example practice protocol for benzodiazepines and z

GPs in this practice will only prescribe benzodiazepine and related substances e.g.
melatonin, zopiclone, zolpidem, zaleplon in with NICE guidance and recommended
best practice.
 All patients presenting with symptoms of anxiety or insomnia will be offered advice
on non-drug options e.g. relaxation techniques, more specialized psychological
interventions (such as cognitive behavioural therapy) as per CG22
Leaflets for patients explaining the causes, symptoms and prevention of insomnia
and anxiety can be accessed via the clinical knowledge summaries website
(www.cks.nhs.uk) or the Royal College of Psychiatrists website
(http://www.rcpsych.ac.uk/mentalhealthinfoforall.aspx )
 All patients will be encouraged to use a sleep diary/anxiety record sheet before
drug therapy is considered
 A sleep diary should be kept for a minimum of 2 weeks and should contain
information about:
Time of going to bed.
Time taken to get to sleep.
The number of episodes of waking through the night.
Total time awake during the night as a result of night-time awakenings.
The time of getting up.
Episodes of daytime tiredness and naps.
Times of meals, alcohol consumption, caffeine consumption, and significant
events during the day e.g. exercise or stress.
Rating of sleep quality (ask the person to rate the quality of their sleep each
night, from 1 to 5, where 1 is very poor and 5 is very good)
Examples of sleep diaries are available on the patient UK website
(http://www.patient.co.uk/pdf/pilsL317.pdf ) & the American Academy of Sleep
Medicine at http://www.sleepeducation.com/pdf/sleepdiary.pdf
Advice on relaxation techniques and an anxiety diary can be downloaded from:
 Good sleep hygiene and regular exercise in addition to cognitive and behavioural
interventions will be advised e.g. Royal College of Psychiatrist leaflet ‘Sleeping
 Benzodiazepines and Z-drugs will only be prescribed if the GP feels that the
condition is severe, disabling and subjecting the patient to extreme distress and for
those who other interventions have not worked
 The indication for starting a hypnotic or anxiolytic will be documented clearly in the
patient records
 Benzodiazepines and Z-drugs will only be prescribed initially in a low dose and for
14 days or less
 The lowest effective dose for the shortest period possible will be used. The
exact duration will depend on the underlying cause but should not continue
for longer than 2 weeks. Up to 4 weeks' use may occasionally be required,
but continued use should always be re-assessed after 2 weeks.
 The maximum duration for any anxiolytic will be four weeks and for any
hypnotic 10 nights.
 The person will be informed that further prescriptions for hypnotics will not
usually be given
 A second prescription will not be issued without the patient being seen again
by a GP.
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 The elderly are particularly vulnerable to adverse drug reactions: if prescribing is
considered essential, doses less than half of those normally recommended will be
 All patients will be advised about the potential for dependence & given a copy of
the letter to new users plus Patient UK Leaflet on ‘Benzodiazepines & Z Drugs’: this
will be documented in their records
 All new prescriptions for benzodiazepines/Z-drugs will be prescribed on the acute
rather than the repeat medication screen
 Patients who have not responded to one of the hypnotics will not be prescribed any
of the other hypnotic drugs (TA77)
 All patients discharged from hospital on a benzodiazepine/Z-drug will have their
records checked to see if they were previously on such a drug: if not the drug will
not be added to their list of medication
 The first choice of hypnotic is: ………………………… (insert name and dose)
 The first choice of anxiolytic is: ……………………….. (insert name and dose)
 Consideration may be given to prescribing in instalments (either repeat dispensing
or as for illegal drug addicts)
 Patients who are already on a regular benzodiazepine or z-drug prescription will be
assessed and counselled with a view to reducing or stopping the dose at least
 Patients on benzodiazepines for over 3months will be sent a copy of the letter to
long term users plus the Patient UK Leaflet on ‘Stopping Benzodiazepines & Z
Drugs’: this will be documented in their records
 If it is appropriate to withdraw a chronic user from a benzodiazepine or Z Drug the
patient will be transferred to an equivalent dose of diazepam (UKMI Q&A 293.1).
This dose will then be gradually tapered off by 2mg diazepam equivalent every 2
 There may be a small minority of people who need to be on a small maintenance
dose of benzodiazepine. Examples are:
 People with severe mental health problems
 People receiving benzodiazepines for management of epilepsy
 Those who are seriously or terminally ill
 People receiving benzodiazepines as part of substance withdrawal
 The rationale for continued use will be documented in the patients’ records
 Prescriptions will not be given in emergency surgeries or out of hours
 Lost prescriptions will not be replaced
 Temporary residents who are regular users will not be prescribed for without proof
of dosage, frequency and date of last prescription. This can be faxed from the
patient’s surgery.
 Temporary residents requesting new treatment will be treated according to these
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Clinical Knowledge Summaries (2009a) Insomnia [Accessed via www.cks.nhs.uk on May
12th 2010]
Clinical Knowledge Summaries (2009b) Benzodiazepine & Z Drug Withdrawal [Accessed
via www.cks.nhs.uk on May 12th 2010]
National Institute for Clinical Excellence (2004) Guidance on the Use of Zaleplon,
Zolpidem & Zopiclone for the Short Term Management of Insomnia TA77. London
National Institute for Health & Clinical Excellence (2007) Anxiety: management of anxiety
(panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in
primary, secondary and community care. CG22 (Amended). London
National Prescribing Centre (2002), Good Sleep Guide, Good Relaxation Guide& Other
Resources MeReC Briefing 17(suppl)
Royal College of Psychiatrists. Sleeping Well. [Accessed via http://www.rcpsych.ac.uk on
May 12th 2010]
St Helen’s Primary Care Trust. A Protocol for Prescribing & Withdrawing Benzodiazepines
UKMI (2010). What are the Equivalent Doses of Oral Benzodiazepines? Q&A
293.1[Accessed via www.nelm.nhs.uk on May 12th 2010
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