Benzodiazepines

1. Benzodiazepines Use and Abuse By Jennifer Rigney

2. Outline What are Benzodiazepines History Mode of Action Most commonly prescribed benzodiazepines Indications Side effects Interactions Use within the Traveller community Addictive properties Prescribing guidelines A Pharmacists perspective Withdrawal syndrome Why they should not be sold/passed on to others The Future Conclusion

3. What are Benzodiazepines? Benzodiazepines are a group of drugs that act on the central nervous system. Used to treat anxiety, stress, sleeping problems and other disorders.

4. History 1903 Barbiturates 1957 Chlordiazepoxide synthesized 1960 Marketed as Librium 1959 Diazepam synthesized 1963 Valium launched 1978 Valium � most widely prescribed drug in the world 1980 Risk of dependence realised Current average time from synthesis to commercial availability is 14 years Safer & Less Toxic than BarbsSafer & Less Toxic than Barbs

5. Mechanism of Action Benzodiazepines work by increasing the efficiency of a natural brain chemical, GABA which decreases the excitability of neurons. This reduces the communication between neurons and, therefore, has a calming effect on many of the functions of the brain.

7. Most commonly prescribed Benzodiazepines All Benzodiazepines are classified as Controlled Drugs in Ireland. Most are CD Schedule 4 Diazepam (Valium,Anxicalm) Alprazolam (Xanax) Bromazepam (Lexotan) Clobazam (Frisium) Lormetazepam (Noctamid) Nitrazepam (Mogadon) Two are CD Schedule 3 Flurazepam (Rohypnol) Temazepam (Nortem) Change of class shows decreased use, mostly older people, could get to a point where they are no longerChange of class shows decreased use, mostly older people, could get to a point where they are no longer

8. Indications Anxiety Short term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable stress. Insomnia Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress. Chronic Muscle Spasm or spasticity associated with MS Status Epilepticus Febrile Convulsions THE USE OF BENZODIAZEPINES FOR SHORT TERM MILD ANXIETY OR MINOR INJURY IS NOT APPROPRIATE.

9. Side Effects of Benzodiazepines Drowsiness & Light-headedness the next day Confusion & Ataxia (especially in the elderly) Increase in fractures -> increase in hospitalisation Amnesia Dependence, Tolerance Dysarthria (Slurred speech) Respiratory depression (more so if taken with alcohol or other CNS depressants). Paradoxical increase in aggression Demotivation - Inhibition of learning behaviour, academic performance Coma demotivational dysarthria - impaired articulatory ability resulting from defects in the peripheral motor nerves or in the speech musculature defect of speech, speech defect, speech disorder - a disorder of oral speech demotivational dysarthria - impaired articulatory ability resulting from defects in the peripheral motor nerves or in the speech musculature defect of speech, speech defect, speech disorder - a disorder of oral speech

10. Interactions Increased Effects with Alcohol Analgesics (Fentanyl) Antibacterials (Clarithromycin, Isoniazid) Antifungals (ketokonazole, itraconazole) Antipsycotics Antivirals Muscle relaxants (baclofen) Decreased Effects with Antibacterial (Rifampicin) Probenecid Theophylline

11. The use of B�s within the Traveller Community Report showed that, despite the 2002 Good Practice Guidelines for the prescribing of benzodiazepines, lack of regulation has resulted in many negative effects on the Traveller Community Dependency Driving under the influence of drugs Workplace accidents Creation of a black market And it showed that Benzodiazepine use and overprescribing problems are not exclusive to Travellers with pre-existing addiction Alcohol & Drug AddictionAlcohol & Drug Addiction

12. Improper Use of Benzodiazepines Exceeding prescribed dose to feel better quicker Self medication � adjusting dose/frequency according to psychological state Sharing medication with other Travellers RATIONAL FOR DEVELOPING GUIDELINES OVER PROTOCOLS MAY NEED TO BE RE-EXAMINED?? Rescheduling all benzodiazepines to CD3 or more? Compulsory phasing of prescriptions for Benzodiazepines

13. Addictive Properties �to what degree do benzodiazepines allow a wide variety of individuals and structures to �cope� with realities that are unfavourable or inadequate?��to what degree do benzodiazepines allow a wide variety of individuals and structures to �cope� with realities that are unfavourable or inadequate?�

14. Prescribing Recommendations Address the cause of symptoms Psychotherapeutic guidance required � Listen to the patient Has the patient tendency to misuse drugs/alcohol? Ensure dose is correct Prescribed for as long as necessary, aiming for shortest time � but not > 4/52 Rebound anxiety, tapering dose, support Reduction/Discontinuation � Careful medical supervision & appropriate psychological interventions

