Prescribed Addiction: Scotland’s silent public health crisis
Scotland has limited specialist services for the increasing number of prescription medication misusers.
As a child, medication and drugs were two distinct things. Medication was the cure to all illnesses and ails. The sugary sweet liquid of cough syrup eased chesty colds. Pills, compacted in their press packets, mellowed a headache. Powdered hot drinks dulled a sore throat.
Drugs were bad. They were addictive. They were snorted, injected, or inhaled. Drugs conjured images of darkened alleyways, inner city squats and dirty needles, not to mention the vast array of damaging stereotypes our society has attached to the narcotic vices. These drugs were not clinical, and they certainly are not prescribed by a doctor.
This year, I watched as a member of my family quietly fell into the depth of prescription medication addiction. At first, the misuse was barely noticeable, and we were unaware just how quickly they were teetering on the edge of dependency, about to fall head-first into the abyss of addiction. I watched as medication consumed every inch of who they were, who they used to be, and who they would become. A bright demeanour and an acerbic wit gave way to slurred words and blurred eyes, and above all, a sense of hopelessness.
Unfortunately, their case is not an isolated one. Scotland is one of the largest misusers of prescription medication benzodiazepines and opioids. The National Drug-Related Death Database has consistently shown them to be the most prominent group of substances involved in drug related deaths in Scotland. Abuse and misuse levels are steep, yet the path to recovery is not always simple. Information is limited, options are scarce, and specialist services are few and far between. Professionals sometimes lack the fundamental knowledge required for this type of addiction.
Often those hooked to prescription medication do not fit the stereotype of what society considers a drug addict to be. Those addicted are often hidden behind their vice and generally function properly, without being susceptible to violence or crime. Priorities in the NHS consistently lie with those addicted to illicit drugs such as heroin, alcohol, or crack cocaine. Prescription medication addicts often slip like sand through the fingers of the NHS.
Diazepam, previously marketed as Valium, is one of the prevailing members of the benzodiazepine bundle. Diazepam misuse in Scotland last year came second only to heroin. A recent BBC documentary highlighted Scotland’s diazepam crisis as the country’s “silent killer”– three-quarters of drug-related deaths involve the drug. These unassuming little pills prescribed by doctors, bought on the street, or sourced on the dark web are used to combat the symptoms of anxiety, insomnia or pain. They are, however, only recommended for short term use. Longer term, they can result in addiction, mental illness and withdrawal symptoms that are both physically and mentally gruelling.
Samuel*, an inpatient who is currently receiving detox recovery ran by Tayside Substance Misuse Service (TSMS), found solace in a toxic cocktail of prescription medication during a particularly dark period of mental illness. He was taking exceedingly high dosages of diazepam, tramadol and alprazolam (more commonly known as Xanax) that he ordered from the dark web.
“I knew I was addicted to tramadol about four or five months after taking it, when I tried to stop taking it and I got withdrawal symptoms. At that point at the back of my mind I knew I was addicted but I had pushed it to the side.” he recalls.
At that point, Samuel went to his local GP, but was not given adequate treatment.
“I was offered no therapy. The doctor took it on herself to try get me off it which was a bad decision, instead of referring me to substance misuse. The doctor started reducing it, however she didn’t know what she was doing,” he says. “She was reducing it by one pill every week and it got down to a point where I just really struggling.
“I had hit a wall, and I felt like it wasn’t working,” he continues. “And that’s when I started taking diazepam and Xanax, and my tramadol usage soared.”
The training GPs receive to manage this form of addiction remains opaque, as some can attempt to taper an individual off medication as much as ten times too fast. The Family Doctor Association (FDA) surveyed 197 GPs and found 80 per cent had prescribed medication to patients who might be addicted. Patients are provided with treatment that is unjustifiably suited to their situation and needs, or are directed to outpatient clinics for detox. These clinics, funded by the NHS, are primarily prioritised and equipped to cater for heroin or crack cocaine addiction, and the process is coupled with lengthy waiting lists. The British Medical Association posits that those addicted to prescription medication generally feel out of place if referred to existing services.
“It’s unfair because they prioritise methadone addicts, heroin addicts and alcoholics. People like me, they don’t think it’s quite as serious. But it is. It can be very psychologically and physically addictive and when that happens it is hard to come off without any help.” Samuel explained.
