It is a great pleasure to serve under your chairmanship this morning, Mr. Taylor. This is my valedictory address as chairman of the all-party group on drugs misuse. I hope to hand over the group’s chairmanship this very afternoon, after serving in that capacity for 10 years. I am sure that I will leave it in good hands.
I am introducing this debate on addiction to and physical dependence on prescription and over-the-counter medicines in the hope that the Government will take the issue on board when they make policies in future. It is now recognised by many that the war on drugs has caused displacement—substance displacement, geographical displacement and even policy displacement. The press kit for the United Nations 2006 International Narcotics Control Board annual report states, at page 11:
“The abuse and trafficking of prescription drugs is set to exceed illicit drug abuse, warned the International Narcotics Board in its Annual Report released today”.
That was on 1 March 2007. The passage continues:
“The Board added that medication containing narcotic drugs and/or psychotropic substances is even a drug of first choice in many cases, and not abused as a substitute. Such prescription drugs have effects similar to illicit drugs when taken in inappropriate quantities and without medical supervision. The ‘high’ they provide is comparable to practically every illicitly manufactured drug.”
Why should a person risk a fine or prison sentence when perfectly legal substances can give them a buzz equal to that obtained from street drugs such as heroin, cocaine and crack cocaine? As we increase the penalties for those who use controlled drugs, as we have done, again, for cannabis users, or increase the number of classified substances—perhaps it will be khat or other legal highs next—people will seek alternatives to give them a buzz. Stronger enforcement merely leads to what I and others term substance displacement.
Concerns have been rising in recent years about the number of people who have become physically dependent on or addicted to legal substances, even overdosing on them, which has sometimes resulted in tragic deaths. The high-profile death of the famous Heath Ledger was only one example of very many. Soon after my election to Parliament in 1997 I came across a former policeman from Dumfriesshire, called David Grieve, who had been addicted to cough mixture containing codeine. He had been drinking litres of it every day. As a result he lost his job in the police force, and he started a charity, called Over-Count, which he still runs today, to give online advice to those who have become addicted to over-the-counter medications. Young Americans who are keen to avoid the risks associated with taking controlled, or street, drugs, have been pharming for several years now, which means that they have been taking cocktails of prescription and over-the-counter medicines to get their high.
The all-party group on drugs misuse decided to launch an inquiry in the 2007-08 parliamentary Session into physical dependence on and addiction to prescription and over-the-counter medication. We published our report in January and it has attracted a lot of media attention. During our research we came across two other reports, one published in the state of Victoria, in Australia, and another in Scotland, whose findings are very similar to ours. Our inquiry was carried out along the lines of a parliamentary Select Committee inquiry. We issued a call for evidence, using a press release, and then on the basis of the more than 100 pieces of written evidence that we received we invited two groups of witnesses to give oral evidence. One group represented organisations such as the royal colleges, trade associations and regulators, such as the Medicines and Healthcare products Regulatory Agency, as well as the pharmaceutical companies, of course. The other group was of patients who had been affected, or organisations representing them. My researcher, Gemma Reay, organised the inquiry and wrote the final report, which can be accessed through a link from my website at www.brianiddon.org.uk, or through the DrugScope website.
The evidence that we received suggests that there are two main groups of legal substances that are causing significant problems: the benzodiazepine tranquillisers and their successor drugs, the so-called zed drugs, and products containing codeine. Nevertheless, we recognise that millions of people have benefited worldwide from the use of those drugs.
Will my hon. Friend say more about benzodiazepines? Is there a further case for getting more statistical information about addiction levels, across PCTs? Is that a possible role for Government? Also, does my hon. Friend recognise that where there have been specialist clinics those have made quite a difference in dealing with addiction?
I shall say more about benzodiazepines in a moment, but yes: I cite the clinic run in Oldham by the well known Barry Haslam—or rather it is not run by him, as it is run by the PCT, but he was instrumental in persuading it to set up the clinic. It is a very useful one, doing excellent work for benzodiazepine addicts.
Benzodiazepines, of course, are class C drugs under the Misuse of Drugs Act 1971. They are popularly known as “benzos” and are used as downers by those who use stimulant street drugs or uppers such as cocaine and crack cocaine. Evidence available from the NHS suggests that there about 200,000 illicit users of benzodiazepines in the UK. The drugs are being smuggled into the UK now in considerable quantities. The ready availability of drugs on the largely unregulated internet has exacerbated drug abuse problems, in my opinion. The Royal Pharmaceutical Society of Great Britain has estimated that about 2 million Britons now get access to medicines through online pharmacies. The Society has devised a logo scheme for online pharmacies that follow its code of conduct for use. However, there are lots of websites on the internet that allow the purchase of prescription medicines without a prescription.
Does the hon. Gentleman think that there is a role for Government in restricting the quantity that can be supplied? For instance, in the press pack provided by the Library the example is given of 60 Solpadeine Plus tablets being made available for a low price from a pharmacy website, with “fast and discreet delivery”. Is the hon. Gentleman concerned about that, and does he think that perhaps the quantity should be controlled?
I do, and shall refer to that issue later, but of course the internet is a very difficult animal to control. We rely on international agreements. We can regulate it domestically, but not as well as we should want to internationally, at the moment.
At least 10 per cent. of the drugs sold on the internet are counterfeit, which adds to the complexity of the problem. An article from the university of Edinburgh published in the British Journal of Clinical Pharmacology reported the discovery of 35 websites from which prescription-only pain relief medicines, some containing codeine, could be purchased without a prescription. The all-party group came across the case of a Welsh woman who had died of an overdose caused by self-medication using medicines available online. Other legal drugs, such as laxatives and antihistamines, are also misused, but we received no individual accounts of misuse of those medicines during our inquiry.
The benzodiazepine class of drugs—Valium and Librium came first—was introduced in the 1960s, and was welcomed by clinicians as a way to treat anxiety and insomnia, in place of the much more toxic barbiturate drugs that had resulted in far too many overdose deaths. At first they were seen to be quite safe, and their addictive properties were overlooked for a number of years. By the 1970s, benzodiazepines were the most widely prescribed of all prescription medicines. They are still widely prescribed: 11.7 million prescriptions were issued for them in 2007. However, many who have tried to stop taking them have experienced severe withdrawal symptoms as a result of their involuntary addiction. I remember Esther Rantzen and her “That’s Life” team highlighting these problems in the early 1980s, and a book was published in 1984 as a result of her campaign. I note that the authors are Ron Lacey and a certain Shaun Woodward—someone who has gone on to other things.
