I had a huge breakdown during the pandemic, so it was trial and error with a few medications until I was put on [antidepressant] Venlafaxine,’ says Amy from London. ‘The pandemic negatively impacted my mental health, especially with isolation from friends and family and stress at work.’
Amy is just one of thousands of people who required medication for the stresses of the past two years. Accessing treatment has been crucial; life saving for many. And yet, as restrictions are finally lifted and ‘normality’ is returning, the issue of prescription drugs is a difficult one to untangle. Demand for medication of all kinds, not just antidepressants but anti-anxiety drugs such as benzodiazepines and opioid painkillers including oxycodone, has dovetailed. Partly due to GPs having few other treatment options during the lockdowns, and seemingly also owing to a culture of fast pharmaceutical solutions — prescription numbers for medications have been rising for years. Now usage is everywhere in London, both medically and, thanks to opportunistic new ‘suppliers’, recreationally, and the question is: are things out of control?
The ease of access to help via online services and phone calls to GPs was important to Amy: ‘I need antidepressants to be able to live a normal life. A lot of my friends, family and colleagues also take antidepressants and it really isn’t anything to be ashamed of.’ But when the official waiting list for NHS mental-health care is 1.6 million and one in four people is waiting three months or more for mental-health help, a more medicalised route is often the quickest fix for GPs and patients.
Yet across the scope of prescription pills, there are risks of dependency. Especially since unlike, say, cocaine, they aren’t illicit. Often users don’t think they’re the ‘addict’ type. ‘An addict as generally portrayed in the media is going to be far from somebody who has inadvertently developed an addiction to benzodiazepines, or alcohol for that matter,’ says Matt Thomas, a consultant on the Forward Trust’s Taking Action on Addiction campaign. ‘Somebody who’s become dependent on prescription medication, or even over-the-counter medication like codeine, is going to find it hard to accept there’s an issue going on. But addiction can happen to anyone.’ Thomas is particularly concerned with where we find ourselves this year and how demand for medication is creeping out of legitimate usage: ‘Given the stresses and strains of 2022 I’m concerned there’s going to be a rise in people self-medicating. Whether it’s the pandemic, the climate crisis, the financial crisis, what’s going on politically and the overwhelming external stimuli of news and social media, there’s a very marked need for people to find coping mechanisms.’
This generation can have drugs delivered to their door like an Amazon package
Some medical authorities worry that GPs have fuelled the demand by being a bit cavalier with prescriptions. More than six million people in England from June to September 2020 received antidepressants, the most on record; this was accompanied by a fall in referrals to psychological therapies services. The mental health charity Rethink warned that medications must go hand in hand with therapy services, and the British Psychological Society expressed similar concern.
Nuno Albuquerque, consultant treatment lead for the UK Addiction Treatment group, has been troubled by the trend: ‘It absolutely was made easier for people to access prescription drugs during the pandemic. Having an over-the-phone consultation for five minutes is nowhere near the level of interaction a GP should be having with every patient. Face-to-face appointments allow for more open and honest communication of symptoms. GPs have to take everything said with merit and more often than not, and because of the overwhelming burden of the pandemic, this would have led to a prescribed drug being issued as the easiest route from A to B.
‘We should be learning from [this]. GPs were never given support or guidance with how to deal with patients over the phone for such a prolonged period of time. IT systems couldn’t cope with the demand. Most importantly, we urge GPs to work back through their patients who were given repeat prescriptions or issued with a new prescription for an opioid drug, because ultimately the more the patient uses this type of drug, the more damage can be caused.’
While TV shows such as Euphoria and headline stories about hundreds of thousands killed by OxyContin have made the United States the assumed focus of an opioid crisis, the fact is from 1998 to 2018 the number of opioid prescriptions issued by GPs in England doubled. In December 2021 The Lancet reported that the UK had the highest consumption rate of prescription opioids for pain management per capita in the world, following drastic decreases in the US, Germany and Canada. By April the National Institute for Health and Care Excellence (Nice) had published guidelines recommending opioids not to be used for the treatment of chronic pain. Little doubt that the pandemic has brought a troubling underlying trend to a head. However, the prescription drugs issue should not be a way to get at under-pressure GPs: there is a bigger picture here, with a deep social need behind it. ‘Increasing consumption is an unconscious way of dealing with exacerbated mental health problems,’ says Thomas — coupled with opportunistic exploitation.
Given the ease with which you can get prescription pills whether you have a prescription or not, legitimate usage is not the only story. ‘Problematic prescription drug use, like all drug use, is often based on availability. People will often acquire drugs based on ease of access,’ says treatment consultant Michael Rawlinson, who works at the Forward Trust’s Clouds House. ‘For example, the emergence of internet marketplaces (including apparently legitimate outlets) and sophisticated drugs networks and markets have lowered the barriers to people attaining prescription and illegal drugs.’
