Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults

Context

Medicines associated with dependence include benzodiazepines, Z‑drugs (such as zopiclone and zolpidem), opioids, gabapentin and pregabalin. Antidepressants, although historically not classified as dependence-forming medicines, can nevertheless cause withdrawal symptoms when they are stopped. This guideline focuses on medicines that are usually used for conditions that are chronic, complex and difficult to treat, such as anxiety and insomnia, chronic pain including neuropathic pain, depression and generalised anxiety disorder. It also covers medicines that were initially prescribed for acute pain but continue to be prescribed over a longer term.

These medicines can provide lasting symptom management with a favourable balance of benefits and adverse effects for many people. But like all medicines, they do not work for everyone and can have negative consequences that outweigh their benefits. Even when people are not getting clinical benefit, these medicines may sometimes continue to be prescribed for various reasons, including concerns about the risk of unpleasant withdrawal symptoms or fear of worsening of the underlying condition.

Dependence is characterised by both tolerance (the need for increasing doses to maintain the same effect) and withdrawal symptoms. Dependence is a common and well described property of a number of medicines and is not in itself a contraindication to continued or new prescribing. Dependence becomes clinically important if treatment reduction or cessation is needed.

Dependence is different from addiction. Addiction also features tolerance and withdrawal but is accompanied by additional characteristics of cravings, lack of control, overuse and continued use despite harm. Addiction is also associated with problematic behaviours including unsanctioned dose escalations and seeking early prescriptions or prescriptions from multiple prescribers. There is considerable debate about these definitions and in practice the terms are often used interchangeably. This guideline uses the term 'problems associated with dependence' to refer to these behaviours; the term 'addiction' has not been used because of its potential to stigmatise.

This guideline applies to people prescribed a medicine associated with dependence and withdrawal symptoms, and is not limited to people at high risk of developing problems associated with dependence.

There is wide variation in the prescribing of medicines associated with dependence or withdrawal symptoms. People with a dependence on prescribed medicines may be reluctant to seek help from their healthcare professionals because of a perceived stigma of dependence, which they may associate with illicit drug use or alcohol misuse.

Professional and policy bodies have issued guidelines on the clinical use of medicines associated with dependence or withdrawal symptoms. However, there are few guidelines that focus on avoiding dependence and managing withdrawal from prescribed medicines. This guideline aims to meet the need for evidence-based advice in these areas. It supports safe practice in all settings in which medicines associated with dependence or withdrawal are prescribed.