For addiction to opioids such as tramadol, there are few specialist services. Often the common option is to switch patients to methadone, a substitute substance used for recovering heroin addicts. Samuel was offered this option, but was conscious that the treatment would hinder, not help his recovery.
“I was told to go on methadone, however I’m not a heroin addict,” he says. “I’m addicted to tramadol. They are completely different drugs and I do not think there are enough people who either specialise or are equipped to deal with this type of addiction.”
Luckily, after an uncertain period of pillar to post with various substance misuse services, Samuel found an experienced GP who created a personalised treatment plan for him.
“Instead of trying to get me off it without thinking about me, she instead began the process of gaining my trust,” he says. “She let me have some control on how I was reducing my usage. She gave me a lot of leeway and she knew that if she’d done what wasn’t best for me I would have lost her trust and would have given up.
“I’m very lucky that I’ve managed to find this option and find a doctor who has gotten to know me personally and has made a plan for me personally. That’s the important thing, as everyone is different,” he adds.
There are currently only a handful of addiction organisations and charities in Scotland that cater to prescription medication misuse. Some in remote areas of the country have had to close their doors due to lack of funding, such as the Community Alcohol and Drugs Services Shetland (CADSS), which saw a 68 per cent cut proposed for 2016/17.
Richard Lister, a development worker for charity CAIR Scotland, provides recovery services for drugs and alcohol addiction. The charity does not currently have a specialist service for prescription medication addicts, yet is seeing a surge of people with this addiction. He believes that a pick and mix of recovery options is needed.
“The things that we provide are vital to people’s recovery. In an ideal world we would have lots of different services providing lots of different opportunities,” he says. “No one thing is going to be the answer, so it would be nice for people to have a combination of services they could pick and choose. Not everyone is the same.”
Another issue is that public information on the matter is scarce. However, Lister believes that too much information could have the power to shock the public: “Information on drugs is usually not directed at addiction to prescription medication such as painkillers or codeine. There isn’t enough information and more would be useful.
“There would be pros and cons to providing more information as it would be based on how we provided the information so people didn’t panic,” he says. “Addiction to prescription medication is more hidden as people aren’t always aware they have an addiction. It’s a difficult area to track.”
To remedy the problem, services should be offered consistently across the country, targeting both recovery as well as prevention.
Dr Andrew Green, British Medical Association (BMA) GP clinical and prescribing policy lead, previously said: “There is the need for specialist services to be consistently available across the country, as patients are often referred to general drug and alcohol services, which do not have adequate resources, and whose skills are different to those needed to manage prescription drug dependence.
“This would ensure patients, carers and families have access to trusted and expert advice and support.”
Support initiatives such as The Road to Recovery, and FRANK, services aimed at preventing drug abuse, tend to focus on illicit drugs. While these initiatives can be effective, they struggle to address the growing popularity of the dark web, a hidden cyber haven for drug markets that only requires a computer to find. Once accessed, there is a vast, virtual pharmacy where the purchases are sent to your door in covert, unassuming packages. A UN report showed that one in six people who use drugs in Scotland order them from the dark web.
Although a glaring public crisis, it appears that adequate services are being called for, yet are not being implemented. The BMA is campaigning for a 24-hour dedicated specialist helpline, a service that could be vital for those struggling and unsure of where to turn. The BMA also called for health departments and local authorities to establish adequate specialist support services for prescribed drug dependence, as well as for clear guidance on tapering and withdrawal management. In addition, addiction experts are warning the public about counterfeit diazepam made in amateur laboratories. Cracking down on a plethora of fake blue pills, that often include botched and harmful chemicals, could save lives.
Lister says, “We absolutely need more services and information out there to deal with the growing number of people addicted to prescription medication.”
For my family, a strong loving base coupled with the motivation to get better and the perseverance to find the right service was the essential recipe for recovery, and the dark cloud of addiction is gradually lifting. From this, we learned that, above all, recovery should be focused on what is important for the individual. It requires a carefully selected combination of appropriate treatment at a local level. It is important for Scotland to break the silence on these issues in order to advance the conversation about how to deal with a hidden, yet very real public health crisis. Every addiction is different, yet everyone deserves the right to recover.
*name has been changed to protect identity.