Misuse of psychotropic substances: outline and recommendations of a conference held in London in March 1980
Author: A.HAMID GHODSE, I. KHAN
Pages: 83 to 90
Creation Date: 1982/01/01
Misuse of psychotropic substances: outline and recommendations of a conference held in London inMarch 1980A.HAMID GHODSE Consultant Psychiatrist, St. George's, St. Thomas , and Tooting Bec Hospitals, and Senior Lecturer, St. George's Medical School, London, United Kingdom of Great Britain and Northern Ireland
I. KHAN Senior Medical Officer, Division of Mental Health, World Health Organization ( WHO) , Geneva, Switzerland
A conference was held in London in March 1980 on the use and misuse of psychotropic substances. The conference noted that there was a preponderance of medical practitioners who prescribed psychotropic substances. The topics covered ranged from the extent of use of psychotropic substances to the effects of their use in producing different types of morbidity. Consideration was given to controls of psychotropic .substances, including steps to reduce their misuse without restricting their legitimate use.
A Conference was held at the Middlesex Hospital, London, in March 1980, sponsored by the Dependence and Addiction Group of the Royal College of Psychiatrists. The objectives of the conference were to assess information on the current state of use and misuse of psychotropic substances as an essential step in promoting measures to control such substances; this would also promote communications among the different professional groups concerned [ 1] .
Since there was a growing concern about the tendency of the general public to believe that psychotropic substances could provide relief for many of the social and inter-personal problems of daily life, the Department of Health and Social Security (DHSS), the Royal College of Psychiatrists in the United Kingdom of Great Britain and Northern Ireland and the World Health Organization (WHO) have independently expressed their interest in elucidating patterns of use of psychotropic substances [ 1] . A steering committee was set up by the Dependence and Addiction Group of the Royal College of Psychiatrists in the United Kingdom to organize a meeting of persons from different disciplines concerned in order to discuss this subject.
For some time, specialists in various branches of medicine had been concerned about the way in which the use of psychotropic substances impinged on their own area of practice, but they had little idea of whether their particular concerns were shared by those in other specialities. Physicians were worried about self-poisoning, health service administrators with prescribing costs, casualty specialists were suspicious about the role of these drugs in many accidents and psychiatrists were concerned about the consequences of long-term use of psychotropic substances and dependence on them. Above all, general practitioners were under pressure to prescribe them. The conference addressed these problems.
A brief summary of some of the data presented at this conference as it related to the United Kingdom is given below, together with a summary of some of the related discussions.
Between l 965 and 1970 there was a 19 per cent increase in prescriptions for psychotropic substances, followed by a further increase of 8 per cent from 1970 to 1975 [ 2] . During the next six-year period there was a 15 per cent increase in prescriptions for non-psychotropic substances, indicating that the trend of increasing prescriptions was not confined to psychotropic substances [ 2] . The trend of replacing one type of psychotropic substance with another also continued.
Prescription data, collected by the DHSS primarily for the remuneration of pharmacists and not for research purposes, reflected the over-all level of psychotropic substances prescription in the community and were an indication of the extent to which these drugs were being prescribed [ 2] . They had several limitations however: a proportion of patients who received prescriptions did not have them dispensed; there was probably a sizeable proportion of patients who had the prescriptions dispensed but did not take the drugs, and prescriptions written for hospital out-patients did not appear in DHSS prescription statistics. Above all, the sampling unit of these data was a prescription, not a patient. Such data did not accurately reflect important parameters such as the total amount of drug prescribed, dosage, duration of treatment or the number of patients receiving treatment. Furthermore, true prescription trends may have been misrepresented. For example, changing from a practice of long-term repeat prescriptions to short-term prescriptions of smaller amounts of drugs would appear in the statistics as an increase in the number of prescriptions even if the total amount of drugs being prescribed was smaller.
Several surveys have suggested that about one in ten men and one in five women take tranquillizers or hypnotics, mainly benzodiazepines, at some time in the course of each year [ 3] . Of these persons, between one half and two thirds take tranquillizers for at least one month at a time. It is estimated that 2 per cent of the adult population studied (600,000) take tranquillizers every day or night of the year and the commonest drugs on repeat prescriptions are the benzodiazepines [ 1] .
Another way to study the extent of use of psychotropics and particularly tranquillizers is to investigate the distribution of anxiety in the community and hence to identify the potential users and the population "at risk". A well designed nation-wide survey of this type suggested that there is a demand for treatment by 10 million people in the United Kingdom who have experienced unpleasant symptoms of anxiety [ 3] .