In 1988, the Committee on Safety of Medicines issued clinical guidelines, recommending that the drugs should not be used for more than four weeks at a time and that patients on those drugs should be closely monitored. Sadly, many of our general practitioners have ignored that advice and, as a result, an estimated 1.5 million to 2 million of our citizens are now addicted to the drugs. The all-party group came across patients who have been prescribed benzodiazepines for more than 30 years. Evidence suggests that repeat prescriptions being handed out without the doctors monitoring their patients is a common cause of such involuntary addiction.
There is a bit of that, but if a GP knows the patient well, he should be able to diagnose the problem. The trouble is that many patients who are refused the drugs by the doctor will revert to the internet for supplies. One cannot blame the GPs for that.
Just as ceasing to use controlled drugs such as heroin and cocaine results in severe withdrawal symptoms, the same symptoms will be felt by patients who cease to take benzodiazepines if they have become dependent on them. Professor Heather Ashton of Newcastle university has developed a withdrawal protocol for such patients. Many of them have struggled to cease their dependence on benzodiazepines for many years, often without knowing about the withdrawal protocol. Patients are commonly incapacitated through their dependence on or addiction to benzodiazepines, or through their self-withdrawal from these medicines. Some are left with long-term health problems, even after withdrawal. Many would say that their lives have been wrecked as a result of being introduced to these drugs.
Many patients, who have not been supported by their doctors and who have become addicted to benzodiazepines, have turned to voluntary organisations for help. I praise the work of groups such as Benzodiazepines: Co-operation not Confrontation, Battle Against Tranquillisers and CITA—the Council for Information on Tranquillisers and Antidepressants. They have worked extremely hard over many years to support benzodiazepine addicts.
It is more difficult to estimate the number of people addicted to over-the-counter products containing codeine, but estimates suggest that the figure is at least 20,000 or 30,000 and that it may be as high as 150,000 or 200,000. The products that cause the most problems contain higher than usual doses of codeine, at 12.5 mg per tablet, and usually the codeine is admixed with another drug, such as ibuprofen or paracetamol. The most common of these products are household brand names.
Is it not a paradox that the manufacturers of brand names such as Solpadiene and Nurofen Plus should be criticised for pushing the analgesic uses of their drugs and for giving insufficient information about the down-side, the risks? They are criticised for not telling us of the alternative and more recreational uses of their drugs, but if they were to warn people they would draw attention to them. That might put ideas into immature heads, which could increase addiction and the abuse of those drugs. Is that a factor, or do people know about it anyway and I am simply being naive?
It is a factor, and I shall comment on what the hon. Gentleman said later in my speech.
Codeine is more abundant in the latex obtained from the poppy papaver somniferum than from its most desirable constituent, morphine, which is turned into heroin using acetic anhydride. The all-party group received evidence to suggest that those addicted to codeine-containing products are taking between 30 and, amazingly, as many as 70 tablets every day. One woman who gave evidence to our inquiry described how the 48 to 60 tablets she was taking every day gave her a “lift” and “helped her along”, and a male respondent told us how much he enjoyed the feeling of “calmness, happiness and control” that his 32 tablets brought him.
Unless the codeine is separated from co-medications such as ibuprofen, those dose levels can cause medical complications such as serious internal bleeding, which often results in death. The codeine can be easily separated from the co-medication, and the methods to achieve this separation can be obtained from the chatrooms regularly used by young people.
The stereotypical addict of codeine-containing products is a middle-aged female. However, more and more people are becoming addicted to them as a result of treating of chronic pain by using codeine-containing drugs and in the absence of an adequate pain management strategy by local clinicians. It would seem that a significant number of codeine addicts also have a co-morbid mental health problem. Some addicts also have a poly-drug problem, involving, for instance, alcohol or other prescription drugs.
Mark Edwards became addicted to codeine following complications arising from an operation that left him with chronic pain. If he had received help to manage his pain, he would probably not have become an addict. Following his experience, he established “codeinefree.me”, an online site to support those who have problems with over-the-counter medicines, especially those that contain codeine products.
People who regularly suffer headaches and who self-medicate with codeine-containing products may develop a symptom that has been termed medication overuse headache. When they are enabled to give up the products, the headaches disappear. The overuse of codeine, of course, desensitises the pain receptors, particularly those in the brain.
People who become addicted to over-the-counter medicines believe that the products that they are buying without prescription are safe and therefore that they cannot become addicted to them. Similarly, patients who receive prescriptions from their doctors believe that they will be protected from serious side-effects, and they too cannot believe that they might become addicted or at least physically dependent on a product prescribed by their GP.
With both tranquilliser and codeine addiction, we found that most GPs either do not recognise the problem that their patients have or are at a loss to know how to deal with them. The plain fact is that it is probably easier today for an illegal drug user to get a referral to a drug and alcohol action team—a DAAT—than it is for those having problems with legal drugs, other than alcohol, to get treatment for their condition.
Our report contains 24 recommendations. They include the adequate training of medical professionals; raising awareness of the problem; proper prescribing and the monitoring of patients; more research to establish the scale of the problem; and, most important, recognition of those patients with problems and the ability to refer them to an appropriate treatment centre.
It is vital that all who work in the health care field, especially nurses, doctors and pharmacists, receive training in substance misuse as well as good prescribing practice. We live in an era of a pill for every ill, yet many patients require only to be listened to and perhaps referred on; for example, to a cognitive behavioural therapist.
The pharmaceutical industry and the patient both have responsibilities, the former to make patients aware of potential problems such as physical dependence or addiction—for instance, in the patient information leaflet or PIL—and the latter to ensure that they read the PIL or listen to the advice given by their doctor or pharmacist. Trade organisations, such as the Association of the British Pharmaceutical Industry and the Proprietary Association of Great Britain, also have responsibilities to ensure that the products produced by their member companies are safe at the point of sale, as does the MHRA, which licenses and monitors the sale of medicines in the UK.
