Dr Des Corrigan on potential lubrication for the constipated decision-making process in Health
There are occasions when I know that I sound like a broken record, and the pregabalin saga is one of those. I have been calling for the reclassification of the gabapentinoids at various committees and in numerous Irish Pharmacist articles since 2017. The fact that I have been totally ignored by the mandarins in the Dept of Health has been easier to bear because I realise that I am in good company, given that the views of the Coroners Society of Ireland and The Irish Times have been similarly dismissed.
Now the Medical Council has got in on the act and perhaps this might lubricate the constipated decision-making process in Health, although I am not convinced that there is sufficient bureaucratic or political will to act in a way that might save lives. The Medical Council views that pregabalin and gabapentin should be reclassified as Controlled Drugs under the Misuse of Drugs Acts is just one of the recommendations in Examining the Over-Prescribing of Benzodiazepines, Z drugs and Gabapentinoids in Ireland: Report of Multi-Agency Working Group on Over-Prescribing, published at the end of February.
The reclassification into Schedule 4 of the Misuse of Drugs Act of pregabalin, which might save lives by reducing diversion onto the black market, should not prevent its legitimate prescription for both licensed indications and its ‘off- label’ uses. I have previously noted the existence of a black market, as described by the Coroners Society in its efforts to reduce the harms caused by polydrug use involving pregabalin. The February 025 Report draws attention to the fact that 41 per cent of the pregabalin in the UK is illicitly sourced.
In order to decrease the numbers requiring prescriptions of the three drug groups, the report also recommends increasing resources for counselling services, pain management clinics and addiction services and for those dependent on these drugs, referral to appropriate drug treatment services is essential. The report also recommends consideration of legislative options to allow private prescribing data to be accessed in order to better monitor and control over-prescribing. In calling for the setting up of a central repository for all prescribing data, the report commented on the lack of a complete picture of the extent of prescribing of these drugs, because the PCRS data on which the authors relied does not include private patients who are not within the DPS or those below the €80 co-payment threshold under the DPS. Thus, it is not really possible to detect and distinguish between irresponsible but deliberate prescribing, and inadvertent over-prescribing.
Notwithstanding the resourcing and data protection issues involved in setting up such a prescription drug monitoring programme, its benefits could include real-time checking for doctor or pharmacy ‘shopping’ and earlier identification of problematic prescription drug use.
Knowing the overall number of prescriptions for pregabalin would help of course because the published research and the Medical Council report highlight a correlation between the increased prescribing and the increased drug poisoning deaths where pregabalin was detected post mortem. But such an overall number cannot, in my opinion, give a full picture of the level of pregabalin actually consumed by patients and others in a given year.
As readers know only too well, the 96 pregabalin products licensed by the HPRA come in a variety of strengths, ranging from 20mg up to 300mg. If researchers were able to develop a Defined Daily Dose of pregabalin and a representative sample of the prescription data investigated to determine exactly how much pregabalin is being used per capita, then we might have a truer picture of exposure levels.
It would also help if we could know whether the tragic deaths linked to pregabalin were occurring in those for whom it had been legitimately prescribed, or otherwise. The team from the National Drug Related Deaths Index have repeatedly stated that it is very difficult if not impossible to establish if pregabalin or any other drug had been prescribed for the deceased. Access to such information might help establish the true extent of deaths associated with non-prescribed use versus fatalities in bona fide patients. Such access could be another benefit of a central repository.
The report also recommended that “further educational initiatives should be developed for doctors, pharmacists and the public to increase awareness of the risks associated with benzodiazepine, Z-drug and gabapentenoid use”. Not surprisingly, this is something with which I wholeheartedly agree.
I feel a certain degree of smugness about this, since I helped set up the Addiction Pharmacy module as part of the Trinity Degree course before I retired from full-time academia. This module is still presented to the Fifth Year M.Pharm students in TCD, although Professors Fabio Boylan & Cicely Roche have taken
I have a strong feeling that there is a need for a comparable ‘Addiction Medicine’ module
for medical students
it to a level that far exceeds anything that I could have dreamt of.
The module integrates theoretical aspects via contributions from pharmaceutical chemistry, pharmacology and pharmacognosy alongside detailed contributions from practitioners, most of whom have a pharmacy background. Thus, not only does it have a knowledge emphasis, but it is also skills-based, for example in the areas of smoking cessation and importantly, brief interventions. Workshops on the role of the pharmacist in harm reduction, on the Methadone Protocol and developing personal resilience also ensures a real- world emphasis within the module.
I have a strong feeling that there is a need for a comparable ‘Addiction Medicine’ module for medical students, as I am not convinced that their level of undergraduate exposure to issues associated with substance use disorders and harm reduction is as good or as complete as it needs to be in this day and age.
This long-held view was strengthened by an article earlier this year in Substance Use and Addiction Journal that looked at substance use disorder curricula in North American medical schools.
Large gaps related to medications for opioid use disorder, treating overdoses and withdrawal, as well as disturbing stigmatising attitudes were identified. The February issue of the Irish Journal of Medical Science published a survey of the perspectives of 34 Irish neurologists on cannabis-based medicines. It concluded that there was a need for educational programmes on the cannabinoid system and cannabinoid-based medicines, again highlighting gaps in medical education.
I am convinced that inputs from knowledgeable pharmacists with experience in the addiction area should be an integral part of any initiative for medical undergraduates and trainees. After all (and to coin a phrase), drugs and medicines are our bread and butter!
Dr Des Corrigan, Best Contribution in Pharmacy Award (winner), GSK Medical Media Awards 2014, is an Adjunct Associate Professor at the School of Pharmacy and Pharmaceutical Sciences at TCD where he was previously Director and won the Lifetime Achievement Award at the 2009 Pharmacist Awards. He was chair of the Government’s National Advisory Committee on Drugs from 2000 to 2011, having previously chaired the Scientific and Risk Assessment Committees at the EU’s Drugs Agency in Lisbon. He chaired the Advisory Subcommittee on Herbal Medicines and was a member of the Advisory Committee on Human Medicines at the HPRA from 2007 to 2024. He has been a National Expert
on Committee 13B (Phytochemistry) at the European Pharmacopoeia in Strasbourg and served on the editorial boards of a number of scientific journals on herbal medicine.
