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Network No 37 (October 2014)
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George Ryan discusses the pharmacological management of pain, identifying potential risks to the development of addiction to medicines and how to manage problems when they arise.
Martyn Hull takes us through the complex issues involved in benzodiazepine prescribing.
Steve Taylor gives an overview of policy issues regarding addiction to medicines and places primary care at the heart of identifying patients with problems and emphasises the importance of localism in providing strong care pathways for this group.
Misuse of pregabalin and gabapentin is a growing concern and we are pleased to provide a summary of an advice document prior to its imminent publication.
This powerful personal account describes the problems addiction to prescription medicines can cause and the great strength individuals have in overcoming dependency. It also highlights the important role of GPs in not only preventing but also supporting people to overcome addiction to medicines.
Misuse of over-the-counter medication is often a hidden problem that can create dilemmas for practitioners when identified. Kevin Ratcliffe describes the issues involved and suggests that there may be more skills and knowledge amongst professional than we might think.
Melanie Davis puts the case for specialist services for people with addiction to benzodiazepines and the importance of tailoring each intervention to an individual's needs.
Pauline Forrester provides an overview of a specialist primary care project to support people with problems with opioid pain medication.
Steve Brinksman is Dr Fixit to a GP who asks for support working with a patient who has developed a problem with over-the-counter medication.
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We are very please to bring you this this special edition of Network on addiction to medicines. We have been running a series of one-day training events on this topic which have seen great demand: each event has sold out. We feel that this is an area that is a growing problem, and we hope that this publication helps you to develop your skills and knowledge in the area. We will be running more ATM training in 2015, so look out for future dates. The Centre for Pharmacy Post Graduate Education also has an e-learning module which can help to develop knowledge and the Royal College of General Practitioners has some useful factsheets on AMT.
It is a busy time for SMMGP with the launch of the Advanced Certificate in Community Management of Alcohol Use Disorders. We are also holding our National Conference in Birmingham on 23rd October. If you don't manage to attend, check our website after the event for presentations.
Addiction to Medicines: Special Edition
We are pleased to publish this special edition of Network newsletter on addiction to medicines (ATM). ATM is gaining increasing attention both in the news and in national policy, and yet there remains a level of uncertainty within the field about how to tackle the issues posed by misuse of over-the-counter (OTC) and prescription only medications (POM). ATM and what to do about it often causes confusion due to a lack of prevalence figures, evidence and guidance, guidelines and advice: and where this does exist, it is not always fit for purpose.
ATM causes a range of issues for individuals, their families and communities. Anonymous author brings home the problems that can be caused, and the ability of individuals to make changes; in this case with support from primary care. However, patchy service provision for ATM can lead to problems. Some areas provide bespoke services, including primary care based, voluntary sector and peer lead services and in other areas local drug and alcohol teams usually provide support. An article by Melanie Davis from the Camden REST project shows how specialist projects can provide bespoke support to those with benzodiazepine dependency. Pauline Forrester also gives an outline of a specialist primary care project working with dependency on opioid pain medicines. As with other dependency-related problems, support for recovery can also be accessed via local mutual aid support groups.
Despite the fact that many services are developing to provide support for ATM, in some areas there remain no commissioned services for those experiencing problems with ATM, leaving people with few places to turn to for help. In this era of localism it is important that we ensure that the treatment response in our local areas is fit for purpose and where gaps exist we should be raising this with commissioners. Steve Taylor from Public Health England Alcohol, Drugs and Tobacco division provides an outline on policy regarding ATM to support discussions with those in strategic positions.
The increasingly problematic misuse of gabapentin and pregabalin is a topic that frequently crops up on the SMMGP forums as practitioners seek advice and support from other clinicians. We are excited to provide a preview of a paper from an expert group convened to address this issue.
We also cover other clinical issues in this special edition. George Ryan discusses the pharmacological management of pain, Kevin Ratcliffe outlines ways of working with misuse of over-the-counter medications and Martyn Hull provides advice on prescribing benzodiazepines.
We hope this special edition of Network newsletter will support practitioners, individuals, their families, and communities in addressing problems with ATM.
Addiction to medicines: the possibilities and pitfalls of the pharmacological management of pain
George Ryan discusses the pharmacological management of pain, identifying potential risks to the development of addiction to medicines and how to manage problems when they arise. Ed
Misuse of prescribed and over the counter medications for pain relief is an increasingly recognised problem but it is likely we are only seeing the tip of a very large iceberg as many of the people misusing these drugs will be doing so with little or no engagement with services. This growing phenomenon presents both clinical and commissioning challenges and this article will consider the clinical challenges in particular.
National Drug Treatment Monitoring System data shows that an increasing number of people already in treatment are identifying prescribed and over-the-counter medications as a problem. For those new to treatment, while there is no firm research or data in this area, anecdotal evidence suggests that the demographics are different to the current treatment population and include significant numbers of middle-aged women who have had no past problems with drugs or alcohol; in my experience, the gender split is almost equal.
Opioids in the management of chronic non cancer pain
Key issues
The prevalence of chronic pain (pain lasting more than 12 weeks) in the USA and Western Europe is in the order of 20%, with a figure of 15% for the UK. Many people experiencing pain will be selfmedicating without seeking the advice and support of healthcare professionals.
"For those new to treatment ...anecdotal evidence suggests that the demographics are different to the current treatment population and include significant numbers of middle-aged women who have had no past problems with drugs or alcohol"
Before prescribing opioid analgesics it is essential to be aware of their limitations and the potential for the development of misuse or mismanagement. An article in the BMJ (Ref 1) about the use of opioids for chronic non-cancer pain was summarised in a follow up article (Ref 2) as "most drugs don't work for most patients". Consequently great care is needed before commencing opioids regardless of any potential for misuse.
If an opioid analgesic is ineffective after four weeks it should be down-titrated and stopped. However, it is worth trying alternative opioids with the proviso of discontinuing them if there is no benefit after four weeks.
Long-acting opioids should be prescribed with minimal use of short acting opioids for breakthrough pain. This may be difficult during the titration period or beyond so it is essential to adopt a pragmatic and sensitive approach to the use of short-acting opioids. A number of screening tools exist to assess the risk of opioid misuse and while the evidence base for these may not be very strong it would be helpful for prescribers to record having used a screening tool should misuse, dependence or an adverse event occur (for an example see Table 1).
Table 1
Prescribing opioids for non cancer pain
Having initiated opioids it is essential to monitor the four As:
- is the client getting improved or adequate pain relief?
- are there any side effects and if so are they tolerable?
- activities of daily living - is the client functioning better on a day-to-day basis?
- aberrant drug behaviour - is there evidence of misuse or dependence?
It may be useful to employ the Chabal checklist to monitor potential misuse. Warning signs include consultations focusing overwhelmingly on opioids, frequent repeat prescriptions/escalating use without escalation of the condition, frequent calls or consultations, lost or stolen scripts, and topping up (see Table 2).
Table 2
Be aware that opioids can cause hyperalgesia. This can take two forms - a worsening of the existing pain or a widespread fibromyalgia type pain. It may be advisable to inform clients of this possibility before prescribing opioid analgesics.
Frequent review at the start of treatment should reduce or minimise the risk of misuse or dependence developing. To be fair, "misuse" is often due to suboptimal practice by prescribers rather than overt or deliberate misuse by clients themselves and they are sometimes placed in a difficult position when a new prescriber makes a unilateral decision to reduce or even cease historically poor prescribing. Whether it's "misuse" or "mismanagement" a sympathetic approach is essential. Any amendment of prescribing should be done collaboratively with the client and with a clear understanding of the aims and outcomes. The aim should be to avoid or to reduce existing polypharmacy and to achieve adequate analgesia with the lowest possible dose of opioid. Morphine equivalence tables can vary quite widely and it is important to use the lower equivalence doses during the up-titration period, possibly using short-acting preparations as an adjunct.
If the decision is made to stop an opioid for any reason - no longer needed after a hip replacement for example - down-titration should take place at a rate which the client is comfortable with and it should be possible to prescribe in a way that allows him or her to self-reduce at their own pace. Providing a very clear and explicit explanation about the use of symptomatic medication to treat any withdrawal symptoms is absolutely essential and goes a long way to reduce the angst and anxiety that people will have about the final discontinuation of opioid medication.
"To be fair, 'misuse' is often due to suboptimal practice by prescribers rather than overt or deliberate misuse by clients themselves"
A particular and worrying cohort of people misusing opioids are those who take large amounts of compound medication where codeine is combined with paracetamol or ibuprofen. While the codeine drives the dependence, the worrying end organ damage is caused by paracetamol to the liver and by ibuprofen to the kidneys or stomach. My Plan A for these clients is to prescribe codeine on its own - in high doses initially making it essential to speak to a client's pharmacist to explain what is happening so that the pharmacist is happy to dispense very large amounts of codeine - in one case codeine 300mg four times daily. It is possible to use buprenorphine or methadone for these clients and the decision has to be made on a case-by-case basis. Bear in mind the possible implications with regard to driving and, with appropriate support vis-a-vis the Driver and Vehicle Licensing Agency (DVLA), it is usually possible for people to keep their licenses. The proposed legislation for drug driving could spell trouble for these clients especially as they need their cars to criss-cross the country, often accompanied by a friend to aid and abet in purchasing larger quantities of medication, to obtain codeine. Discussions regarding the DVLA might be a useful motivational tool to encourage and support reducing and stopping the medication.