All those bodies should raise awareness of the dangers of buying products on the internet. The MHRA works with internet service providers to close down websites found to be operating illegally, but it has jurisdiction only in the UK. In the past five years, however, it has been successful in 18 prosecutions of operators of websites trading medicines illegally in the UK. Primary care trusts also have a responsibility to ensure that benzodiazepines and zed drugs are prescribed responsibly, that general practitioners who prescribe outside the guidelines justify that behaviour to them and that the patients affected are monitored adequately so that the problems described this morning do not develop.
Our all-party group believes that codeine-containing packs should contain no more than 18 tablets and that all sales should be accompanied by appropriate advice on the addictive potential of these medicines. In some countries, the advertising of codeine-containing products has been banned and, in others, such as the USA, they have been made prescription-only medicines—POMs. However, we would not wish to burden doctors any more than they are already, and, in any case, there is a move in this country towards self-medication, with a greater role for pharmacists in advising patients. I welcome that. A 2006 study conducted in Northern Ireland concluded that, on average, a pharmacist would see about two over-the-counter medicine misusers a week, but a 2001 study conducted in Scotland put the figure a little higher—at an average of five per pharmacy per week. So the problem is not unknown in pharmacy shops.
The National Treatment Agency was set up in 2000 and has been very successful in treating those referred to it who are addicted to controlled—or street—drugs. However, we believe that it is not geared up to treating those with the problems that I have been describing. The stigma associated with controlled drug addiction, and the shame associated with those who have become involuntarily addicted to prescription and over-the-counter medicines, means that such patients are hardly likely to volunteer for referral to the facilities provided by DAATs. In our report, therefore, we have recommended that the Department of Health provide centres for treatment within the NHS, but separate from those provided by DAATs. Throughout our report, we stress the importance of voluntary organisations in helping patients, but their resources have become extremely stretched in recent years. I plead with the Government to support them more.
Finally, it is important that the Department of Health commissions research to measure the extent of these problems and monitor future prescribing and sales of the problem medicines. I hope that my hon. Friend the Minister—I am glad that he is answering this debate—can persuade the Minister of State, Department of Health, my hon. Friend the Member for Lincoln (Gillian Merron) to meet me with a small delegation to discuss these problems in more depth and to seek a sensible way forward.
It is a pleasure to follow the hon. Member for Bolton, South-East (Dr. Iddon). His all-party group was the first that I joined when I entered this place; his leadership is exemplary and a fantastic example of how an all-party group should be run. It is one of the most proactive groups in this place. He has done a fantastic job and will be a great loss to this House.
I joined the group owing to personal involvement: my mother was an addict. When she was originally diagnosed with alcoholism, in the 1970s and 1980s, the answer was to prescribe medication, which is what the GP did. But he did not stop at one prescription. After five or six years, she ended up taking about seven or eight types of medication. She would not stop taking one type, but simply start taking an extra one. At that time—this remains a huge problem—there was very little understanding of the interaction between all those types of drugs. But the situation gets even worse than that. Although the situation with prescription drugs has improved over the past 10 to 15 years, there remains a problem with their interaction with things that can be bought in the supermarket. For instance, cough mixtures contain morphine and codeine, which simply fuel past addictions. However, in my experience, assistance with, and understanding of, full-blown addiction to over-the-counter drugs is very limited.
There are huge differences between an illness, a condition and an addiction, and the treatments for all three have their own peculiarities. However, each one is also inter-linked, and treating an addiction, like treating an illness or condition, can actually make it worse, so education on those three terms is extremely important. I recently attended a seminar, in this place, run by Mind and spoke to some of those present. Until then I had never thought about the difference between mental health and mental illness, but the issues involved are quite different. Over-the-counter drugs have a hugely detrimental effect on people with mental illnesses. It is easy to overdose on these drugs, whether through, for example, paracetamol, codeine in tablets or Nurofen. It is extremely easy to get into that position. The problem affects all age groups, and is not confined to the old, the young or the middle-aged. One of the huge tasks before us is on education, not just of individuals, but of service providers.
Hon. Members should try this for themselves: enter a supermarket and try to buy three or four bottles of cough mixture. It will sell them. Then go to a pharmacist and ask for the same. It will say, “You can’t have them.” There is a huge imbalance in the controls for pharmacists and off-the-shelf buys, and obviously that is exacerbated by the internet.
The hon. Gentleman raised another huge concern about the support services. During a recession, budgets are always cut, whether through local health boards, PCTs or borough councils, and I am worried that the fringe element—as it is seen—of support will be the first to be hit, despite being the very services that support people with addictions. For example, the Drug and Family Support Group, in my constituency, relies on donations and funding from borough councils. It is one of the few organisations in my borough that deals with such problems, and the consequences of losing that support will be dire.
Counselling services—we have heard about some today, but there are many others—need to be core funded. Too many support groups have to go cap in hand for funding. We also need to consider how people are signposted to services in our local communities and constituencies. Through GP services, they tend to be signposted to the first support group in the book, but there are so many groups helping so many different things. From personal experience, I know that it is very difficult to work through the minefield of support.
I urge the Minister and the Secretary of State to read the report, of which I had the privilege to be a part, and to consider its recommendations. They were made in the hope that we can improve the situation. The suffering of an addict spreads throughout their family; it affects not only the addict, but so many others within the family and the community. I fear that the problem is growing. People often turn to some form of medication during periods of recession, depression and anxiety, and before they know it, their drug taking can spin out of control.
It is a pleasure to take part in this debate. I urge everyone to read this excellent report—I was part of it, so I would say that, would I not?—and I hope that its recommendations will be taken forward.
I congratulate my hon. Friend the Member for Bolton, South-East (Dr. Iddon) on his years of service on the all-party group on drug misuse. He will be sadly missed when he leaves. He has brought to that group a scientific rigour from his professional background that has been a continual challenge to the evidence-free policies on drugs, including medicinal drugs, by a succession of Governments.
I had a striking contribution yesterday from someone whom we will call “John” who illustrated vividly how society has been conditioned to believe that there is a pill for every ill. His 11-year-old daughter was asked in school to make a list of 10 medicines that she had taken, or that she knew about. Coming from a family who do not use medicines for ordinary complaints—they allow the ordinary diseases of life to take their course—she could only manage to write down one medicine while the rest of the class had no difficulty in writing down 10 that they had taken themselves. The school was so alarmed by that that it contacted my correspondent and asked him whether he belonged to a particular religious sect and whether he wanted his daughter withdrawn from the class because he might have objections to drugs. A parent who takes a purely rational approach to drugs, to the great health of their children, is treated as someone who is so exceptional that they have to be asked whether their children should be taken out of the class.
