NP SPPR National Prescribing Service Ltd No. 4 July 1999 Prescribing Practice Review Reviewing long term use of benzodiazepines, pp1-4 Managing the new patient with insomnia, pp5-6 Enclosed patient material Benzodiazepines Reviewing long term use: a suggested approach Start with reviewing one or two patients. Continue to review all your patients over the next year. There are few specific psychiatric conditions where long term use is indicated. Many patients may be using these drugs without any medical indications. Patients can expect to have a better sleep quality, be more alert and enjoy a better quality of life when they cease taking benzodiazepines. The elderly benefit from a reduced risk of falls and fractures. The following approach will require you to book several long consultations. Some patients, such as polydrug users, may require specialised services. The aim with most patients is to cease use but for some the outcome may be stabilisation or dose reduction. 4,5,6,7,8 Visit 1: Visit for repeat prescription or during annual medication review Advise the patient that you wish to review their benzodiazepine use with them Provide the usual prescription for long term users known to you. Involve the patient as a partner and agree on a schedule for review. Remind the patient that benzodiazepines should not be ceased abruptly. Discuss the problems of long term use 3,5,7 Benzodiazepines are often prescribed for problems that are more effectively managed with non-drug therapies Tailor advice to the patient, eg: dependence occurs in about one in three patients patients over 60 years are more vulnerable to confusion, memory problems, over-sedation and falls drivers and machinery operators have an increased accident risk the drug may be ineffective because of tolerance, may be causing disturbed sleep or nightmares, or rebound insomnia on withdrawal adverse mood effects include depression, emotional anaesthesia, aggression, increased suicide risk in elderly for alcohol consumers there is potentiation of adverse effects in chronic airways limitation: risk of worsening respiratory function in pregnancy and lactation: risks to foetus, neonate and breastfed infant.
Reviewing long term use: Visit 2: Medication review and management plan Review benzodiazepine use Review therapeutic objective Assess dosage, pattern of use and use of other psychoactive drugs Discuss when use commenced and the reason for initial prescription. Ask about past, present, daytime and night-time use of all benzodiazepines including other doctors prescribing. Prompt for actual dosage taken (strength, frequency, increasing doses). Ask about all other medicines including complementary medicines, alcohol, caffeine, tobacco and illicit drugs. Assess adverse effects If necessary seek information from carers, family members, nursing home staff Ask: In what ways are the effects of the drug interfering with your life? Assess: psychomotor effects (confusion, ataxia, incoordination, clumsiness, shakiness, falls, bladder incontinence) cognitive effects (anger, vagueness, drowsiness, forgetfulness) paradoxical effects (feeling panicky, sleepiness). Assess symptoms of dependency/withdrawal Ask: How do you feel if a dose is missed? Do you always carry your benzodiazepines? Do you feel edgy in the early evening before your next dose? Have you ever tried to cut down or stop use? Milder withdrawal symptoms include anxiety, insomnia, headache, dizziness and tinnitus. Withdrawal symptoms may occur between doses during continuous use (inter-dose withdrawal). Patients may think these symptoms are due to the original problem. Assess history of depression Depression can occur as a consequence of benzodiazepine use and withdrawal, however symptoms from use or withdrawal may also mimic symptoms of depression. If the depression is benzodiazepine-related, resolution may take months after withdrawal; monitor regularly, providing reassurance and support. Anti-depressants should not be routinely prescribed nor used as an alternative to a hypnotic. Assess medical problems Assess the management of other medical problems, eg pain, gastrointestinal reflux, nocturnal asthma.
a suggested approach Agree upon a management plan Assist patient to consider the options of continuing, reducing or ceasing use Provide tailored advice and discuss the problems of long term use. The stable benzodiazepine dependent patient without other adverse effects needs to understand dependency and make an informed decision regarding use. The patient experiencing adverse effects needs to understand the problem, as do carers and family members. Decide whether to continue prescribing If the decision is to reduce or cease use: discuss the timing of withdrawal and negotiate a withdrawal plan discuss the problems associated with withdrawal. If the decision is to continue use: check for excess sedation especially in the frail, elderly patient inform patients that intermittent use ensures continued effectiveness, eg no more than 2-3 times per week plan regular review and seek agreement to obtain all prescriptions from you and from a single pharmacy suggest trialing a lower dose especially in elderly patients. Visit 3: Start withdrawal program Develop a withdrawal plan (also see NPS News4) Some people will respond well to a reduction regimen, information and support; others will require intensive counselling. Stabilise then taper the dose over several weeks reducing by 10-20% per week. Allow the patient time to stabilise between each reduction. Titrate dose to the severity of withdrawal symptoms. For those using higher doses, stabilise on an equivalent dose of diazepam and give in 3-4 divided doses daily. (Caution is required in the elderly where diazepam accumulation may occur.) Hospital care may be required for patients using high doses, patients with a history of previous seizure or psychosis, or for more rapid withdrawal. Review weekly for at least 6 weeks monitor sleep patterns and withdrawal symptoms using a patient diary, adjust doses if required, reinforce goals and benefits, watch for depression and relationship difficulties.
