1. Proposals for Way Ahead
This article and proposed solution is aimed at prescribed benzodiazepines. This document includes benzodiazepines and Z drugs (zaleplon, zolpidem, zopiclone) which are similar to benzodiazepines. The proposals are one way that could, with the cooperation of doctors help to solve the problems associated with prescription benzodiazepines, although not all people already dependent on prescription benzodiazepines will be willing or able to come off them. The proposals offer methods of determining as far as possible, the extent of the problem, and potential measurable solutions.
The problems of prescription-related benzodiazepines involve (a) new patients, and (b) patients who have become dependent on, or addicted to, benzodiazepines through long term use. The common theme is that the medication has been supplied by doctors who, in many cases, have little knowledge of the potential dangers of this type of medication. Despite information available to the medical profession for the last 20/30 years, it is only recently that reductions have been seen in the number of prescriptions issued for benzodiazepines. The reductions mainly apply to new patients of whom fewer are prescribed this type of medication, and where they are prescribed, the guideline of prescribing for only 2/4 weeks are more often adhered to. This bigger problem appears to be with people who have been on benzodiazepines for longer periods of time and have become dependent. This could be because GPs see few patients who wish to be taken off the medication, and are unsure of the approach to take, even though they know that the long-term use, in the majority of cases, does more harm than good. The situation points to a need for greater emphasis on this subject being given during their medical school education.
2. New Patients
If the problem of benzodiazepine dependency via repeat prescriptions is to be overcome, then the access door to this route has to be 'Closed'. As stated above, improvements are occurring, but it is vital that measurable data is obtained to prove this and ensure that it continues. With all dependency substances, whether it be tobacco, alcohol or drugs, it is difficult to predict who will become dependent or who will have problems during withdrawal. It is therefore vital that all patients are treated as if they will become dependent on a substance known to be of an addictive nature, prescribed by their GP, a person whom the patients trust.
It seems remarkable that with the patients limited knowledge as to the time it can take for people to become dependent on benzodiazepines, and also the devastating effects they can have on a person's life, that patients can be prescribed benzodiazepines without being fully informed of the dangers.
There are many different reasons that doctors prescribe benzodiazepines, some reasons given by doctors, include: anxiety, panic attacks, phobias, insomnia, (Ashton 2002), muscle relaxation and many others. Whatever the reason for the prescription, the effects, if used long-term, can cause the same adverse effects on the person's life. Benzodiazepines can be useful in the short-term, but should not be used as the first resort as seems to happen in today's “quick-fix” society. Reports from both patients and doctors tell of patients being prescribed benzodiazepines for bereavement, pain relief, and menopause none of which are recommended for treatment using benzodiazepines.
If a new approach is desirable, what should be put in place so that the repeat prescription route does not continue?
2.1 An education programme should be instituted to ensure that all GPs understand the effects if they continue to prescribe benzodiazepines for longer than the recommended time-scales laid down by the BNF, i.e. 2-4 weeks.
2.2 The decision to put new patients onto benzodiazepines should only be taken after other approaches have been considered, i.e. cognitive and psychological therapy etc,and only then when the patient has been given enough information to make an educated decision as to whether or not to undertake this method of treatment. For this to be meaningful, the positive advantages as well as the associated dangers, should be fully explained. A leaflet 'Benzodiazepines and Z Drugs' outlining what benzodiazepines are, what they are used for etc., is available to GPs, and all medical staff, via Patients UK on www.prodigy.nhs.uk which was updated June 2006. Waiting lists for psychological therapies, in most areas, are either over nine months or there is no waiting list at all because there are no therapists. There is need for 10,000 extra therapists, 5000 of these should be “clinical psychologists” whose training should be much more heavily slanted towards therapy, especially Cognitive Behavioural Therapy (CBT) and 5000 “psychological therapists”, who could be trained from among the 60,000 nurses, social workers, occupational therapists and counsellors already working on mental health in the NHS.( London School of Economics and Political Science 2006).
2.3 Any new patient prescribed benzodiazepines should only be given a first prescription for a maximum of two weeks. All details of the patient as well as the medication should be recorded on the surgery computer, which should be linked to the network of the PCT so that records are automatically made to the PCT Medicine Management Team, who should be the controlling authority with regards to “over-prescribing”.
2.4 The GP should make a further appointment with the patient for the two weeks ahead, when he should decide to either stop prescribing the benzodiazepine or to continue for a maximum of a further two weeks (with the patient's consent). Again, this would be recorded on the computer, and if a second prescription has been given, a warning flag will be highlighted to the Medicine Management Team, who will then notify the GP that another prescription should not be issued to that particular patient for a continuation of benzodiazepines under this course of treatment.