The effect of these substances on psychomotor performance assumes importance in ambulant patients undertaking risk-prone activity as part of their everyday life. Many people of working age consume such medication at some stage of their working lives, in many cases over a period of several months. Some experimental evidence was presented that such medication can cause short- and long-term impairment of the performance of tasks which are analogous to many in skilled and other work. There is also some epidemiological evidence that such medication may be associated with greater liability to road traffic accidents, and it seems reasonable to suppose that these drugs might contribute to some accidents at work. Because of the complex interaction between personality, mental state, psychoactive drugs used and performance situation, it is not suggested that the use of benzodiazepines will necessarily cause an accident. However, there remains sufficient cause for concern that increased use of these substances may place the individual at greater risk of industrial, home or road traffic accidents [ 4] .
The data available from different surveys on self-poisoning in accident and emergency departments, poisoning units and regional poisoning treatment centres, all confirm these drugs as the main agents [ 4] . Another major morbidity of psychotropic drug use is dependence upon them. The most commonly used psychotropic substances, the benzodiazepines, have been shown to produce dependence and a definite withdrawal syndrome can be recognized in animal experiments and in humans. Tolerance can also develop to the anxiolytic effects of this group of drugs. Benzodiazepines are fully capable of inducing both physical and psychological dependence. In view of the extremely wide usage of these substances, documented cases of dependence are rare. However, the extent of chronic usage of benzodiazepines, although reflecting the chronic nature of the indications for their use, may mean that a proportion of users become dependent, even at normal therapeutic dosage, and benzodiazepines are also among the drugs abused by the narcotic dependent population [ 5] .
Experiments such as the Campaign on the Use and Restriction of Barbiturates (CURB) in the United Kingdom [ 6] , aimed at the education of medical practitioners which would lead to voluntary control of prescribing, could prove to be a useful tool in the prevention of morbidity due to certain drugs. The CURB campaign was a unique venture in which a group of doctors used a combination of educational and commercial-style promotional techniques to influence prescribing practices of barbiturates [ 6] .
In the United Kingdom the Medicines Act, 1968, provides statutory control over the safety, quality and efficacy of medical substances including psychotropic substances [ 7] . Under the terms of this Act, the Committee on the Review of Medicines (CRM) was formed in 1975 and the Psychotropic Sub-Committee held its first meeting in December 1977 to review 1,200 products ; these contained 453 substances which were marketed with psychotropic indications. The CRM and the Psychotropic Sub-Committee completed their review of anti-depressants, barbiturates and barbiturate combination products in 1979, and of benzodiazepines in 1980. The benzodiazepines presented the CRM with three major problems: (a) whether they were addictive; (b) whether they had long-term efficacy; (c)the problems of daytime hangover effects [ 7] .
The CRM found that there was insufficient evidence to establish the long-term (i. e. over 2 to 4 months) efficacy of benzodiazepines in the treatment of either anxiety or insomnia (the same recommendation as made by the Federal Drug Administration (FDA) in the United States of America in 1979) [ 8] . The CRM concluded that the true dependence potential of benzodiazepines was probably low. However, they conceded that withdrawal effects did exist with these substances and were dose dependent. They thought that enough evidence was available to recommend warnings both with regard to withdrawal effects after normal therapeutic dosage and also to the possibility of dependence occurring when a high dosage was given for long periods. With respect to the residual effects of benzodiazepines, the CRM recommended that attention should be drawn to the difference in the degree and severity of daytime impairment that existed between long- and short-acting benzodiazepines. Long-acting benzodiazepines are likely to carry a warning that the patient should not drive or operate machinery during therapy, irrespective of whether it is for insomnia or anxiety. With regard to barbiturates, the CRM considered the only indication allowed was "severe intractable insomnia" and found no evidence that barbiturates had specific anti-anxiety effects, different to the main sedative action. The CRM also recommended that warnings with regard to the addiction potential of barbiturates should be included in the licence for sale. It was also believed that barbiturate combination products were unsafe on the grounds of toxicity in overdose, dependence and enzyme induction. It was indicated that doctors frequently had no knowledge that barbiturates were present in the preparation [ 7] .
Although the CRM has no power to interfere with the therapeutic freedom of the prescribing doctor in the United Kingdom, it can affect the prescribing doctor in two ways. It puts the onus on the manufacturing industry to produce drugs which are safe, efficacious and of high quality. In addition, recommendations made by the CRM are contained in the review data sheet of that product which gives guidance and advice to the doctor; this can encourage a more careful use of these drugs.
Counselling in general practice by a counsellor may prove to be a way of reducing prescriptions in general and prescriptions for psychotropic substances in particular. In turn, it may contribute to a reduction of doctor-facilitated drug dependence and the number of prescriptions.
The application of behavioural treatment of selected adult neurotic patients by a nurse-therapist, among many other benefits, may reduce prescriptions for psychotropic medication.