Visit 3 continued... Implement relaxation/cognitive techniques and remind patient to practice them. Consider referral to a clinical psychologist, drug and alcohol counsellor, psychiatrist or social worker if necessary. Use self-help groups if available. Where the patient cannot cease use completely, patient and doctor should be content with partial reduction. Discuss patient s concerns regarding withdrawal For example: common symptoms of withdrawal reassure that the pace of reduction will be reviewed regularly unpleasant experiences during previous attempts explain that a planned gradual withdrawal with support is more likely to be successful worsening symptoms on withdrawal explain that withdrawal symptoms can mimic the original problem but are self-limiting inability to cope with insomnia/worry/stress offer concrete help such as advice on sleep hygiene, structured problem-solving deal with unresolved issues masked by long-term drug use. A sample withdrawal schedule 5 For the patient taking 2 x 5mg nitrazepam (Alodorm, Mogadon )at night or 2 x 10mg temazepam (Euhypnos, Nocturne, Normison, Temaze,Temtabs ) at night No. of tablets to be taken Mon Tue Wed Thu Fri Sat Sun Week 1 1 1 2 2 1 1 2 2 1 1 2 2 1 1 2 Week 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 Week 3 1 1 1 2 1 1 1 2 1 1 1 2 1 Week 4 1 1 1 1 1 1 1 Week 5 1 2 1 1 2 1 1 2 1 1 2 Week 6 1 2 1 1 1 1 1 1 2 2 2 2 2 2 Week 7 0 1 2 0 1 2 0 1 2 0 Week 8 0 References for further information 1. Australian Bureau of Statistics. 1995 National health survey: use of medications, Australia. Canberra: Australian Bureau of Statistics; 1999. Report No: 4377.0. 2. Mant A, Mattrick R, de Burgh S, Donnelly N, Hall W. Family Practice 1995;12(1):37-43. 3. RACGP. Guidelines for the rational use of benzodiazepines. Sydney: The Royal Australian College of General Practitioners; February 1993, amended January 1994. 4. Mant A, de Burgh S, Yeo G, Letton T, Shaw J. Anxiety & insomnia: think twice before prescribing. 3rd ed. South Melbourne: Royal Australian College of General Practitioners; 1997. 5. Mant A, Walsh RA. Drug and Alcohol Review 1997;16:77-84. 6. Ree E. Beyond benzodiazepines: helping people recover from benzodiazepine dependence and withdrawal. TRANX Australia. Burwood 1997. 7. Australian Medicines Handbook 1998. Adelaide. 8. Norman TR, Ellen SR, Burrows GD. emja Mental Health Information Centre, Medical Journal of Australia, http://www.mja.com.au. 9. Therapeutic Guidelines Ltd, Therapeutic Guidelines Psychotropic 3rd ed, 1996-1997. 10. To sleep or not to sleep: here are your questions. Therapeutics Letter. Issue 11, 1995; November/December.
Five point plan for management of insomnia 2,4,9,10 1. Discuss and agree to the therapeutic objective with the patient For example, to reinstate sleep without medication. 2. Assess the complaint: Insomnia is a symptom Take a sleep-wake history (a sleep diary can be helpful) and evaluate daytime functioning. Address unrealistic expectations of sleep quality and quantity. Assess medical/psychiatric factors that may affect sleep, eg stress, depression, sleep apnoea, nocturnal asthma, angina, dyspnoea, oesophageal reflux, nocturia or pain. Assess use of medication that may affect sleep, eg benzodiazepine withdrawal, caffeine, alcohol, nicotine, sympathomimetic agents, corticosteroids, beta 2 agonists, theophylline, SSRIs, beta blockers, HMG-CoA reductase inhibitors, some antiparkinsonian drugs, excess thyroid hormones. 3. Treat or improve management of underlying problem/s For example, where insomnia is stress related, assist patients to manage stress with structured problem-solving and relaxation therapy; improve management of pain or other medical problems. 4. Educate the patient Ensure good sleep habits Provide individualised advice on sleep hygiene: regular time of arising and retiring (including weekends), avoiding naps regular daytime aerobic exercise which increases stage 4 sleep If you haven t yet received your copy of NPS News 4 (posted with Australian Prescriber) that includes a case study that can be used to claim Practice Incentives Program payments, please call us to be added to the mailing list.
Five point plan for management of insomnia...continued avoid nicotine, excess alcohol, caffeine, strenuous exercise or a heavy meal close to bedtime; reduce caffeine intake gradually warm milk /carbohydrate snack or a warm bath before retiring. Use the patient material attached to reinforce these messages. Ensure a good sleep environment For chronic insomnia try behavioural therapies Ensure a comfortable temperature and quiet, dark environment for sleep. Stimulus control therapy, sleep scheduling therapy and sleep restriction therapy. 5. The use of hypnotics should not be first line therapy If a benzodiazepine must be used, aim to avoid regular nightly use Agree with the patient to limit use to the shortest possible time. Discuss the potential problems and warn of the risk of dependence. If continuous treatment is needed, limit to less than two weeks. Limit the quantity to be dispensed to 10-14 tablets/capsules. Intermittent use may be indicated for severe long standing disorders not relieved by non-drug measures. Warn patients of possible rebound insomnia on cessation; avoid further prescribing. Follow up the patient to ensure benzodiazepine use is not continued. N P S National Prescribing Service Limited Our goal To improve health outcomes for Australians through prescribing that is : safe effective cost-effective. Our programs To enable prescribers to make the best prescribing decisions for their patients, the NPS provides information education support and other resources. National Prescribing Service ACN 082 034 393 9 Leichhardt St Darlinghurst NSW 2010 Phone: 02 9332 3944 l Fax: 02 9332 3955 l email: sjackson@zip.com.au If you haven t yet received your copy of NPS News 4 (posted with Australian Prescriber) that includes a case study that can be used to claim Practice Incentives Program payments, please call us to be added to the mailing list.