Prescription drugs – The Opium of the People?

Publication of the statistics on General Pharmaceutical Services in N. Ireland is not I suspect a much-anticipated annual event and this might go some way to explain the lack of media attention when the report was released last week except for a brief overview in the Irish News. The report provides the facts and figures on the medicines we used, misused and abused last year and, for me at least, it makes for interesting if not depressing reading. It would be better if I could confidently say that the £444 million our Health Service spent on the 43.1 million prescriptions dispensed in 2019/2020 represented value for money. The data suggests this might not be the case. I must firstly state that medicines are an extremely important aspect of modern healthcare and there is compelling evidence of the benefit to society from the availability of a range of safe and effective medicines. The role of pharmacy, my profession, if anything, must be to support the proper use of medicines meaning; the right medicine for the right medical condition to achieve the right outcome and, most importantly, to improve the patient’s quality of life. This is the ideal but for much of my professional work, the real world proves less than ideal. There is an extensive, and poorly studied, cultural aspect to medicine taking that complicates this ideal.

In the last fiscal year, we spent £229.83 per head of population on medicines where the devolved Health Services of; Wales, Scotland and England spent much less. England spent £161.29 per head of population and Scotland, £182.43. Given that England has less social deprivation, Scotland might be a better comparator for N. Ireland but I still struggle to find much evidence that the £50 per person more we spent compared to Scotland delivered any additional health and well-being for our population. This additional £85 million I would suggest would be better invested in, for example, community pharmacy services to improve medicine use and perhaps community development services to support the significant social challenges and poorer health outcomes for those in the lowest socio-economic group. In the absence of proper support, this group consumes a higher proportion of medicines.

For too many years the Health Service has been starkly aware of the discrepancy between our medicine costs compared with other UK regions. Huge efforts have been made to reduce inappropriate medicine use and whereas improvements were made this report seems to suggest we are slipping backwards. Some 25% of the medicines dispensed last year were classified as central nervous system medicines; a very broad category including; depression, anxiety, movement disorders, pain and much more. We use much more antidepressant drugs than other UK regions and this use is most prevalent in areas of high social deprivation. I rather tire of the excuse that this is because of our “legacy of the Troubles”. That is much too lazy and politically expedient a conclusion. Social deprivation drives poorer health outcomes including poorer mental health and that’s why antidepressants are so widely prescribed but they certainly are not a long-term solution.

We also seem to be in an epidemic of pain. A stand-out medicine in the report is co-codamol, a combination of paracetamol and codeine used for pain management and which also is highly addictive. It is this latter feature that might be the main driver for our excessive use of this medicine. Codeine is an opioid and in the body is converted to morphine which, at the higher doses of two 30 milligram tablets (60 milligrams), is equivalent to 10 milligrams of morphine sulphate; a Schedule 2 controlled drug. At the 60mg dose there is no doubt of an analgesic effect but this is only a moderate effect and only for acute condition. It is relatively ineffective in chronic pain control. There is surprisingly little evidence for the effectiveness of the lowest dose of the codeine/paracetamol combination compared to paracetamol alone. It is likely that the only additional benefits from two co-codamol 8/500 tablets compared to two paracetamol, is constipation and a fuzzy feeling. Ibuprofen alone, or in combination with paracetamol, is the most effective treatment for acute, mild to moderate pain.

Co-codamol stands out in the report as the only drug listed on two key tables. It is listed number three in the ten most frequently prescribed medicines with 1.25 million prescriptions last year. It is also listed in the top ten most expensive medicines with an annual spend of £44 million. As it is a relatively ineffective in the management of chronic pain with a strong potential for addiction, this report might be highlighting the emergence of a significant public health problem.

The lower dose version, co-codamol 8/500, is currently available over-the-counter (OTC) and is widely used, and this use is additional to the figures in the report. There are concerns about its use and it is likely that OTC supply will be blocked by the medicines regulator the Medicines and Healthcare Regulatory Authority (MHRA) within the next 12 to 18 months. Ironically the OTC version predates the current rigorous assessment of medicine safety and efficacy and it seems it only exists because of the legal requirement to keep the daily dose of codeine below the level that legally requires it to be a prescription only medicine.

Co-codamol is only one of a long-list of medicines that require more rational use so that they really help patients and improves public health rather than being, literally, the opium of the people.

Photo by stevepb is licensed under CC BY-NC-SA