In my own practice, I frequently use buprenorphine with very good results. Generally speaking once people have been stabilised on buprenorphine they can reduce and either stop it altogether or continue on a low dose for purposes of analgesia. For example one service user is currently taking buprenorphine 200mcg three or four times daily for pain relief. All options should be considered; one service user had an inpatient assisted withdrawal.
The prescribing component of management is, usually, relatively easy but successful outcomes require effective and sensitive keyworking of a rather different nature to that used with our traditional client group, especially for those service users who are taking these medications for reasons other than pain relief, e.g. low self-esteem, insomnia, and body dysmorphism to give some examples from my own experience.
In summary; think carefully before commencing opioids; review and monitor people frequently at the start of treatment; be prepared to stop and change opioids in the light of a client's response; be alert to the possibility of hyperalgesia; be pragmatic, creative and empathic when managing misuse, however it has arisen; and aim for low dose monopharmacy wherever possible.
The point of Graph 1, which can be replicated across the country, is not the rising volume and cost of pregabalin and gabapentin prescribing: it is that these are known to be drugs of misuse. At the same time as we have almost slain the "benzo beast", from a prescribing point of view, we are creating another monster in its place with the gabapentoids.
Graph 1
The effects of the gabapentoids are "like alcohol without the hangover". They induce euphoria, loss of inhibitions, high energy and cause poor hand-eye coordination, drowsiness and impaired balance. Tolerance varies widely and they potentiate the effects of alcohol and benzodiazepines. Withdrawal symptoms include depression, anxiety, palpitations, agitation, panic and seizures.
While the latest Office of National Statistics data for drug-related deaths for England and Wales does not implicate these drugs there have been cases of drug-related deaths involving gabapentoids in Scotland. The adverse consequences are greatly increased when they are used in combination with alcohol, benzodiazepines and opioids/opiates.
Historically, the blame for the increase in prescribing of these drugs was laid at the door of the Prison Service. The Prison Service some time ago identified the problem relating to these drugs and has taken considerable measures to reduce their use. Currently it would seem that their use is driven especially by pain clinics for the treatment of neuropathic pain with some marginal impact from mental health services using them for the treatment of generalised anxiety disorder and some orthopaedic departments for pain relief.
Neuropathic pain is difficult to diagnose with certainty and there are no commonly available investigations or tests to confirm the diagnosis. Typical features are: allodynia - pain due to a stimulus that does not normally cause pain; hyperalgesia; skin and/or sensory abnormalities on examination symptoms; and signs neuroanatomically consistent with underlying cause; and "burning" or "shooting" pain.
The symptoms and signs of neuropathic pain are easy to describe and simulate and practitioners will be faced with the difficult choice of deciding whether or not to believe people who present with credible and plausible features of neuropathic pain. Add to that the fact that National Institute for Care and Health Excellence considers pregabalin quality-adjusted life year (QALY) cheap while clinical commissioning groups will see it as an expensive drug and prescribers find themselves between several rocks and hard places.
Knowledge doesn't necessarily help; how to make sense of the 16 or so neurophysiological processes and 20 or so neurotransmitter chemicals relating to neuropathic pain? A pragmatic approach is to have a trial of amitriptyline and if there is no benefit then neuropathic pain is unlikely. This may not be underpinned by evidence with a capital E but it is a useful litmus test nonetheless.
The decision to prescribe pregabalin or gabapentin should, naturally, be undertaken on a case-by-case basis. And, as always, one should look beyond the prescription pad as a first or any response and consider nonpharmacological approaches such as cognitive behavioural therapy, manual therapy, self management or mindfulness to name a few alternative approaches.
If you are going to refer clients to pain clinics it is vital to have an understanding of what their prescribing practices are and whether they use non-pharmacological approaches. Waiting times in excess of five weeks can result in clients presenting with more symptoms when they attend the pain clinic. It may be preferable to manage clients in primary care if referral to a pain clinic is likely to make the situation worse. This is an extremely challenging issue for prescribers in terms of squaring clinical, economical and ethical circles and there are no easy solutions.
"Withdrawal symptoms include depression, anxiety, palpitations, agitation, panic and seizures"
Considerable thought is necessary in terms of making the diagnosis of neuropathic pain and considerably more is necessary with regard to all aspects of its management, especially prescribing. As well as clinical challenges there are also commissioning and training considerations to take into account.
It is likely that most services, like mine, will be seeing a steady trickle of clients misusing these drugs, and will be taking a sympathetic and effective clinical and psychosocial approach to their management, developing increasing skills while doing so. However, given the rather different demographic and other characteristics of this client group there will be a need to train practitioners in their management. While this pragmatic approach is reasonable in the short term, managing increasing numbers of these clients without addressing the commissioning implications of continuing to deliver optimum clinical and psychosocial support to this group will be unsustainable in the longer term.
1. Freynhage, A (2013) Opioids for chronic non cancer pain BMJ 2013;346:f2937
2. Stannard, C BMJ (2013) ;347:f5108
A pragmatic guide to benzodiazepines
Martyn Hull takes us through the complex issues involved in benzodiazepine prescribing. Ed
Benzodiazepines (BZ) were first introduced in the 1960s, and rapidly became the prevalent hypnotic due to recognised advantages over barbiturates. It was, however, soon realised that they had their own issues, particularly with respect to dependence, tolerance and withdrawal symptoms.
BZs are still widely prescribed in clinical practice for a variety of conditions. They are very effective as anxiolytics and hypnotics (Ref 1, Ref 2, Ref 3, Ref 4)yet are associated with significant problems when prescribed longterm. It is this combination that means that they provide such a challenge for us in practice.
Clinical guidelines are unambiguous, and have long-stated that BZ should be prescribed for a maximum of 2-4 weeks (Ref 2), but in truth, many people are prescribed them for much longer: herein lies the issue.
It is estimated that up to 1 million people in the UK are dependent on BZs (Ref 5) and many long-term users have difficulties stopping them because of withdrawal symptoms.
During the 1970s and 1980s, BZ prescribing increased markedly, but total use of BZs and Z-drugs together has stabilised more recently, though not reduced.
Properties and clinical actions
There are a large number of BZs available; all have similar properties, although their potency greatly varies. They are rapidly absorbed orally, and lead to peak effects within two hours. The more fat-soluble drugs (e.g. diazepam) are absorbed faster than less fat-soluble BZs (e.g. oxazepam) hence are generally associated with increased misuse potential. Those with long halflives (e.g. diazepam and nitrazepam) are more likely to produce residual effects such as sedation and falls the next day.
The actions of BZs are mediated by enhancing the activity of GABA, an inhibitory neurotransmitter, explaining the characteristic effects of sedation, amnesia and motor incoordination.
The duration of clinical action of most BZs is usually considerably shorter than their elimination half-life because once absorbed, they are rapidly redistributed into fatty tissue. Although noticeable clinical effects usually wear off within a few hours, most BZs continue to exert subtle effects within the body, which may become apparent during continued use. Diazepam, for example, is typically given 2-4 times daily for anxiety, despite its elimination half-life being about two days and its active metabolite having an elimination half-life of four days.
Tolerance develops to BZs, though this can vary for different drug effects, and can vary between individuals. This can have a significant impact as users may, for example, be at increased risk of sedation/overdose by increasing a dose to combat a diminishing effect on anxiety.
Adverse effects and specific problems with long-term use
BZs are usually effective when first prescribed and nearly all the disadvantages and problems come from long-term use. These can be associated with considerable physical, mental and social health problems.
Problems include over-sedation, forgetfulness, depression, withdrawal, tolerance, anxiety, panic attacks, emotional blunting, suicidal thoughts and agoraphobia. These and other side effects are more pronounced in the elderly, and may cause confusion and dizziness, and result in falls and fractures.
With slow reduction and psychological support, in most cases, the underlying symptoms (anxiety, panic, agoraphobia etc) resolve.
Specific problems:
- increased anxiety can be caused by BZs (develop during treatment) or when reducing dose in long-term use;
- memory impairment and cognitive effects through poor concentration and, probably, a specific deficit in memory;
- emotional blunting: a common complaint whereby inhibition of arousal results in an inability to feel normal emotional highs or lows;
- weakening of coping skills: patients use them as part of their repertoire of coping mechanisms;
- depression can be aggravated by BZs, or can develop for the first time (usually resolves within six months of stopping);
- paradoxical excitement: increased anxiety, insomnia, nightmares or aggressive behaviour;
- dependence: characteristic withdrawal syndrome:
- Anxiety and agitation;
- Distorted perceptions e.g. abnormal body sensation;
- Major incidents such as fits (rare).
- The risk of withdrawal symptoms increases with:
- longer use;
- higher doses;
- use of high-potency BZs;
- in patients with chronic psychiatric and personality problems;
- in patients with a history of alcohol dependence;
- in patients with chronic physical health problems.
- a protracted withdrawal syndrome occurs in a minority, most of whom have taken BZs for years;
- successful withdrawal is possible in most patients who are dependent on BZs, though consideration needs to be given as to when and how to detoxify; extra help and services may be needed (Ref 6);
- it is important to enquire about alcohol, as this may be substituted for BZs.
Patients taking BZs will broadly fall into three different categories, although there is overlap between groups:
- Therapeutic users who may have been appropriately initiated on treatment, but inadvertently continued long-term;
- Illicit users - often high-dose, and possibly in the context of polydrug use;
- Patients with mental health issues felt clinically to require long-term BZs.
