OPEN LETTER TO PROFESSOR STEVEN FIELD

CHAIR OF COUNCIL - ROYAL COLLEGE OF GPs
14 Princes Gate
Hyde Park
London SW7 1PU

Dear Professor Field,

GP OVERPRESCRIBING OF ADDICTIVE DRUGS

I am writing to you regarding serious concerns I and many others have about the widespread iatrogenic benzodiazepine and z drug addiction which has existed in the UK over the last 50 years. I am writing as an ex-involuntary addict and as someone who has researched this subject from its beginnings in the 1960s when Valium addiction was becoming a problem.

I was prescribed Ativan in 1975 for anxiety and in hindsight I realise that I became addicted in a matter of weeks.  I wanted to discontinue Ativan but could not because of the horrific withdrawal symptoms; successive GP' surgeries then continued prescribing it for the next 35 years, mostly on repeat prescriptions without the need to see a doctor, as none of them had the knowledge to help me discontinue.

They were not even able to suggest a basic diazepam tapering schedule including an equivalents table to calculate how much diazepam to switch over to or any knowledge of the type, severity or duration of the withdrawal symptoms.

I finally found withdrawal information on the internet and managed to discontinue this year, after 14 months, using the diazepam taper method recommended in Professor Heather Ashton’s manual Benzodiazepines: How they work and how to withdraw. This took over a year and I used support and advice available from The Council for Information on Tranquillisers and Antidepressants in Liverpool and the Bristol and District Tranquilliser Project as none of my past GPs could offer help and their only advice was "do it slowly". These charitable organisations were started in the 1980s to offer support and advice to people wanting to discontinue addictive prescription drugs. The physical and psychological withdrawal symptoms have been crippling; I am still very unwell and am worried whether I will ever completely recover from the damage inflicted by these drugs.
 
I have since found many people similar to me who have been made seriously ill as a result of taking benzodiazepines; their stories of suffering are harrowing. They all say that withdrawing from benzodiazepines has been the most destructive and devastating experience in their lives.

I am not writing to discuss my own individual case but to express my and others concerns regarding this serious issue in the UK.

Media research points to a figure of 1.5million people currently dependent upon benzodiazepines and z-drugs in the UK; about 180 per surgery. I have been corresponding with the Dept of Health, the MHRA and the Commons and Lords with regard to these issues. It is through this correspondence and my research that I am becoming aware of the part that GPs’ prescribing habits, lack of training and ignorance of numerous Department of Health guidelines issued since 1980, have been responsible for this national scandal continuing for so long.

The health system has created this problem but does not appear to wish to treat it. It seems no-one is accepting responsibility.

I note from the RCGP’s website that:
"The Royal College of General Practitioners is the professional membership body for family doctors in the UK and abroad. We are committed to improving patient care, clinical standards and GP training."

Problems with addiction to benzodiazepines were emerging in the 1960s and various guidelines have been issued to GPs since, the main ones being:
The Committee on Review of Medicines report in 1980; the Committee on Safety in Medicines publication in 1988; the Mental Health National Service Framework (NSF) guidelines in 1994 and their publication in 1999; the Dept of Health publication in 1999; NICE’s publication in 2004 and the Chief Medical Officer’s update 37 also in 2004.

All these stated that "benzodiazepines should be prescribed for just two to four weeks for relief of severe or disabling anxiety or severe or disabling insomnia in patients who are extremely distressed".

Doctors have largely ignored these guidelines and prescriptions for benzodiazepines are on the increase.

Diazepam prescriptions are up 11% this year. In 2007 Dept of Health statistics show that there were 11.5 million prescriptions for benzodiazepines, 5.5 million for z drugs and a third of these were for 56 tablets or more suggesting large numbers of patients on long-term treatment; 852,000 of these were for lorazepam which is one of the most problematic and 10 times the strength of diazepam.

If the RCGP is committed to patient care, clinical standards and GP training, why hasn’t it made efforts to ensure that its members read important drug safety guidelines and put them into practice? Many doctors are obviously out of their depth and need guidance. They have created the problem by creating and sustaining addictions but do not know how to rectify the problem.

The Department of Health’s review of policy on addiction to prescription drugs and OTC medication has already been in progress for 12 months. The report itself is now scheduled for the end of 2010 with policy discussions to take place into 2011. What role has the RCGP played in this review? Also, in the interim period, will you be sending advice to GPs to avoid new addictions? Also, what plans does the RCGP have to deal with current ones?

