Benzodiazepines Co-operation Not Confrontation (BCNC)
www.bcnc.org.uk
We need to look at the way ahead if we are to solve the problems associated with benzodiazepines/Z drugs. Throughout this document read benzodiazepines/Z drugs wherever benzodiazepines is written. There are a few aspects that need to be considered before making more definite proposals.
The first thing we need to consider, as BCNC group, is the problem of prescription-related benzodiazepines. How can we overcome this type of problem, which in almost all cases can be put down to lack of understanding of problems associated with this type of medication, by some of the medical profession, and in particular some doctors, despite information being made available over the last 20-30 years? It would seem that even more emphasis needs to be put on the education of doctors, with reference to the effects of long-term usage of benzodiazepines, which would hopefully ensure that future generations of doctors will be fully aware of the dangers associated with this type of medication.
The second part that has got to be drawn into the equation, if the problem is to be solved, is the use of street benzodiazepines and the treatment of people who have fallen into this trap. This may well be the harder to solve, with the drug culture that is increasingly prevalent throughout the country.
Let us look firstly at the repeat prescription part of the equation (a) from the perspective of new patients and (b) from the perspective of patients who have already become dependent on, or addicted to, benzodiazepines.
New PatientsIf the problem of benzodiazepine dependency via repeat prescriptions is to be overcome, then the access door to this route has to be “Closed”. We must always remember that, as with all dependency substances, whether it be tobacco, alcohol, or drugs, no person can predict who will become dependent or who will have hard times during withdrawal, from any particular substance. It is therefore vital that all patients are treated as if they are definitely going to become dependent on a substance, that is known to be of an addictive nature, and which is being prescribed by their GP, a person who the patients have learned to totally trust.
It seems remarkable that with the limited knowledge that most patients have, as to the time it can take for people to become dependent on benzodiazepines and also the devastating effects it can have on the rest of a person’s life, that patients can be prescribed benzodiazepines without being fully informed of the dangers. After all one has to sign consent forms before one undergoes surgery.
There are many different reasons for prescribing benzodiazepines, including anxiety, bereavement, pain relief, menopause, muscle relaxant, as well as many other reasons. Whatever the reason for being put on benzodiazepines the effects can cause the same devastation on the future life of the patient. Whilst accepting that benzodiazepines can be a useful medication in the short term but at the same time accepting the devastation they can cause, then it should only be used as the last resort, rather than the first resort as seems to happen in these days of “quick-fix” society.
So if we accept that a new approach has to be taken, then in the case of new patients, what do we need to put in place so that the repeat prescription route doesn't continue for future generations?
It is vital that an education programme is put in place to ensure that all GPs understand the results that their prescribing can have on their patients if they continue to prescribe for longer than the recommended time scales laid down by the BNF, i.e. 2-4 weeks.
The decision to put a patient onto benzodiazepines should only be taken after all other available approaches have been considered and only then when the patient has been given enough information such that he/she can make an educated decision as to whether or not to undertake such treatment. For this to be meaningful, the positive advantages that could be achieved, by usage of the drug, as well as the dangers should be fully explained. In the cases of anxiety the first line treatment should be psychological but due to the long waiting lists for this service it is vital that more clinical psychologists are trained as outlined in The Depression Report issued by the LSE in June 2006'. A leaflet outlining what benzodiazepines are, what they are used for, how they work, is already available to GPs, and all medical staff, via Patients UK or on their website www.prodigy.nhs.uk which was updated June 2006 and is Prodigy validated.
Any new patient put on benzodiazepines should only be given a prescription for a maximum of two weeks with the dosage for the elderly being only half the adult dosage. 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 would be the controlling authority re “over prescribing”. Software to undertake this task is already available and can be purchased.
The GP should make a further appointment with the patient for two weeks ahead, at which time he should decide either to stop prescribing the benzodiazepines or continue for a maximum of a further two weeks (Providing the patient is happy to continue for a further two weeks). Again, this would be recorded on the computer and if a second prescription has been given, then a warning flag is highlighted to Medicine Management team, who will then notify the GP that the recommended period of usage for this medication has been reached under this course of treatment.