There is commonality among different groups of BZ users with respect to treatment, though different approaches may be undertaken for different groups.
General principles are:
- before starting a reduction, tackle any underlying problems, ensure any physical or psychiatric health problems are addressed (Ref 7) and inform the patient about the problems of long-term BZ use, process of withdrawal and possible effects;
- tailor the dose reduction to the individual and taper it (Ref 8);
- assess the need for additional support and therapies and monitor frequently enquiring about general progress and withdrawal and rebound symptoms;
- if patients experience difficulties with a dose reduction, encourage them to persevere and suggest delaying the next step down but don't revert to a higher dosage;
- if withdrawal symptoms might be a problem, consider substitution of short- or medium-acting BZs by long-acting compounds (diazepam) (Ref 9);
- the decision to prescribe longer-term (maintenance) BZs should be rare and made with care.
BZ use in the context of illicit drug misuse
BZ misuse is a serious problem in people who use drugs, especially polydrug users, and there is little evidence available to guide practitioners:
- as well as being taken orally, they can be snorted and/or injected (Ref 10);
- up to 90% of attendees at drug treatment services have reported their use (Ref 11).
Typical characteristics of illicit BZ users:
- more likely to be male, <30 years;
- can seek a high/buzz or mind numbing/amnesiac effects;
- often seek escalating doses, and often binge with other drugs (e.g. opioids);
- preference for rapid-onset/potent BZs;
- typically take BZ in a single dose to maximize euphoria/buzz;
- may use to alleviate withdrawal symptoms from other drugs, particularly crack and heroin;
- may also, however, be used as self-medication to lift mood or improve coping skills;
- use leads to higher risk-taking behaviour and social dysfunction, and can increase risk of overdose (Ref 12, Ref 13, Ref 14), increase risks associated with opioids (Ref 15) and increase risk of contracting blood borne viruses (Ref 11);
- may be difficult to engage in treatment and can relapse after cessation compared to therapeutic users whose relapse rates are low after successful detoxification.
Treatment for illicit BZ users
The usual assessment must be undertaken. Dependence should be confirmed by history and symptoms, and at least two consecutive positive screens should be provided; there should be no negative screens in the preceding four months. The benefits of prescribing should outweigh the risks (including diversion).
Prescribing is not an option for non-dependent binge users: in such cases, psychological interventions are appropriate. If considering prescribing, all BZs should ideally be converted to diazepam because:
- diazepam has a long half-life which allows a smooth and gradual withdrawal;
- diazepam comes in different strengths which allows flexibility when planning dose reductions;
- diazepam can be issued on an FP10MDA interval prescription, allowing for daily pickup (or supervised consumption where local arrangements exist).
Note: if there are definite problems caused by the rapid onset of diazepam (e.g. BZ-seeking behaviour, difficulty reducing) an alternative slow-onset BZ such as oxazepam could be used.
If prescribing:
- patients should be offered detoxification;
- it is rarely appropriate to start a dose of more than 30mg diazepam daily (this dose will protect against BZ-withdrawal fits); a lower starting dose may be appropriate;
- daily dispensing should be stipulated at first, and may be appropriate to continue throughout treatment;
- a structured detoxification regime set from the onset of treatment - for example reducing over 12-16 weeks to zero - is often a pragmatic option and protects against the potential for inadvertent maintenance prescribing;
- longer-term prescribing must always be balanced against the risks, especially the negative effects on memory and cognitive skills, and should not be standard practice.
If there is concurrent opioid dependence, refer/treat the opioid dependence first with opioid substitute treatment (OST). Many patients are able to control their BZ use themselves (precluding the need for a BZ prescription), even in cases when it appears there is clinical dependence. If use of BZs persists - and the patient is dependent - reassess the reasons. If it is felt that BZ prescribing would be beneficial, then implement a structured detoxification as detailed above.
Due to the potentiating effect of BZs and opioids, for patients stable on OST undergoing a BZ detoxification, it may be appropriate to titrate the dose of the OST as the BZ dose is reducing (this can alleviate some of the withdrawal symptoms).
Stop the prescribing of BZs if illicit BZ use persists or alcohol dependence is present.
Much of this article is built upon the excellent benzodiazepine guidance written by Chris Ford and Fergus Law.
1. American Psychiatric Association, US (1990) "Benzodiazepine dependence, toxicity and abuse: A task force report of the American Psychiatric Association". Washington DC.
2. National Institute for Health and Care Excellence. (2011) "Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults". CG113. London.
3. Baldwin, D. S., I. M. Anderson, et al. (2005). "Evidencebased guidelines for the pharmacological treatment of anxiety disorders: recommendations from the British Association for Psychopharmacology". Journal of Psychopharmacology 19(6): 567-596.
4. Wilson, S. J., D. J. Nutt, et al. (2010). "British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders". Journal of Psychopharmacology 24(11): 1577-1601.
5. Ashton H. (2004) "Benzodiazepine dependence". In: Haddad P, Dursun S, Deakin B, editors. Adverse syndromes and psychiatric drugs. Oxford: Oxford University Press;. pp. 239-260.
6. Hallstrom, C. (1990). "Medical aspects of benzodiazepine abuse". Practical Reviews in Psychiatry 2(9): 3-5.
7. Baillargeon, L., P. Landreville, et al. (2003). "Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial." CMAJ Canadian Medical Association Journal 169(10): 1015-1020.
8. Denis, C., M. Fatseas, et al. (2006). "Pharmacological interventions for benzodiazepine mono-dependence management in outpatient settings". Cochrane Database of Systematic Reviews 3: CD005194.
9. Voshaar, R. C. O., W. J. Gorgels, et al. (2006). "Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program." Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie 51(7): 445-452.
10. Seivewright, N. (1998). "Theory and practice in managing benzodiazepine dependence and misuse". Journal of Substance Use 3(3): 170-177.
11. Gossop M, Marsden J, Steward D, Kidd T. (2003) "The National Treatment Outcome Research Study (NTORS): 4-5 year follow-up results". Addiction 98(3): 291-303.
12. Bleich, A., M. Gelkopf, et al. (1999). "Correlates of benzodiazepine abuse in methadone maintenance treatment. A 1 year prospective study in an Israeli clinic". Addiction 94(10): 1533-1540.
13. Darke, S. (1994). "The use of benzodiazepines among injecting drug users". Drug & Alcohol Review 13(1): 63-69.
14. Strang, J., P. Griffiths, et al. (1994). "Survey of use of injected benzodiazepines among drug users in Britain". BMJ 308(6936): 1082.
15. Lintzeris, N., T. B. Mitchell, et al. (2006). "Interactions on mixing diazepam with methadone or buprenorphine in maintenance patients". Journal of Clinical Psychopharmacology 26(3): 274-283.
Prescription and over-the-counter medicines: national policy, local action
Steve Taylor gives an overview of policy issues regarding addiction to medicines and places primary care at the heart of identifying patients with problems and emphasises the importance of localism in providing strong care pathways for this group. Ed
We have little data with which to properly understand the extent to which people are misusing or dependent on prescription and over-the-counter medicines - obtained legitimately, diverted or bought from the internet - but the available indicators suggest the problem may be growing.
Benzodiazepine and z-drugs have continued to receive the most attention but pain medicines (opioid and others, like gabapentin and pregabalin) are fast becoming a source of concern in the media, community and prisons. At a national level it is difficult to disentangle inappropriate prescribing from legitimately-increased prescribing to better treat patients' anxiety, depression and pain. And the legitimacy of purchases of over-the-counter and internet medicines is largely hidden and unknowable. Responding sensitively and appropriately to individual patients and their problems is always going to be the key.
Since the All-Party Parliamentary Drugs Misuse Group reported in 2009 on the findings of their year-long review inquiry, government has taken additional steps to support local areas and their clinicians to prevent and treat misuse of and dependence on medicines. 2010's national drug strategy saw prescription and over-thecounter medicines included in considerations of dependence on all drugs. The health minister's roundtable events in 2011 agreed a consensus statement that covered four areas for improvement:
- support to GPs and other healthcare professionals;
- improve access to treatment and support;
- improve the commissioning of services;
- highlight best practice to improve public and professional awareness.
National partners, including Substance Misuse Management in General Practice (SMMGP), the Royal College of General Practitioners (RCGP), Medicines and Healthcare products Regulatory Authority (MHRA), and many others, have developed resources to support improvement, including online and face-to-face learning, factsheets, guidance for pharmaceutical manufacturers, and a Public Health England (PHE) guide for National Health Service (NHS) and local authority commissioners. PHE has recently put a couple of example of local medicines initiatives on its Recovery Resources microsite. And, with PHE support, the Faculty of Pain Medicine is developing a core resource on pain management so that the medical colleges and others have consistent, agreed advice on which to draw. This follows earlier guidance on managing persistent pain in secure settings.
Local areas have the responsibility to assess and respond to local need. In addition to National Drug Treatment Monitoring System data on treatment demand, they can use practice-level data on prescriptions, the results of practice audits and local intelligence to understand where problems are arising, how they might be prevented, and who needs what forms of treatment where.
Addressing the breadth of the problems with medicines demands a breadth of solutions, with local authority public health and the NHS working closely together to commission integrated pathways of care. Primary care remains the first port of call for patients experiencing health problems, with specialist drug services there to provide expertise, advice and support, and to work with the most complex cases.