I now refer to the transcription below from your interview on ITV West last year:

‘Professor Steven Field, Chair of the Royal College of General Practitioners, said:
“We now try to prescribe (benzodiazepines) only for a few days because we know that it's very difficult to get people off these drugs, but there are still a lot of people on benzodiazepines and tranquilisers that have been on for many years…..the patient doesn't want to come off the drug because they've tried before and they get all of these horrible withdrawal side effects which are very similar to coming off heroin or cocaine and indeed in my experience it can be more difficult to get people off benzodiazepines.

"What we’ve got to try to do is work with the patient to bring them off very slowly and very gradually, but the best thing to do is to not prescribe them in the first place…..some of the drugs, in some people, it can be three or four days of the drug before they get hooked. And what you find is that they can't have a day without them. They start to get very anxious, very sweaty, very panicky. In others it's even worse - it's not just that they can't do a day without them they need two or three or more, to actually keep them calm. So each patient is very different. Bringing people off the drug is very different and you have to do it slowly and really tailor it to the patient.”
(ITV West interview, March 09)’

This information has been known since Professors Lader, Tyrer and Einarson’s work in 1979/80 and the Committee on Review of Medicine’s investigation into benzodiazepine withdrawal symptoms in 1980. Why hasn’t the RCGP acted on this information?

It is not similar to coming off heroin as you state in your interview. This is a common mistake that GPs make. You cannot come off them using willpower and this is poor and dangerous medical advice. What medical and scientific advice was this based on? Heroin withdrawal can take as little as a week; benzodiazepine withdrawal can take months or years and many people are still suffering withdrawal symptoms after 2 years or more.

Most GPs do not recognise these symptoms as lasting more than two months. It is common practice to then misdiagnose them for re-emergence of the original symptoms or development of new ones; these are then frequently treated by dosage increase or additional medication making eventual withdrawal even more difficult. Some patients have also been advised to discontinue too abruptly or forced by the withdrawal of prescriptions to ‘go cold turkey’, causing seizures and protracted withdrawal symptoms lasting years. Protracted withdrawal symptoms have also been largely denied by the medical profession against overwhelming evidence from patients and scientific evidence to the contrary.

I am informed by the Dept of Health that NHS Clinical Knowledge Summaries ‘benzodiazepines and z drug withdrawal’, largely based on Professor Ashton’s work, is available online for GPs’ guidance; neither my last nor current surgery were aware of this when ‘managing’ my withdrawal. It is the duty of the RCGP taken to ensure doctors read and implement guidelines.

There has also been endless concern about benzodiazepine addiction covered by countless television documentaries eg Panorama, Brass Tacks, the Cook Report, and newspaper articles and concerns raised by MPs, academics and the public. What justification has the RCGP had for taking no action in the face of 30 years of widespread public concern?

I will now refer to your comments in the Sunday Telegraph:

‘Sunday Telegraph May 2nd 2010 - Prescriptions of Valium, the highly addictive pill for stress and anxiety disorders, have risen by more than 11% in three years. Senior doctors expressed alarm that the drug diazepam, commonly known as Valium, is now being dispensed almost 5 million times a year in England. The Royal College of General Practitioners said GPs should be referring those suffering from anxiety for counselling, not drugs which could result in a lifelong addiction.

"They warned that the pills, once dubbed "mother's little helpers", were very difficult to stop taking, and should no longer be recommended to most patients.

"NHS figures show that in the first nine months of 2009, more than 3.6 million prescriptions were written for diazepam in England – an 11% rise on the 3.25 million dispensed in 2006, and an increase of 17% in a decade. If the trend continues, it will amount to more than 4.8 million prescriptions issued in 2009, according to figures held by the NHS Prescription Pricing Authority. The drug can be given for stress and anxiety but GPs are told to only allow its short-term use, and are encouraged to refer patients for counselling, or in some cases to prescribe antidepressants. Prof Steve Field, chairman of the RCGP said he was "shocked" by the figures uncovered by The Sunday Telegraph.’

I find the statement that you, as Professor and Chairman of the RCGP was shocked, shocking to me.  If I, as a lay person, can trace the problem through from the 1960s then surely you, as chair of the RCGP and an eminent professor and practicing GP, can too.

I find the statement that you are ‘shocked’ after 40 years of blindingly obvious evidence surreal. Do you read Dept of Health statistics or guidelines or the British Medical Journal or newspapers? Do you not watch television? Again, the writing was on the wall in the 1960s and the evidence there to see from the late 1970s; to express shock in 2010 is an insult to those affected.