At the end of either the two week or four week period, dependent on what prescriptions have been given to the patient, the GP should then make a further appointment for one week ahead at which time 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 would be given assistance to withdraw as laid down in later parts of this document.
- Any new patient prescribed with benzodiazepines, should be given the minimum dosage thought to be appropriate for the prognosis, and the choice of benzodiazepine should be diazepam, wherever possible, which has a long half-life. This would mean that if dependency did occur, it would be easier to start a withdrawal programme. In the case of the elderly or those with liver damage or other organic illnesses a benzodiazepine with a shorter half life and no active metabolites may be a more appropriate choice.
Patients Dependent on Prescription-Supplied Benzodiazepines
Under the new system, due to come in effect from October 2006, there will be some 152 PCTs and it is vital, especially with the reorganisation that is taking place, that each of these PCTs carries out an audit to determine the number of patients who are, within their domain, dependent on prescription benzodiazepines. This audit should include patients who have been receiving prescriptions for a period greater than 4 weeks and should include patients who are being prescribed benzodiazepines as anxiolytics, hypnotics or anticonvulsants. The figures from the audit would be factual, rather than the extrapolations which are used at the present time. These give variation from 750,000 to 1.5 million people. Without these figures, it becomes virtually impossible to determine the future treatment requirements or the amount of help that will need to be provided.
With the current computer capabilities available, it should be possible to carry out the audit based on a surgery-by-surgery basis, within each PCT area .This audit could be undertaken under the control of that particular PCT's Medicine Management team and utilising the community pharmacists. This initial audit would form the basis by which future audits are compared, thereby enabling the effectiveness of any plans which are undertaken, to be factually assessed. Audits could be undertaken on a bi-yearly basis so that any adjustments deemed necessary, could be undertaken at an early date rather than carrying forward inherent faults.
The problems associated with benzodiazepine withdrawal are very individual and do not conform to withdrawals such as those from tobacco, alcohol or heroin which can have relatively short withdrawal times. People who suffer from benzodiazepine dependency have to be withdrawn over a relatively long period of time, which can be many months or years. It is this uniqueness that means help and support has to be given not only during the withdrawal procedure, but for a considerable period of time afterwards, and this makes it time consuming, as well as worker-time consuming. It is for these reasons that people need to be specially trained into understanding the problems which can be associated with withdrawal from benzodiazepines.
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 patients’ rate of reduction. It is both time wasting and expensive in terms of human effort to force people to withdraw and is only counter productive.
One of the problems presently associated with benzodiazepine withdrawal, is that patients are pushed into undertaking a withdrawal programme by GPs who have very little knowledge of how to handle such a procedure, and this often ends up with patients turning to other supplies such as the Internet or illegal suppliers etc. They then tell their doctors that they have been feeling great and have no problems associated with withdrawal and of course, having been deceived, the doctor counts it as a success, and uses the same procedure for the next patient he/she feels should withdraw. 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 benzodiazepine, 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 classes of medication. 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 giving to patients with details and guidance on this subject, to enable people to make an educated decision on whether or not they want to withdraw.
It also highlights the importance of a patient who is considering withdrawal, having a full support structure in place. This should begin at the GP’s surgery and include not only the medical profession, but family support, as well as self help group support and any other type of support that can be identified. It is important for the doctors to ensure that these are available and should actively point patients in the direction of any local voluntary sector/community, support groups that could be of 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 enormous amount of work needed to overcome the benzodiazepine problem to be carried out. The following lays down some of these building blocks and offers possible solutions to enable them to be used.1. Each PCT should have a person, a focal point, who would oversee all aspects of benzodiazepine usage within the PCT. This person would need to be trained specifically in all aspects of benzodiazepine control and withdrawal. This training could be sourced from an external supplier. This person, when fully trained, would then be responsible for the educating of all PCT staff including GPs, nurses and all other professional staff, in all aspects of benzodiazepine usage and associated problems. He/she would extend this work to cover all GP surgeries within the area covered by the PCT. He/she would also be the focal point for all prescriptions issued within the PCT area and would be responsible for ensuring that the issuing of 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 of all prescriptions, as well as the analysis of these, to ensure that the use of benzodiazepines within the PCT area, is not on the increase, but as one would hope, is on a downward trend.
This position would lend itself to somebody with pharmacy/medical training.