However, such drug taking is not a new phenomenon. If any of us had gone to see Dr. Freud in Vienna, he would have prescribed for us the drug that he took himself. He gave it to all of his family and every one of his patients in the belief that it was greatly beneficial and harmless. That drug was cocaine. A generation later, the drug of use for what we would now call depression or mild exam sickness was bromide, which created its own psychosis.
Going on from that, in the ’50s and ’60s, we had the dibenzodiazepines. Following that came the tricyclics and then the selective serotonin reuptake inhibitors, or SSRIs. When those drugs were introduced, they were all said to be beneficial, which they rarely were, and it was said that they would not create dependency, which they did. In fact, they all did a great amount of harm, so it is not something that is just happening now. None the less, the examples quoted are striking and important. The pharmaceutical industry has done a great deal of good. In many ways, it has produced miracles of science. On BBC 2 tomorrow night at 9 o’clock there is a programme called “The Price of Life”, which I recommend everyone to watch. It looks at the way in which medicinal substances are marketed, created and sold. Behind the many good things that are done is a greedy, self-absorbed market that puts its profits as its highest goal.
We must look at the way in which lives have been damaged by our belief that for every moment of boredom, distress, grief, pain or discomfort, there is an answer in a pill; it is not true. I should like to talk at great length about the problems of pain. Pain is a construct, and the least successful way of dealing with it is to take a pill. There are much more sophisticated ways in which to deal with pain. I constantly say that if Beethoven had been on painkillers or Michelangelo had been on antidepressants, we would never have heard of them. Such pills are the antidote to the creative process. There are other ways in life in which we can deal with the affliction of pain. Often, the least successful and most dangerous way to do it is through using drugs that are vastly overused to the detriment of the happiness and health of millions of people.
I commend the all-party report. I had the great privilege of being invited to chair one of the group’s evidence sessions. I learned a great deal from it. I saw how people had had their lives deeply affected by the overuse and misuse of medicinal drugs. On the evidence of this report, I hope that my hon. Friend will hear that there will be a meeting with Ministers and that there can be a major advance in the way in which we dispense drugs.
It is a pleasure to serve under your chairmanship, Mr. Taylor. Like previous speakers, I pay tribute to the hon. Member for Bolton, South-East (Dr. Iddon) and thank him for providing leadership on this issue. Moreover, I echo the comments made by the hon. Member for Blaenau Gwent (Mr. Davies) when he said that this debate shows how powerful all-party parliamentary groups can be when they do their job and provide leadership on an issue. In this case, the issue was not getting sufficient public attention or leadership. I should like the hon. Member for Bolton, South-East to pass on our thanks to the whole group.
Rightly, successive Governments have spent a lot of time, energy and money dealing with the problems associated with illegal drugs. I am sure that we all support that effort. There have been different ways of approaching the problem, but the thrust has always been to deal with the social and personal impact of illegal drugs. None the less, we must start by saying that such an approach has led to the more difficult problems associated with perfectly legal drugs—prescription-only drugs and over-the-counter medicines—not receiving the attention that has so rightly been brought into focus. However, we must strike a balance between dealing with the problems associated with those drugs and allowing people to continue to benefit from their appropriate use. The all-party report provides some practical suggestions on how the issue can be taken forward.
I also want to draw attention to the all-party parliamentary group on involuntary tranquilliser addiction, of which I am a member. It focuses on a specific part of the problem. Today, the hon. Members for Blaenau Gwent and for Newport, West (Paul Flynn) described very powerfully their personal involvement in the issue. Although I have had no personal involvement in such matters, I have had to deal with a number of constituent cases, including that of Simon Kaberry, whose father, Sir Donald Kaberry, was MP for the constituency of Leeds North-West for 33 years. Whether or not I can match that length of service, we will have to see, but it has been a pleasure to work with Simon and to hear about his problems. His prescription of daytime tranquillisers, in place of sleeping pills back in the early 1990s, has ruined his life. He was defrauded of a significant amount of money, and was granted legal aid to sue those who were responsible for his negligent prescriptions. That case is still going on. That is a high-profile and extreme case, but, as we have heard, the cases of addiction are all too common. We do not know exactly how many people are addicted to prescription-only medicines let alone those who are addicted to over-the-counter medicines. Could more work be done to establish that figure? Difficult though that would be, it is important to understand the scale of the problem.
There are guidelines on prescription-only tranquillisers, including of benzodiazepines, which have already been mentioned, but are they working? We know that such tranquillisers are widely abused drugs. Wasted medication, over-prescription and mis-prescribing, as in the case of Mr. Kaberry, are potential explanations for the availability of drugs. It has been estimated that prescribing medication that is wasted costs £100 million a year, which must be a concern. Where have the substances that we are talking about today gone, and into whose hands have they been put?
As the hon. Member for Bolton, South-East said, an estimated 1.5 million people are addicted to benzodiazepine drugs and 2 million people were addicted to a broader group of drugs. He also said that some drug users are using prescription tranquillisers as part of a regular drug routine. However, other people are stuck in a cycle, having been properly prescribed drugs—at least they believe that they have been properly prescribed them. Again, people access the drugs for different reasons, which is another factor that makes the situation difficult to deal with.
The Royal Pharmaceutical Society of Great Britain has expressed concerns that there is currently no referral system specifically for misusers of prescription-only and over-the-counter medicines, yet pharmacists have an important job in signposting people to other health professionals and organisations as appropriate. Will the Minister consider action that would assist and educate pharmacists in that regard? Does he have any plans to regulate pharmacy technicians through legislation? That could also have a part to play. What training is given to pharmacists to provide them with more information on dealing with abuse of prescription-only and over-the-counter medicines, including information on identifying the signs, as we have heard that pharmacists play an important role in that area?
Another problem is that drugs are widely available in supermarkets. That will clearly be more difficult to target, but could the kind of restrictions that registered pharmacists rightly operate be at least put in place for supermarkets to ensure that people do not have easy access to inappropriate quantities of drugs that are likely to be indicators of abuse?
