Antidepressants are not “addictive” drugs, although they can cause withdrawal symptoms, a final NICE guidance has concluded.
The guideline covers the safe prescribing and management of withdrawal in adults for medications such as opioids, benzodiazepines, gabapentinoids, Z-drugs, and antidepressants.
A draft version of the guidelines released in October called them “drugs associated with symptoms of dependence or withdrawal.”
But the new NICE guideline, published yesterday, refers to the same set of drugs as “an addictive drug or antidepressant”.
He said: “Medications associated with addiction include benzodiazepines, Z-drugs (such as zopiclone and zolpidem), opioids, gabapentin and pregabalin.
“Antidepressants, although historically not classified as addictive drugs, can nevertheless cause withdrawal symptoms when stopped.”
The new guideline released today also endorsed the project’s recommendations that GPs should provide regular check-ups for patients taking antidepressants and chronic pain medications that may lead to addiction or withdrawal.
And he confirmed that secondary care clinicians who “recommend an addictive drug or antidepressant to start or continue in primary care” should explain to the patient that their primary care team will prescribe and review it.
However, he added: “If the primary care team refuses to prescribe the medicine or wishes to delay it, the secondary and primary care teams will discuss the medicine and involve the person in those discussions, explaining the reasons for any delay. “
The guideline also reiterated that GPs who decide to prescribe ‘addictive’ drugs or antidepressants should consider whether there are any factors that may increase a patient’s risk of developing problems associated with addiction.
However, he added that GPs should ‘not refuse the drug solely on the basis of any of these factors’.
And he said prescribing could be delayed if GPs needed ‘additional time’ to ‘consider options and consult with colleagues’.
The NICE guideline said: “Recognize that these decisions are also difficult for the prescriber, particularly when it comes to supporting someone in distress and in the presence of risk factors for developing problems associated with addiction, and that additional time may be needed to consider options and consult with colleagues.
“Consider delaying prescribing if the person needs more time to think about their options or if the prescriber needs to consult with other members of the healthcare team. If the prescription is delayed, ensure that a follow-up appointment is arranged.
It also recommended that GPs “take steps to reduce the risk of developing problems associated with addiction, such as starting with a low dose, and consider avoiding modified-release opioids”.
“Once an effective dose has been established, avoid automatically increasing the dose if the response is not sustained,” he added.
And he recommended a tailored approach to agreeing any dose reduction schedule with patients, including making sure the planned rate of reduction is “acceptable” to them.
He said GPs should consider giving patients “additional control” over the rate of reduction, for example by “delivering their usual daily dose in a form that allows them to reduce the amount in small decrements at the rate of their choice, rather than delivering successive doses”. prescriptions for reduced daily doses”.
He added: “Explain that although withdrawal symptoms are expected, the tapering schedule may be changed to allow intolerable withdrawal symptoms to improve before proceeding with the next tapering.”
The new guidelines do not cover the prescription of gabapentinoids for epilepsy, opioids for acute pain, cancer or end-of-life pain, or the management of illicit drug addiction.
It follows new draft guidelines on quitting antidepressants – released in November – that say GPs could support patients for months if they experience serious side effects, including suicidal thoughts and panic attacks .
This was NICE’s third attempt to write a guideline on the subject, with final publication expected next month.
NICE previously revised its depression guidelines in 2019 to warn against “severe” and prolonged withdrawal symptoms from antidepressants, after initially saying such symptoms were “mild”.
This follows a 2019 report from Public Health England which warned that one in four patients had been prescribed a potentially addictive drug, including antidepressants.
Safe prescription and withdrawal management for drugs associated with addiction or withdrawal symptoms
Offer regular check-ups (by phone, video, or face-to-face) for people taking an opioid, benzodiazepine, gabapentinoid, Z-drug, or antidepressant. Base review frequency on:
the preferences and situation of the person
the type of medicine they are taking and the dose
factors that could indicate a need for frequent examinations, for example if:
the person has additional care needs (such as people with a learning disability or cognitive impairment)
the person is taking the medicine for the first time
there are potential adverse effects or problems associated with addiction
the drug is used outside of its authorized indications
there is a risk of drug misuse.
Consider increasing the frequency of examinations when adjusting the dose. Consider the person’s clinical and support needs when agreeing the frequency of examinations.
Offer additional unplanned reviews if necessary, for example if the person:
reports adverse drug reactions
become pregnant or planning a pregnancy
has a change in his or her physical or mental health, or social situation
starts taking medication from another prescriber
requires a dose change.
Working with other healthcare professionals
Secondary care health professionals who recommend the initiation or continuation of an addictive drug or antidepressant in primary care should explain to the person that:
the medication will be prescribed by their primary care team
the primary care team will need to review the medication
if the primary care team refuses to prescribe the medicine or wishes to delay it, the secondary and primary care teams will discuss the medicine and involve the person in these discussions, explaining the reasons for any delay
the secondary care team may not continue to manage and provide the medication if agreed after discussions.
Make decisions about prescribing and taking an addictive drug or antidepressant
When making decisions about prescribing medications, consider whether there are any factors that might increase the risk of developing addiction-related problems, but don’t withhold the medication based on just one of these factors. Explain and discuss the risk with the person. Factors that could increase the risk include:
a comorbid mental health diagnosis
a history of drug or alcohol abuse
not having a clear and defined diagnosis to support the prescription
taking an opioid with a benzodiazepine.
Recognize and recognize that decisions about medications can be difficult for someone in distress.
Recognize that these decisions are also difficult for the prescriber, particularly when supporting someone in distress and in the presence of risk factors for developing addiction-related problems, and that additional time may be required to consider options and consult with colleagues.
Consider delaying the prescription if the person needs more time to think about their options or if the prescriber needs to consult with other members of the healthcare team. If the prescription is delayed, make sure a follow-up appointment is scheduled.
Take steps to reduce the risk of developing problems associated with addiction, such as starting with a low dose, and consider avoiding modified-release opioids. Explain the importance of these steps to the person.
Discuss with the person the range of doses likely to be safe and effective. Start with a low dose and agree to frequent, regular reviews to ensure adjustments can be made in a timely manner to test efficacy, safety and acceptability and to find the lowest effective dose. Once an effective dose has been established, avoid automatically increasing the dose if the response is not sustained.
When agreeing a dose reduction program with the person:
explain the risk of abrupt cessation and that the safe rate of withdrawal varies from person to person and may vary over time for the same person
balance the risk of adverse effects from continued drug exposure while minimizing the risk of withdrawal symptoms by slowly reducing the dose and weaning off
ensure that the planned rate of reduction is acceptable to the person
explain that although withdrawal symptoms are to be expected, the tapering schedule can be modified to allow intolerable withdrawal symptoms to improve before proceeding with the next tapering
consider giving the person additional control over the dose reduction process (for example, delivering their usual daily dose in a form that allows them to reduce the amount in small decrements at a rate of their choice, rather than delivering successive prescriptions of reduced daily doses). doses)
agree regular intervals to review and adjust the reduction schedule if necessary
make sure the person knows who to contact if there is a problem.
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