Prescribing drugs of dependence in general practice

Part B - Benzodiazepines

Summary of recommendations

Last revised: 01 Nov 2019

Introduction

Drugs of dependence have important therapeutic uses, but there is a need to ensure the supply of these medicines is clinically appropriate. A key measure is accountable prescribing that can be supported by a range of strategies at the practice level. Please refer to RACGP’s Prescribing drugs of dependence in general practice, Part A – Clinical governance framework for information about these strategies.

Since 2002, approximately 7 million prescriptions for benzodiazepines have been dispensed in Australia each year, for conditions such as anxiety and insomnia. There is concern a portion of these prescriptions is causing or contributing to patient harm. This is a practical guide general practitioners (GPs) can use to minimise harm and maximise benefits to patients.

Evidence-based recommendations are collated here and there is further information in the body of the guide.

Within the key principles and recommendations, the term ‘should’ refers to a recommended action, ‘must’ refers to an obligation, ‘must not’ to a prohibition, and ‘may’ refers to a discretionary action. Recommendations denoted with ‘Rec’ and a number are those taken from existing evidence-based guidelines and are accompanied by a link to the original source and grading. Each ‘Rec’ has a hyperlink allowing you to click through to the references. Other links are provided to sections in the body of the document. Recommendations without a ‘Rec’ are practice points.

For definitions of key terms, refer to Appendix A.

Incorporating key principles of accountable prescribing, practice systems of care and patient-focused care:

  1. Prescription of benzodiazepines, as with any treatment, should be based on a comprehensive medical assessment; a diagnosis; thoughtful consideration of the likely risks and benefits of any medication, as well as alternative interventions; and a management plan derived through shared decision making and continual clinical monitoring.
  2. GPs should be aware of the common concerns associated with benzodiazepines, such as potential dependence, withdrawal, problematic drug use (including diversion and misuse) and known harmful effects, including falls, potential cognitive decline and motor vehicle accidents. These risks should be discussed with patients.
  3. Treatment seeks to maximise outcomes for the health and social functioning of the patient while minimising risks. To minimise risks, benzodiazepines should be prescribed at the lowest effective dose for the shortest clinical timeframe.
  4. Avoid prescribing benzodiazepines to patients with comorbid alcohol or substance use disorders or polydrug use. GPs should consider seeking specialist opinion in the management of these patients. Patients who use two or more psychoactive drugs in combination (polydrug use) and those with a history of substance misuse may be more vulnerable to major harms.
  5. Benzodiazepines are generally regarded by clinical practice guidelines as a short-term therapeutic option. Long-term use, beyond 4 weeks, should be uncommon, made with caution and based on thoughtful consideration of the likely risks and benefits of benzodiazepines.
    • If alternatives to benzodiazepine treatment fail, have limited benefit or are inappropriate (either psychologically or pharmacologically), supervised benzodiazepine treatment may remain an acceptable long-term therapeutic option.
    • Long-term benzodiazepine prescriptions should be at the lowest effective dose, preferably given intermittently, and regular attempts at reduction should be scheduled. Continued professional monitoring of health outcomes is required.
    • Benzodiazepines should be prescribed from one practice and preferably one GP and dispensed from one pharmacy.
  6. GPs may wish to use the diagnosis of substance use disorder (SUD) rather than dependence, addiction or abuse; this is based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition’s, (DSM-5’s) sedative, hypnotic or anxiolytic use disorder criteria. This is a more neutral term that may reduce stigmatisation of patients with problematic use of benzodiazepines and other drugs or alcohol.
  7. GPs should develop strategies to manage inappropriate requests for benzodiazepines by patients.
  8. All patients, including those who use benzodiazepines and other drugs or alcohol problematically, have the right to respectful care that promotes their dignity, privacy and safety.

Insomnia is a common problem that can cause significant distress and reduced functioning. Chronic insomnia can be more challenging to manage, as it may be associated with an underlying cause, or be an independent disorder that can precipitate or worsen other comorbid conditions (eg depression). The understanding of chronic insomnia is still evolving.