2. Each GP surgery should have a surgery nurse, suitably trained in benzodiazepines, or pharmacist, who would work with the GP, and would be responsible for educating all patients, who are treated by that surgery, about the problems associated with benzodiazepines. He/she would, during routine health and medication checks, discuss the dangers associated with long term usage of benzodiazepines, and the possibility of withdrawal. He/she would not put pressure on any patient, to withdraw, but would give all available information, including leaflets, available from the Prodigy Knowledge, local voluntary groups etc. He/she would suggest that thought should be given to withdrawal, and ensure that patients feel that the door has been left open for them to come back for further discussions when they have absorbed the information given He/she will ensure that appropriate records are made of all visits and will keep the GP fully informed of the outcomes. Any withdrawal programme can only be undertaken with the agreement of the GP, although the nurse/pharmacist would be involved in the formulation of patient programmes, and would be involved in the operating of such programmes. Care would need to be taken in cases where patients have been prescribed benzodiazepines for psychoses and such patients may need to be referred back to the psychiatrist for benzodiazepine withdrawal.
3. In the event of a patient agreeing to undertake a withdrawal program, the GP should agree with the patient a rate of withdrawal. Because neither the patient nor doctor will have a feel as to what sort of withdrawal symptoms the patient will experience, then it is better to start at a slower rate which should be of the order of 10% of the normal dosage with at least three weeks between reductions. The reduction must remain flexible throughout the whole of the withdrawal programme, but should always proceed at the rate decided by the patient, who inevitably, will go at a rate dictated by his/her body response.
4. Support by the nurse/pharmacist should be on a regular two/four week basis during the whole of the withdrawal programme, and for a minimum of a further six months after the completion. The support should involve the patient having a meeting at the surgery to make sure that the withdrawal symptoms are at acceptable levels, and if not, further reductions should be left until these symptoms begin to subside. Particular care must be taken to assess any increased depression, and if this occurs, then this again would stop further reductions until the depression has been stabilised.
5. A further follow-up on withdrawal symptoms should be carried out for a further twelve months, based on patients visiting the surgery on a monthly basis.6..PCTs should make space available within the local hospital for meetings to take place between voluntary groups and individuals taking part in withdrawal programmes, or those wishing to get help and advice on joining a withdrawal programme.
7. A better working partnership between the doctors and organisations in the voluntary sector who deal with and are familiar with benzodiazepine withdrawal. This would be cost effective to the doctor and also beneficial to the patient to have an additional system for support and advice from people with personal experience of their problem.
Street Benzodiazepines
People, who have fallen into the benzodiazepine trap via street drugs, should be treated in exactly the same way as those who have become dependent through prescription supplied benzodiazepines. These people are usually handled by the drug and alcohol team because in many cases their problems are more complex and often involves them being on illegal drugs as well as benzodiazepines. It is therefore vital that the staff who run this service are included in the overall training of staff on benzodiazepines.
1. A member of the D and A team should be made responsible for the overview of street benzodiazepine dependency, and should liaise with the person with overall responsibility for the PCT.
2. Where other drugs are involved, benzodiazepines should be the last drug to be considered for withdrawal3. Wherever possible, the patient should be treated in the surgery situation for his/her withdrawal program but specialised drug/alcohol units may be needed for withdrawal from combined dependencies such as benzodiazepines and opiates.
4. Patients should not be subjected to the one chance at detoxification and if unsuccessful no further help available.
5. Patients should receive the same psychological therapies as those that would be given to prescription patients.
6. Patients who have overcome alcohol withdrawal should be made aware that they should not resort to alcohol during benzodiazepine withdrawal, because the combination of the two can have bad effects on the withdrawal symptoms
Footnote
The author and his wife have had discussions with Morecambe Bay PCT, on this subject for over two years, and are pleased to say that some of the issues discussed in this document are at present being trialed by MBPCT. These trials are being carried out by MBPCT through Andrea Loudon, Head of Pharmacy and Medicine Management, and her team of Prescribing Support Pharmacists under the Project Leadership of Simon Butterworth. They are in the process of developing an innovative approach to both benzodiazepine control and reduction in prescription medication. They are working on a "whole system" approach which involves prescribing, dispensing and the patient.
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