by Max Larkinson & James Bamford
Earlier this year the Public Accounts Committee (PAC) published a report on Addiction Services in Northern Ireland (NI), highlighting a steady increase of both alcohol- and drug-specific deaths (Figure 1, below). The use of prescription drugs, including anti-depressants, has been a significant issue in NI for nearly a decade, with usage and prescription rates far higher than in other parts of the UK. This blog article explores the use of prescription drugs in NI, the causes, implications and the effects of COVID-19, as well as the Department of Health’s new 10-year strategy to help combat substance abuse.
Figure 1: Drug related deaths in Northern Ireland
Types of prescription drugs
Prescription drugs encompass a wide range of medication, from statins to blood pressure tablets and anti-depressants to antibiotics. Some prescription drugs are open to misuse through either illegal purchase, use of someone else’s medication or using prescribed medication in a way other than intended. The three most commonly recorded prescription drugs that are implicated in drug-related deaths are diazepam, tramadol and pregabalin. These three drugs are thought to be particularly problematic due to their addictive nature and more severe side effects (Table 1, below).
| Diazepam | Tramadol | Pregabalin | |
| Type of drug | Anti-depressant | Painkiller | Anti-epileptic |
| Class of drug | Benzodiazepine | Opioid | Gabapentinoids |
| Used to treat | Anxiety, seizures, alcohol withdrawal | Post-operation, severe injuries, chronic pain | Epilepsy, chronic pain, anxiety |
| Mode of action | Slows brain activity | Blocks pain signals to brain | Reduces pain signal and slows brain activity |
| Side effects | Addiction | Physical dependence | Euphoria, relaxation, hallucinations |
| Withdrawal symptoms | Hallucinations, convulsions | Anxiety, depressions, depersonalisation | Depression, anxiety, suicidal thoughts |
Table 1: Commonly misused prescription drugs
Prevalence of prescription drugs in NI
In 2014, research undertaken for The Detail, entitled The Script Report, highlighted the prevalence of prescription drugs in NI. Prescription rates for more than 40 of the drugs examined in the study were greater in NI than in England. The report also revealed that prescription rates of anti-depressants in particular, exceeded those in more than 20 different countries, including the rest of the UK, Canada and Australia.
Since The Script Report was published, the rate at which prescription drugs are prescribed in NI continues to be greater than those of its UK counter parts. In 2020, a NI Audit Office (NIAO) report on Addiction Services found that prescription rates for both diazepam and pregabalin were higher per person in NI than any other part in the UK. For diazepam, the rate of prescription in NI was 3.5 times that of England.
The misuse of prescription drugs in NI also appears to have increased. Drug-related deaths have been steadily increasing, reaching an all-time high of 218 in 2020 (Figure 1). The majority of these deaths involve prescription drugs, almost all deaths featuring diazepam, tramadol or pregabalin. Pregabalin is most common, implicated in 35% of drug-related deaths recorded in 2019, diazepam in 26% and tramadol in 13% (Figure 1). Pregabalin in particular, is a major cause for concern given the rapid rise of related deaths. As can be seen in Figure 1, this number has gone from five deaths in 2014 to 70 by 2020.
What are the reasons for substance abuse in NI?
Deprivation
As with other parts of the UK, the prescription rates of drugs such as anti-depressants in NI correlate strongly with deprivation. A recent study found that GP practices in areas of high deprivation, the majority of which were located in metropolitan areas, had prescribed 40.3% more drugs per patient compared to practices located in low deprivation areas. Those living in more deprived areas were also five times more likely to die from a drug-related death, this is reflected in Figure 2, where the majority of these deaths are located in the Belfast area.
Figure 2. Map of Northern Ireland indicating areas corresponding to drug-related deaths, deprivation and access to in-house GP practice counselling.
In Figure 2, the drug-related deaths (number of deaths and age-standardised mortality rate per 100,000 population) and deprivation (multiple deprivation measures, MDM, score) are shown by local government district (LGD). Access to counselling (percentage of GP practices offering in-house counselling) is shown by constituency. By zooming in on the deprivation map, the MDM score for Super Output Areas (SOAs) is revealed, providing deprivation rankings of smaller areas.
Mental health
Another factor contributing to the prevalence of prescription drug misuse in NI is the issue of mental health. In NI, mental health is the largest cause of ill health and disability, and rates of mental health issues here are greater than elsewhere in the UK. In 2020, a Youth Wellbeing Survey revealed that in NI anxiety and depression is 25% more common in people under 19 years old than in England, Scotland or Wales. While the prescription of anti-depressants or other medication is often an effective treatment method for mental ill health, the addictive nature of certain drugs, such as diazepam and pregabalin (Table 1), increases the risk of misuse.
