Benzodiazepine prescribing in General Practice - 2011 update

1. Benzodiazepine prescribing in General Practice - 2011 update John McGirrCommissioning Officer for substance misuse

2. Benzodiazepines and Z Drugs Despite warnings regarding the long-term use of benzodiazepines or z-drugs, approximately 15.5 million Benzo/z Drug prescriptions are dispensed each year. Evidence suggests the majority of prescribingexceeds the licensed period and therefore is not in the best interest of the patients 56% of prescriptions for the three most commonly prescribed benzodiazepines were for people older than 65 years of age [NHS CKS 2009] [Greenwich PCT 2009-10 Benzo receptors ADQ per STAR PU]

3. Benzodiazepines and Z Drugs Older people are more vulnerable to the adverse effects of benzodiazepines, e.g. falls, fractures, cognitive function and memory impairment [ DTB,2004; Wagner et al, 2004; Ashton 2005] Stopping long-term benzodiazepines in elderly people has been found to improve their working memory and reaction times, increase levels of alertness, and improve concentration. [Curren et al,2003]

4. Benzodiazepines and Z Drugs Nationally - Greenwich NHS currently prescribes more benzodiazepines than Bradford City and is second only to Leicester city* [NHSBSA 2009] Locally – Although improving, Greenwich NHS is currently the third highest prescriber in London. [NHSBSA 2009/2010] *based on population size and profiles

5. Benzodiazepines and Z Drugs Apr-Jun 09

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8. Benzodiazepines and Z Drugs • Key concerns for patients are: • Develop tolerance to the effects of benzodiazepine ( within 3-14 days of continuous use) • Gain little therapeutic benefit from chronic consumption • Increased risk of side effects • Develop dependency over good sleep hygiene • Develop withdrawal symptoms when prescription ceases [Jin On – prescribing advisor ,pharmacy team, NHS Greenwich]

9. Benzodiazepines and Z Drugs • Key concerns for GPs are: • Breach of Contract – Excessive prescribing is referred to in schedule 6,paragraph 46 of the GMS contract and in schedule 6,paragraph 44 of the PMS contract • Negligence liability - When the GP prescribes either drug for unlicensed indicators ( longer than recommended by the manufacturer), the legal responsibility for prescribing falls to the GP who signs the prescription NB- Schedule 6 included in 2010 revised PMS/APMS/GMS contracts [Jin On – prescribing advisor ,pharmacy team, NHS Greenwich]

10. Benzodiazepines and Z Drugs • Causal factors for dependence : • High dose prescribing (+30mgs daily) • Longevity of prescribing (+14 days) • Shorter-acting benzodiazepines (e.g. lorazepam -Ativan and alprazolam -Xanax) • A history of anxiety disorders and/or depression • Withdrawal symptoms: Common symptoms include: • insomnia, anxiety • irritability, restlessness • agitation, depression • tremor, panic attacks • dizziness or perceptual disturbances (for example hypersensitivity to physical, visual, and auditory stimuli).

11. Benzodiazepines and Z Drugs • Establishing dependency; • There are three types of dependence that are recognised; • Therapeutic dose dependence • Prescribed high dose dependence • Recreational high dose dependence

12. Benzodiazepines and Z Drugs • Therapeutic Dependence: • Low doses over a number of years. • Have come to ‘need’ benzos to function normally. • Have continued to use benzos long after the original indication(s) have disappeared. • Have experienced withdrawal symptoms when they have reduced or stopped. • May have a history of contacting surgery for repeat prescribing. • They experience anxiety if their prescription is not ready or delayed. • May have increased their dose from the original prescription. • May display anxiety symptoms, panics, agoraphobia, insomnia, depression and increased physical symptoms despite continuing to take benzos. • (Ashton 2002)

13. Benzodiazepines and Z Drugs • Prescribed high dose dependence, • e.g. 30mg Diazepam or more • Some patients who start on prescribed benzos begin to ‘require’ ever increasing doses: • Will try to persuade the GP to increase their dose/ number of tablets • Have been known to present at hospitals or register at another practice to obtain more tablets • May combine benzo misuse with alcohol consumption or other sedative drugs. • Tend to be highly anxious, depressed and may have a personality disorder. • Tend not to use illicit drugs but will source illicit supplies from the ‘street’, relatives or friends

14. Benzodiazepines and Z Drugs • Recreational High Dose dependence • High dose dependence in this category may develop as poly drug users attempt to increase the intensity of the ‘kick’ they get out of illicit drugs – especially opiates – and to cope with the withdrawal symptoms and effects of others such as cocaine and amphetamines or alcohol. • Individuals develop a very high tolerance making it difficult to detect the actual scale of drug consumption. • Users may be exceeding 100mgs daily in a single does ( doses of up to 100mgs have been reported in clinical practice) • There may be a concurrent alcohol problem – the user may have been introduced to benzos during previous alcohol detoxification

