Quality Prescribing for Benzodiazepines and z-drugs A Guide for Improvement 2024-2027

6. Examples from practice and case studies

NHS Greater Glasgow and Clyde

Over the last 20 years the health board has used a variety of strategies to help general practice and others to minimise inappropriate B-Z prescribing.

Practice-level:

2002 saw the introduction of general practice clinical pharmacist-led interventions. Initially facilitation involved baseline audits; developing, agreeing and implementing practice B-Z prescribing policy; identifying people for review; creating individualised B-Z reduction schedules; updating and educating prescribers; re-auditing, monitoring and feedback on B-Z prescribing achieved. Then in 2004 prescribing pharmacist-led face-to-face clinics with people. Both methods have proved to be effective. However, pharmacist-led clinics have demonstrated to more reluctant prescribers that a reduction in inappropriate B-Z prescribing can be achieved. For people that are identified as appropriate for review, a third continue their current B-Z and dose, a third reduce their dose, and a third stop treatment. Referrals to specialist Alcohol and Drug Recovery Services were not required.

General practice clinical pharmacists who piloted the initial work supported and mentored their pharmacist and pharmacy technician colleagues. Cascading and sharing their experiences enabled more than 40 general practice pharmacists to deliver B-Z reduction clinics in numerous practices, by 2014.

Community Pharmacy

Pharmacist prescribers who worked in general practice and community pharmacies located close to practices started the review process and continued to manage reviews and reductions with individuals that routinely attended their pharmacies. This was well received by people prescribed B-Z therapy, as it saved them time making appointments at their general practice.

HSCPs and Board

2013 saw the introduction of board wide B-Z review quality prescribing indicators:

1. Preferred preparation - 2mg diazepam tablets instead of 5mg/10mg tablets.

2. Review and potential reduction targets.

3. Board wide voluntary ban on the prescribing of diazepam 10mg tablets (‘blues’) in primary and secondary care due to their street value and abuse potential.

The indicator work was incentivised and funded via the Quality and Outcomes Framework (QOF) general practice contract; however, many practices were interested and willing to review their B-Z prescribing and wanted to understand and share in the successes that neighbouring practices achieved.

Locality work took place with 11 general practices (the Dumbarton corridor project) February to May 2013. In February 2013, 15 GPs from the practices attended a workshop. Backfill was paid to allow attendance. A brief presentation was given by the HSCP lead pharmacist outlining current B-Z prescribing, guidelines, best practice and long-term risks associated with B-Z use. GPs were then given the opportunity to reflect on the content of the presentation. This was followed by discussion on:

1. When it is appropriate to prescribe short-term

2. Possible responses to individuals when a B-Z is not indicated

3. Approaches to reducing and/or stopping B-Z

4. Alternative pharmaceutical options

GPs then discussed recommending their next steps in practice and their immediate actions. Practices then contributed to an evaluation of this workshop and its early outcomes, by the end of May 2013. This achieved an overall reduction in B-Z prescribing (reduction in defined daily doses per 1000 individuals).

Opportunistically, in 2016, the central prescribing team encouraged practices and HSCP to review B-Z use due to cost-efficiency work to address the extreme price hikes for lormetazepam, nitrazepam liquid and temazepam.

The general practice clinical pharmacists have shared their learning and experiences with practice pharmacists and primary care teams working in other Scottish health boards and at national events and workshops within boards.

NHS Forth Valley

An anxiolytic and hypnotic workstream medicines management target was introduced in 2014/15 and continued in 2015/16. Practices could choose to participate as one of the three prescribing options, which were incentivised via the general practice contract and Quality and Outcomes Framework (QOF).

The anxiolytic and hypnotic workstream required three practice actions:

1. Draw up a practice policy on the prescribing of anxiolytics and hypnotics. All partners in the practice were to be in agreement with the policy and have read the Forth Valley Primary Care Guidance on benzodiazepines. All locums and reception staff made aware of the policy.

2. Ensure that individuals know about the new practice policy for prescribing of anxiolytics and hypnotics. Practices were advised to identify all people who had received the following medicines in the previous three months: diazepam, lorazepam, loprazolam, lormetazepam, oxazepam, nitrazepam, temazepam, zopiclone, zolpidem and zaleplon for review, with suggestions given on prioritisation. Individuals were contacted by the practice and appropriately informed of the risks associated with hypnotic/anxiolytics and the new practice policy.

3. Make a ≥20% reduction in DDDs/1000 people (from an Oct-Dec 2013 baseline). This was to be achieved through flexible reduction regimes and no new people were to be started on a hypnotic or anxiolytic unless they met the licensed indications. New people were informed that they would receive a short-term course, that would not be repeated. The ≥20% reduction would be achieved by Oct-Dec 2014.

