GHA holds firm on decision to restrict Lidocaine prescriptions

The GHA’s decision to restrict the prescription of Lidocaine patches drew flak at a recent public meeting, but health managers insist there is no scientific evidence to support widespread use of the analgesic drug for common conditions such as lower back pain.

In the City Hall, members of the public quizzed the GHA’s Director General, Patrick Geoghegan, and Chief Pharmacist Ed Freestone not just over the decision to stop prescribing the patches, but also the absence of alternatives.

Lidocaine had been prescribed here in the past for a range of conditions including lower back and musculoskeletal pain, but recent reviews in the UK show the evidence supporting such use is “very weak”.

The GHA is holding firm on the move despite the public backlash, although an appeals process allows for individual cases to be reviewed, in some cases successfully.

After the meeting, Mr Freestone told the Chronicle the patches cost the GHA £250,000 in 2019 even though they were not an effective treatment.

He explained that for lower back pain, the best treatment is therapy and not pain killers.

No alternative pain killers are being offered as there are none on the market which have been found to be an appropriate treatment, Mr Freestone explained.

He added two UK reports from external assessors found the evidence base for the use of Lidocaine patches to treat back pain was “awful” and that the drug is “virtually” not in use in the UK.

The drug was withdrawn from use in Gibraltar after the GHA found it was “spending money on something that didn’t work”, Mr Freestone said.

Yesterday, against the backdrop of continued public concern about the decision, the GHA advised the drug would not be reintroduced.

“The GHA has carried out a major exercise in the reform of the medicines used on the GPMS scheme supported by its clinicians, using the published evidence and guidance to inform its decisions, whilst being sympathetic to patients’ views,” Director General Prof Patrick Geoghegan said.

“Where there has been good evidence to support individual cases, this has been heard and the policy adapted, which is about showing empathy for patient concerns.”

“The fact that appeals are successful is showing evidence of informed patient-specific decision-making, not always a one-size-fits-all approach.”

“As I have said all along, it is the clinicians who are making the decisions on the most effective approach, including drug prescribing for the people of Gibraltar.”

“The GHA is here to help, but we ask the public to listen and collaborate with the clinical advice given.”

The statement from Prof Geoghegan followed on from continued questions, not just from the public but also the GSD.

The process to remove the drug from the prescription list, the GHA said, involved a review and recommendations from experienced specialists.

The GHA said the clinicians were consulted and given around three months to raise any concerns before this came into force.

“There is then a very clear and transparent appeals process to enable specific patient needs to be addressed,” the GHA said.

“Rather than being seen as weakness, the GHA sees this as strength: where it can be identified there is clinical need for flexibility, then that is shown, through a peer review process, whilst keeping the general position in place, reducing the use of medicines of limited clinical value.”

At the time, the GHA followed NHS guidance and found that Lidocaine patches were only approved for use in the treatment of Post Herpetic Neuralgia (PHN) by the UK Medicines and Healthcare products Regulatory Agency.

PHN is a common complication after a person has had shingles, which causes a lasting pain in the areas of skin in which previously there were shingles.

Lidocaine patches are approved for use to alleviate pain form PHN and NHS guidance recommends the drug to be used for short periods of 10 days or less.

Mr Freestone said the drug is not addictive.

After a new review in June 2022, the drug is only permitted in the NHS to treat PHN and focal neuropathic pain with allodynia.

The GHA adopted a very similar policy, restricting its use to these two conditions, and has approved its use for PHN since the new policy came in.

“Lidocaine patches have been historically used in Gibraltar for many other conditions, for which the evidence base is very weak so cannot be endorsed for use,” the GHA said.

“These conditions include low back pain, and musculoskeletal pain, where the evidence supporting its use in these conditions is not sufficient to justify its continued use.”

“The formulary development has been a major change in the way the GHA operates its approvals for the use of medicines, and there is now real oversight of what is prescribed for what condition, when and in some cases by who.”

“The committee always tries to ensure that appropriate alternatives are suggested when declining requests, but these may not be an alternative medicine.”

“Conditions like low back pain do not respond to medicines well, and not at all usually after three months, so prescribing another medicine then is not appropriate and alternative interventions will need to be accessed.”

The GHA added that sometimes medicines are “archaic” and reviews are required.

The GHA said it will continue to review and refine its formulary, in the light of the changing
evidence and science underpinning medicine use, or changes in the guidance published.

“The Committee overseeing this process, meets monthly and is scrupulous in examining all the request for change and additions placed before it,” the GHA said.

These recommendations are then shared with the GHA Executive team who then ratify, or otherwise, the recommendations.

The GHA said it is very empathetic to patients’ needs and is trying to ensure it can move resources from those of limited clinical value to those medicines of higher clinical value, as these resources can only be used once.

“The GHA believes that this process has enabled it to support patients with high demand clinical needs with newer and more effective medicines,” the GHA said.

“This reduces the potential toxicity of the treatments so there is less iatrogenic disease, achieves better long term outcomes, and reduces the need for routine blood tests, which if it had not done this would have been even more challenging.”