H C 3 O N CI N Prescribing drugs of dependence N in general practice, Part B CH 3 Benzodiazepines N N H C 3 O O N H N CI N OH CI N CI N H C 3 O CI N O2N N O H N F www.racgp.org.au Healthy Profession. OH Healthy Australia. CI N CI Prescribing drugs of dependence in general practice, Part B – Benzodiazepines Disclaimer The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates. Whilst the text is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices. Accordingly, The Royal Australian College of General Practitioners and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Recommended citation Prescribing drugs of dependence in general practice, Part B – Benzodiazepines. Melbourne: The Royal Australian College of General Practitioners, 2015. Published by The Royal Australian College of General Practitioners 100 Wellington Parade East Melbourne Victoria 3002 Australia Tel 1800 473 247 Fax 03 8699 0400 www.racgp.org.au ISBN 978-0-86906-430-6 Published June 2015 © The Royal Australian College of General Practitioners, 2015. We recognise the traditional custodians of the land and sea on which we work and live. Prescribing drugs of dependence in general practice, Part B Benzodiazepines i Foreword Benzodiazepines have a chequered clinical history and continue to produce polar opinions in the medical community. Benzodiazepines have been associated with both benefits and harms for patients, and a clear guide for accountable prescribing has been requested from multiple agencies. Drug therapies will only ever have a partial role in managing complex bio-psychosocial issues that characterise mental health care. In the modern health environment, we have to explore and use non-drug therapies, and redefine the place of existing medications. This guide represents a synthesis of the best available evidence for benzodiazepine use in the primary care setting. Consistent with all medications, prescribing benzodiazepines requires clear patient selection and ongoing clinical monitoring to optimise outcomes. The risk–benefit ratio of benzodiazepines changes considerably with concomitant psychoactive drugs, or comorbid alcohol or substance abuse or misuse. In completing this guide, we acknowledge the work of the key advisers and reviewers, and the many people who have provided constructive feedback. The Royal Australian College of General Practitioners (RACGP) welcomes feedback on this guide to continually improve services at the general practice level. Please use the feedback section on our website to help co-create this guide. Prescribing drugs of dependence in general practice, Part B ii Benzodiazepines Acknowledgements The RACGP gratefully acknowledges the generous contribution of the following authors and reviewers of the RACGP’s Prescribing drugs of dependence in general practice, Part B – Benzodiazepines. Clinical editor Dr Evan Ackermann, Chair, RACGP National Standing Committee for Quality Care; University Medical Centre, Southern Cross University, Queensland Medical writer Raquel Newman Reviewers Dr Caroline Johnson, Department of General Practice, the University of Melbourne, Victoria; RACGP National Standing Committee for Quality Care Dr Simon Holliday, General Practitioner, Taree, New South Wales; Staff Specialist, Drug and Alcohol Clinical Services, Hunter New England Local Health District, New South Wales Dr Walid Jammal, Senior Medical Advisor, Avant; Clinical Lecturer, University of Sydney Dr John Buchanan, Consultant Psychiatrist, Melbourne Thank you to the following organisations, groups and individuals for feedback and advice: NPS MedicineWise Australian Medical Association RACGP National Standing Committee for Quality Care RACGP National Standing Committee for Standards RACGP National Standing Committee for General Practice Advocacy and Support RACGP Victorian Faculty, Drug and Alcohol Committee RACGP Queensland Faculty RACGP South Australia & Northern Territory Faculty RACGP National Faculty of Aboriginal and Torres Strait Islander Health RACGP National Rural Faculty RACGP National Faculty of Specific Interests – Addiction