Misuse of pregabalin and gabapentin is a growing concern and we are pleased to provide a summary of the Faculty of Pain Medicine's core resource on pain management prior to its imminent publication. Ed
Whenever SMMGP deliver our Addiction to Medicines training day we are invariably asked about the abuse potential of the neuropathic pain treatments pregabalin and gabapentin. Concern about this has been widespread amongst treatment services and those who regularly work with problematic drug users in both community and criminal justice settings. Public Health England (PHE) have responded to these concerns by drawing together a range of interested stake holders including the British Pain Society, the Royal College of General Practitioners, the Faculty of Pain Royal College of Anaesthetists, Royal College of Psychiatrists and SMMGP to produce advice for prescribers of these drugs. "Advice for prescribers on the risk of the misuse of pregabalin and gabapentin" is due to be published soon and whilst it should not be considered as the definitive guidance on dealing with the problems relating to these drugs its purpose is to raise awareness of the potential issue with a wide range of prescribers, many of whom may not be aware that some people misuse these drugs. It will also provide some useful pointers on how to try and prevent problems arising and advice on strategies to consider should a problem be identified. Prior to its publication, SMMGP are pleased to provide a summary of the key findings of the report.
Using gabapentin and pregabalin
Pregabalin and gabapentin have an established role in the management of a number of long-term conditions including epilepsy, neuropathic pain; and for pregabalin the treatment of generalised anxiety disorder. In common with most medications the drugs do not work for everyone but a proportion of patients benefit sufficiently to notice an improvement in their quality of life.
Practitioners should prescribe pregabalin and gabapentin appropriately to minimise the risks of misuse and dependence, and should be able to identify and manage problems of misuse if they arise. Most patients who are given these drugs will use their medicines appropriately without misuse.
Prescribing for patients who are known or suspected to have any form of problematic drug use may present a greater risk for misuse, diversion or dependency. Prescribers must therefore make a careful assessment of the potential benefits against the risks. However, it should be noted that such patients may also have a higher prevalence of the indicated conditions for these drugs and some may benefit from their use.
Patients who are offered these drugs need to be informed sufficiently to consent to the treatment plan. Patients should be aware of the likely efficacy of the drugs for management of their symptoms and also about the risk of harms, including dependence.
Whilst patients should not be excluded from access to medications which may help them because of a current or past problem with misuse or dependence it is essential that relevant consideration is given in how, and even whether to prescribe these drugs. Prescribing decisions should be discussed in full with the patient and the patient should be made aware of the importance of their co-morbidities in making a safe prescribing decision.
Alternative drugs which are less prone to misuse can be used as first line treatments for the indicated conditions for which pregabalin and gabapentin are now used, and may be tried preferentially in higher risk settings or in patients who may be more likely to be harmed by the drugs.
Clinical indications
The drugs are licensed in the UK for the treatment of focal seizures and for the management of neuropathic pain, and pregabalin is also licensed for the treatment of generalised anxiety disorder. In Canada and the US, the drugs are licensed for the treatment of pain associated with fibromyalgia and, although not licensed for this indication in Europe, are established parts of the pharmacological repertoire of fibromyalgia management.
Minimising risk
When these drugs are prescribed for neuropathic pain or fibromyalgia, they should be prescribed for a test period, to ascertain if they are effective. The dose should be titrated up to the maximum tolerated within the suggested dose range. If the patient has no improvement in symptoms, the drug should be reduced and stopped. If they are successful, it is suggested that there should be a reduction on an annual basis, to ascertain ongoing effectiveness.
Gabapentin and pregabalin should be prescribed for their licensed indications. Although the drugs are commonly prescribed for non-neuropathic pain syndromes there is little evidence to support the practice. Evidenced based interventions such as physical rehabilitation for back and musculoskeletal pain with or without simple analgesia are likely to be more effective. If a decision is made to prescribe the drugs for unlicensed indications, the rationale should be discussed with the patient, appropriate consent acquired and all discussions clearly documented.
"Individuals misusing gabapentin and pregabalin variably describe improved sociability, euphoria, relaxation, and a sense of calm"
Why are they misused?
The drugs have a similar mechanism of action and both have propensity for misuse. Gabapentin and pregabalin are structurally similar drugs acting via the alpha-2-delta subunit of voltage gated calcium channels. The mechanism by which the drugs may induce dependence is not well worked out.
Gabapentin and pregabalin are associated with significant euphoric effects compared to placebo. Individuals misusing gabapentin and pregabalin variably describe improved sociability, euphoria, relaxation, and a sense of calm. Gabapentin and pregabalin can cause depression of the central nervous system, resulting in drowsiness, respiratory depression and even death.
Both gabapentin and pregabalin have central nervous system adverse effects which are addictive when used with other centrally acting drugs, particularly opioids.
Pregabalin and gabapentin are predominantly excreted unchanged in the urine; they undergo respectively negligible or no metabolism in humans. They do not inhibit drug metabolism in vitro, and are not bound to plasma proteins, so they are unlikely to produce, or be subject to, pharmacokinetic interactions.
Evidence for misuse
Misuse of gabapentin and pregabalin has been noted in clients attending substance misuse treatment and recovery services and within secure environment settings for some years. Currently, pregabalin appears to be more sought after for misuse than gabapentin. There is a growing illegal market, and these drugs are also being bought through online pharmacies.
There have been numerous anecdotal reports of misuse of gabapentin and pregabalin in the UK and a review of the literature carried out for the advice document revealed descriptions of pregabalin abuse in Europe and Scandinavia. Pregabalin was also listed as a new recreational psychoactive substance by the relevant EU agencies in 2010. Concerns about misuse of pregabalin in the US have led to it being scheduled indicating that it has abuse potential. Gabapentin and pregabalin have been mentioned on death certificates as adjunctive substances in patients dying of drug poisoning.
In the UK there is evidence that the drugs are readily available amongst those held in secure environment settings where they may be abused or used as a commodity to trade. Prescribing per capita of pregabalin and gabapentin in secure settings is double that in the community and it is unlikely that this represents differences in prevalence of the licensed indications of these drugs in these populations.
Dealing with problematic use
If dependence on pregabalin or gabapentin, or other misuse (including diversion) is suspected or identified the patient needs to be reviewed and the concerns of the prescriber should be discussed and then clearly documented.
Where misuse or dependence on gabapentin or pregabalin is suspected or confirmed then a management plan should be devised. It may be that specialist advice for management of the dependence is available and if so this should be sought. If it is felt that these drugs are still clinically indicated and are effective if taken as prescribed then it may be that an agreement on suitable controls on access to, and maximum daily use of the drug is instigated. However reassessment of the patient may lead to an appropriate decision to offer a planned withdrawal of the medication, particularly if the medication does not appear any longer to be required for the main clinical indication.
Where a prescriber is satisfied through careful assessment that the use of the drug is completely inappropriate (such as only ever taking occasionally or diverting the whole supply) then it would be appropriate to simply stop prescribing. This decision should be undertaken only after a comprehensive assessment and the reasons why clearly documented.
Safely reducing
The summary of product characteristics for gabapentin and pregabalin indicate that both drugs can be discontinued over one week. However the advice document suggests a more gradually tapering dose that allows observation of emergent symptoms that may have been controlled by the drug:
- pregabalin: reduce the daily dose at a maximum of 50- 100mg/week;
- gabapentin: reduce the daily dose at a maximum rate of 300mg every four days.
It may of course be decided to reduce more slowly than this.
Key messages
There is a role for both gabapentin and pregabalin across their licensed indications and for the vast majority of patients they will be used in an appropriate way.
They are not without risk if misused and the potential problems range from acute CNS depression where taken for psychoactive effects (especially if taken with other CNS depressants) to dependency. There are also issues around the potential for diversion.
A careful assessment before prescribing can minimise the risk of these problems and should be supported by regular review of both effectiveness and patterns of use.
These drugs can be withdrawn safely using a tapered reduction which is suitable to carry out in a primary care setting.
My addiction to prescription medicines: a personal story
This powerful personal account describes the problems addiction to prescription medicines can cause and the great strength individuals have in overcoming dependency. It also highlights the important role of GPs in preventing and also supporting people to overcome addiction to medicines. Ed
My journey into addiction to prescription medicines began just over 17 years ago. In December 1996 I was diagnosed with colorectal cancer AJCC Stage III-C. I underwent surgery to remove the tumour, however, due to postoperative complications I was prescribed a mixture of cephadine, paracetamol, metronidazole and dihydrocodeine which I continued taking during the reversal of the ileostomy and throughout chemotherapy and radiotherapy. What then followed was another four years where I underwent three separate laser surgeries to remove growing internal scar tissue which caused narrowing to the intestinal tract. Every time I ate I had painful side effects and at this stage I was prescribed 60mg X 2 codeine phosphate tablets to be taken after meals. This became my medication of choice as it helped alleviate most of the painful effects I was experiencing at the time. I remember asking my GP how long I would have to take these tablets for and his response was that it would be for the rest of my life. He felt that it was the most effective and safe option to regulate/slow down the digestive process and enable me to have a quality of life. Once the scar tissue problem was resolved, my dosage was reduced to 30mg X 8 daily which I continued to take for the next eight years. I found that if I was tired or stressed I would take more tablets to the point that no matter how many I took, the pain would not go - these were the most challenging times.