Again, I ask why the RCGP has not played a helpful role or accepted some responsibility for causing and sustaining addiction in the UK.

People addicted to prescription drugs also say they regard themselves as involuntary addicts because they depended on their doctors; these drugs were taken in good faith from someone in a position of trust. When I asked to be referred for emotional support my doctor ticked the category ‘substance misuse’. I followed the advice of a succession of doctors to the letter, so I can only deduce that if addiction to prescribed drugs is construed as ‘misuse’ then all my doctors from 1975 to date should be arrested and charged with drug dealing.

The only real help for people has come in the form of Professor Ashton’s manual and charitable organisations that provide vital help-lines. The RCGP has, as far as I am aware, provided no research, no guidance for GPs, no training for GPs and no help for patients. Why not?

I note from looking at the itinery for the RCGP Annual Primary Care Conference 7-9 October 2010 at Harrogate that there is nothing on benzodiazepine dependency; neither was there anything last year.  Evidently, therefore, despite being shocked you do not consider this warrants discussion.

No-one so far has apologised to the patients; would the RCGP like to apologise for all the suffering caused by its members over a 40-year period?

Finally, I am writing this letter to request that the RCGP address this problem as a matter of urgency and to ask you to tell me what action you will be taking to rectify the damage done and ensure that all existing involuntary addicts are offered the help they deserve.

Yours sincerely

John Perrott
Lancaster

Comments

[Ed]

I know a doctor in a drugs treatment service who is agitating to have people addicted to prescribed benzodiazepines treated. He's fighting an uphill struggle, though, because in order to satisfy [the previous] government targets, the DAAT is funding services twice as much for Problematic Drug Users - heroin users who are committing crimes - than for other drug users. It's time for all the targets to be taken down.

[Matthew]

Ed, with regards to your comment, have you considered that with limited resources available (because public money is being used to pay off the deficit), services, an DAAT's have to prioritise the drug users that are most at risk / in need, which is largely heroin or crack users?
Having targets means that services are pushed harder to see more people and give them better quality treatment.
People being prescribed benzos / "z" drugs are perfectly well able to be treated by the GPs that are prescribing them rather than be referred to a specialist drugs treatment agency. The issue is about the complicity and willingness of GP's, not about the way services for users of other drugs are commissioned.

[Ed]

Matthew, the problem isn't the targets in themselves, it is the game-theory mindset that allows executives to decide how they are going to achieve them. I don't deny that heroin users committing crimes are in need of treatment, but treatment in this field is useless until a need for it is perceived: and with prisons harder to get into than Iran, this group is being denied the chance to have enough negative experiences to trigger that perception.

It's not only people using prescribed benzos that are losing out. Folk who use large amounts of strong cannabis are also being put to the back of the queue, as are heroin-users who don't commit crimes beyond obtaining their drug of choice. It seems to be a mark of our topsy-turvy societal values that people who cause the most trouble are given the most help - whether or not they want it - whereas those who suffer in silence are treated with contempt.

[John Perrott]

If anyone has concerns regarding benzodiazepine or z drug addiction I recommend that they contact the Council for Information on Tranquillisers and Antidepressants, Bristol and District Tranquilliser Project or BATAID, as I did.They have been providing help for over 20 years.
Also read Professor Ashton's manual available online.

[patrick]

Doctor robert crawford is the man about addiction he is a pom living and treating in new zealand

[patrick]

until doctors get to terms with their own addictions there will be no education 5 out of ten are addicted

[William Mansfield]

Had a reply yet?

[e-dysfunction]

If anyone has concerns regarding benzodiazepine or z drug addiction I recommend that they contact the Council for Information on Tranquillisers and Antidepressants, Bristol and District Tranquilliser Project or BATAID, as I did.They have been providing help for over 20 years.
Also read Professor Ashton's manual available online.

[John Perrott]

I have had a reply which prompted another letter from me as he avoided addressing specific issues I raised. Professor Field replied to my second letter as well but again avoided all questions regarding accountability. I quoted prescribing statistics for 2007-9 and also provided evidence from academics. I have written again asking him to answer these and all this correspondence is on www.appgita.com

Professor Field stands down as Chair of the RCGP this Saturday and I am promised a response to all questions he has so far avoided. I will be taking the matter further with his successor, Dr Clare Gerada and I will post all correspondence on the APPGITA website.