Legacy of conflict
According to the Lancet, conflict-related traumatic experiences among the population as a result of the Troubles contribute to the greater prevalence of mental health issues in NI, than in other UK nations. While the population included in more recent studies of prescription rates in NI are less likely to have experienced direct conflict, it is acknowledged that transgenerational trauma could play a role. Furthermore, the Northern Ireland Commission for Children and Young People (NICCYP) has stated that children and young people in particular, continue to be at risk of violence and abuse by paramilitary and criminal gangs which can have a direct impact on their mental well-being.
Impact of COVID-19 on substance abuse
While it is still too early to tell the true impact that the global pandemic has had on substance abuse, including the misuse of prescription drugs, the effects on mental health are already becoming clear. A combination of social isolation, increased unemployment, school closures and an increase in domestic violence rates across the UK are thought to have exacerbated pre-existing mental health issues and created new ones. In addition to this, many health and support services, including addiction services, were temporarily suspended or switched to online and telephone appointment systems. While still important, the change in quality of service remains to be determined. Therefore, it may be reasonable to expect that the increased mental ill health as a result of the COVID-19 pandemic, could lead to an increase in misuse of prescription drugs.
Impact of prescription drug misuse in NI
Misuse of prescription drugs can have a broad range of negative health, social and economic outcomes:
Health outcomes
All drugs have side effects. When prescribing a drug, these side effects are balanced against the symptoms that the drug is designed to treat. When certain prescription drugs are misused, for example with pregabalin (Table 1) the user can develop a dependence which brings with it a range of negative health outcomes including experiencing withdrawal symptoms, the potential to overdose and, in extreme circumstances, death.
Social outcomes
Increasingly, prescription drugs which are misused are obtained through illegal means. Through this process, users and suppliers are often involved in antisocial behaviour, damage to property, violence and other criminal activities. This includes the previously mentioned NICCYP warning regarding young people and organised crime.
Economic outcomes
The Department of Health (DoH) has estimated that alcohol misuse results in a loss of around £900 million per year, including costs associated with health and social care; impact of antisocial and criminal behaviour; and, impact on employment. While there are currently no similar estimates for the cost of drug misuse in NI, population-based estimates using the UK’s total drug misuse costs come to approximately £600 million per year. In contrast, the annual budget for implementing the previous drug and alcohol strategy was £8 million. A further £8 million is also ring-fenced for addiction services from the DoH mental health budget.
What help and support is currently available in NI?
In some cases, for mild to moderate depressive illness, alternative therapies such as cognitive behavioural therapy and counselling can be as effective as anti-depressants. However, the PAC report published earlier this year commented on the ‘often long waiting lists’ associated with such therapies. The Committee also criticised the withdrawal of funding from Community and Voluntary Sector organisations which it described as providing ‘effective harm reduction services’ that ‘should be a priority’, such as Needle and Syringe Exchange and Take Home Naloxone.
While the services mentioned above are available in some Health and Social Care Trust sites, such as Antrim and Omagh, their availability is not consistent throughout the country and so access can be limited. This postcode lottery is also in effect for counselling, including mental health and substance abuse counselling. As of 2021, more than 30% of GP practices in NI did not offer an in-house counselling service. These practices are more likely to be located in areas of increased deprivation, creating regional disparities (Figure 2).
New strategy: Preventing Harm, Empowering Recovery
The DoH published its new strategy for combating substance abuse in 2021, as a commitment to ‘New Decade New Approach’. The ten-year strategy aims to improve services and reduce harm relating to substance misuse. A number of actions were outlined, including improved education of the general public to increase awareness; updating the Prescription Drug Misuse Action Plan; and, increased equal access to high quality treatment and support services.
While the new strategy presents the opportunity for welcome change, the PAC report mentioned earlier highlighted some concerns. Of the extra funding required by the strategy, more than £6 million per year has yet to be secured. The Committee indicated that properly funding this strategy was a ‘clear spend-to-save’ initiative and that improper funding would hinder its implementation. Another area of concern was the quality of data provided by public sector services, as well as the Community and Voluntary Sector, that much of the strategy is based on. In some cases, there were gaps in the information provided and in other circumstances, the data collected was mainly usage, rather than outcome-based. While still informative, a lack of outcome-based data makes it hard to evaluate the effectiveness of an action put in place by the strategy.
Conclusion
The misuse of prescription drugs in NI is a long running and increasing problem. Both prescription rates and prescription drug-related deaths are on the rise and exceed those in other UK nations. The misuse of these drugs is linked to deprivation, mental health and NI’s lasting trauma from a legacy of conflict. Unfortunately, the COVID-19 pandemic has contributed to these factors and exacerbated deeply rooted health inequalities. The new strategy published last year by the DoH to tackle these issues has yet to be fully implemented, but it is certainly a welcome step in the right direction.