Throughout this period I excelled professionally, but at times found it hard to concentrate. There was never an issue with getting tablets. I was initially given repeat prescriptions of 200 tablets, but I increased it to 500 tablets, saying that it was difficult to get time off work to collect prescriptions. There were intermittent reviews of my medication, but during these periods I explained to the GP that it was something I needed to be on for the rest of my life and they never questioned me further. I was articulate and clear about my condition and said that it was due to the tablets that I was able to continue working and to have the quality of life that I did. Over the years I tried from time to time to come off of the codeine completely and to not have to worry about having to take tablets 3 times a day or, if I ran out, having to get to the doctors for repeat prescriptions or to friends where I left "stashes" of tablets just in case. I would try going "cold turkey", managing to get through the first 10-12 hours without too much trouble, but after this time was faced with stomach cramps, headaches, panic attacks and insomnia and each time I quickly resumed my codeine use. I realised I had become dependent on increasing amounts of codeine and needed a constant supply. I didn't know how to stop.
In 2012 I moved doctors. My new GP sent me for blood and liver function tests and the results showed that there was a problem with my liver function. I asked my GP at that point for help to reduce and stop my codeine phosphate medication. He agreed to review my progress every month and I set myself a target of reducing my intake by 15mg at a time. The side effects were bad - partly psychosomatic and partly physical. Each time I reduced the dosage, symptoms for the first 48 hours included insomnia, restlessness, hot and cold sweats and stomach cramps. By October 2013 I was down to 15mg x 3 daily. I tried co-codamol in place of codeine but it did not work so I cut the 15mg codeine tablets in half. The side effects usually lasted a week following the reduction of dosage and then tapered off. Luckily I was not working at this time, so I was able to rest and go for long walks to take my mind off the cravings.
Between January and March 2014, I managed to get myself down to 7.5 mg a day, but the fear of coming off codeine completely meant that the side effects were the worst I experienced. 19th March 2014 was the last time I took codeine. Do I feel any different? I can honestly say that looking back I have not felt as alert as I do now for a long time. My concentration levels are a lot better, although there are huge gaps in my medium-to-long term memory. I have no codeine cravings and although I still have problems with my digestion, I know now that taking codeine does not make a difference. It has been a long addiction, but thankfully I managed to complete the journey with the help of a GP who listened and gave me the support I needed to conquer my dependency.
Hooked on pharmacy: using our skills to work with over-the counter medications
Misuse of over-the-counter medication is often a hidden problem that can create dilemmas for practitioners when identified. Kevin Ratcliffe describes the issues involved and suggests that there may be more skills and knowledge amongst professional than we might think. Ed
Misuse of over the counter (OTC) medicines is not a new phenomenon. For many decades, pharmacists have been the guardians of the sale and supply of medicines. Readers will no doubt be familiar with misuse of laxatives or of sedating antihistamines ("sleepers") for example. Misuse of OTC opiates is also an area requiring constant vigilance. Despite a number of safeguards, opioid painkillers in particular have become part of the bigger substance misuse picture. Whilst these medicines can be smuggled, diverted or stolen, increasing numbers of people are turning to the internet to obtain opioid painkillers. UK-registered internet pharmacies are regulated by the same rules governing the sale of medicines as UK community pharmacies (including restrictions on the number of opioid painkillers that can be purchased). However, the internet is global and is readily available to the vast majority of the population. It is not difficult to see why some people utilise the internet to obtain their opioid painkillers from sites outside the scope of UK medicines regulations. Before online purchasing became more mainstream, people would often make long, convoluted journeys each day to visit many different pharmacies in order to obtain the medicines they felt they needed (so-called "doing the run").
"It is not difficult to see why some people utilise the internet to obtain their opioid painkillers from sites outside the scope of UK medicines regulations"
There are over 40 codeine and dihydrocodine-containing products available in the UK for purchase without a prescription. The majority are combined with other painkillers such as paracetamol or ibuprofen. This in itself creates additional problems in cases of misuse as it is not unusual to find people taking over 30 tablets on a daily basis. Polydrug use (especially alcohol and/or benzodiazepines) may also be a factor. Often, cases of OTC opioid addiction are not picked up until the patient experiences physical manifestations from the massive doses of ibuprofen or paracetamol that they have been taking. This also highlights another issue; people misusing OTC opioids are quite difficult to spot. Typically, they will not have a previous history of dependence. More commonly, they are likely to have (at least initially) poorly managed chronic pain. They are likely to be self-medicators in that they do not want to "bother the doctor" or they perceive their GP as unhelpful. It is very likely that they will be keeping their misuse a secret, even from their friends and family.
"It is very likely that they will be keeping their misuse a secret, even from their friends and family"
Once someone does present, the next challenge facing prescribers is the lack of formal guidance to help decide how to proceed (codeine dependence isn't really covered in the Orange Book (Ref 1), for example). However, there is a lot of clinical experience out there around opioid dependence, and it could be argued that the general principles are similar for other illicit opioid users. This is a good news story, as it means that services already have the skills needed to do this. It is important to bear in mind that many people looking for support with an OTC opioid problem may have considerable anxiety about attending a drug service. Visiting their GP may feel more "normal" to some. In either case, spending time listening to the patient's story and then educating the patient with the options available will go a long way to reducing the stigma they may feel and addressing some of their concerns.
Psychosocial support is a crucial element. In many cases, the initial reason for starting the opioid painkiller is long gone, but people may continue to take them not only to avoid unpleasant withdrawals but also because they feel psychologically better when they take these medicines. Many describe taking extra tablets when their mood is low or to cope with stressful events. Understanding the benefits and adverse effects an individual is getting from their medicine use can help assess how motivated they are to stop. It is also useful to understand what the triggers for additional use are, and the lengths that the person will go to in order to obtain their medication. It goes without saying that if the underlying cause of the pain is still there, this will need to be addressed in order to maximise the chances of successful recovery from dependence on opioid painkillers.
Prescribing of an opioid substitute is often a viable option, and clinical experience appears to favour buprenorphine. There are a number of advantages of using this drug, including the fact that it is long-acting, leaves the individual with a clearer head, does not require large doses, and offers the option of instalment dispensing and supervised consumption. However, it is important to discuss how the medication works, in particular precipitated withdrawal, in order to manage expectations for the first few days of treatment. It is also worth considering the possible effects of caffeine withdrawals as some OTC medications contain this drug.
"It is important to bear in mind that many people looking for support with an OTC opioid problem may have considerable anxiety about attending a drug service"
Some people may choose the option of methadone, particularly where sleep is an issue, although the stigma attached to this drug is often quite acute. Some have argued that it may be more appropriate to prescribe the patient's drug of choice (i.e. codeine or dihydrocodine); whilst there is limited evidence of success as a first line option, this may be a consideration where opioid substitutes have failed. However, this would be off-license use (good records are therefore essential) and does involve the patient taking frequent doses due to the short-acting nature of these drugs (with the potential to reinforce "pill-popping").
Whatever medication is agreed, the basic principles are readily recognisable. Firstly, titrate to patient comfort levels, reviewing frequently initially and monitoring for side effects. If using buprenorphine or methadone, doses are likely to be lower than those used to stabilise heroin users. Following stabilisation, and of course when the person is ready, reduce at a pace that they can manage, providing psychosocial interventions throughout. Ensure the person has access to appropriate support where needed. In addition to local resources, there are a number of peer support groups available online; Overcount and Codeinefree are well known. As always, the prescription is a small (albeit important) part of the treatment; the psychosocial interventions are the key. Eventual detox off the medication is part of the process and not the end.
Sound familiar? Dependence on OTC opioids is something that drug services and many GPs already have the skills to deal with. This is a largely hidden problem currently; even the government acknowledge that there are no reliable prevalence figures but recognise that the problem exists. These people are out there and need our support. Is your service geared up for this?
1. Department of Health (2007) Drug misuse and dependence: UK guidelines on clinical management
Camden REST service: a specialist project for people with addiction to benzodiazepines
Melanie Davis puts the case for specialist services for people with addiction to benzodiazepines and the importance of tailoring each intervention to an individual's needs. Ed
I am the manager of the Mind in Camden REST (Recovery Experience Sleeping Pills and Tranquillisers) Service, a project that has helped people with addiction to benzodiazepines since 1988. Ours is the only service catering to this cohort in the Greater London area and one of only four specialist projects in the whole of the UK. We are funded to work with people from the London Boroughs of Camden and Islington, although we are able to offer limited telephone support outside these areas.
It is important that there are specialised projects for those taking prescribed medication because conventional drug projects often do not understand the needs of benzodiazepine users. Many people who use prescribed drugs have expressed that they do not want to go to an agency where they are treated in the same way as a class A drug user. Many specialist drug services will not accept benzodiazepine users unless they are also taking other substances. We believe those who are involuntarily addicted to prescribed medication should have as much support as those who are using these drugs illicitly, and that more services like ours are needed.
Addiction to benzodiazepines can affect anyone. Many people are prescribed addictive drugs as a consequence of other events in their lives. We provide targeted support to address the issues that people have been prescribed the drug for in the first place, including insomnia, stress and anxiety via peer support and counselling. We operate a mindful, person-centred approach believing that people are best able to control and make choices about their own behaviour. We exert no pressure on people to come off benzodiazepines, although we encourage them to do so. We offer information to make clear the problems created by long-term benzodiazepine use, and the necessary support, empathic engagement and encouragement to withdraw from minor tranquillisers, should the person decide to do so.
