Domhnall MacAuley: Tranquiliser and analgesic dependence

Domhnall MacauleyGPs warned to steer clear of tranquiliser trap,” Reading the headline—I expected the usual GP bashing. But, the headline misled and the story was based on a joint statement by the Royal College of General Practitioners and the Royal College of Psychiatrists, supported by medical, nursing, social work, and lay bodies on the risks of addiction to painkillers and tranquilisers. It caught my partner’s attention too; someone put the Times on staff room coffee table—a rare sight. Today’s headline states “Victims of tranquiliser trap are being neglected.” But not by all. We put a huge effort into trying to minimise the use and abuse of tranquilisers in our practice. Let me tell you what its like.

Tranquiliser and analgesic abuse costs our doctors and receptionists endless time, energy, and angst. Our aim is always to reduce dependence. It may start quite simply; some well meaning hospital doctor might suggest a short course of anxiolytic, an A&E doctor recommends analgesia, or a GP colleague initiates treatment. Some patients may take a short course and stop but many don’t.

Our practice policy is that no one is issued a repeat prescription for a benzodiazepine or strong analgesia. Every patient must speak to a doctor on each occasion before being issued with a prescription. You can imagine the workload implications. Encouraging reductions, weaning people off, and saying “No,” creates endless phone calls, and long discussions (and occasional arguments) with patients. Just when you feel you are making progress, there is another crisis, they persuade their counsellor or CPN or a well meaning doctor to write us a note recommending treatment. It is a mine field—patients on high doses take a long time to reduce and, by their very nature, often face many personal and emotional crises. No one wants deprive a patient of a treatment they need, especially if a medical colleague has recommended this treatment in the past, but the medication may be worse than the illness. Sometimes there is progress. Sometimes it is a mirage. Patients buy (or sell) them on the street, borrow them from their friends, shop around GP partners and locums.  They lose them, are going on holiday, or visiting relatives, and ask us to phone the pharmacist to release their weekly dispensed prescription. When new patients register we try to make our policy clear, but sometimes they do not tell us about their medication and are angry and upset when they are faced with our practice policy. In the past we negotiated a verbal agreement, documented on the computer record for all to see. More recently, we introduced a written contract.

Dependency on prescription drugs is a real problem. We make a huge effort, but at great cost to all the staff. There is a major social and community problem. Doctors cannot cure it alone. We need more help.

Domhnall MacAuley is primary care editor, BMJ.