Deaths related to drug poisoning in England and Wales reached a record high in 2020 of 4,561 with half those deaths involving a pain relief opiate such as Codeine or a synthetic opiate like fentanyl — up 48 per cent from 2010. ‘Dark web’ marketplaces feature whole sections on such prescription drugs and hundreds of buying options. Blister packs of Xanax are available for delivery within two days in London, using ‘stealth shipping’.
‘I know there’s an epidemic of school-aged children using benzos, particularly Xanax — I’ve done some work at a school education level and it’s something that’s incredibly popular with mid-teenagers at the moment,’ says Thomas, who has been through an addiction to benzodiazepines. ‘With a combination of GPs, pharmacies, online and the street, I managed to have a constant supply. It was very easy to get hold of them, way too easy because they are really, really hard to come off.’
The truth is the black market for pharmaceuticals is not that black. ‘Study drugs’ are in the news; stimulants such as Ritalin and Modafinil, which students use to help with cognitive function. Modafinil is for ‘people with narcolepsy, sleep apnoea, or those with a changing shift pattern that makes it difficult to get enough rest during sleeping hours’. That’s according to an online pharmacy where I arrived at checkout with a box for £89.99 after easily navigating a ‘consultation’ — if that’s what you call a checklist with leading questions. Many websites don’t even require a questionnaire.
No wonder Joe Sheerer, programmes manager at the Amy Winehouse Foundation is worried about young people’s access to drugs, which are also ‘shoppable’ on social media. ‘Dealers will set up a fake Snapchat account, which lists available drugs, and then post them out remotely,’ says Sheerer. ‘The young people I’ve talked to won’t give out their number to do a drug deal on the phone, they use social media platforms. And often the drugs are fakes — you don’t know what’s in them.’ The Independent found one in five 13- to 15-year-olds has seen drugs for sale on social media. Snapchat announced last month it was restricting its ‘Quick Add’ friend recommendation feature for 13- to 17-year-olds via which dealers have been targeting minors.
But for Sheerer, the solution to this problem is about examining not only the increase in supply but the human demand: ‘As a society we need to be looking at educating and supporting people more. While there is criminality that needs to be tackled — gangs and dealers — it’s also got to be about why young people are taking the drugs. When I went home as a kid, I was safe, but for this generation on social media, the pressures continue, they aren’t getting a break. And then they can have drugs delivered to their door like an Amazon package.’ The foundation’s work takes place in schools with a variety of programmes focused on personal issues rather than straight anti-drugs rhetoric. ‘We concentrate on prevention, the ways in which young people can feel better about themselves,’ Sheerer says.
While scurrilous forces are at work — be that big pharma or drug gangs — and are being battled in the capital (last July the City of London Police’s Serious Organised Crime Team raided six premises and seized 1,200kg of Class C pharmaceuticals made in India), to tackle the issues truly requires a total rethink of how we view addiction, medication and mental health support. Dr Alex George’s #postyourpill social media campaign recently showed not only how many people are on medication, particularly antidepressants, but the value in bringing discussions out into the open. In the stigmatised world of medication where legitimate users in need of help are too ashamed to talk about it, no wonder young people are choosing black-market routes to find support. A secret package ordered online may well be preferable to having to talk to parents, GPs and a system of slow, underfunded mental health services headed up by people who are dismissive of it (Nadine Dorries, Mental Health Minister at the time, claimed during the lockdown restrictions last year, ‘We are not in the middle of a MH crisis,’ when urgent and emergency mental health referrals were at the highest level ever recorded.)
In Nuno Alburqueque’s experience dealing directly with patients, he recommends a slower and more holistic approach. ‘We need eye contact and time to explore. When someone comes to us with an addiction, we might not remove the medication — which can be scary — but gradually reduce it and find alternatives, like acupuncture or cognitive behavioural therapy. It’s difficult because they have been depleting the National Health Service for years. Now more than ever you need tools and services to help mental health but it’s difficult because they are limited compared to the demand.’
The answer, surely, is to be able to talk about the need for medication. Not seek to remove it but to aid legitimate usage as part of a fully rounded support system for those in need, and a cultural change where getting help isn’t stigmatised. Amy said she has seen a generational shift. ‘It’s so important to break the stigma as too many people suffer in silence. My dad initially struggled coming to terms with my mental health. Now my family are much more open, accepting and supportive and I honestly couldn’t have got through my struggles without them — I’m glad I eventually opened up.’ From a services point of view, Thomas stresses, ‘institutions like the Forward Trust can help when the wheels comes off, but we want to educate the public to show the wheels don’t have to come off before they ask for help’.