Our philosophy is that withdrawal from benzodiazepines needs to be gradual and at the user's own pace. People are advised on how to plan a sustainable programme, which does not overload them. The service recommends the Professor Ashton manual as a guideline for reduction and withdrawal. People are supported through their taper and for as long as they need post withdrawal. Many of our clients have taken benzodiazepines or related compounds for much of their adult lives: the average age of clients is 55. Recovery is therefore usually gradual and many life skills need to be learned or relearned.
We tailor our service to an individual's pressing need. We involve family, friends and professionals if required by the client to build networks and sustain recovery and offer consistent staff and volunteer support.
We recommend people have medical support throughout their reduction process and will write letters to GPs, if instructed, with suggested withdrawal programmes. It is important that we work with GP surgeries to identify, reach out to and support people who want to withdraw.
The Department of Health roundtable group produced a consensus statement (see RCGP web site) on addiction to medicines towards the end of 2012 which REST signed. The vast majority of our clients were in agreement with doing so as were our management committee. We were under no illusion that this would be the complete answer to the problem. We felt it did not go far enough but was an enormous improvement on earlier drafts in that it gets the message across that prescribing the drugs for periods of more than 4 weeks can lead to addiction. It also means that our contact details are on the document so anyone suffering from benzodiazepine addiction who sees the statement and wants our help can contact us.
However, we would have liked the document to better address the complexities of addiction to prescribed medication and to more fully reflect the knowledge and understanding of the specialist benzodiazepine services, all of which are user led. We are concerned that the statement has not been properly acted upon. Campaign work therefore continues to highlight concerns not addressed by the statement. Part of the initiative to inform on the problems associated with benzodiazepine use is that we supply service users from the REST project to speak at SMMPG (Substance Misuse Management in General Practice) Addiction to Medicines training events. REST has so far supplied two service users who are addicted to prescribed sleeping pills and minor tranquillisers who have told their stories. They also identified what treatment they would like to have received from their GPs when seeking support to withdraw from these pills. The feedback has been that this information has been useful and will influence current practice for the better.
The message we would like to convey is that withdrawal is best done at the user's own pace. In experience going back 20 years, we have found that a slow withdrawal is more effective, both in terms of not resuming use of this medication and of making the process of withdrawal more bearable. In our extensive experience, clients who have successfully and sustainably managed withdrawal have on average taken a year to do so. Although there are guidelines available to GPs we are concerned that these are not always observed.
Every client is of course different and the circumstances which led them to be prescribed benzodiazepines will also be individual. I find nearly all of our clients (and I have seen hundreds over the years) experience symptoms after they have reduced their dosage. I think it is vitally important to take every case on its own merits, against a backdrop of flexible and helpful guidelines - helpful to the user that is.
"The message we would like to convey is that withdrawal is best done at the user's own pace"
Principally the problem is with the use of the drug over the time limits (2-4 weeks) recommended in the British National Formulary (BNF) and National Institute for Health and Care Excellence (NICE) guidelines. For those clients already dependent on benzodiazepines a serious issue is the all too common imposition of rapid withdrawals. This causes incredible distress to the majority of people who experience it. The new guidelines in the BNF and NICE (which the REST project was involved in changing) will help our case that withdrawal needs to be gradual, and we will endeavour to let prescribers and others know that the guidance has changed.
My hope is that the situation for all those who are dependent on benzodiazepines can be improved and that no new addicts are created. What is so lost from many debates on this issue is a coherent, user led policy for those addicted to benzodiazepines, and little by the way of appropriate withdrawal services to support them. We therefore continue to campaign at a national level for the issue of addiction to benzodiazepines to receive the necessary appropriate investment and support for this situation to be addressed.
Pauline Forrester provides an overview of a specialist primary care project to support people with problems with opioid pain medication. Ed
Overview of service
A dedicated over-the-counter (OTC) and prescription-only medicines (POM) substance misuse practitioner, focusing on opioid pain medicines (OPM), who links with GP surgeries and pharmacies.
To respond to the needs of, and provide support to, people who are dependent on or misuse OPM.
Target group
People dependent on or misusing OPM who have complex needs.
The need for the service
Wirral Drug and Alcohol Services' shared care has grown over 20 years to a team of 30 substance misuse practitioners, covering all 63 GP surgeries on the Wirral. Since 2008, and through conversations with GPs, practitioners have become increasingly aware of the need from primary care for support for people who are dependent on or misuse OPM.
In response, the service worked with the primary care trust's medicines management team and used Electronic Prescribing Analysis and Cost (ePACT) data provided by NHS Business Services Authority to look at prescribing patterns in local GP surgeries. The analysis found there were areas where opioid pain medicine prescriptions (such as dihydrocodeine, oral morphine, codeine, and tramadol) were at unusually high levels or long term, or both. The findings were used to help support a case, made by the service's management to local commissioners, for funding a full-time substance misuse practitioner who would focus on OPM in all the surgeries on the Wirral. Historically, there had been no mechanism in place for GPs to refer people dependent on or misusing these drugs into treatment, with little other support available locally (outside online support groups). The fact that most users didn't view themselves as "drug users" in the traditional sense, and in turn were reluctant to use drug and alcohol services, further strengthened the case.
The post was recruited to internally from the shared care team. It is consequently held by a worker who is very experienced and skilled in working with the local GP surgeries, having long- established relationships with the area's doctors. This is something the service has found vital to the success of this work.
What the service does
The OTC and POM substance misuse practitioner runs campaigns in GP surgeries and pharmacies, highlighting what the drug and alcohol service provides. GPs and pharmacists with patients who are dependent on or misuse OPM now have a single point of contact for referrals. The generic substance misuse practitioners who cover the surgeries in the area can also refer patients to the OTC and POM substance misuse practitioner, and offer support and advice to GPs. Once users are identified, there is a threeway conversation between the OTC and POM substance misuse practitioner, users and their GPs, where the options available are discussed and a package of care is developed collaboratively.
Patients are offered psychosocial interventions (such as motivational interviewing and cognitive behavioural therapy, as well as support in managing anxiety and triggers) that are appropriate to their need and available locally. The worker who currently holds this post is trained to deliver a range of interventions to users, but will also refer them to other agencies and to the service's clinical psychologist (who specialises in personality disorders). The practitioner can also arrange residential and community detox, alternative prescribing (i.e. medication that is easier to reduce), and access to support groups. The practitioner (who has a caseload of around 30 people) will also establish where the patient would prefer to be seen: in the GP surgery, at the drug and alcohol service, or at home.
Work with partners
With its 20-year history of working with GPs, the drug and alcohol service has strong working relationships with the area's surgeries. It also works closely with local pharmacies, voluntary sector organisations, mutual aid and other support groups (such as Codeinefree, and the local pain clinic.
Since the creation of the post in 2010, the OTC and POM substance misuse practitioner has seen 205 people. Of these, 64 have been discharged drug free and 23 transferred to either another substance misuse practitioner or agency. The remainder have either returned to their GP having reduced the medication they are taking, transferred to medication that still manages their pain but has a reduced risk of misuse or dependency, or disengaged from treatment.
How these outcomes were achieved
The service credits several factors, including:
- the experience and skills of the OTC and POM substance misuse practitioner, who was recruited based on good advocacy and communication skills, confidence and ability to build rapport;
- the competence of the practitioner in delivering a range of psychosocial interventions;
- excellent working relationships with primary care at worker and management level;
- the service's ability to tailor interventions to individual need and advise on medications;
- the fact the clinical director of the service is a practicing GP.
Dr Fixit's advice - Addiction to medicines
Steve Brinksman is Dr Fixit to a GP who asks for support working with a patient who has developed a problem with Nurofen Plus. Ed
Dear Dr Fixit, Carol is a 45-year-old patient who has recently come to me with epigastric pain and on further discussion she tells me that she has been taking increasing numbers of Nurofen Plus over the past year, sometimes up to 32 tablets per day as she finds she needs to take more to get any effect. She was prescribed codeine 4 years ago for 2 months following a fracture to her arm, and found that it helped her cope better some days at work (she is a solicitor). When her prescription for codeine stopped she began to buy over-the-counter codeine containing preparations and says that she did not feel it was a problem until a year ago when her mother became ill and came to live with her and she began to use these every day. She says she has tried to stop but has felt very unwell when she does so and has failed. She says her husband and children are not aware of the problem and she is desperate to stop
Dependency on over-the-counter (OTC) or prescription only medication (POM) is an increasingly recognised problem and forms part of the spectrum of addiction to medicines (ATM). This most commonly involves benzodiazipines, opioid analgesics and neuropathic pain treatments such as pregabalin and gabapentin. In Carol's case it seems she has developed an opioid dependency following prescription treatment with codeine and then subsequent OTC use.
"I have always found that the biggest issue in cases like Carol's is identifying the problem and now that you have managed that you should have a solid foundation for helping her to change"
She has presented with epigastric pain and whilst there appears to be a reasonably clear picture of opioid withdrawal it is important to establish through a thorough history and examination that there isn't an acute medical condition that might necessitate emergency admission or outpatient referral.
