BENZODIAZEPINES AND Z DRUGS: THE HIDDEN STORY

ACTION FOR CUMBRIA

NOTE: This page is also viewable in a series of powerpoint files
Presentation 1	Presentation 2	Presentation 3	Presentation 4	Presentation 5	Part 6

Page Menu

Presentation 1 - Benzodiazepines and Z Drugs: The Hidden StoryAction For Cumbria

Presentation 2 - Psychological therapies – Penrith, Cumbria

Presentation 3 - Benzodiazepine Prescribing in Primary Care

Presentation 4 - Substance Misuse and Benzodiazepines Pattern of Use

Presentation 5 - Improving Mental Health and Well Being in Cumbria Meeting 30 January 2008

Part 6 - Groupwork Feedback

Wednesday 30 January 2008

09:00 – 09:30   Arrival and Coffee
09:30 – 09:50   Chairman’s welcome and scene setting: Nigel Maguire, Director of Market Development Cumbria Primary Care Trust
09:50 – 10:20   Key-note Presentation: Improving Access to Psychological Therapies: Dr Alan Cohen, Senior Clinical Advisor in Primary Care, Care Services Improvement Partnership (CSIP)
10:20 – 10:40 Benzodiazepine Prescribing in Primary Care: Dr Jeff Rudman, Cumbria Primary Care Trust GP Prescribing lead
10:40 – 11:00   Coffee
11:00 – 11:30   Substance Misuse and Benzodiazepines: Dr. Neville Wright, Consultant Psychiatrist, Cumbria Partnership NHS Trust
11:30 – 11:45   Improving Mental Health and Well Being in Cumbria: Vernon Watson. Associate Director, Cumbria PCT
11:45 – 12:45   Group Discussion and Action planning
                               Best practice – how do we consistently apply everywhere the good practice we already have
                                *Where are the gaps – what action needs to be taken
                                 *How and who will take action from here and how will we know if it is effective
12:45 – 13:15   Lunch
13:15 – 13:45   Summary and Close: Nigel Maguire

Presentation 1

Benzodiazepines and Z
Drugs: The Hidden StoryAction For Cumbria

Purpose of Today

By the end of the today we will have:

Gained a clearer view about what is happening across Cumbria
Agreed what needs to change
Agreed who will take leadership roles to bring about the change

We’re Going to Hear About:

National programme for improving access to psychological therapies
Current approaches to ensuring best practice in benzodiazepine in primary care
Benzodiazepines and substance misuse
The PCT plans for improving mental health and emotional wellbeing
Most importantly, your views and commitment

Towards Early Intervention

Policy and resources have been focussed on people with the most complex needs
About to consult on significant changes to mental health services in Cumbria, under banner of Closer to Home.
The aim will be to redress the balance between services for people with severe and enduring mental illness, and that much larger number of people who are suffering from acute and chronic mental distress.
This will allow us to intervene upstream, preventing situations from getting worse, and helping people to avoid more illness and dependence on specialist services

Things to Consider

We will reflect on:
The role of benzodiazepines within the Cumbrian healthcare system
The benefits and disbenefits of benzodiazepines as a form of treatment
The patterns of benzodiazepine prescribing and use in Cumbria
The availability of benzodiazepines through non prescribed sources and street leakage
What we are already doing to improve the local situation in prescribing

Some Possible Objectives

Ensure best practice in benzodiazepine prescribing is effectively managed
Ensure best practice in supporting individuals prescribed benzodiazepines is followed
Develop services to support individuals who with the support of their prescribing doctor wish to reduce or withdraw from the use of benzodiazepines
Reduce the availability and misuse of benzodiazepines from street leakage

Opportunity for Change

We have a wide range of stakeholders here, which reflects the concern about the use of benzodiazepines.

We are likely to have a wide range of views about the nature of our problems in Cumbria, and the possible solutions.

We need to bring together a range of solutions which in combination will have real impact

A special thanks to

Mr and Mrs Allan and Thelma Weatherburn
Dr Alan Cohen

For their contribution to this event

Presentation 2

Psychological therapies – Penrith, Cumbria
Summary

The development of the Improving Access to Psychological Therapies (IAPT) programme
The current state of play
The role of primary care and general practice

First, there was the case for change

The impact of untreated depression & anxiety

1 in 6 adults (16% population)
10% new mothers (of whom only 20% receive any treatment)
1.3m older people
700k children and younger people
30% of GP consultations
Long Term conditions
Medically unexplained symptoms

What happened?