15. Before prescribing benzodiazepines Take a full history including an alcohol and licit and illicit drug history. Inform the patient of the side-effect profile of benzodiazepines and offer an information leaflet. Consider and treat, if possible, any underlying causes. Consider referral to other services. Consider alternative therapies. Consider delaying prescribing until a subsequent visit Talk about why patient is not sleeping Relaxation therapy. Avoidance of stimulant drugs and beverages Increase physical activity & mental stimulation Explain that 8 hrs sleep not always necessary Avoid 'catnaps' during the day. A relaxing bath or a good book can facilitate sleep. Yoga/ Meditation/ Exercise. Consider alternative medication Kalms (Valerian) Natrasleep (Hops & Valerian) Natracalm (Passion flower) Rescue Remedy Talk about why patient is not sleeping Relaxation therapy. Avoidance of stimulant drugs and beverages Increase physical activity & mental stimulation Explain that 8 hrs sleep not always necessary Avoid 'catnaps' during the day. A relaxing bath or a good book can facilitate sleep. Yoga/ Meditation/ Exercise. Consider alternative medication Kalms (Valerian) Natrasleep (Hops & Valerian) Natracalm (Passion flower) Rescue Remedy

16. When prescribing for the 1st time Initiate with the lowest recommended dose, but this may need to be adjusted depending on patient�s response. Do not prescribe for longer than 4 weeks. Use phased dispensing where possible. Ensure that agreements between doctor and patient are documented. Record all details of medication prescribed and duration of treatment. Clear, effective and speedy communication concerning benzodiazepine usage should always take place between the prescribing professionals both within and between services.

17. Benzodiazepine dependent patients or pts in receipt of continuing prescribing Issue small quantities at a time Review regularly � monthly Use a long acting benzodiazepine in dosages no higher than diazepam 5 mg three times daily (or equivalent) Make patients aware of the risks of long term benzodiazepine use and document this communication. Signed consent forms should be used where appropriate. Encourage dependent pts to withdraw, offer them a detoxification programme at regular intervals (at least annually) and document A significant number of requests for repeat benzodiazepine prescribing are associated with addiction problems, primarily alcohol, or in urban areas, opiate misuse. A doctor who suspects this is the case should seek specialist advice

18. From a Pharmacists� Perspective Alerting system Phased prescriptions Work with GP�s to encourage guideline based prescribing Intervene when prescriptions are presented for early dispensing Educate patients about the addictive nature and dangerous side effect profile of benzodiazepines

19. Methods for withdrawal of B�s Any Benzodiazepine withdrawal programme should be carefully planned and structured, the aim being to gradually reduce to zero the amount of drug being taken. Gradual Dose Reduction Substitution Dose reduction then immediate substitution Greater flexibility in dosing of longer acting Diazepam Adjuvant pharmacotherapy Reduce the physical symptoms of withdrawal Tremor, Sweating, Insomnia. Convulsions BENZODIAZEPINES ARE HIGHLY ADDICTIVE

