Prescription medicine misuse and dependence

People use several overlapping terms. Misuse generally means taking a medicine other than as prescribed, for example taking more, taking it more often, taking someone else's supply or using it for the effect rather than the intended reason. Dependence means the body or mind has adapted so that stopping causes withdrawal or a strong urge to continue.

The NHS defines addiction as not having control over doing, taking or using something to the point where it could be harmful. It explains that being addicted means not having the substance causes withdrawal symptoms, or a come down, so it is easier to carry on, and that often more and more is needed to get the same effect.

Dependence can develop in people who have taken a medicine exactly as directed, which is why it should not be treated as a moral failing.

In 2017 the Public Health England review identified five classes for examination in adults: benzodiazepines, mostly for anxiety; z-drugs, sleeping tablets with similar effects; gabapentin and pregabalin (gabapentinoids) used for epilepsy, nerve pain and, for pregabalin, anxiety; opioids for chronic non-cancer pain; and antidepressants.

The review found that in 2017 to 2018 around 11.5 million adults in England, 26% of the adult population, were dispensed at least one of these medicines. It says benzodiazepines, z-drugs, opioid pain medicines and gabapentinoids are associated with dependence and withdrawal, and antidepressants with withdrawal. Most people take them for a short time, but a group continue long term.

The NHS pages on diazepam and codeine say that taking diazepam for longer can cause addiction and withdrawal, and that it is possible to become addicted to codeine. The NHS says to talk to your doctor if you are worried about addiction.

There is no single checklist, but patterns that suggest a problem include needing larger amounts for the same effect, running out early, thinking about the next dose much of the time, feeling unwell or anxious between doses, taking medicine for reasons other than the original one, hiding use, or continuing despite harm to health, work or relationships.

The NHS notes that a strain of managing an addiction can seriously damage work life and relationships, and that substance misuse can have serious psychological and physical effects. Other warning signs include sedation, confusion, falls, or using alcohol or other drugs with the medicine, which raises the risk of overdose.

Friends and family may notice mood changes, drowsiness or secrecy before the person does. Raising it kindly, and suggesting a GP visit, is usually better than confrontation.

The Public Health England review reports that higher initial opioid doses and prior mental health problems were associated with long-term opioid use and dependence respectively, and that prescribing opioid pain medicines for longer than 90 days was associated with overdose and dependence. Low income and use of shorter-acting benzodiazepines were associated with long-term benzodiazepine use.

The NHS says some studies suggest the risk of addiction is partly genetic, and that environmental factors, such as being around other people with addictions, are thought to raise risk. Stress, unemployment, poverty and emotional or professional pressure can also trigger addiction.

The NHS codeine page lists a history of addiction to alcohol, prescription medicines or recreational drugs as a reason the medicine may not be suitable, so tell your prescriber about any past difficulty.

The NHS says stopping diazepam suddenly can cause withdrawal symptoms, and says not to stop codeine suddenly because this can cause withdrawal symptoms such as feeling agitated or anxious. Tapering, meaning a gradual reduction agreed with a prescriber, is the usual way to reduce risk.

The Public Health England review heard from patients who reported harmful effects and withdrawal symptoms on stopping benzodiazepines, z-drugs, opioids and antidepressants, and that these symptoms could last many months. They also felt that doctors did not always recognise withdrawal, and that non-medicine options and reviews were lacking.

Severe symptoms such as seizures, confusion, hallucinations or thoughts of self-harm are emergencies. Call 999 or go to A&E.

The NHS says that if you need help for a drug problem you are entitled to treatment in the same way as anyone else who has a health problem. A GP may be a good place to start, and will usually refer you to the local drug service. If you are not comfortable talking to a GP, you can approach a local drug treatment service directly, and the Frank website lists services. Charities and the NHS provide most drug treatment, and private treatment must be paid for.

At a first appointment staff ask about drug use, work, family and housing, and may ask for a urine or saliva sample. The NHS says you will agree a treatment plan and be given a keyworker. Plans may include talking therapies such as CBT, substitute medicine for opioid dependence such as methadone or buprenorphine, detoxification to cope with withdrawal, and self-help groups such as Narcotics Anonymous or SMART Recovery.

Where intensive treatment is needed, it may be as an inpatient or in residential rehabilitation. Staff can also offer testing and treatment for hepatitis or HIV as part of reducing harm.

Take medicines exactly as directed, keep them in their original packaging, and do not share them. The NHS advises not to drink alcohol while taking diazepam because it increases the risk of side effects, and says it is best not to drink alcohol with codeine. Combining sedatives with alcohol, opioids or other sedating drugs raises the risk of dangerous breathing problems.

The Public Health England review warns that inappropriate limiting of medicines can increase harm, including the risk of suicide, and may lead some people to seek medicines from illicit or less-regulated sources such as online pharmacies. That is why it recommends shared decision-making, regular reviews and access to appropriate advice, and why people who want to stop must never be stigmatised.

Anyone who has taken too much, or whose breathing is slow or shallow, or who cannot be woken, needs an ambulance. Call 999 and stay with them.

If you are worried about someone, encourage them to see their GP, and offer to go with them. The NHS says you can also call Samaritans free on 116 123 to talk anonymously about any type of addiction. Family members can find local support groups for relatives through the drug service.

On the NHS, the pathway begins with the GP, who can review the medicine and arrange a supervised reduction or referral to a drug or pain service. People who choose private care for dependence should still keep the GP informed, since prescribing and monitoring need to be coordinated and sudden changes to supply can be risky. Services and availability vary by area.