2005: Manifesto commitment to improved access to psychological therapies

2006: 2 demonstration sites created

Doncaster and Newham each funded with £1.5m

Demonstration Site Progress report

Access

5,000 more people treated
70% GP referrals
30% Self-Referrals (anti-stigma & inclusive)
Wait times down to 2 weeks
3 days to assessment

Service Models (Stepped Care)

Low Intensity (>8 hours)
High Intensity (>20 hours)

Demonstration Site Progress report

Right Results

Systematic outcome monitoring system
Health & well-being gains
Exceeded NICE guidelines (>50% recovery rate)

Social Inclusion

100% job retention
30% back to work or education
7% off benefits

Choice and user experience

90% satisfaction rates
89% able to make choices

Then what happened?

May 2007: 11 “Pathfinder” sites, each funded with £200K

The IAPT Pathfinders

11 PCT-led Pathfinder sites

1 in each SHA area
Service redesign & capacity planning
1 additional site in Bury (NW) CAMHS

Progress

109 (70%) PCTs expressed an interest in Pathfinders
76 (50%) full applications
Sites announced 31 July & commitment to Regional Networks

And then...

October 2007: SoS announces £30m/ £100m/£170m new funding for IAPT programme

What the investment will provide:

800,000 more people treated; 400,000 recovered
20,000 fewer people on sick pay & benefits
3,000 more psychological therapists
Universal GP access to therapies
Waiting times down from 18 months to 2 weeks

The Characteristics of an IAPT Service

Multi-disciplinary team

Teams of therapists

Equality of access
Delivering NICE compliant treatment

Stepped care system

Low intensity interventions <7
High intensity interventions >20

The Characteristics of an IAPT Service

Routine outcome monitoring

Clinical and service indicators
At least 90% of patients/users/people will have outcome data

Right workforce

60:40 high:low intensity workers
Supervision requires that at least a third of workers are fully trained.

What an IAPT service delivers

Psychological therapy services

NICE compliant

Links/partnership with employment services
Links/partnership with social care

Need not be delivered by a statutory sector provider

The Role of Primary Care - Commissioning

Development of a commissioning tool kit

Designed for any commissioner

Practice Based Commissioning

Does PBC have a role?
What are the risks associated with PBC?

The Role of Primary Care - Clinical

Identification, management and onward referral (where clinically indicated) to the new service

The generalist approach:

Association between mental and physical health
Use of acute services

Appropriate prescribing

Anti-depressant prescribing
Benzo prescribing

Information sharing

about the new service
with the new services

Physical health

Strong associations exist between depression and
Ischaemic Heart Disease
Diabetes
COPD

Better management improves outcomes, and burden of disease in these areas

Acute services

Close association between physical symptoms and mental distress
Probably one of the elements in why recognition of mental health conditions in primary care can be “poor”
Lots of referrals to acute out patient services, for people with medically unexplained symptoms

Clinic

%

Chest 59%

Cardiology 56%

Gastroenterology 60%

Rheumatology 58%

Neurology 55%

Dental 49%

Gynaecology 57%

Prescribing

Will IAPT services slow the inexorable growth in prescribing of anti-depressants?

Awaiting detailed evaluation from St George’s HMS

Benzo and Z withdrawal

http://www.benzo.org.uk/manual/bzcha02.htm
http://cks.library.nhs.uk/benzos_z_drug_withdrawal/in_summary/scenario_starting_withdrawal
http://www.pjonline.com/medicinesmanagement/editorial/200503/features/p03benzodiazepine.html

Benzo/Z drug withdrawal

Guidelines on withdrawal process are consistent that...

Psychological assessment is necessary
Psychological support during and after withdrawal is necessary

In the past adequate and timely availability of this support, and in the management of common mental health problems, has been poor
IAPT provides the opportunity to deliver that psychological support

What happens next?

PCT delivery incentives

PSA target
HSC Outcomes Framework objective
NHS Operating Framework 08/09

SHA leadership for local implementation

Performance management
Ensuring Regional Workforce & Training solutions
Capacity (& demand) planning
Commissioning Toolkit

A forward look: 2008/09

Each SHA will identify at least 2 sites to act as training centres of excellence for therapists
Each SHA will identify providers of training
Each SHA has a budget for development, including…

GP lead
PC lead
Development fund

It is up to each SHA how the development budget is used!

Summary

IAPT programme entering a planned dissemination phase
Engaging with groups other than “adults of working age”
Engaging with commissioners
Developing regional networks as part of the programme of dissemination and spread.