15. Benzodiazepines and Z Drugs • Options for management of patient group; • Explore alternative treatments; • sleep teas • relaxation therapies • anxiety management courses • cognitive therapy • relationship counselling • Employee assistance programmes (where available) • Referral to psychosocial support – address underlying issues • Letters to patients – evidence that this strategy steadily reduces long-term benzodiazepine use in general practice • Referral to specialist drug services – where co-morbidity is evident • Discuss detoxification options – manage patient expectations of treatment

16. Benzodiazepines and Z Drugs • Options for management of patient group; • Be realistic about detoxification – is the patient ready? • Anticipate time frame for detox – can be between several weeks and several years! (dependent on prescribing history- duration, amount) • Allow for stabilisation periods - but do not increase the dose • Listen to the patient’s concerns and refer to alternative support therapies • Time to Talk • Family support • Employee support scheme ( where available) • Relationship counselling

17. Benzodiazepines and Z Drugs • Options for management of patient group; • Review frequently – to enable early discussion and management of any problems • Provide advice and encouragement during and after the drug withdrawal • If the patient fails on the first attempt, encourage them to try again • Remind them that reducing dosage, can still be beneficial. • If another detox attempt is considered, reassess the person first, and treat any underlying problems (such as depression) before trying again

18. Benzodiazepines and Z Drugs Example of Reduction programme for long term prescribed patient Daily Dosage Morning Night TotalStarting dosage diazepam 20mg 20mg 40mg Stage 1 (1-2 weeks) diazepam 18mg 20mg 38mg Stage 2 (1-2 weeks) diazepam 18mg 18mg 36mg Stage 3 (1-2 weeks) diazepam 16mg 18mg 34mg Stage 4 (1-2 weeks) diazepam 16mg 16mg 32mg Stage 5 (1-2 weeks) diazepam 14mg 16mg 30mg Stage 6 (1-2 weeks) diazepam 14mg 14mg 28mg Stage 7 (1-2 weeks) diazepam 12mg 14mg 26mg Stage 8 (1-2 weeks) diazepam 12mg 12mg 24mg Stage 9 (1-2 weeks) diazepam 10mg 12mg 22mg Stage 10 (1-2 weeks) diazepam 10mg 10mg 20mg Ashton Manual 2002 Benzo.org.uk

19. Benzodiazepines and Z Drugs Worth noting: ‘withdrawing benzodiazepines gradually is recommended to allow a smooth, gradual fall in the level of drugs in the blood, thus minimizing withdrawal symptoms’ Lingford-Hughes et al, 2004: Ashton,2005: BNF 56,2008: Lader et al,2009

20. Benzodiazepines and Z Drugs • Options for management of new prescribing: • Encourage alternatives as a first line of discussion • Refer to specialist support – where appropriate (e.g. Time to Talk) • Avoid prescribing over the licensed period • Do not prescribe for more than a two week period • Do not repeat prescribe without a consultation and review • Do not allow the patient to pressurise you. NHS CKS 2011

21. Benzodiazepines and Z Drugs • Examples of Clinical Guidance & Best Practice • BNF • Licence parameters • NHS Grampian guidelines • Sussex partnership guidelines • Nice Guidelines

22. Benzodiazepines and Z Drugs Benzodiazepines and opiate use: Risk factors associated with illicit or prescribed opiates (Heroin or Methadone) ‘There may be an increased risk of side effects such as drowsiness, sedation, low blood pressure and slow, shallow breathing that can potentially be fatal, if this medicine [benzodiazepine] is used with other medicines [illicit or prescribed] that have a sedative effect on the central nervous system’ Benzo.org.uk

23. Benzodiazepines and Z Drugs • Benzodiazepines and opiate use: • Advise the patient of the risks of using with opiates/alcohol • Always refer the patient for opiate detox as a priority - CRi PCDAS • Inform the treatment provider of the poly drug use – with patient consent • Allow stabilisation on opiate replacement drug therapies before initiating a detox • Discuss the pros and cons of detox with the patient • Be supportive throughout detox period – acknowledge progress

24. Benzodiazepines and Z Drugs • Further information and guidance available from the following: • http://www.cks.nhs.uk • http://www.patient.co.uk/health/Benzodiazepines-and-Z-Drugs.htm • http://www.smmgp.org.uk/download/guidance/guidance006.pdf • http://www.nice.org.uk/nicemedia/pdf/TA077fullguidance.pdf • Chris Dunster – Lead clinical practitioner , CRi Primary Care Drug and Alcohol Service • John McGirr – Commissioning Officer , Greenwich Drug & Alcohol Action Team

25. Benzodiazepines and Z Drugs • Questions?