As with so many areas of public policy, the internet presents a difficult challenge. One problem is that by trading on the internet or in supermarkets, we lose the link that has traditionally existed between the community and the pharmacy. Pharmacy staff might have a good and close relationship with other organisations, including the doctors who prescribe the medicines and, when necessary, the local police, but supermarkets and the internet do not. It is much more difficult to monitor the patterns of purchase that suggest misuse in supermarkets and on the internet than in pharmacies.
No one is suggesting that we can turn the clock back and that drugs should not be available on the internet, but we need to review access to over-the-counter medicines on the internet. Does the Minister see any way of applying the control of entry requirements for pharmacies to online mail-order pharmacies? I do not know the answer to that question, and I suspect the Minister does not, but it might be worth considering the matter. The Royal Pharmaceutical Society has suggested that its logo could be used to identify bona fide pharmacies, whether they are existing chemists, as we call them, or supermarkets or online facilities. That could help. If the Minister thought that that was appropriate, there would need to be guidelines and a system for monitoring the logo and, especially, a system for clamping down on anyone who used the logo fraudulently. That would have to be traceable.
The debate on such drugs should now change. The practical solutions that the all-party group on drugs misuse have suggested could and should be looked at as a framework. The Government should consider the solutions—they do not have to accept all of them—and introduce measures to tackle this difficult issue. It would also make sense to look at labelling and further education so that people can become more aware of the dangers. As has been shown, many are not aware of those dangers. As the hon. Member for Newport, West said, there must be more education within and outside the medical profession about other treatments and therapies, particularly for pain. I am glad that the Government have been moving in that direction. Bringing the subject under discussion into that debate could be extremely helpful.
As with many questions on this matter, we do not know the answer—it is important to say that—but we clearly agree that the solutions must be research based. On labelling, we must be mindful of the danger that the hon. Gentleman described, but we could deal with that problem by talking about the dangers in an appropriate way.
This is an important debate. I thank the hon. Member for Bolton, South-East for introducing it and the all-party group for its report. I would like to think that we will come back, perhaps in a year, to see how much of the report the Government have taken up. I hope that the matter will be taken very seriously by the Minister and that we see progress on this difficult but very important issue.
I am pleased to be under your guidance again this morning, Mr. Taylor.
I join other hon. Members in congratulating the hon. Member for Bolton, South-East (Dr. Iddon) on the comprehensive and detailed way in which he set out the contents of his report this morning and on the enormous amount of work that he and his colleagues have done to collate all the evidence that they took in an easily understandable way. His introduction clearly highlighted some of the key issues. He described the scale of the problem, even though further research is needed to get a more accurate handle on the numbers. He also mentioned substance displacement, as well as an issue referred to by the hon. Member for Leeds, North-West (Greg Mulholland)—internet regulation and the complex problem of regulating online pharmacies—and called for greater acknowledgement that further research is required on a range of issues.
The hon. Member for Blaenau Gwent (Mr. Davies) made an interesting contribution that highlighted his own and his family’s personal experience of the problem. He was right to raise the issue of mental health, to which I will return, and pointed out rightly that drug misuse can affect people of all ages, although one interesting fact in the report is that the majority of misusers are female. I could not find any detailed analysis of why that is, so perhaps the solutions need to address the core of the problem. The issue certainly requires further investigation and research.
I am grateful for that intervention. I am sure that that is a contributory factor. It is in stark contrast to the recent report demonstrating that men are much more likely than women to die of cancer. There are interesting divergences across many of the illnesses and problems from which people in the UK suffer.
The hon. Member for Blaenau Gwent made a good point about supportive services in his constituency. I can assure him—not that it is any consolation—that in my constituency in rural Lincolnshire, we have exactly the same problem with funding streams coming to an end, normally after three years, and councils being squeezed for money to spend. There are issues across Wales and England with regard to support services.
It is clear that misuse has an impact not only on the lives of those who suffer but on the lives of their carers or wider family and community supporters. I suspect that that impact will be exacerbated by the current recession. The hon. Member for Newport, West (Paul Flynn) was right to point out that the problem is not a new one but has a long history, and to point out the impact of pain and pain relief. I am sure that he would be the first to acknowledge that one of the main factors that seems to lead to misuse is a lack of pain management, as the report highlighted. There are clearly two sides to the issue.
There has been a great deal of debate, research and Government policy thinking on the misuse of illegal substances, but the report rightly highlights that to date, there has been no significant focus on the misuse of legal substances. Clearly both the current and—hopefully—the future Government will need to consider it more closely. There is evidence to suggest that prescription drugs are often used in conjunction with illegal substances. The two are not mutually exclusive, which makes research even more complex than it might seem at first. It might increase the effectiveness of the overall war against drugs if the misuse of some prescription and over-the-counter medicines were considered alongside the misuse of illegal drugs and, indeed, the combination not just of illegal and legal drugs, but of legal drugs and alcohol, which is another legal drug.
It is a challenging topic, and the report went into exactly the right amount of detail, highlighting analysis of the problems while including the personal experiences of some of the people to whom the all-party group talked. Some people might dismiss the problem as superficial, but it is clearly not. It is serious when it leads to loss of life and suicide, which are mentioned in the report.
The hon. Gentleman might have seen in the pack kindly provided to us by the Library that in 2005 some 8,500 deaths resulted from the use of OxyContin, as we call it in this country, in the United States alone. That number exceeds the combined number of deaths from cocaine and heroin use that year in the United States. That is how serious the problem is becoming across the pond, and it is drifting across to this country as well.
I am grateful for that intervention. The hon. Gentleman is absolutely right to highlight that; I did see that figure. One suggestion made in the report deserves further consideration: many coroners are saying that when suicides occur, any prescription drug that the individual was taking should be noted and investigated further.
[Mr. David Wilshire in the Chair]
In many cases of addiction to prescription medicines, the GP is aware of the situation. As the hon. Member for Bolton, South-East said in response to my intervention, GPs know their patients best, but GPs often do not feel suitably qualified to assist patients in reducing their dependence. More must be done to make GPs aware of the possibility of addiction and help them to deal with patient dependence. Part of that could involve ensuring that GPs are aware of the British national guidelines on the optimum length of prescriptions for medicines. They must also be suitably trained to prescribe alternative treatments, such as talking therapies—I will have some questions about that for the Minister in a moment—without being hindered by excessive waiting times or limited access, as currently happens too often.