Further information

Presentation 3

Presentation 4

Substance Misuse and Benzodiazepines
Pattern of Use

Primary intoxicant
Adjunctive intoxicant - opiates
                                           - alcohol

Stimulant facilitation - Amphetamine – S.E. control
                                         - Cocaine - ‘chill’, ‘come down’

Self medication - hypnotic
                               - anxiolytic

detoxification

Type & Route

Diazepam (Valium), almost exclusively oral

Temazepam – oral or i/v

Lorazepam – oral

Clonazepam – oral

‘Benzo like’ substances

Zopiclone – oral/i/v

Chlormethiazole – oral

Meprobamate/Baclofen – oral

SOURCES

Diazepam – Asia, former Soviet block, Southern Europe,

                        local prescription

Temazepam – Former Soviet block, Southern Ireland,

                            vetinary

Lorazepam/Clonazepam – Locally prescribed/Southern Europe

‘Benzo like’ – Locally prescribed/Southern Europe

Consequences of Misuse

Intoxication - Falls/RTA’s, other accidents
                         - Criminality – ‘invisibility’
                         - Aggression – rare paradoxical reactions
                          - Amnesia

Acute overdose - alone surprisingly safe
                               - combination with opiates/alcohol

DANGEROUS

D.R.D’s

Consequences of Misuse (cont)

Chronic Heavy Use          - Very little general medical
                                                    - Decreased cognitive function?? Permanent
                                                    - Physical & psychological DEPENDENCE

Withdrawal                          - Fits, muscle twitches
                                                    - Anxiety, perceptual changes, mood disorder
                                                    - Psychosis (transient)

Reduces efficacy of S.M. treatments

                        Nothing like as bad as alcohol !

APPROPRIATE USES

Why not ban them?
Most effective and safest acute anxiolytics

Psychiatric emergencies - rapid tranquillisation
                                                - short term adjunct to
                                                -   antidepressants/antipsychotics/mood stabilisers

Acute stress reactions   - Bereavement
                                             - RTA’s, etc
                                             - Flying & other phobias
Short term hypnotics

Treat for anxiety disorders – Third line (B.A.P. 2005) especially treatment resistant
                                                  G.A.D.

Detoxification                – Alcohol/mainstay
                                            - Chlordiazepoxide (Librium)
                                           - Lesser role in other substances
Medical procedures      - Endoscopy, etc.

Detoxification

Convert to Diazepam equivalents
                - tablet choice
                - daily pickup facility

Gentle withdrawal, duration proportional to length of misuse
                   6 weeks to 6 months!

Firm but sympathetic approach, some role for alternative therapies.

Prophylactic antidepressants sometimes indicated.

Solutions

No maintenance prescribing for addiction issues (2007 orange guidelines)

Better control of repeat prescriptions

Drug user education, not just harmless medical drug

Better provision of specialist treatment for anxiety disorders – psychological and pharmacological

Better access for drug misusers to above!

Interval prescribing facility for Librium?

Presentation 5

Improving Mental Health and Well Being in Cumbria Meeting 30 January 2008

POLICY DRIVERS

Policy has been targeted on people with the most complex needs
Increasing awareness of the need for more front line and preventative work
Depression and anxiety among the most debilitating health conditions a person can experience (NICE).
Improving Access to Psychological Therapies

PLANS FOR CUMBRIA

A Primary Care Mental Health Service

Aims of Change

To redress the balance between services for people with severe and enduring mental illness, and that much larger number of people who are suffering from acute and chronic mental distress.

WHO WILL USE THE SERVICE

Patients with “common” mental health problems

Vulnerable groups identified in Primary Care

Vulnerable populations

ACCESS ROUTES

Referrals by phone, fax, secure email, or in person.
Maximum of 2 weeks to appointment with an appropriate service provider.
Later, opening up to referrals from local agencies.
Each practice to have a proportional service for its population (2 wte per 20,000 population)

Intervention/Management

Step 1:

   Support to primary care in delivery of services

Step 2:

   Integrated Care Pathways for common conditions

   Scoring tools common to the team and to General Practice

   Up to 7 sessions

Part 6

Groupwork Feedback

Top 5 Priorities

Quick Actions

Longer Term Issues/Actions

Top 5 Priorities

Primary care mental health team development needed as soon as possible.
     Creating support and generating alternatives

Limiting / reducing the prescribing of benzodiazepines

Use of ‘PCT special measures’- tackling individual practices to get greater consistency

Education:

          Public education
          Medical education- GPs and Consultants, not forgetting acute hospitals
          Broader clinical awareness across teams such as District Nurses
          Improving links e.g. with schools and other agencies
          Culture change needed
Expertise and data- needs coordinating

Quick Actions

Night sedation policy across Cumbria
Access to non drug strategies
Incentivising reduction in prescriptions- ?QOF
No new automatic repeat prescriptions
Patient information leaflet-Cumbria wide
Dissemination prescription information by practice
Cumbria wide policy and prescribing guidelines
Share best practice e.g. Mary port and St Pauls….
Simple interventions-e.g. letters, flashcards
Making use of data- better use and spread
Community pharmacists, use their intelligence
Think twice or don’t, if you must make it limited, beyond that strict review-simple messages