2.5 At the end of either the two-week or four-week period, the GP should make a further appointment for one week ahead, when he should determine whether or not the patient is experiencing any withdrawal symptoms. [This is a patient safeguard, but if the patient has developed a dependency (and there are reports of this occurring in as little as one week), then the patient should be given assistance to withdraw as laid down in later parts of this document].
2.6 Any new patient prescribed benzodiazepines should be given the minimum appropriate dosage for the type of benzodiazepine selected. Wherever possible, diazepam should be the choice as it has a long half-life, so that if dependency did occur, it would be easier to start a withdrawal programme. Diazepam may be inappropriate for some patients e.g. the elderly, demented or those with liver disease because it requires extensive metabolism; in these cases a suitable benzodiazepine should be selected. In the elderly, dosages should be half the dosage of those recommended (BNF).
3. Patients Dependent on Prescribed Benzodiazepines
Long-term use of benzodiazepines is associated with considerable general and mental health problems, including over-sedation, road traffic accidents, accidents in the home and at work, falls and fractures, forgetfulness, general cognitive impairment, depression, anxiety, panic attacks, emotional blunting, suicidal thoughts and agoraphobia. (Ashton 2002)
Withdrawal can have a beneficial effect in general. In the case of the elderly, it can improve memory and reaction time, increase levels of alertness and improve quality of life (Curran et al 2003).
Under the new NHS system which came into effect in October 2006, there will be some 152 PCTs, and it is vital that each of these carries out an audit to determine the number of patients within their domain who are potentially dependent on prescription benzodiazepines. This audit should include patients who have been receiving prescriptions (for any indication) for more than four weeks. This audit would be factual. Surveys of general practices show that there are over 180 long-term prescribed users per general practice. Up to 1 million people in the U.K. Could be affected (Ashton 2007). The figures given by the old Morecambe Bay PCT of between 10,000/12,000, if applied directly across the whole country would give figures in a excess of 1 million. Without these factual figures, it is impossible to determine the future treatment requirements or the amount of help that will be needed. The numbers are such, that the only way to overcome this problem is by working with the doctors through the surgery system, which is ironical because that is where the problem started.
With current computer capabilities available, it should be possible to carry out the audit on a surgery-by-surgery basis, within each PCT area. This audit could be undertaken under the control of that particular PCTs Medicine Management Team, utilising the community pharmacists. This initial audit would form the basis by which future audits are compared, thereby enabling the effectiveness of any measures taken to be factually accessed. Audits could be undertaken bi-yearly so that any necessary adjustments could be made at an early date.
The problems associated with benzodiazepine withdrawal are individual and differ from withdrawals such as those from tobacco, alcohol or heroin – which can have relatively short withdrawal times. People with benzodiazepine dependency need to be withdrawn by gradual dosage reduction, which can take many months or years. This uniqueness means help and support is needed not only during the withdrawal procedure, but for a considerable time afterwards and this makes it time consuming, and worker-time-consuming. For these reasons, people need to be specially trained to understand the problems involved.
It should be highlighted to all professionals that successful withdrawal can only be achieved by working with people who are willing to withdraw and the withdrawal must always be at the patient's rate of reduction. It is time-wasting, expensive in terms of human effort, and counter-productive to force people to withdraw (Heather et al 2004). Motivation can be changed by giving the patient detailed information and a full explanation of this information but not all long-term users of benzodiazepines are considered suitable for withdrawal because of significant comorbidity which is common in long-term benzodiazepine users (Bowie et al 2006).
One problem associated with benzodiazepine withdrawal is that patients are sometimes pushed into undertaking withdrawal by GPs who have little knowledge of how to handle the procedure. This may result in the patient turning to other supplies such as the Internet or illegal sources. They may then deceive their doctors into thinking that they have no withdrawal symptoms. The doctor may then count this as a success and use the same procedure for the next patient. This might make his/her surgery figures look good, but what it really does is just shuttle the numbers around and make a law abiding citizen into a criminal.
A “blue print” for withdrawal from benzodiazepines has been produced by the Prodigy Guidance in their document 'Benzodiazepine and Z Drug Withdrawal', which is available on their website www.prodigy.nhs.uk . This document gives details on how doctors should consider the problems associated with patients who wish to withdraw from these medications. It gives various scenarios that are likely to be met by the medical professionals when dealing with such problems, and suggests the way ahead when dealing with people who wish to withdraw. In addition, it produces leaflets for patients with details and guidance on this subject, to enable people to make an educated decision on whether or not they want to withdraw.
The only problem with this document is that it gives tables on suggested withdrawal procedures based on the work by Professor Heather Ashton, who gave approximate rates and times between reductions for guidance, but these have been used as “The Bible”. Professor Ashton has pointed this out in the introduction to her 2002 issue of her manual “Benzodiazepines”: 'How They Work and How to Withdraw' (www.benzo.org.uk/manual/).
