ICB level.
Patient reviews of DFM are one of the quality targets included in the Medicines Optimisation Cost Improvement plans for 2023/24 across North East Essex.
Practices identified as outliers in their prescribing choices/habits of DFMs are routinely challenged by the Medicines Optimisation Teams.
NHS North West London – Focusing on opioids and pain management
NHS North West London ICB (NWL ICB) is aware of the recently published publication from NHS England and is currently working with our local AHSN – Imperial College Health Partners (ICHP) on how this is implemented across our system.
The work undertaken in conjunction with ICHP has focused around the reducing harm from prescribing of high dose opioids work stream. This was based on the NHSE MedSIP programme. https://www.england.nhs.uk/patient-safety/patient-safety-improvement-programmes/#MedSIP
NWL ICB has an Opioid Strategy Group (https://www.nwlondonicb.nhs.uk/professionals/referral-guidelines-and-clinical-documents/chronic-pain) which focused on this work stream. This is also being reviewed by the NW London Med Safety Network Group which has committed to work with ICHP on this work stream. The scoping work covered by the opioid strategy group will complement the work needed for the NHS England work, the ICHP has been helping with this work so there’s no duplications.
There’s no local policy but the ICB is looking into this.
NHS Northamptonshire – Considering, focus seemingly on opioids
The ICB is committed to undertaking a review of the guidance in 2023/24. As part of this process, we will consider our statutory duties, review existing commissioned services (if applicable) and consider what actions are needed. As part of the above process, we will review existing policies and assess whether new policies are required. Our prescribing forums will participate in the review and where appropriate our prescribing guidelines will be updated to reflect any changes in practise. With particular regard to opioids there are already plans in place to launch a system-wide programme in July with a remit of supporting patients with chronic non-cancer pain, whilst minimising harm.
NHS Mid and South Essex – Focusing on opioids and pain management
The ICB is in the process of commissioning a Community MSK and Pain Management service which will include clinics for managing patients on high dose opioids and provide appointments to support patients to withdraw/reduce their dosage. Regionally a communications programme has been commissioned to educate people on the effects of long-term high-dose pain medication and empower people living with pain to make informed decisions about their health. The Clinical Nurse Specialist for Pain Management has been providing talks at GP educational sessions on both managing patients on high dose opioids and supporting reduction of does in primary care. The Integrated Care System has developed a local guidance document for Opioid Tapering for Chronic Non-Cancer Pain to provide a framework for Primary Care to identify, assess risk and support opioid withdrawal for patients who are continuing to be prescribed opioids for chronic pain. By developing the required supporting tools and guidance. Chronic pain management guidelines have been developed and tapering guidelines are in development.
NHS Cambridge and Peterborough – Focusing on pain management and opioids; Change Grow Live provide predominantly substance misuse services
Yes, we are aware, and this has been discussed within the Medical Directorate of the Integrated Care Board. We are currently reviewing the recommendations, which includes working alongside our local authorities and currently commissioned services including Change Grow Live. -misuse
Yes, a system deprescribing policy is currently being drafted and we expect this to be ratified through our System Area Prescribing Committee later this year. Yes, education for our system clinicians and patients will be included in our implementation plan due to progress during this year. This will include use of a patient campaign ‘ Painkillers don’t exist.’
NHS South West London – Refused FOI under Section 21, “reasonably accessed by other means”, which it was not, as none of the information requested was found on this link. Appealed refusal.
NHS South West London ICB does hold some of this information. The ICB considers that this information is exempt from disclosure under Section 21 (Information reasonably accessible to the applicant by other means) of the Act, which provides an exemption from the duty to disclose information which is accessible to the Applicant by other means. This information is already available in the public domain and can be accessed here.
NHS Nottingham and Nottinghamshire – Predominantly focusing on opioids and pain management. No withdrawal services for iatrogenic dependence. Antidepressant guide does not mention long-term/permanent harms or withdrawal schedules
Currently the ICB commissions services to help patients with pain management, however these are not specific services for helping patients who have become dependent, through no fault of their own, to prescribed medicines identified in the PHE review. At present, the ICB does not have a commissioned service for this. The Medicines Optimisation team intend to formally discuss the report at a future meeting of the ICB Clinical and Care Professionals Leadership Group (CCPL). The group provides clinical healthcare professional leadership and advice to the ICB Board. The report has been shared with members of the Medicines Optimisation team and discussed with a selected number of frontline clinicians at locality level to raise awareness and obtain feedback to help inform the discussion at the CCPL.
The ICB does not hold this information, it is dependent on the outcome of the CCPL discussion.
The ICB has a range of resources to support prescribers to implement in prescribing practice when prescribing medicines associated with dependence or withdrawal symptoms. Further work on this will depend on the outcome of the CCPL discussion and subsequent actions from their recommendations. The report focuses on personalised care / shared decision making and using structured medication reviews (SMRs) as part of the review process. The ICB Medicines Optimisation team have been working for some time with GPs / PCNs to influence prescribing practice and support clinicians to adopt new prescribing practices. Examples of these activities include:
- Opioids and gabapentinoid medicines were part of the prescribing visit report for each GP practice last year and information about prescribing of gabapentinoid medicines features in the report this year. This includes prescribing data to help the practice reflect on their prescribing and reference to local / national guidance to influence prescribing practice.
- Our medicines safety work programme for this year includes work focussing on shared decision making when prescribing gabapentinoid medicines. It involves informing GP practices of the MHRA drug safety alerts in relation to respiratory risk when prescribing gabapentin / pregabalin and then supporting practices to identify / prioritise patients for SMR using the personalised care approach. Dependence forming medicines will continue to be a focus with the medicines safety programme in the future, with potential work areas to include antidepressant prescribing. We have also undertaken work with prescribers to review prescribing of high dose opioid medicines in the last couple of years.
- Nottinghamshire Area Prescribing Committee publications include guidance that is relevant to this area of prescribing and emphasises personalised care. Examples are given below; this guidance / information sources are shared with GPs / PCNs to support the work we are doing with prescribers in GP practices:
- Management of Chronic Pain in Patients above 16 years of age – The Overarching Guide for Primary Care Clinicians
- Management of Neuropathic Pain for Adults in Primary Care
- Opioids for Non-cancer Pain in Adults
- Opioid Deprescribing for Persistent Non-Cancer Pain
- Primary Care Guide to Antidepressants Prescribing, Stopping & Swapping
- Benzodiazepines and Z-Hypnotics Guidance on Prescribing and Deprescribing
- We also have a range of de-prescribing resources which includes information for patients and carers – https://www.nottsapc.nhs.uk/de-prescribingstomp/
- We have also produced podcasts that consider prescribing / deprescribing in pain management –
NHS Bath and North East Somerset, Swindon and Wiltshire – No action taken
No action taken since publication of Framework.
The ICB does not hold this information as the prescribing will take place in the provider sector eg GP practices, Acute Trust, Community Services, Mental Health Trusts (not an exhaustive list)
Any prescribing information related to these drugs can be found here.
NHS Bedfordshire, Luton and Milton Keynes – Treated as substance misuse
The ICB does not hold this information. Please request from Public Health teams in Local Authorities who manage substance misuse services.