I am sorry to interrupt the hon. Gentleman’s interesting speech, but I am greatly encouraged by the idea that he might have a leading role in a future Government. We know that all parties act against illegal drugs, because no one who has a vested interest in defending them can do so publicly, but if a future Government were to campaign to reduce the use and abuse of legal medicines, they would meet ferocious opposition from the pharmaceutical industry, which would denounce the Government for keeping medicines away from the public. If his party were in government, would it be courageous enough to take on the pharmaceutical companies?
I do not see that as the issue. The issue is ensuring that over-the-counter and prescription medicines are used responsibly. Most patients in this country use access to medicines responsibly to better their lives, but we are discussing misuse. Any responsible Government should focus on misuse, which is not necessarily the same thing as attacking the pharmaceutical industry, as the hon. Gentleman suggests. The pharmaceutical industry plays a significant role in alleviating the pain and suffering of many people in this country. It is misuse that we need to focus on, not the market as a whole.
One way to do so—I know that the Government have started to think about it, and we are certainly keen to find ways to facilitate it—is to ensure that GPs and pharmacists work together more closely for the betterment of patients in their respective communities. In the Prime Minister’s constituency in Scotland, I went to a GP’s surgery with an embedded pharmacist. She holds her own surgeries, where people come to discuss what prescription medicines they are on and GPs come to her for advice. That is something that we need to consider. Some primary care trusts are reducing the number of prescriptions for medicines that could be classed as addictive. I would certainly like to see examples of best practice replicated more widely across the country. As hon. Members have said, it is difficult to get a handle on the number of people who are affected by misuse, particularly as many become dependent on painkillers after inadequate pain management strategies for existing conditions. That deserves greater focus.
Pharmacists could play a greater role in treating minor ailments and illnesses so that GPs’ time is freed up to deal with more serious cases. We support an increase in the use of medicines use reviews, which can be early indicators of unhealthy or over-extensive patterns of prescription medicine use. They also provide a good opportunity for pharmacists to discuss a patient’s use of over-the-counter medicines. As the report stated, the issue of unsupervised repeat prescriptions should be considered. Pharmacists could play a greater role in disseminating to patients information about public health, the dangers of taking too many over-the-counter or prescription drugs that might have an addictive quality, and access to local drug and alcohol teams and talking therapies.
We are concerned about the high concurrence of drug dependency and mental health problems and believe that more must be done to tackle underlying mental health problems. There should be greater focus on the provision of mental health services. We supported the roll-out of crisis resolution teams, early intervention and assertive outreach. In what has been an apolitical debate, I am sorry to say that mental health services still do not get the priority that the depth of suffering demands on many issues, including resources, waiting times, quality assurance mechanisms and health outcomes. When there is a concurrence of drug dependency and mental health, it must be addressed.
We support more use of talking therapies and cognitive behavioural therapies, rather than the prescription of medicines for mental illnesses. However, people can wait for up to two years for those treatments. I understand that 86 per cent. of people with schizophrenia do not receive such treatments. The Minister will recall that in October 2007, the then Secretary of State announced a £170 million pledge for talking therapies. Has all that money been spent, and if so, how? How many of the additional 3,600 therapists have been recruited? In 2004, the Government announced that they would locate employment advisers in GP surgeries to assist people in tackling their mental illnesses and returning to the workplace. How many have been appointed? When does he expect the national outcomes measurement project, which will result in standardised outcome measures for mental health, to be fully operational?
Do the Minister and his civil servants agree with the report’s recommendation that further research should be undertaken into the scale of the problem of prescription and over-the-counter drug misuse, and into the long-term impacts of such addiction? If so, when will the research funding allocation be made and when does he envisage the research being completed?
I shall reiterate some points made by other hon. Members. On pack sizes, the British Medical Journal has reported that fewer people have been admitted with, or have died from, paracetamol poisoning since the pack size was reduced. How far has the Medicines and Healthcare products Regulatory Agency got in considering a reduction in pack sizes for medicines that contain codeine?
What stage have the Government reached in their consultation on the point of sale of medicines? The Minister will recall that the pharmacy White Paper proposed changes to the sale point of medicines to correct the anomaly that makes it possible to buy paracetamol at a petrol station, but not at a GP surgery. Has that consultation been completed? If so, what decisions have been taken about increasing access to over-the-counter medicines and when were they taken? The hon. Member for Leeds, North-West rightly said that pharmacists should receive additional information to enable them to look for and recognise the symptoms displayed by people who misuse prescription or over-the-counter medicines.
Will the Minister confirm what progress has been made on the barcoding system that was mentioned in the excellent report? Has the pilot shown that barcoding reduces the availability of counterfeit products? Will that measure be rolled out more widely?
I will not reiterate the points that have been made on internet pharmacies. That issue is extremely complex, especially given the international element. It would be helpful if the Minister explained what progress the Department is making on that.
The Department should consider a few other areas that were highlighted in the report. First, it should look at research into depression. There is a clear link between depression and the misuse of prescription and over-the-counter medicines. Secondly, we should have more clinical trials in this country. Hon. Members will be aware of the reluctance of pharmaceutical companies to enter into clinical trials in this country for a variety of reasons. We must have a broader representation of such trials in this country. Thirdly, as I mentioned earlier, attention should be given to the fact that the majority of misusers are female.
The lack of a pain management strategy often leads to misuse. Clearly, there should be public education about the harm that can be caused by the misuse of the illicit drugs we are discussing and by mixing them with other illegal and legal drugs such as alcohol. That information and education must be accessible and understandable for those at whom it is targeted. Far too often, such information is inaccessible, particularly for those who are digitally excluded. We must find ways of taking information to people and patients, rather than waiting for them to access it.
As hon. Members have mentioned, the Government should also consider the potential benefits of alternative treatments. However, such provision must be relevant to the circumstances of each patient.
The report makes it clear that there should be greater focus on this issue. I hope that in the time they have remaining, the Government will provide that focus.
