THERE has been a lot of helpful and challenging information in your coverage of prescription drug problems, A Bitter Pill, this week. The use and misuse of gabapentin, pregabalin and antidepressant medicines was highlighted on Tuesday (October 3). These are all prescription medicines, typically prescribed by a patient's GP – but also increasingly traded with a street value.

What isn't made clear is that gabapentin and pregabalin are almost universally prescribed by GPs for persistent pain of a neuropathic type. Neuropathic means damaged nerve pain and the most clear-cut is a complication of long-term diabetes when burning lower limb and foot pain can result. Pregabalin is very rarely prescribed for anxiety or seizures.

Because opioid drugs including codeine are clearly addictive, it is inevitable that GPs consider whether these neuropathic pain killers might be effective as an alternative. The complexity of chronic pain, often experienced by people with other health problems, requires improved availability of pain psychological therapies via specialist pain management clinics. Actually, our first line treatment for neuropathic pain is with lower dose amitriptyline which had widespread use as an antidepressant in the 1960s and 70s.

Antidepressants are used not just for mood disorder but also to good effect for anxiety disorders, of which there were 8.2million cases in the UK in 2013. In both diagnoses, GPs adopt a first, do not prescribe approach, while assessment, information and non-drug approaches are considered. Talking therapies such as Cognitive behavioural therapy (CBT) and Mindfulness and stress management training are more available in the NHS than in the past but not readily so.

For those who benefit from a course of antidepressants, it is usual to consider tapering the dose and stopping after nine-12 months. However, at this point, both in those with a mental health diagnosis and those with persistent pain, there can be a reluctance to risk that change. This is especially so for those who either have addiction problems or experience an unhappy life where the next social or family crisis is just round the corner.

Anti-depressants are not addictive. The commonly prescribed SSRI medicines such as citalopram and fluoxetine do have some odd discontinuation symptoms (sometimes referred to as withdrawal) which are nearly always transient and avoided by planned gradual reduction in dose. It is important to remember that best research suggests that only around 60 per cent of those treated appropriately with antidepressants will benefit fully.

The BMA has called for improvement in the prevention and management of prescribed drug dependence with particular reference to prescribing of benzodiazepines and Z drugs, used for anxiety and insomnia. There is already widespread effort from GPs, pharmacists and practice teams to tackle this. All are aware of guidance that these should be prescribed with great care and for no longer than two to three weeks. Further advice and help on that front will be appreciated perhaps especially from pharmacists who are well placed to spend time face to face with patients if funded.

Philip Gaskell,

General Practitioner locum,

Woodlands Lodge, Buchanan Castle Estate, Drymen.