The first step is comprehensive medical assessment, including identification of any underlying issues, and diagnosis.

Where treatment is indicated:

  • First-line therapy should be non-drug interventions. Cognitive behavioural therapy (CBT), which may include stimulus control, sleep restriction, relaxation techniques and sleep hygiene education is well supported by evidence. It should therefore be offered to patients, including older adults. (Level A Evidence) Rec 1.
  • Decisions to prescribe pharmacological treatment should be made on an individual basis, after serious consideration of all risks and possible benefits.
  • Effective pharmacological therapies include benzodiazepines and Z drugs (benzodiazepine receptor agonists), and both should be treated with the same cautions. (Level A Evidence) Rec 2, Rec 3
  • Short-term or intermittent dosing of benzodiazepines should be used to reduce the risk of tolerance and dependence. (Level B Evidence) Rec 4, Rec 5.
  • Pharmacological treatment should be accompanied by specific patient education, regular review and continued efforts to employ the lowest effective dosage of medication, and to taper medication when conditions allow.

Note: When access to CBT is an issue, GPs and practice nurses may consider offering brief behavioural therapy to patients (refer to www.racgp.org.au/your-practice/guidelines/handi/interventions/mental-health/ brief-behavioural-therapy-for-insomnia-in-adults).

Anxiety disorders are common and exist as a spectrum of conditions that vary from mild to severe. Comprehensive clinical assessment is the first step in management. Effective management requires obtaining a diagnosis and recognising that patients may not present with a single disorder (eg patients may experience generalised anxiety, panic disorder as well as depression).

Where treatment is indicated:

  • First-line therapy for generalised anxiety disorder (GAD), panic disorder, and panic attacks should include CBT due to its effectiveness at reducing the symptoms of anxiety in the short and long term. (Level A Evidence) Rec 6. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medications are effective across the range of anxiety disorders and are generally suitable for first-line pharmacological treatment of anxiety. (Level A Evidence) Rec 7.
  • Benzodiazepine use in anxiety disorders is mostly limited to severe or treatment-resistant cases.
  • Benzodiazepines have proven benefit for GAD, social anxiety disorder and panic disorder. Benzodiazepines have not shown benefit for obsessive compulsive disorder (OCD) or post-traumatic stress disorder (PTSD). (Level A Evidence) Rec 8.
  • Short-term benzodiazepine use as occasional adjunctive therapy may be effective at reducing worsening of symptoms that can occur in the first few days to weeks of initiating antidepressant medication.

Note: When access to CBT is an issue, internet-based or computerised CBT programs have been shown to be effective (visit www.racgp.org.au/your-practice/guidelines/handi/interventions/mental-health/internetbased-or-computerised-cbt-for-depression-and-anxiety).

Benzodiazepines are an effective component of an alcohol withdrawal program. However, not every patient withdrawing from alcohol will require medication. Comprehensive medical assessment (including assessment of social support and the use of formal assessment tools) is required to determine the most appropriate approach for alcohol withdrawal (ie in the primary care or specialist alcohol services setting).

Where assisted withdrawal from alcohol is indicated:

  • Benzodiazepines (eg diazepam, oxazepam) are the drugs of choice for treatment of acute alcohol withdrawal (including alcohol withdrawal delirium), but should be limited to a maximum of 7 days. (Level A Evidence) Rec 9.

When discontinuing benzodiazepines, consider using a stepped approach, starting with minimal interventions and moving to more intensive measures.

Minimal interventions such as advisory letters or GP’s advice should be considered as an initial step in benzodiazepine discontinuation.

  • The strength of the GP–patient therapeutic alliance is an important positive factor that assists the successful withdrawal of benzodiazepines.
  • If benzodiazepine use disorder has become moderate or severe, it can become a long-term and distressing problem. However, gradual dose reduction interventions are possible for many patients titrating the dose reduction against the level of withdrawal symptoms experienced. Additional psychological therapies increase the effectiveness of gradual dose reduction.
  • Switching from a short half-life benzodiazepine to a long half-life benzodiazepine before gradual taper may assist patients with problematic withdrawal symptoms on reduction.
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