Once this has been excluded an assessment of her codeine use should be carried out. This should include how many tablets she takes, how does she acquire these, what impacts is it having on her, including her home, financial, work and social life. Does she exhibit opioid withdrawal symptoms and what side effects might she be getting from the codeine and in this case the ibuprofen as well? It is useful to establish how she goes about obtaining these as a variety of sources can be used. Since legal restrictions were brought in 2009, pharmacies can only supply up to 32 tablets/capsules and therefore quite complex journeys can be used to visit multiple pharmacies on different days to ensure an adequate supply of medication. This behaviour alone would suggest to me a dependency (see WHO web site) issue even without physical withdrawal.
Increasingly the internet is also used as a supply route for medication and by using non-UK regulated pharmacies it may be possible to obtain much greater numbers of tablets.
Having established that there is a significant dependency issue the next step is to decide on an appropriate management plan. As long as she has no acute medical problem then a drug diary to look at her consumption levels may be useful alongside a urine or oral swab test to confirm opiate use. Nurofen Plus contains 12.8mg of codeine so this allows a fairly accurate assessment of her drug use. If she is dependent a decision needs to be made as to whether a medically assisted withdrawal is appropriate. This will involve supporting much more than just her physical opiate dependency, as it would with any drug user. Consideration should be given to transferring her to prescribed codeine to mitigate the adverse effects of the ibuprofen she is ingesting whilst a management plan is being formulated.
If a medically assisted withdrawal is considered appropriate then a decision has to be made as to the most suitable agent for this. The main options would be:
- Use the drug of choice i.e. codeine using a tapering regime to gradually cut this down. This has the advantage of familiarity and as codeine is available in 15 and 30mg preparations a gradual reduction can be planned. The disadvantages are that this is the drug she has problems controlling her use of and it is short acting so the necessity of needing to take four times a day can reinforce anxiety about her ability to cope.
- The other option for medically assisted withdrawal would be to use some form of opioid substitute treatment; methadone, buprenorphine and slow release morphine would all have their advocates in this situation. All are long-acting so reduce the need to take regular medication. Methadone and buprenorphine consumption can also be confirmed via urine or salivary sampling although of course it is fairly widely known that they are used as treatments for heroin dependency and may therefore have some attached stigma.
It is essential that psycho-social interventions are delivered alongside, ideally before the assisted withdrawal. I would also encourage her to access mutual aid such as Narcotics Anonymous or SMART Recovery. There are also local specialist peer support groups in some areas, and online peer support such as Codeinefree which can be very helpful.
Some people may well derive benefit from acknowledging the problem to their partner and/or family however this isn't universally true. It is certainly something to discuss with her during the early stages of assessment and treatment.
A great advantage of working in a primary care environment is also the ability to follow people up sometimes over months or even years if necessary so I would ensure that a plan of review is not only in place but booked whether we are embarking on a medically assisted withdrawal or not.
I have always found that the biggest issue in cases like Carol's is identifying the problem and now that you have managed that you should have a solid foundation for helping her to change.
Advanced Certificate in the Community Management of Alcohol Use Disorders On-line training course, plus face-to-face day
SMMGP is introducing a new advanced course on the management of alcohol use disorders in primary care.
The course is designed for practitioners such as those who wish to advance their skills to "Practitioner with Special Interest" level.
The content of the course focuses on the management of alcohol use disorders including:
- How to design a primary care based alcohol service.
- Understanding local commissioning structures and processes.
- How to design robust care pathways.
- How to engage with local commissioners to influence service design.
- Comprehensive assessment.
- Patient log.
- Management of complex physical and mental health issues
- Management of special groups including pregnant women, people with dual diagnoses, older people and people who use drugs and alcohol.
- The central role of psychosocial interventions.
- Prescribing, including community detoxification for people with complex problems.
- Relapse prevention and harm reduction.
The format of the course comprises both theory and practice. Throughout the course participants will work towards completing a framework of skills and knowledge that will include online e-learning modules and workbook; attendance at face-to-face training; undertaking a field visit; and assignments and reflective learning from clinical practice.
Each participant will be guided through the process by a tutor. The total study time will be 10 days and the course will require completion in a minimum of 6 months and a maximum of 24 months. A CPD certificate will be awarded on completion of the course.
Target audience for this course includes GPs, nurses and pharmacists and other primary care practitioners. Participants will be expected to have completed the RCGP Certificate in the Management of Alcohol in Primary Care Level 1 and must work with some people with alcohol use disorders (see RCGP web site for details)
Accreditation/Endorsement will be sought from Royal College of General Practitioners (RCGP), Royal College of Nursing (RCN), and Centre for Pharmacy Postgraduate Education (CPPE).
Date of course: Registration for this course is now open.
Cost: The cost of the course is £1700.00 (No VAT is charged).
Registrations: Please contact Sarah Pengelly by e-mail at email@example.com
Network Production Group
Kate Halliday (SMMGP Programme Lead)
Clinical Editor:
Steve Brinksman
Associate Editor:
Elsa Browne (SMMGP Operational Lead)
Elsa Browne
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143 Kingston Road
Tel: 020 7972 1980
To make changes to your subscription of Network please contact Sarah Pengelly.
Would you like to write an article for Network newsletter? Please contact us.
Whilst we encourage open debate and dialogue, the views expressed within this newsletter are not necessarily the views of SMMGP.
Network ISSN 1476-6302
SMMGP works in partnership with The Royal College of General Practitioners (RCGP).
This edition of Network has had funding from Health Education South London (HESL).
The views expressed in this newsletter are not necessarily the views of HESL.


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"One of the finest prog metal releases of recent years. Exceptional" Prog Magazine
"Soaring solo-tastic Australian progressive metal" Metal Hammer
The song "For The Innocent" continues to tell the story of the ill-fated Trapeze Artist who has to navigate the tormenting path of sacrifices to fulfil her dreams of being the world greatest performer following on from the narrative on Her Halo and Out of Subconscious. Discussing the concept guitarist/songwriter Dean Wells elaborates; "We chose to do For the Innocent as a band video based on the response we get from the song at our shows, it has a really great energy and is really fun to play, so we were trying to capture that in this performance based film clip." The songtakes you through the life of the Trapeze Artist, a flash o f her past up until now, a glimpse of her beauty that once was, and her passion that once existed.
In Her Halo Melbourne, Australia's Progressive Metal ensemble Teramaze have created an incredibly layered and textual story of real depth, drama and intensity about events that unfold within a travelling show; the facades, the elation, the extravagant performances and the conflict that lies within everyone involved. The album is the band's first release for Music Theories Recordings which is a part of the Mascot Label Group(Flying Colors, Gov't Mule, Joe Bonamassa, Black Stone Cherry) and they have also teamed up with Tom Maher Management, the home to Anthrax and Motorhead.
Check out the video for Out of Subconscious
And watch Her Halo to follow the story
Website: http://teramaze.com.au/
Twitter: @teramazemusic
Label: www.mascotlabelgroup.com
Teramaze is:
Dean Wells – Guitars / Backing Vocals
Nathan Peachey – Vocals
Dean Kennedy – Drums
Luis Eguren – Bass Guitar
Marc S. Boriosi has many passions including writing, editing, producing, and modern culture. His company, The Levity Ball, is an innovative website that highlights the latest trends and most talented artists in fashion, music, and the arts.
s are closed.
April 12th, 2017
Long gone are the days of VHS porn tapes and trying to sneak home a Playboy magazine. Since 1994[...]
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Continuing their run of star-studded residency announcements, Ushuaïa Ibiza Beach Hotel has confir[...]
February 13th, 2017
We live in a very angry world these days. Politics, jobs, etc. etc.... everything these days is [...]
February 13th, 2017
Breegan Jane knows a thing or two about keeping and creating a busy schedule. Besides being a [...]
January 30th, 2017
Mara Marini is originally from Winnipeg, Canada, and currently living in West Hollywood Californ[...]
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Oh, the noise. It's a never-ending calculated stream of money and business and lowest-common den[...]
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She may not know former Governor of Alaska Sarah Palin personally, but she knows a whole lot of [...]
December 13th, 2016
Chicago, IL --- Mascot Records has announced the global release of Black Sites debut In Monochro[...]
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Known internationally for the past thirty years as a renowned clairvoyant and psychic who has he[...]
October 19th, 2016
It is time we all take charge of our toilet habits and get ourselves a Potty Boss (http://www.po[...]

subset: commoncrawl


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Located within 2 miles (3 km) of Vance County Historical Museum, Quality Inn places you within a few miles (5 km) of Owen Davis Park. This 75-room hotel welcomes guests with free breakfast and conveniences like free in-room WiFi and free self parking. Kerr Lake Country Club is also a short drive from this Henderson hotel.
Start your day off right with a free continental breakfast. Enjoy a leisurely bite to eat at Cabana Mexican Grill, the hotel's onsite restaurant.
Quality Inn's 75 air-conditioned rooms provide microwaves, refrigerators, and coffee makers. Flat-screen TVs come with cable channels, and guests can stay connected with free WiFi. Bathrooms offer hair dryers and free toiletries. Other standard amenities include free newspapers, free local calls, and ironing boards.
Property features
Guests of Quality Inn enjoy a nightclub, free WiFi in public areas, and a conference center. There's free parking if you drive. A multilingual staff is on hand to assist with tours/tickets and securing valuables. Additional amenities include a seasonal outdoor pool, express check-in, and express check-out.
