GUIDANCE FOR PRESCRIBING AND WITHDRAWAL …

1 Title: GUIDANCE FOR PRESCRIBING AND WITHDRAWAL OFBENZODIAZEPINES & HYPNOTICS IN GENERAL PRACTICEI dentifier:Across NHSB oardsOrganisationWideDirectorateClinical ServiceSub DepartmentAreaYESThis controlled document shall not be copied in part or whole without the express permission of theauthor or the author s date:October 2008 Author:Lucy EaglesPolicy application:NHS GrampianPurpose:The purpose of the following information and GUIDANCE is to disseminate thelessons learned in the specialist unit in order that a greater attention to rigourin assessment and a more holistic approach to treatment can reduce thereliance on maintenance PRESCRIBING of for implementation:Departmental:Heads of Service / Clinical LeadsArea:General PractitionersReview:This policy will be reviewed every two years or sooner if current treatmentrecommendations policy is also available in large printand on computer disk.

2 Other formats canbe supplied on call the Pharmacy Medicines Unit on01224 556525 or 556088 for a 2006 Review date: October 2008 GUIDANCE FORPRESCRIBING & WITHDRAWAL OFBENZODIAZEPINES &HYPNOTICS INGENERAL PRACTICECONTENTSPageINTRODUCTION .. 1 OPENING STATEMENTS .. 1 SECTION 1 .. 3 ASSESSMENT OF BENZODIAZEPINE 3 ACTUAL ASSESSMENT .. 3 SECTION 2 .. 6 MANAGEMENT OF BENZODIAZEPINE & HYPNOTIC 6 BENZODIAZEPINE REDUCTION .. principles for benzodiazepine dose Of Benzodiazepines and Their Diazepam Equivalents .. 6iii. Table of Diazepam 5mg Equivalents .. 7iv. Management of polydrug dependence opiates, cocaine and benzodiazepines.

3 In pregnancy .. 8 NOTES ON ALCOHOL DETOXIFICATION USING 8 SECTION 3 .. 9 SUGGESTIONS FOR CLINICAL PRACTICE IN PRIMARY Policy: .. relating to GP initiated action to reduce benzodiazepine PRESCRIBING .. 9iii. Patient Information Leaflets on Benzodiazepines .. 10 REFERENCES AND FURTHER READING .. 11 Contributors .. 11 Appendix 1: ALGORITHM FOR BENZODIAZEPINE REDUCTION .. 12 Appendix 2: PATIENT INFORMATION RECOMMENDED REDUCING REGIME FROM 30mg 13 Appendix 3: PATIENT INFORMATION RECOMMENDED REDUCING REGIME FROM 80mg 14 Appendix 4: PATIENT INFORMATION RECOMMENDED REDUCING REGIME FROM 200mgto 80mg .. 15 Appendix 5: WITHDRAWAL FROM ZOPICLONE 15MG WITH DIAZEPAM SUBSTITUTION.

4 16 UNCONTROLLED WHEN PRINTEDG uidance For PRESCRIBING And WITHDRAWAL Of Benzodiazepines & Hypnotics In General PracticeVersion 1 Date October 2006, Review date October 20081 GUIDANCE FOR PRESCRIBING AND WITHDRAWAL OFBENZODIAZEPINES & HYPNOTICS IN GENERAL PRACTICEINTRODUCTIONThe purpose of the following information and GUIDANCE is to disseminate the lessons learned in thespecialist unit in order that a greater attention to rigour in assessment and a more holistic approachto treatment can reduce the reliance on maintenance PRESCRIBING of benzodiazepines. It is furtherintended that the damaging effects of long-term anxiolytics use will be detected, acknowledged,treated, and prevented from recurring in the recommendations for practice and the statistics quoted in this text are derived mainly from themost recently published Cochrane Reviews and the Database of Abstracts of Reviews ofEffectiveness (DARE, 2003).

