Practice prescribing of hypnotics & benzodiazepines is measured and compared at a local (prescribing performance) and a national (QIPP indicator) level.
* Continuing concern over long term use (1)
* Taking a benzodiazepine and/or hypnotic was associated with double the risk of death from any cause compared with no prescription for these drugs. Dose-response associations were found and there were approximately 4 excess deaths linked to these drugs per 100 people followed for an average of 7.6 years after their first prescription. (2)
* Driving whilst under the influence of drugs is a significant cause of injuries and deaths on the road. (3)
* Patients are not always given appropriate information and advice on the risks associated with long term use (4):
* Tolerance & addiction
* Drowsiness, clumsiness, forgetfulness, confusion, impaired judgement
* Falls & fractures – in people older than 60 years, these drugs are associated with an increased risk of falling of between 50-70% in relative terms. (5)
* Association with increased risk of dementia and increased cancer incidence in those prescribed high doses (6)
How is usage measured? Hypnotic ADQ per STAR PU – This is a measure of the total quantity of Benzodiazepines and Z-drugs prescribed, weighted for age and sex of a practice’s population.
At the start of the project x Surgery was the 4th highest prescriber out of 50 East Berkshire practices. x Surgery Q2 (Oct-Nov 13) 2013/14 ADQ 461
What action was taken in X Surgery?
- Practice meeting to agree course of action with all prescribers. A consistent message is vital for success and helps to prevent patients pressurising or singling out a particular GP.
- Search – patients prescribed these drugs during April – July 2013.
* Exclusion criteria: Housebound, care/nursing home (reviewed separately by care home pharmacist & responsible GP) and palliative care patients; one off supplies e.g. for back spasm, fear of flying and for epilepsy treatment.
- Analysis consistently shows that a simple letter intervention reduces benzodiazepine use in patients who have been using them long-term (7). Letter sent to remaining patients to:
* Explain concern over the patient’s long-term use of named hypnotic/s
* Highlight potential side effects when taken over a prolonged period.
* Ask the patient to consider a reduction in their use. – Include advice on how to gradually reduce or cease use in a manner that is feasible and will decrease the likelihood of withdrawal symptoms.
* Invite the patient to discuss the issue further with own GP or by booking into pharmacist led clinic.
- For those receiving a letter, these drugs were moved from repeat to acute and limited to 56 days supply.
- A 2nd short reminder letter sent to non responders 3 months after the initial letter, also informing the patient that the maximum length of supply was now 30 days in line with CD regulations (June 2014).
- Posters advertising clinics and detailing risks of long term use put up in waiting rooms
- Agree initiation & prescribing policy for new prescribing – support leaflet supplied
- Full range of support leaflets and reduction schedules available in all consulting rooms.
- Monthly pharmacist (independent prescriber) led clinics offering 20 minute appointments. Scope of practice demonstrated by Benzodiazepines learning module via MHRA Training and Continuing Professional Development (CPD) and personal CPD records.
- Reception staff / prescription clerks’ informed.
- Raised awareness with local community pharmacies by providing self help leaflets & posters
Main audit observations
o 196 patients prescribed hypnotics, 95 patients prescribed benzodiazepine, 25 prescribed both.
o Included 37 patients care home residents
o 4 RIP during project
o Age range 5 – 101 years
o Length of supply range 1 day – 100 days
o 99% on repeat
o 107 patients with fall/fell in consultation, recording total of 238 falls, often leading to GP appointments, OOH/MIU/A&E attendances & hospital admissions. This included 14 fractures, 54 A&E/admitted and at least 3 road traffic accidents.
o There was occasional documentation of addiction & tolerance discussions.
o Identify & address any underlying cause of insomnia, anxiety & depression
o Promote non drug therapies such as sleep hygiene methods and relaxation techniques using diaries & self help leaflets.
o Involve patient support network
o Guided by patient, negotiate flexible, gradual withdrawal schedule
o Convert to diazepam if appropriate
o Rebook for review, ongoing support and encouragement as appropriate
o Continue dose reduction at pace comfortable to patient
o Monitor withdrawal effects until stopped completely or at lowest dose to control effects of withdrawal. Where complete withdrawal may not be an achievable goal there is still benefit to be gained in reducing use to the minimum effective dose. (Ref BNF).