Prescribing drugs of dependence in general practice, Part B

1. Introduction
1.1 Aims
☰ Table of contents

The arrival of benzodiazepines into clinical practice in the 1960s was met with enthusiasm. It allowed doctors to offer patients a class of medication with a range of properties (eg sedative/hypnotic, anxiolytic, anticonvulsant, muscle relaxation) at a time when there were few effective therapeutic alternatives. Benzodiazepines were effective and appeared safe in comparison to barbiturates, chloral hydrate and other drugs, which were problematic due to toxicity and overdose.1

Due to the seeming paucity of side effects, rapid onset of effect and a pressing mental health need, benzodiazepines were quickly used and prescribed short- and long-term for anxiety, depression, insomnia, mental illness and neuromuscular conditions. By the 1970s, they were the most commonly prescribed drugs in the world.2 In 1978, more than 2.3 billion doses of diazepam were sold in the US alone.3

In the 1980s, evidence of the addictive nature of benzodiazepines grew and it became generally accepted that benzodiazepines brought their own problems. In 1988, the Committee on Safety of Medicines (UK) published the first guideline for benzodiazepine use and recommended limiting the length of treatment to 2–4 weeks.4 Since then, many international guidelines have advocated for the reduction in prescribing benzodiazepines, particularly short-acting benzodiazepines for long-term disorders such as anxiety.

However, there has been – and still is – a wide divergence between recommendations and clinical practice.

In Australia, nearly 7 million benzodiazepine prescriptions are currently recorded through the Pharmaceutical Benefits Scheme (PBS), Repatriation PBS and private scripts each year.5 Benzodiazepines have remained a major anxiolytic therapy, and given the trend towards larger quantity scripts, not just for short-term use.5

There is growing apprehension in Australia regarding the harms associated with the sanctioned and unsanctioned use of benzodiazepines.6 The misuse of alprazolam is particularly problematic. It appears to be disproportionately associated with misuse, fatal and non-fatal overdoses, paradoxical excitation, and withdrawal and rage responses, as well as traffic accidents and crime-related harms.7

The conditions where benzodiazepines are most commonly prescribed (ie anxiety and insomnia) remain sources of debate in medical circles. General practitioners (GPs) must consider multiple factors when prescribing benzodiazepines, including potential prescription abuse. Good clinical governance and an evidence-based approach remain key to safe and appropriate prescribing (refer to RACGP’s Prescribing drugs of dependence in general practice, Part A – Clinical governance framework).

1.1 Aims

This guide aims to provide assistance to GPs in the appropriate prescribing of benzodiazepines in the context of general practice.

It is designed to discourage inappropriate use and reduce harms by providing GPs with:

  • evidence of the advantages and disadvantages associated with the use of benzodiazepines
  • support for appropriate prescribing of benzodiazepines within regulatory frameworks
  • support for safer prescribing within their practices
  • alternatives to benzodiazepines, including non-drug options
  • tools for managing patients who are prescribed benzodiazepines such as objective goals and time limited prescribing
  • tools for recognising and managing higher risk situations.

Implementing principles from this guide should reduce the risk that GPs will be involved in an adverse event associated with prescribing benzodiazepines.

  1. Mehdi T. Benzodiazepines revisited. BJMP 2012;5(1):a501.
  2. Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry 2005;18(3):249–55.
  3. Dell’osso B, Lader M. Do benzodiazepines still deserve a major role in the treatment of psychiatric disorders? A critical reappraisal. Eur Psychiatry 2013;28(1):7–20.
  4. Committee on Safety of Medicines. Current problems – Benzodiazepines, dependence and withdrawal symptoms. London: Committee on Safety of Medicines, 1988. [Accessed 12 June 2015].
  5. Islam MM, Conigrave KM, Day CA, Nguyen Y, Haber PS. Twenty-year trends in benzodiazepine dispensing in the Australian population. Intern Med J 2014;44(1):57–64.
  6. Nicholas R, Lee N, Roche A. Pharmaceutical drug misuse in Australia: Complex issues, balanced responses. Adelaide: National Centre for Education and Training on Addiction (NCETA); 2011.
  7. Drugs and Crime Prevention Committee (DCPC). Inquiry into the misuse/abuse of benzodiazepines and other forms of pharmaceutical drugs in Victoria – Final report. Melbourne: DCPC; 2007.