5 Recommendations are included from the Protocol for the Treatmentof Benzodiazepine WITHDRAWAL , which was developed by recognised expert, Professor HeatherAshton (University of Newcastle, 2002). This publication is available to download free from theInternet at , an invaluable website for professionals and patients from the Royal College of General Practitioners and the Royal College ofPsychiatrists are also STATEMENTSThe National Performance Assessment Framework for NHS Scotland takes account of anxiolyticand hypnotic PRESCRIBING and it is a national priority to reduce this within each Health Board British National Formulary (BNF) and Committee on Safety of Medicines (CSM)

6 Provide clearguidance on the indications for these in the controlled drug regulations HDL (2006) 27 recommend that prescriptions forbenzodiazepines should be limited to a quantity necessary for up to 30 days clinical upon prescribed benzodiazepines is now recognised as a major clinical ARE NO LICENSED INDICATIONS FOR THE PRESCRIPTIONOF BENZODIAZEPINES FOR MORE THAN 2 TO 4 WEEKSCSM ADVICE makes it clear that: i. Benzodiazepines are indicated for the short-term relief (2 4 weeks only) of ANXIETY that issevere, disabling or subjecting the individual to unacceptable distress, occurring alone or inassociation with insomnia or short-term psychosomatic, organic or psychotic illness.

7 Ii. The use of benzodiazepines to treat short-term mild anxiety is inappropriate and unsuitable. iii. Benzodiazepines should be used to treat insomnia only when it is severe, disabling, orsubjecting the individual to extreme distress (BNF Section ).UNCONTROLLED WHEN PRINTEDG uidance For PRESCRIBING And WITHDRAWAL Of Benzodiazepines & Hypnotics In General PracticeVersion 1 Date October 2006, Review date October 20082 Key points to consider in relation to PRESCRIBING There are no licensed indications for PRESCRIBING benzodiazepines for more than 2-4 weeks. Dependence on even small doses of benzodiazepines can result in anxiety, insomnia and otherdistressing WITHDRAWAL symptoms if the drug is stopped abruptly.

8 Benzodiazepines are not indicated or advised for the treatment of opiate addiction. Older people are more sensitive to the CNS side effects of benzodiazepines, such asconfusion, amnesia, ataxia and hangover effects and are therefore at an increased risk of can increase the risks of road traffic accidents, increase toxicity with alcoholand suicide risk. Known opiate addicts have a high chance of becoming dependent on indications Prevention of dependence by appropriate initial PRESCRIBING is the most desirable situation. The British National Formulary lists the following indications for the PRESCRIBING ofbenzodiazepines: Short term use in anxiety or insomnia.

9 As an adjunct in alcohol WITHDRAWAL . Status epilepticus. Febrile convulsions. Muscle spasm. Perioperative WHEN PRINTEDG uidance For PRESCRIBING And WITHDRAWAL Of Benzodiazepines & Hypnotics In General PracticeVersion 1 Date October 2006, Review date October 20083 SECTION 1 ASSESSMENT OF BENZODIAZEPINE DEPENDENCEB enzodiazepines are potentially addictive drugs; physical and psychological dependence candevelop within weeks of regular use. Benzodiazepines are increasingly used in conjunction withother substances of abuse. They are used in this context to increase the kick obtained fromopiates, and to alleviate the WITHDRAWAL symptoms of other drugs of abuse such as cocaine,amphetamines and ASSESSMENT i.

10 Check for Evidence of Benzodiazepine Dependence Note the patient s physical presentation drowsiness, disinhibition, dilation of pupils, andnote the frequency or consistency of presentation over several weeks. It is recommended that the patient s benzodiazepine use be assessed over a 3-monthperiod before a diagnosis of dependency is made unless there is compelling evidence at anearlier point. ii. Try to Establish the PATTERN of Benzodiazepine usage: Date of onset of benzodiazepine usage and which drug(s). Date of onset of dependency and frequency of usage. Average daily dose and dose intervals. Duration of any successful WITHDRAWAL from benzodiazepines.