Manor House Surgery Benzodiazepine or Z-Drug Prescribing

Newly Registered Patients.

All patients who join the practice who are already prescribed a benzodiazepine or a Z-drug will be invited in to start a reduction programme.  Posters will be on display in the reception area advising all new patients of this policy. 

The only exception to this will be the minority of patients who fall into one of the categories listed below.

  • With severe mental health problems under care of a psychiatrist
  • On benzodiazepines for treatment of Epileps
  • Who are seriously or terminally ill.

Current Patients requesting medication for anxiety/sleep.

Before treating insomnia or anxiety with benzodiazepine or z-hypnotics consider the following:

  • Treat the underlying causes of insomnia e.g. depression, other psychiatric disorders, pain, pruritis, urinary frequency and dyspnoea. Sleep disturbance is very common in depressive illness and early wakening is often a useful pointer.
  • Abuse of drugs and alcohol are common causes of insomnia
  • Address the administration and timing of other medicines e.g. SSRIs in the morning, sedating antidepressants at night
  • Consider psychological treatments including relaxation, counselling and cognitive behavioural therapy as appropriate
  • Reassure the individual that 5-6 hours sleep at night is normal for older people especially if the individual “cat-naps” during the day

In insomnia, good sleep hygiene should be encouraged which may include the following:

  • Avoid stimulants before bedtime (e.g. tea, coffee, cola, alcohol and nicotine)
  • Avoid watching television, reading, eating, drinking etc in bedroom
  • Increase daily exercise where possible but not before bedtime
  • Get up at normal time and ensuring no lie-ins or daytime napping

For patients who have not received these drugs regularly, clinicians’s will only prescribe hypnotics and anxiolytics for a maximum of 14 days and at the lowest effective dose. They will only be prescribed if the clinician feels that the condition is sever, disabling and subjecting the patient to extreme distress and / or for those where other interventions have not been successful. The following guidance published by NICE will apply:

  • The indication for starting a hypnotic or anxiolytic will be documented
  • Other possible causes of sleep disturbance will be recorded ( eg. Pain, dyspnoea, depression) and treated appropriately
  • All patients will receive advice on non-drug therapies for anxiety and insomnia
  • Patients will be advised on the potential problems of dependence (i.e addiction)
  • A second prescription will not be issued without a follow-up visit to the GP
  • Benzodiazepines or “Z” drugs should not be taken for more that 2 – 4 weeks (including tapering off).

Patients currently prescribed benzodiazepines or Z-drugs.

Patients who are already on a regular benzodiazepine or “Z” drug prescription will be assessed and if appropriate, counselled for a withdrawal scheme with the aim to gradually reduce drug dosage to zero.

Prescriptions for hypnotics and anxiolytics should not be routinely available on repeat. However the practice accepts that there may be a small minority of people who need to be on small maintenance dose of benzodiazepine. Examples are people:

  • With severe mental health problems under care of a psychiatrist
  • On benzodiazepines for treatment of Epilepsy
  • Who are seriously or terminally ill
  • Lost prescriptions will not be replaced.

If a patient takes higher doses than prescribed and runs out of medication before the next prescription is due, they will not be prescribed extra tablets.

The practice will undertake a regular review and audit of the prescribing practice of benzodiazepines and “Z” drugs to ensure compliance with national and local guidelines.

Reducing your Benzodiazepines - Advice for Patients

What are benzodiazepines?

Benzodiazepines are drugs that can reduce anxiety and help sleep problems. They should only be used for very short periods in patients with severe symptoms.

What are the effects?

Short term:

  • Reduced alertness.
  • Drowsiness. This may affect your ability to drive or operate machinery.
  • Reduced tension and anxiety.

Long term:

  • Dependence on the drug.
  • Reduced alertness may lead to accidents or falls
  • Poorer memory.
  • Lack of emotion.
  • Tasks take longer to complete.
  • The short-term effects continue.

What may happen when the drug is withdrawn?

  • Your muscles may ache and strange sensations may be felt on the skin.
  • You may feel restless and anxious.
  • You may feel sick and weight loss may occur.
  • You may sweat more than normal.
  • You may have difficulty sleeping.
  • You may feel more frightened or panicky. At first you can have a reduced ability to cope with stress.
  • Eventually your anxiety will disappear and you will become more assertive.