Monitoring prescriptions for drugs among a small group of doctors led to critical self-audit of prescribing habits and to appropriate modification in some areas. If the philosophy of "small is beautiful" were adopted (monitoring on a small scale rather than on a large scale), this can highlight issues of common interest to doctors within a group practice.
Psychotropic substances are commonly, even usually, prescribed for five principal symptoms which tend to dominate any discussion on this subject. These symptoms are: inability to cope, anxiety, sleeplessness, depression and pain. They have a number of features in common [ 8] . First, they are all symptoms which everyone has experienced at one time or another, and the point at which they are regarded as being sufficiently severe to warrant medical intervention and treatment is somewhat arbitrary. Secondly, all of these symptoms are concomitants of other symptoms and many arise in consequence of the experience of other symptoms. For example, people can feel anxious because they have a lump, or be sleepless because they are in pain; it is often extremely difficult to disentangle any one symptom from the much wider range of symptoms that the patient may be experiencing concurrently. All of these five symptoms may be due to a wide range of underlying conditions; in other words, they are completely non-specific. Moreover, each one is capable of arising in an entirely non-medical context just as easily as in a medical context. Finally, they are all normal, reasonable and natural responses to real-life situations, and even when they are indisputably severe, they may still be reasonable responses to a particularly difficult situation [ 3] , [ 8] .
The widespread use of psychotropic substances to treat these symptoms may be potentially harmful in several ways. There may be a failure to investigate, diagnose and treat the underlying problems whether medical, personal, or societal that have given rise to the symptoms. Psychotropic substances may also be harmful in the sense that they are potentially toxic substances with a variety of side-effects. It is, perhaps, more serious and more sinister that they can alter in significant ways the personal characteristics of those affected, making them, for example, even less capable of meeting the demands of everyday life and of making their full contribution to work, family etc. Furthermore, it seems probable that many, if not all psychotropic substances are in some circumstances capable of inducing dependence even under controlled medical conditions and to use such a substance is always a cause for anxiety. There is also the problem of their abuse and misuse, which may be chronic persistent misuse or an acute overdose, whether accidentally or deliberately. Drug overdoses occur frequently and give rise to consider- able problems of diagnosis, treatment and rehabilitation. Few therapeutic substances in common use create a similar need for high quality medical intervention. There is also the question of the cost of psychotropic substances which, although substantial, is declining as a relative proportion of the total cost of drugs in real terms.
When possible solutions are considered in the over-all problem of the excessive use of psychotropic substances an attempt could be made to control their prescription. Voluntary control by the profession itself is of course a possibility but this would entail considerable re-education of both doctors and patients together with making more use of counselling skills. It might also be possible to bring about a greater control of the pharmaceutical industry, perhaps through some regulation of advertising. It is probable, however, that there may be a need for tighter control of the distribution of these drugs and, perhaps one day, some kind of control of their basic production.
The World Health Organization has now recommended, on the basis of the 5th and 6th review of psychoactive substances [ 9] , [ 10] that diazepam and 25 other benzodiazepines be placed under Schedule IV of the Convention on Psychotropic Substances, 1971.
The most obvious solution is, however, the most difficult to carry out. It is clear that the symptoms for which the drugs are being taken often have social origins which are, in principle at any rate, amenable to some kind of radical prevention. If there is too much pain, anxiety, depression, sleeplessness and inability to cope, perhaps steps should be taken to change the environment which contributes to the occurrence of such symptoms so that fewer drugs need to be taken.
l. R. Murray and others, eds., The Misuse of Psychotropic Drugs (London, Gaskell, Special Publication 1, 1981).002
P. Williams, "Trends in the prescribing of psychotropic drugs", in The Misuse of Psychotropic Drugs , R. Murray and others, eds. (London, Gaskell, Special Publication 1, 1981), pp. 7 - 12.003
M. R. Salkind, "Anxiety in the community", in The Misuse of Psychotropic Drugs , R. Murray and others, eds. (London, Gaskell, Special Publication 1, 1981), pp. 79 - 82.004
H. Ghodse, "The London casualty survey", in The Misuse of Psychotropic Drugs , R. Murray and others, eds. (London, Gaskell, Special Publication 1,. 1981), pp. 49 - 53.005
M. Lader, "Benzodiazepine dependence", in The Misuse of Psychotropic Drugs , R. Murray and others, eds. (London, Gaskell, Special Publication 1, 1981), pp. 13 - 16.006
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A. W. Clare and P. Williams, "Factors leading to psychotropic drug prescription", in The Misuse of Psychotropic Drugs , R.Murray and others, eds. (London, Gaskell, Special Publication 1, 1981), pp. 83 - 88.009
World Health Organization, Fifth Review of Psychoactive Substances for International Control, Geneva, 16 - 20 November 1981. Geneva, 1981, pp. 1 - 24 (MNH/81.37).010
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