- Free continental breakfast
- Free WiFi in rooms and public areas
- Free parking
- Onsite dining
Quality Inn
Hotel Amenities
Favorite amenities
Hotel Amenities
The hotel offers a restaurant. A complimentary breakfast is offered. High-speed wireless Internet access is complimentary. Event facilities measuring 5100 square feet (459 square meters) include a conference center. This business-friendly hotel also offers a seasonal outdoor pool, a nightclub, and tour/ticket assistance. Complimentary self parking is available on site.
- Total number of rooms - 75
- Free newspapers in lobby
- Free breakfast
- Express check-in
- Express check-out
- Tours/ticket assistance
- Free WiFi
- One meeting room
- Meeting rooms
- Multilingual staff
- Nightclub
- RV, bus, truck parking
- Restaurant
- Safe-deposit box at front desk
- Conference center
- Free self parking
- Conference space size (feet) - 5100
- Conference space size (meters) - 459
- Outdoor seasonal pool
- Wedding services
Family Friendly Amenities
- Family Hotel
- Free Wi-Fi
- Refrigerator
- Microwave
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Free self parking, RV, bus, truck parking
Room Amenities
Quality Inn offers 75 air-conditioned accommodations with complimentary newspapers and coffee/tea makers. Flat-screen televisions come with cable channels. Refrigerators and microwaves are provided. Bathrooms include complimentary toiletries and hair dryers.
Guests can surf the web using the complimentary wireless high-speed Internet access. Business-friendly amenities include desks and phones; free local calls are provided (restrictions may apply).
- In-room climate control (air conditioning)
- Free newspaper
- Air conditioning
- Phone
- Free local calls
- Refrigerator
- Coffee/tea maker
- Microwave
- Free toiletries
- Hair dryer
- Iron/ironing board
- Television
- Desk
- Cribs/infant beds available
- Cable TV service
- Flat-panel TV
- Free WiFi
- Rollaway/extra beds (surcharge)
Where to Eat
Guests are offered a complimentary continental breakfast.
Cabana Mexican Grill - This restaurant specializes in American cuisine and serves breakfast, brunch, lunch, and dinner. Guests can enjoy drinks at the bar.
Nearby Things to Do
Recreational amenities at the hotel include a seasonal outdoor pool.
If you have requests for specific accessibility needs, please note them at check-out when you book your room.
Hotel Policies
Check-in time starts at 3 PM
Check-out time is 11 AM
Payment types
Children and extra beds
- Children are welcome.
- Kids stay free! Children 18 years old and younger stay free when using existing bedding.
- Rollaway/extra beds are available for USD 10.00.
- Cribs (infant beds) are available.
- Pets allowed for an extra charge of USD 15.00 per pet, per night (maximum USD 15.00 per stay), plus a deposit of USD 100 per stay
- 2 per room (up to 50 lb)
You need to know
Extra-person charges may apply and vary depending on property policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
Optional extras
- Pet deposit: USD 100 per stay
- Pet fee: USD 15.00 per pet, per night (maximum USD 15.00 per stay)
- Rollaway beds are available for an additional fee
Hotel Name
- Quality Henderson
- Quality Inn Henderson
We should mention
Children 18 years old and younger stay free when occupying the parent or guardian's room, using existing bedding.


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+ Locations, Office Hours & Directions
Dr. Jonathan Abrams is an anesthesiologist in Summit, who manages patient pain levels before, during, and after surgical procedures.
We invite you to write a review about your experience with Dr. Abrams.
(706) 434-8906
99 Beauvoir Avenue, Summit, NJ 07901-3533
|Doctor Specialties
|Anesthesiology & Interventional Pain Management
|Practice Specialty
|Multi Specialty
|Languages Spoken
|43 See them all
|Doctor's Specialties
|Anesthesiology & Interventional Pain Management
|Doctor's Title
|Practice Specialty
|Multi Specialty
33 Overlook Road, Suite 311, Summit, NJ 07901
|Doctor Specialty
|Practice Specialty
|Languages Spoken
|Doctor's Specialty
|Doctor's Title
|Practice Specialty
NOTE: Please contact the doctor's office to confirm your coverage before making an appointment.
Dr. Jonathan Abrams graduated from Other in 1986.
Dr. Abrams has two offices in New Jersey where he specializes in Anesthesiology and Interventional Pain Management.
Dr. Abrams works with forty-two doctors including Dr. Ruoxu You and Dr. Tejal Mehta.
As an anesthesiologist in Summit, NJ, Dr. Abrams ensures patients are free of pain before (pre-op), during, and after (post-op) a surgical procedure. By administering anesthesia, Dr. Abrams ensures that patients do not feel the pain of a surgical procedure.
As an interventional pain management specialist in New Jersey, Dr. Abrams focuses on relieving chronic pain in patients. Interventional pain specialists offer pain relief by blocking or interrupting the transmission of neurological pain signals in the brain. Dr. Abrams may perform treatments such as spinal cord and nerve stimulation, nerve or medial branch blocks, medication management, or the implantation of drug delivery systems.
Please Note: The information displayed below is sourced from the 2014 Medicare Physician and Other Supplier National Provider Identifier (NPI) Aggregate Report. It's important to remember that the statistics below are not inclusive of all patients treated by Dr. Abrams, but only those who participate in Medicare.
Read the most recent articles about Anesthesiology
See our Privacy Policy and Terms of Use.


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Track Listing: 1. Rhinoceros; 2. Bright Idea; 3. New Leaf; 4. Zaftig; 5. Bas Relief; 6. Blue On One Side; 7. Wing & Prayer; 8. Low Slung/High Strung; 9. Like it Never Was.
Personnel: Drew Gress (bass instrument); Tim Berne (alto saxophone); Ralph Alessi (trumpet); Craig Taborn (piano); Tom Rainey (drums).
We need your help and we have a deal. Contribute $20 and we'll hide the six Google ads that appear on every page for a full year!


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Georgian cuisine is probably the most important attraction of the country. Since the traditional Georgian feast is an integral element of culture, Georgian entertainment should match its high level. Georgians have managed to make their cuisine not only magically delicious but also bright, original, exquisite, unique and unforgettable.
Therefore, Georgian cuisine absorbed the best culinary traditions of many people of Transcaucasia, Asia and the Black Sea coast. The western part of Georgia was affected by Turkish cuisine, the eastern – by Iranian. Therefore, in the western Georgia widespread are the corn flour flat cakes– mchadi, while in the eastern Georgia people prefer white bread baked in huge deep circular clay ovens.
The easterners use corn flour to cook thick mash - ghomi - and eat it instead of bread with meat and vegetable dishes. Eastern Georgians cook mutton, use many animal fats along with the core Georgian meat – beef, while in the Western Georgia they eat much less meat and favor poultry – chicken and turkeys.
In western Georgia, they prefer rennet cheeses- suluguni and Imeretian. As for the eastern Georgia, there they prefer spicy and salty cheeses – Kobian, Tushian and Georgian. Both western and eastern Georgia is famous for their special spice sauce from nuts and spices used with meats.
However, these insignificant differences cannot be the reason of distinguishing between western and eastern cuisines. There is only one "Georgian cuisine" when it comes to reception of a guest of honor. And of course only the freshest ingredients, obligatory sauces, seasonings, spices and greens are used for cooking …
"When God was distributing portions of the world to all the people of the Earth, the Georgians were having a party and doing some serious drinking. As a result, they arrived late and were told by God that all the land had been distributed. When they replied that they were late only because they had been lifting their glasses in praise of Him, God was pleased, and gave the Georgians that part of Earth He had been reserving for Himself." (The Legend)


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Actor Aishwarya Rai Bachchan, 38, got rave reviews for the traditional attire she wore on her first trip abroad, post motherhood, at the Dubai World Cup.
The mother of the four-month-old looked chic in an ethnic red Sabyasachi tunic that she paired with golden sandals.
"It's wonderful to be here and see such finely dressed women in their hats and beautiful dresses," Aishwarya Rai Bachchan said at the presentation ceremony
Aishwarya was there as Longines brand ambassador to present Most Elegant Lady prize to Carolyn Coe.
It was Beti B's first trip as well. "Yes, I am travelling with my baby and it's just wonderful to be in Dubai," she told Gulf News.


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We look forward to welcoming you back to The Peterborough Arena on 14th & 15th October 2017.
The 2016 National Festival of Railway Modelling hosted over 30 layouts from a variety of major scales and gauges plus over 100 quality traders and demonstrators. Visitors were able to stock up on essentials for their hobby and enjoy a family day out, our Peterborough Show offers something for everyone.
We were excited to introduce the Garden Rail Area including exhibitors; The Garden Rail Specialists, The G Society and Chalk Garden Rail and Michael Smith was also in attendance with his G-Scale layout 'Roche Junction'.
Visitor comments included "Enjoyed the show very much indeed on Saturday - was there from 9.30 till 5, and even thought of returning the next day! That's how good it was! But unfortunately had other commitments. Great layouts, excellent trade, useful demonstrations - all in a fabulous spacious venue. What more do you want? I'm fortunate in being able to go to lots of exhibitions each year. This one has been my favourite so far. Even though I'm planning to attend two more I'm guessing Peterborough will be hard to beat! Thanks to all those involved"
The show is sponsored & supported by:
Booking for the National Festival of Railway Modelling will open Summer 2017
Admire over 30 hand-picked layouts which will be on display at the show.
There will be over 100 exhibitors trading throughout the weekend.
Find out which Clubs & Societies will be attending the show.
The place to meet the team and learn something new!
Everything you need to know about getting here and more.