The Prodigy document also highlights the importance of a patient who is considering withdrawal, having a full support structure in place. This should begin at the GPs surgery and include not only the medical profession, but social services support to ensure, where applicable, that all the benefits which are due to the patient, are in place; family support, as well as self-help group support and other identifiable types of support. It is important for the doctors to ensure that these are available and they should actively inform patients of local voluntary support groups that may also be available to help.
It is all very well having the guidelines in place, but it is vital to put the building blocks in place as well, in order to enable the work needed to overcome the benzodiazepine problem to be carried out. The following lays down some of these building blocks and other possible solutions to enable them to be used.
3.1 Each PCT should have a designated person to oversee all aspects of benzodiazepine usage within the PCT. This person would need to be trained specifically in all aspects of benzodiazepine prescribing and withdrawal. This training could be sourced from an external supplier. This person would be responsible for educating PCT staff, including GPs, nurses and other professionals in benzodiazepine usage and associated problems with this work extending to cover all GP surgeries within the area. He/she would also be the focal point for all benzodiazepine prescriptions issued and be responsible for ensuring that prescriptions to new patients meet the requirements laid down in the earlier section of this paper. He/she would also be responsible for the monitoring and analysis of prescriptions to ensure that the use of benzodiazepines within the PCT area is not increasing, but is on a downward trend. This position would be suitable for somebody with pharmacy/medical training.
3.2 Each GP surgery should have a trained surgery pharmacist to work with the GP, and be responsible for educating patients about the problems associated with benzodiazepines. He/she would, during routine health and medication checks, discuss the dangers of long-term benzodiazepines usage and the possibility of withdrawal or reduction of dosage. He/she would not pressurise patients to withdraw, but would give information, including leaflets available from Prodigy Knowledge, and local voluntary groups, etc.. He/she would suggest that thought should be given to withdrawal, and ensure that patients could return for further discussion. He/she would ensure that records are made of all visits and would keep the GP fully informed of the outcomes. Any withdrawal programme could only be undertaken with the agreement of the GP, although the surgery pharmacist would be involved in the formulation and operation of patient programmes.
3.3 If a patient agrees to undertake withdrawal, the GP should agree with the patient a rate of withdrawal. Because neither the patient nor doctor may know what symptoms may be experienced, it is best to start withdrawal at a slow rate, with reductions of the order of 8-10% of the usual dosage and approximately three or four weeks between reductions. The reduction must remain flexible throughout the withdrawal programme, but should always proceed at the rate determined by the patient, dictated by his/her body response.
3.4 Support by the surgery pharmacist should be on a regular fortnightly basis during the withdrawal programme, and for a minimum of a further six months after the completion. The support should involve a meeting at the surgery to make sure that any withdrawal symptoms are at acceptable levels, and if not, further reductions should be left until these symptoms subside. Particular care must be taken to assess any increased depression which may require appropriate treatment.
3.5 Follow-up visits should continue monthly for a further twelve months.
3.6 PCTs should arrange meetings at the local hospital between voluntary groups and individuals taking part in withdrawal programmes, or those wishing for help and advice on joining a withdrawal programme.
3.7 Patients dependent on prescription benzodiazepines often have problems if they are admitted to hospital, especially in an emergency, due to their medication being stopped. It is vital that communications exist between the surgery and hospital to ensure the continuation of the medication in order to avoid serious consequences.
3.8 The preferred method of withdrawal is to undertake this with the patient being on diazepam which often means changing a patient over to diazepam from the benzodiazepine currently being taken. Equivalences of the various benzodiazepines to diazepam and how to undergo the change over are given in the Prodigy document.
1. Ashton, C H: Benzodiazepines. How They Work and How To Withdraw (2002).
2. Ashton, C H: All Party Action Group on Tranquilliser addiction. London: House of Commons, November 7, 2006.
3. Bowie, A; McAvoy, B; Spencer I, Et al (2006): Randomised Controlled Trial of Two Brief Interventions Against Long-Term Benzodiazepines Use.
4. Curran. H V; Collins R; Fletcher S, Et al (2003): Older Adults and Withdrawal From Benzodiazepines Hypnotics in General Practice: Effects on Cognitive Function, Sleep, Mood, and Quality of Life.
5. Heather N, Bowie A, Ashton H, McAvoy B; Spencer I, Brodie J, Giddings D: Randomised Controlled Trial of Two Brief Interventions Against Long-Term Benzodiazepine Use: Outcome of Intervention.
6 London School of Economics and Political Science: The Depression Report. A New Deal for Depression and Anxiety Disorders.
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