Medicine Network RACGP National Faculty of Specific Interests – Pain Management Network RACGP National Faculty of Specific Interests – Aged Care Network RACGP National Faculty of Specific Interests – Psychological Medicine Working Group Dr Beres Joyner, General Practitioner, Rockhampton, Queensland; RACGP National Faculty of Specific Interests – Aged Care Network Janet Shaw, Manager, Reconnexion, a Service of EACH, Victoria Dr Sara Bird, Manager, Medico-legal and Advisory Services, MDA National Dr Mike Civil, Chair, RACGP National Standing Committee for Standards Dr Jenny James, Substance Misuse Medical Coordinator, Aboriginal Medical Service Western Sydney Karen Booth, RN, President, Australian Primary Health Care Nurses Association Prescribing drugs of dependence in general practice, Part B Benzodiazepines iii Dr Mark E Montebello, Senior Staff Specialist and Medical Team Manager, Drug and Alcohol Service, South Eastern Sydney Local Health District Peter Boyles, Pharmaceutical Services Branch, Department of Health and Human Services, Tasmania Dr Adrian Reynolds, Clinical Director, Alcohol and Drug Service, Southern Mental Health and Statewide Services, Tasmania; Clinical Associate Professor, University of Tasmania Dr Noel Plumley, Addiction Medicine Specialist, Tasmanian Alcohol and Drug Services Dr Richard O’Regan, Addiction Medicine Consultant, Drug and Alcohol Office North Metro Community Drug Service, Department of Health, Western Australia Dr Chris Holmwood, Director, Clinical Consultation Liaison and Standards, Drug and Alcohol Services, South Australia Dr Stephen Christley, Public Health and Clinical Systems, Department for Health and Ageing, Government of South Australia Dr Adam Pastor, General Physician and Addiction Medicine Specialist; Director, Addiction Medicine, Northern Territory Dr Malcolm Dobbin, Senior Medical Advisor (Alcohol and Drugs), Mental Health, Drugs and Regions Division, Department of Health, Victoria Drugs of Dependence Unit, Pharmaceutical Services Branch, Department of Health, Western Australia Drugs of Dependence Unit, Medicines and Technology Policy and Programs, Department for Health and Ageing, South Australia Medicines and Poisons Control, Department of Health, Northern Territory Pharmaceutical Services Unit, Legal and Regulatory Services Branch, New South Wales Ministry of Health Medicines Regulation & Quality, Department of Health, Queensland Pharmacy Board of Australia Australian Health Practitioner Regulation Agency Consumers Health Forum of Australia The Royal Australasian College of Physicians Laureate Professor Nicholas J Talley, President, The Royal Australasian College of Physicians Brigitte Cusack, Program Officer, Medication Management, Eastern Sydney Medicare Local Dr Tim Senior, Chair, RACGP National Faculty of Aboriginal and Torres Strait Islander Health Dr Ronald McCoy, Education Strategy Senior Advisor, RACGP Dr Michael Wright, General Practitioner, RACGP National Standing Committee for General Practice Advocacy and Support Dr Andrew Byrne, General Practitioner, Redfern, New South Wales Dr Dennis Gration, General Practitioner, Belgrave, Victoria Dr John Scopel, General Practitioner, RACGP National Faculty of Specific Interests – Refugee Health Network Dr Glynn Kelly, Deputy Chair, RACGP National Standing Committee for Standards Dr Margaret Daley, Advisor, Medical Indemnity Protection Society Dr Genevieve Hopkins, General Practitioner, Red Hill, Queensland Dr Brendan Kay, General Practitioner, Warrnambool, Victoria Dr Michael Tan, General Practitioner, Blacktown, New South Wales Dr Paul Neeskens, General Practitioner, Board Member, RACGP Queensland Faculty Dr Cameron Loy, General Practitioner, Deputy Chair, RACGP Victorian Faculty Prescribing drugs of dependence in general practice, Part B iv Benzodiazepines Acronyms ADIS Alcohol and Drug Information Service ATODS Alcohol, tobacco and other drugs AUDIT Alcohol Use Disorders Identification Tool AWS Alcohol Withdrawal Scale CAS Clinical Advisory Service CBT Cognitive behavioural therapy CIWA-Ar Clinical Institute Withdrawal