I congratulate my hon. Friend the Member for Bolton, South-East (Dr. Iddon) on securing this important debate. As hon. Members have said, he has taken a keen interest in this issue over many years, not least through the all-party parliamentary drugs misuse group, which he has chaired with great distinction over the last 10 years. I was unaware that he would be standing down from that role today. I put on record our thanks and congratulations to him on the excellent job he has done. He has been determined through his efforts to raise the profile of addiction to prescription and over-the-counter medicines. He will be a hard act to follow.
The hon. Member for Blaenau Gwent (Mr. Davies) spoke movingly of the impact his mother’s experiences had on his family and the wider community. My hon. Friend the Member for Newport, West (Paul Flynn) and the hon. Member for Leeds, North-West (Greg Mulholland) talked about constituents who have come to them with experiences of misuse and about how they have responded to them. The hon. Member for Leeds, North-West also highlighted the complexities and dilemmas in this difficult area of policy.
The hon. Member for Boston and Skegness (Mark Simmonds) has clearly read the pharmacy White Paper because he has been reading it back to me. I am pleased about that and was grateful to hear his suggestions. He will be glad to know that the White Paper is being implemented as we speak and that many of his thoughts about the role of pharmacies and pharmacists are part of Government policy.
For the Government, it is important to address all drug addiction, including addiction to prescription and over-the-counter medicines. We want to make it clear that tackling drug misuse of any kind is a Government priority, and we have made massive strides in reducing the harm that drug misuse can do to individuals and to society as a whole. We have made a substantial investment in drug treatment through the pooled drug treatment budget that has been allocated to primary care trusts on behalf of local drug partnerships. In the past 10 years, investment has increased from £142 million in 2001-02 to £406 million in this financial year. Of that sum, £24.7 million has been earmarked specifically to support treatments for young people.
We are committed to getting drug misusers off their drugs of addiction, and we are supporting drug users in working towards that goal. As we have heard today, drug addiction can be a long-term, chronic, relapsing condition that requires treatment over an extended period. Independent research shows that drug treatment is one of the most effective treatments in the NHS. For every £1 we spend on drug treatment, we make a saving of £9.50 for society as a whole. Some 83 per cent. of those treated in 2007-08 either completed treatment successfully or were still in treatment on 31 March 2008, so we are keeping 78 per cent. of people in treatment for at least 12 weeks because we know that staying in treatment for 12 weeks has a lasting and positive impact on reducing the harms associated with addiction and that it is a key measure of effective treatment.
In the three years from 2007 to 2010, we are investing £54.3 million of new funding, over and above the pooled drug treatment budget, to fund the expansion of in-patient detoxification and residential rehabilitation services to help drug users to beat their addiction. The hon. Member for Blaenau Gwent spoke of his worries about cuts to public spending affecting this area. As I have just described, the Government have invested considerable extra money in drug treatments and dealing with the causes and effects of addiction, and we will continue to make that investment. The hon. Member for Boston and Skegness said that he did not want to introduce a discordant party political note into the debate, but perhaps he should suggest to his hon. Friends on the Opposition Front Bench that his party’s pledge to cut public spending on health, education and other public services by 10 per cent. would have a devastating impact on the NHS services that we seek to deliver. I am pleased to tell the House that we have recently made available an additional capital sum of £11.8 million in the current year to enhance further the quality of drug treatment services.
The all-party group on drugs misuse has made several recommendations on issues such as training for medical professionals, awareness among prescribers about the potential for dependency and the need to monitor prescribing practices. Let me address the specific concerns that my hon. Friend the Member for Bolton, South-East has raised. We have a new national initiative to improve the training of all future doctors regarding substances of misuse. In 2007, my right hon. Friend the Member for Bristol, South (Dawn Primarolo), then the Minister for Public Health, launched the “Substance Misuse in the Undergraduate Medical Curriculum” guidance document for all medical schools. That innovative work was funded by the Department of Health and was produced with the agreement of all UK medical schools and all the key national bodies involved in undergraduate medical education. It describes the core substance misuse curriculum that has been agreed and that should be used for the comprehensive training of medical students, and it has now been published and widely distributed.
The project is now in its final phase of implementation, and further Department of Health funding is being made available to all the medical schools in England, over the next two years, to incorporate the curriculum into all the schools’ training programmes. As a result, on qualification, medical students should be able to demonstrate awareness of the range of substances that can be misused, including prescription and over-the-counter medicines, and should be able to describe the principles of good prescribing. The impact of that will be significant. Some 6,000 new doctors qualify each year, and it is estimated that the combination of undergraduate training and continuous professional development training will, over the next 10 years, ensure that approximately 60,000 doctors are better equipped to deliver competent practice in substance misuse.
The second area that my hon. Friend the Member for Bolton, South-East talked about was awareness. The Medicines and Healthcare products Regulatory Agency, which monitors the safety of all medicines in the UK, is working with over-the-counter trade associations on a package of measures to support the safe and effective use of codeine, and advice on that will be sought from the Commission on Human Medicines. In addition, strengthened patient information and warnings about the risks of addiction and overuse were introduced in 2005 for medicines containing codeine and dihydrocodeine. At the same time—for the benefit of the hon. Member for Boston and Skegness, who asked about this—a voluntary agreement was reached with manufacturers to restrict the size of over-the-counter packs to 32 tablets.
The MHRA, in association with its expert group on patient information, has reviewed patient information for the products that are most often subject to abuse or misuse, such as laxatives and sleeping aids, and has produced best practice advice on minimising the risk of abuse or misuse. The MHRA uses a variety of methods to collect information on the safety of prescription and over-the-counter medicines, and health care professionals and patients are encouraged to report suspected adverse drug reactions to it via the yellow card scheme. Also, there is a legal requirement on pharmaceutical companies to report reactions to their products. If action is needed to address safety concerns or problems of misuse and dependence, a number of regulatory options are available, such as withdrawing the product from the market or amending the labelling and patient information leaflet that accompanies a medicine to warn health care professionals and patients about such risks—a point was made about labelling earlier. Similarly, the legal status of medicines may be changed.
Is the Minister satisfied with the yellow card scheme? Only half a dozen adverse reactions to Vioxx were reported here, but the United States, which has a more rigorous way of measuring adverse reactions, decided that there had been 144,000 heart attacks and strokes as a result of using Vioxx, and it was therefore banned in this country and in America. Had we depended on the yellow card scheme, we would never have discovered the danger of that simple painkiller. Do we not need to improve the current system?
