NHS Fife Guidelines for Benzodiazepine Prescribing in Benzodiazepine Dependence
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NHS Fife Guidelines for Benzodiazepine Prescribing in Benzodiazepine Dependence Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 1 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013 Contents Flowchart for Benzodiazepine Withdrawal ……………………………………………………………3 Establishing type of dependence. ........................................................................................... 4 Assessment of Benzodiazepine Dependence .............................................................................. 5 Management of dependence in therapeutic dose users ........................................................... 6 Management of dependence in prescribed high dose users. ................................................... 7 Management of dependence in illicit and recreational users. .................................................. 8 Psychological support. ................................................................................................................. 9 Pharmacological support............................................................................................................ 10 Appendices Appendix 1 Example Patient Letter (regular user) ................................................. 11 Appendix 2 Information leaflets and advice from the internet ................................ 13 Appendix 3 DRUG DIARY ..................................................................................... 14 Appendix 4 Benzodiazepine conversion table ....................................................... 15 Appendix 5 Withdrawal regimes for therapeutic dose users ................................. 16 Appendix 6 Withdrawal regimes for high dose users ............................................ 18 Appendix 7 Self-help guides for psychological support ......................................... 20 Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 2 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013 Flowchart for Benzodiazepine Withdrawal Patient taking benzodiazepine Assess. Establish dependence and pattern of usage Prescribed therapeutic dose Prescribed high dose Recreational high dose and dependence dependence abuse Monitor benzodiazepine use for Complete drug diary for at 2 3 months & complete at least least weeks two drug screens. Establish boundaries, set goals Is patient topping up Is minimum intervention prescription with illicitly obtained appropriate? Patient ready to reduce usage? benzodiazepine? Yes No No Yes Yes No Advise self-reduction of illicitly Continue to support reduction obtained benzodiazepine to Letter and FAQs using motivational interviewing. prescribed or therapeutic level. Do not Brief intervention Consider referral to prescribe doses of diazepam to Self-help booklet DAPL/FIRST/Psychology compensate for illicitly obtained drugs Agree gradual dose reduction converting to diazepam with twice daily Yes Patient reduced use to 30-40mg No dosing if appropriate. equivalent diazepam? Prescribe 2mg or 5mg diazepam only Reduce daily dose by about 1/8th (range 1/10th to ¼) every 2 or 3 weeks Withdrawal Symptoms? No Yes Maintain at present dose until symptoms improve-avoid increasing the dosage again Continue reduction at agreed Address any underlying mental rate health problems offering psychological or pharmacological support Renegotiate rate of reduction if required STOP COMPLETELY (Time needed can vary from 4 weeks to a year or more) Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 3 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013 Following the introduction of benzodiazepines in the 1960s as the treatment of choice for anxiety and insomniaFife Guidelines and their widespread for Benzodiazepine use from the Prescribing1970s onwards in it Benzodiazepinehas been recognised Dependence that long term use can result in physical and psychological dependence as well as tolerance to their use. In addition to patients prescribed benzodiazepines the illicit use, particularly by opioid drug users is a major problem for users in and out of drug treatment. High doses of prescribed and illicit benzodiazepines are taken and users become extremely tolerant to the sedative effects. Benzodiazepine withdrawal syndrome is characterised by insomnia, anxiety, loss of appetite and body- weight, tremor, perspiration, tinnitus, and perceptual disturbances. Abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. For this reason patients exhibiting dependence should undergo gradual withdrawal of the benzodiazepine. Establishing type of dependence. Patients may exhibit dependency on a therapeutic dose or non-therapeutic dose – the latter group being subdivided into “prescribed high dose dependence” and “recreational high dose abuse and dependence” groups. Therapeutic Dose Prescribed High Dose Illicit and Recreational Use Dependence Dependence (eg ≥30mg diazepam) Dependence Characteristics of Therapeutic Dose Dependence – Patient may have: taken benzodiazepines in prescribed low doses for months or years. gradually come to “need” benzodiazepines in order to carry out normal activities of daily living. continued to take their medication even though original indication has disappeared. experienced withdrawal symptoms when they try to reduce or stop the drugs. contacted the prescriber frequently to request repeat prescriptions. experienced anxiety if there is a delay to the next prescription. increased the dosage since the original prescription experienced anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines. Characteristics of Prescribed High Dose Dependence – patient requiring ever larger doses may: try to persuade doctor to escalate doses and/or number of tablets on the prescription. present at hospital or register at further practices to obtain more tablets combine benzodiazepine misuse with excessive alcohol consumption or other sedative drugs be highly anxious, depressed or have personality disorder tend not to use illicit drugs, but may obtain benzodiazepines from relatives or acquaintances. Characteristics of Recreational High Dose Abuse & Dependence – Often develops as polydrug abusers attempt to enhance the effect of opioids or to “come down” from stimulants. A very high tolerance develops making it difficult to detect the actual scale of drug consumption. Users may be taking well in excess of 100mg daily in a single dose to maximise the effect. There may be a concurrent alcohol problem and the user may have been introduced to benzodiazepines during previous alcohol detoxification Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 4 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013 Assessment of Benzodiazepine Dependence 1. Establish PATTERN of benzodiazepine usage 2. Establish DEPENDENCE if 3 or more or the following are present in the same 12-month period: Date of onset of usage ……………………………… 3 to 5 indicators – mild to moderate dependence Benzodiazepines used ………………………………. 5 to 7 indicators – moderate to severe dependence i) Tolerance – a need for increased amounts to achieve desired effect OR Average daily dose and dose intervals …………….. - diminished effect with continued use of same amount Previous successful withdrawal from use? ………… ii) Withdrawal – previous attempts to cut down result in withdrawal symptoms OR - substance is taken to prevent withdrawal symptoms If yes, longest period of abstinence? ……………… iii) Substance taken in larger amounts or over longer period than originally intended Any other drug or alcohol used?.............................. iv) Persistent desire or unsuccessful effort to cut down or control use v) Great deal of time spent obtaining substance or recovering from its effects vi) Important activities (social, work related or recreational) given up or reduced vii) Continued use of drug despite clear evidence of harmful effects 4. Establish CATEGORY of dependence: DSM-IV Diagnostic Criteria for Substance Dependence Therapeutic Dose Dependence Started for a reason and continued 3. Additional considerations (to inform but not prevent detox): High Dose Dependence Concomitant severe medical or psychiatric illness Started as a prescription and then escalated No other drug or alcohol problems History of severe withdrawal (including PROVEN history of seizures) Recreational High Dose Abuse & Dependence Completion of drug diary (for at least 2 weeks, up to 3 months may be appropriate) Used and abused by people who use drugs: illicit, POM or OTC and/or alcohol Confirmation of dependence by drug screening (urine but consider oral fluid) See page 4 for more detail Level of motivation to change Dr. A. Baldacchino, Liz. Hutchings, Addiction Services Issued: April 2013 Review Date: April 2016 5 Approved by NHS Fife ADTC on behalf of NHS Fife Date June 2013 Management of dependence in therapeutic dose users Management can include minimal interventions, gradual dose reduction and gradual dose reduction with additional psychological support. Minimal interventions (1 and 2 below) are suitable in early/mild dependence. 1. Write to the patient: explain problems associated with long-term benzodiazepine use and the need to reduce their prescription encouraging a gradual reduction or cessation if possible. (appx 1) 2. Brief Intervention: Simple