20. Why Benzodiazepines should not be sold or passed on The National Drug-Related Death Index Benzodiazepines were implicated in 31% of drug related deaths Huge increase in number of cases seeking treatment for misuse Age profile of under 18 yr olds seeking help had risen They are a Controlled Drug requiring GP management Are highly addictive Withdrawal effects are very unpleasant Should only be taken by the patient they are prescribed for as drug choice and dose are specific to pts needs Should not be sold or passed on even if symptoms are similar. You are not helping anybody by sharing this medication with them. Benzodiazepines are safe when used within the guidelines They are highly addictive even when used for short periods You are not helping anybody by sharing this medication with anybody They can be fatal when used with other drugs/alcohol Are Controlled drugs and require medical supervision Should be taken by the person they are prescribed for. Directions for use should be followed exactly Withdrawal from long term use of Benzodiazepines is difficult but with motivation & support is possible This class of drugs need to be monitored carefully by GPs to ensure addiction is at a minimum curtailed and hopefully prevent addiction in the future Drug choice and dose are specific to patients needs and other people even those with similar symptoms Idea that it is seen to be helping someone out has to change � not to be used as coping mechanism � Mammy little helper! Source ? Online Deaths linked to common anxiety drug soar USERS of a commonly prescribed drug to treat anxiety and depression have been warned of its addictive and potentially fatal effects after a report revealed soaring misuse rates and identified it as a factor in 31% of all drug-related deaths. The National Drug-Related Deaths Index, also shows drug-related deaths in which benzodiazepines were implicated increased from a total of 65 in 1998 to 88 in 2007.  The report also reveals a huge increase in the number of cases seeking treatment for misuse of the popular prescription sedative.  National Drug Treatment Reporting System, shows that just 1% of cases were under 18 years of age in 2003 but, by 2008, it had risen to 13%. Wednesday, December 15, 2010 Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1sRtnxv Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1qeRs1m Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1qw6DxuRead more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1rYE5eK Benzodiazepines are safe when used within the guidelines They are highly addictive even when used for short periods You are not helping anybody by sharing this medication with anybody They can be fatal when used with other drugs/alcohol Are Controlled drugs and require medical supervision Should be taken by the person they are prescribed for. Directions for use should be followed exactly Withdrawal from long term use of Benzodiazepines is difficult but with motivation & support is possible This class of drugs need to be monitored carefully by GPs to ensure addiction is at a minimum curtailed and hopefully prevent addiction in the future Drug choice and dose are specific to patients needs and other people even those with similar symptoms Idea that it is seen to be helping someone out has to change � not to be used as coping mechanism � Mammy little helper! Source ? Online Deaths linked to common anxiety drug soar USERS of a commonly prescribed drug to treat anxiety and depression have been warned of its addictive and potentially fatal effects after a report revealed soaring misuse rates and identified it as a factor in 31% of all drug-related deaths. The National Drug-Related Deaths Index, also shows drug-related deaths in which benzodiazepines were implicated increased from a total of 65 in 1998 to 88 in 2007. The report also reveals a huge increase in the number of cases seeking treatment for misuse of the popular prescription sedative. National Drug Treatment Reporting System, shows that just 1% of cases were under 18 years of age in 2003 but, by 2008, it had risen to 13%. Wednesday, December 15, 2010 Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1sRtnxv Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1qeRs1m Read more: http://www.examiner.ie/home/deaths-linked-to-common-anxiety-drug-soar-139493.html#ixzz1T1qw6Dxu

21. The Future Development of proposals under Misuse of Drugs legislation to introduce stricter controls on benzodiazepines and an initiative to tackle overprescribing Minister of State Dept of Health with responsibility for Primary Care Roisin Shorthall made the announcement following the launch of a report on a pilot project to tackle benzodiazepine use in Ballymum on June 21. Minister of State with responsibility for Primary Care R�is�n Shortall is developing proposals under the Misuse of Drugs legislation to introduce stricter controls on benzodiazepines and an initiative to tackle overprescribing. She made the announcement following the launch of a report on a pilot project to tackle benzodiazepine use in Ballymum on June 21. Ranking� the issue of the abuse of benzodiazepines as �a priority� of hers, Minister Shortall said she intended to introduce an initiative soon to tackle overprescribing. �We need to look more closely at prescribing patterns for benzodiazepines in order to identify those areas that are out of line with best practice,� said the Minister. �I�ve asked the HSE to look at this and report back to me.� She added that work on this initiative was planned to get under way in the coming months, and that it would have an impact on consumption levels of benzodiazepines in Ireland, which she said were �unacceptably high�. The Minister was speaking at the launch of a report into a pilot project in Ballymun, which involved local GPs working in partnership with an addiction counsellor, to see how innovative approaches could be successfully adopted to address benzodiazepine problems in primary care. Department of Health with responsibility for Primary Care Minister of State, Department of Health with responsibility for Primary Care Minister of State with responsibility for Primary Care R�is�n Shortall is developing proposals under the Misuse of Drugs legislation to introduce stricter controls on benzodiazepines and an initiative to tackle overprescribing. She made the announcement following the launch of a report on a pilot project to tackle benzodiazepine use in Ballymum on June 21. Ranking� the issue of the abuse of benzodiazepines as �a priority� of hers, Minister Shortall said she intended to introduce an initiative soon to tackle overprescribing. �We need to look more closely at prescribing patterns for benzodiazepines in order to identify those areas that are out of line with best practice,� said the Minister. �I�ve asked the HSE to look at this and report back to me.� She added that work on this initiative was planned to get under way in the coming months, and that it would have an impact on consumption levels of benzodiazepines in Ireland, which she said were �unacceptably high�. The Minister was speaking at the launch of a report into a pilot project in Ballymun, which involved local GPs working in partnership with an addiction counsellor, to see how innovative approaches could be successfully adopted to address benzodiazepine problems in primary care. Department of Health with responsibility for Primary Care Minister of State, Department of Health with responsibility for Primary Care

22. Conclusion Benzodiazepines are safe when used within the guidelines They are highly addictive even when used for short periods Cause many road traffic accidents due to driving under the influence of drugs They can be fatal when used with other drugs/alcohol Are Controlled drugs and require medical supervision Should be taken only by the pt they are prescribed for. Directions for use should be followed exactly Withdrawal from long term use of Benzodiazepines is difficult but with motivation & support is possible