My hon. Friend raises an excellent point about comparisons between strategies that work in different countries. These matters are never quite comparable, but I shall certainly draw his concerns about the efficacy of the yellow card scheme to the attention of the Minister of State, Department of Health, my hon. Friend the Member for Lincoln (Gillian Merron), who has responsibilities for public health and this area of policy.
Several hon. Members have expressed concerns about the internet and how people obtain prescription drugs. We know that some people obtain benzodiazepines and other medicines through internet pharmacies, from abroad and by other illicit means. The MHRA continues to monitor internet activity and takes action against any identified breaches of legislation, where possible. The safety, quality and efficacy of medicines purchased via the internet cannot be guaranteed, and their effects on patients cannot be monitored, which is why we control tightly the supply of medicines and prescription-only medication in the UK. The MHRA has warned that online supplies of medicine may well pose risks to consumer health, and recommends that prescription-only and pharmacy-only medicines should be obtained through registered pharmacies.
Action is also being taken through designated internet days of action, which are organised and conducted on a number of dates during the year. They involve working alongside international regulators with the specific aim of taking down websites that act illegally. More such days of action are planned throughout 2009 and beyond.
On the question of prescribing and monitoring, we are using a number of mechanisms to promote and support high-quality, clinically effective prescribing and medicines management right across the NHS to ensure patient safety and to help improve patient care and service delivery. We have made sure that prescribers have access to a wide variety of impartial, trustworthy information resources to support their prescribing, including resources from the British National Formulary, National Prescribing Centre information and advice, and guidance from the independent National Institute for Health and Clinical Excellence. Such resources will assist prescribers in making clinically cost-effective prescribing decisions. A wealth of information is available through the National Library for Health and various academic and professional journals. NHS prescribers also have access to advice from the network of local drugs and therapeutics committees, and from PCT pharmaceutical advisers.
It is an obvious thing to state, but no medicine is 100 per cent. risk free. However, we expect individual prescribers to be aware of the potential for addiction and to ensure that medicines are prescribed appropriately depending on a patient’s individual needs. In exercising their professional and clinical judgement, prescribers should always consider the available guidance and the best practice that is shared within the prescribing community. At a more local level—this has been raised in the debate—pharmaceutical advisers, who are mainly pharmacists, are employed by strategic health authorities or primary care trusts with the common aim of encouraging and securing rational and cost-effective prescribing and providing a source of advice and support for prescribers in their area. There are now more than 1,200 advisers, many of whom conduct face-to-face reviews with GPs and carry out reviews of prescribing activity.
In this country, primary care trusts and their pharmaceutical advisers have very effective electronic information systems for prescribing in general practice. They routinely monitor detailed prescribing information and can easily identify unusual or excessive prescribing by individual doctors. Such a system further supports the monitoring of the quality and safety of prescribing and is another important factor that contributes to improving practice in this area. The General Medical Council has produced guidance for doctors to ensure that proper standards in the practice of medicine are maintained, including in relation to the prescribing of medicines. If the proper standards are not maintained, the General Medical Council has the power to remove a doctor’s right to practise medicine.
A fourth area mentioned by my hon. Friend the Member for Bolton, South-East was research. The 2008 drug strategy highlighted the importance of further research in the drugs field to boost our understanding of addiction and to identify opportunities for new forms of treatment or prevention. Since then, work has been under way to develop a cross-Government research programme on drugs. Our analysis in the Department of Health has revealed—I think that my hon. Friend pointed this out—the need for additional information about dependence on prescribed drugs and over-the-counter drugs.
I am pleased to have this opportunity to let the House know that, starting next month, resources have been identified in the Department to undertake a review of the information that we already have. That review will identify the key gaps in data and consider what additional work needs to be taken in hand, and it will take the points made in the report of my hon. Friend’s all-party group on drugs misuse very seriously; indeed, it will also take seriously the points made by him and other hon. Members today.
On treatment, in line with what my hon. Friend seeks, primary care trusts are responsible for deciding on the provision of treatment and services that reflect local needs and priorities, including in relation to tranquilliser addiction.
I also want to talk about the availability of other treatments in providing support for mental health problems. In response to the point made by the hon. Member for Boston and Skegness, I can tell the House that the Government are investing significantly in the Improving Access to Psychological Therapies programme—IAPT, as it is known—to widen the range of treatment available for people with common mental health problems. The hon. Gentleman was critical of the funding and the support that has been provided for mental health services. Let me tell him that mental health services have received a 44 per cent. increase in funding and only a few months ago—just before Christmas—the World Health Organisation commended highly the strategy for mental health services in England and said that it was one of the best in Europe.
I will not accept any criticism from the hon. Gentleman and his party about the work that we have been doing to support and invest in mental health services. IAPT offers a range of NICE-approved therapies, including guided self-help, counselling, cognitive behavioural therapy, behavioural activation and exercise. Annual funding is rising to £173 million in the third year—2010-11—to train 3,600 extra therapists and treat 900,000 more people in those three years. This Government are proud of that record of investment and progress, which will make a real difference to supporting people with mental health problems. Those services can be provided in primary care, secondary mental health services or secondary substance misuse services depending on need.
The current range of measures that I have described might, in part, explain the fall that we have seen in benzodiazepine prescribing over the last decade. I am grateful to my hon. Friend the Member for Bolton, South-East for noting that in the all-party group’s report. In terms of over-the-counter medicines abuse, it is likely that the range of measures and safeguards that we have established in the UK have contributed to our having fewer problems than other countries. I recognise that, considering the size of these problems, the evidence is limited and I assure my hon. Friend that I am not complacent about such an important issue. I will, of course, draw to the attention of the Minister of State, my hon. Friend the Member for Lincoln, my hon. Friend’s request for a meeting with him and other officers of the group to present the findings of the report. I am sure that she would be delighted to meet him—although it is a bit naughty of me to say so on her behalf because she is not here—to learn about and discuss these issues in more depth.
I hope that what I have highlighted today reassures my hon. Friend the Member for Bolton, South-East and, indeed, the whole House that, as a Government, we are determined to do all in our power to minimise drug dependency in all its forms. This debate has been very useful in highlighting these important matters, and I congratulate the all-party group and my hon. Friend on securing the debate and presenting the findings of the group’s report here today.