Carers Proposals for the Way Ahead for Prescription Benzodiazepines
and Z drugs Dependency

By

A Weatherburn

1. Proposals for Way Ahead

This paper has been taken from a larger article which is available by clicking here.

The proposed solution concerns prescribed benzodiazepines and Z drugs (zaleplon, zolpidem, zopiclone). It suggests one way that, with the cooperation of doctors, could help to solve the problems associated with prescription benzodiazepines.

2. New Patients

2.1 An education programme should be instituted to ensure that GPs understand the effects of prescribing benzodiazepines for longer than the time-scales recommended by the BNF, i.e. 2-4 weeks.

2.2 The decision to start a patient on benzodiazepines should only be taken after other available approaches have been considered, i.e. cognitive or psychological therapy, etc., and only then when the patient has been given enough information to make an educated decision. For this to be meaningful advantages and disadvantages of the medication should be fully explained. A leaflet 'Benzodiazepines and Z Drugs' is already available to GPs, and all medical staff, via patients UK on the website www.prodigy.nhs.uk.

2.3 Any new patient prescribed benzodiazepines should be given a first prescription for a maximum of two weeks and at the same time a further appointment for two weeks ahead should be made when the GP should decide either to stop prescribing the benzodiazepine or to continue for a maximum of a further two weeks. At both visits details should be recorded on the surgery computer, which should be linked to the PCT giving access to the Medicine Management Team. If a second prescription has been given, a warning flag should be highlighted by Medicine Management saying no further prescription to be issued under this course of treatment.

2.4 A further appointment should be made for one week at the end of the course of medication whether this has been two or four weeks at which the doctor should determine if the patient is experiencing any withdrawal symptoms (this is a patient safeguard). If positive, assistance should be given as laid down later in this document.

2.5 Dosages for new patients should be kept to the minimum appropriate dosage for the type of benzodiazepine selected.

3. Patients Dependent on Prescribed Benzodiazepines

From October 2006, there are some 152 PCTs, each of which should audit the number of patients who have been receiving prescriptions for more than four weeks.

A guidance for helping with withdrawal from benzodiazepines has been produced by the Prodigy Guidance in their document 'Benzodiazepine and Z Drug Withdrawal' (see their website  www.prodigy.nhs.uk ).

3.1 Each PCT should have a designated person with overall responsibility for all aspects of benzodiazepine usage within the PCT for both new and long term prescription patients. This person would need to be trained specifically in all aspects of benzodiazepine prescribing and withdrawal as well as being responsible for educating PCT staff, GPs, nurses and other professionals in benzodiazepine usage and associated problems and would cover all GP surgeries in the area.. This person would be responsible for the monitoring, and analysis of all prescriptions, to ensure that the use of benzodiazepines within the PCT area is fully monitored and any changes in trend can be quickly spotted.

3.2 Each GP surgery should have a trained surgery pharmacist to work with the GP, and be responsible for educating patients during routine medication checks about the problems associated with benzodiazepines including the dangers of long-term usage and the possibility of withdrawal. No pressure should be put on any patient to withdraw. Information, including leaflets available from Prodigy Knowledge and local voluntary groups, etc., should be made available to patients. Discussions should be such that the patient feels able to return for further discussions at a later date. The Pharmacist would ensure that all visits are recorded and that the GP is informed of the outcomes. The withdrawal programme would only be with the agreement of the GP, although the pharmacist would be involved in the formulation and operation of patient's programmes.

3.3 If a patient agrees to a withdrawal/reduction, then a programme that is flexible throughout its entirety should be agreed between patient and GP. It should start with a slow rate of reduction of the order of 8-10%, of the usual dosage, every 3/4 weeks, 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 actual withdrawal programme, and on a monthly basis, for a minimum of a further twelve months, after achieving total withdrawal.

 3.5 Serious consequences can occur when patients dependent on prescription benzodiazepines are taken into hospital, especially if admitted in an emergency, due to medication stoppage. It is vital that hospital medical teams are aware of this and communications exist between the surgery and hospital, to avoid this situation.

3.6 The preferred method of withdrawal is using diazepam. This often entails a changeover to diazepam from the patients current benzodiazepine, before commencement of the withdrawal programme. Equivalences tables and changeovers are given in the Prodigy Document.