Why does this happen?

  • Benzodiazepines in the brain block your emotional responses.
  • When you reduce the drug, your brain becomes over-stimulated again. This can magnify your feelings and senses.

This is why your doctor will very slowly reduce your medication to ease the withdrawal process. Hopefully these side effects will be kept to a minimum.

The Good Relaxation Guide

Dealing With Physical Tension

The following tips should help towards better relaxation

    1. Value times of relaxation. Think of them as essentials not extras. Give relaxation some of your best time not just what’s left over.
    2. Build relaxing things into your routine every day and take your time. Don’t rush. Don’t try too hard.
    3. Learn a relaxation routine, but don’t expect to learn without practice.
    4. There are many relaxation routines available. These can help you to reduce tension and to learn how to use your breathing to help you relax.
    5. Tension can show in many ways – aches, stiffness, heart racing, perspiration, stomach churning etc. Don’t be worried about this.
    6. Keep fit. Physical exercise, such as a regular brisk walk or a swim, can help to relieve tension.

Dealing With Worry

    1. Accept that worry can be normal and that it can be useful. Some people worry more than others but everyone worries sometimes.
    2. Write down your concerns. Decide which ones are more important by rating each of them out of ten.
    3. Work out a plan of action for each problem.
    4. Share your worries. Your friends or your doctor can give you helpful advice.
    5. Doing crosswords or sudoku, reading, taking up a hobby or an interest can all keep your mind active and positive. You can block out worrying thoughts by mentally repeating a comforting phrase.
    6. Practice enjoying quiet moments, e.g. sitting, listening to relaxing music. Allow your mind to wander and try to picture yourself in pleasant, enjoyable situations.

Dealing With Difficult Situations

    1. Try to build up your confidence. Try not to avoid circumstances where you feel more anxious. A step by step approach is best to help you face things and places which make you feel tense. Regular practice will help you overcome your anxiety.
    2. Make a written plan and decide how you are going to deal with difficult situations.
    3. Reward yourself for your successes. Tell others. We all need encouragement.
    4. Your symptoms may return as you face up to difficult situations. Keep trying and they should become less troublesome as your confidence grows.
    5. Everyone has good days and bad days. Expect to have more good days as time goes on.
    6. Try to put together a programme based on all elements in ‘The Good Relaxation Guide’ that will meet the needs of your particular situation. Remember that expert guidance and advice is available if you need further help.

The Good Sleep Guide

The following tips should help you get into a good sleep pattern:

During The Evening

    1. Put the day to rest. Think it through. Tie up loose ends in your mind and plan ahead. A notebook may help.
    2. Take some light exercise in the early evening.
    3. Wind down in the course of the evening. Try and avoid anything mentally demanding within 90 minutes of bedtime.
    4. Don’t sleep or doze on the sofa or armchair. Try to keep your sleep for bedtime.
    5. Avoid drinks such as coffee/tea/cola after 6pm. These contain caffeine and can keep you awake. Do not eat a heavy meal before bedtime.
    6. Make your bed and bedroom comfortable. Not too cold or hot.

At Bedtime:

    1. Go to bed when you are “sleepy tired” and not before.
    2. Do not read or watch TV in bed. Try to keep these activities for another room.
    3. Set the alarm for the same time every morning until your sleep pattern settles down.
    4. Put the lights out when you get into bed.
    5. Consider trying a relaxing drink such as camomile tea, Horlicks or Ovaltine.
    6. Let yourself relax and tell yourself that sleep will come when it’s ready.
    7. Enjoy relaxing even if at first you don’t fall asleep.

If You Have Problems

    1. Sleep problems are common and not as damaging as you might think. Try not to get upset or frustrated.
    2. If you are awake in bed for more than 20 minutes then get up and go into another room.
    3. Do something relaxing for a while and don’t worry about tomorrow. People usually cope quite well after a restless night. Try reading something light or listen to relaxing music.
    4. Go back to bed when you are “sleepy tired”.
    5. Remember the tips from the section above and use them again.
    6. A good sleep pattern may take a number of weeks to establish. If you have had sleep problems for years then it can take longer. Be confident that you will get there in the end!