Practices were provided with an anxiolytic and hypnotic pack containing sample patient information leaflets, practice policy, poster, a reviewing B-Z flowchart, link to the local primary care benzodiazepine guidelines, invite letters and a management plan agreement. The National Therapeutic Indicator (NTI) data was provided to practices and used to monitor the outcomes. Baseline starting points were as below:

Table 7: NTI monitoring data for NHS Forth Valley

NTI Monitoring	Time Period	Lower Quartile	Median	Upper Quartile
NHS Forth Valley	Oct-Dec 2013	12.84	18.26	22.37
NHS Forth Valley	Oct-Dec 2015	8.72	13.84	17.23

Case study 1: Anxiety

Background (age, sex, occupation, baseline function)

• 24-year-old female
• Office administrator

History of presentation/ reason for review

• Reports a 12-week history of increasing anxiety including worry, mild irritability, difficulties concentrating and marked sleep disturbance
• Increasingly difficult to control her worries which is having an impact at work. Going to work early and staying late as taking extra time to both complete and then check over her work due to concerns she may make a mistake
• Parents have noticed she is more on edge, restless and seems tired all the time

Current medical history and relevant comorbidities

• No mental or physical health comorbidities

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• None

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Single, no dependents
• Lives at home with her parents
• Social drinker
• Non-smoker
• Very supportive close group of friends, parents, and older brother that she has been able to talk to about her anxiety

“What matters to me” (ideas, concerns and expectations of treatment)

• Keen to reduce time she spends worrying, improve sleep, and feel less tense.
• Although experiencing some difficulties at work, she is keen to avoid time off and is still managing to go to the gym
• Keen to avoid medication
• Ask person to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• GAD-7 score 8 (mild anxiety). However, as the anxiety is affecting her daily tasks of living, she is experiencing moderate anxiety

Most recent relevant consultations

• Presents as very motivated, has clear goals that including reducing the time she spends worrying, improved sleep, and feeling less tense
• Caffeine intake assessed and discussed
• Medication options are explored alongside psychological options. Has avoided coming into the practice as she is keen to avoid medication however expresses an interest in accessing CBT which she has looked up online. Comfortable using computers, see this as a flexible way to receive support that she can manage around her work and social commitments
• Reports no family history of suicide. No plans or intent to harm herself or others
• Agreed plan:
  • Medication options will not be commenced at this stage. Sleep hygiene discussed and written information given
  • Referral to Daylight, a cCBT package for Generalised Anxiety Disorder (GAD) with a review in the practice in four to six weeks’ time or if symptoms worsen

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems.
• Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address:

• Motivated and keen to reduce anxiety and time spent worrying
• Improve focus at work
• Improve sleep
• Prefers to avoid medication

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address:

• None

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• None

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/ intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• Medication options explored but not appropriate at present, interested and preference for cCBT and non-pharmacological management (e.g. sleep hygiene, physical activity, caffeine reduction)

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• No current plans or intent to harm herself or others
• No family history of suicide
• Has good family and friends support network
• Prefers non-pharmacological treatment to start with
• Reducing the use of medicines that are not indicated or appropriate avoids the risk of ADRs

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• No medicines prescribed. Reducing the use of medicines that are not indicated or appropriate reduces the environmental impact from medicines

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address:

Agreed plan

• Medication options will not be commenced at this stage
• Sleep hygiene and non-pharmacological options discussed. Written information given with links to self-help resources
• Referral made to a cCBT program (e.g. Daylight) for GAD. Review in the practice planned for four to six weeks’ time

Key concepts in this case

• Moderate GAD
• Non-pharmacological preferred by the individual and matches with stepped-care model as per NICE guidelines
• Online computerised CBT fits with the individual’s preference, needs, and ease of access

Case study 2: Sleep problems

Background (age, sex, occupation, baseline function)

• 32-year-old male

History of presentation/ reason for review

• Requesting diazepam for ongoing sleep problems
• When discussing sleep, he is avoiding going to bed and describes increasing anxiety at night reporting flashbacks and recurring nightmares related to a serious assault last year. In general his emotions are “all over the place” making him feel “out of control” and reporting memory problems. The assault has triggered memories of trauma earlier in his life
• In providing a safe place where his concerns were acknowledged he discloses he has been using street benzodiazepines and OTC Solpadeine Max® (co-codamol – codeine 12.8mg and paracetamol 500mg per tablet). He has also been increasing his alcohol consumption to block out his thoughts which he finds overwhelming
• He reports that his mood is low with fleeting thoughts of suicide
• On discussing polydrug use he becomes more tearful and agitated. He is aware of risks having witnessed a friend’s non-fatal overdose. This prompted him to come to the practice to see someone as he thought a prescription might help reduce risks with street and over-the-counter drugs. He would have more confidence in what and how much he was using coming from a legitimate source

Current medical history and relevant comorbidities

• No mental or physical health comorbidities

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• No prescribed medicines
• Previously prescribed dihydrocodeine for pain related to injuries from assault
• Buying OTC Solpadeine Max®.
• Allergies: amoxicillin – rash

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Single, no dependents
• Lives alone
• Alcohol estimates 40 units a week – has been trying to reduce intake

“What matters to me” (ideas, concerns and expectations of treatment)

• Keen to have safe option to control symptoms – reduce street benzodiazepines and over-the-counter co-codamol use
• Ask person to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• No recent bloods or tests

Most recent relevant consultations

• None

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems
• Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address:

• Keen to have safe options to control his symptoms including sleep and mood
• Wants to reduce avoidable harms from street and over-the-counter drugs, and alcohol use

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address:

• No essential medicines prescribed

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• No current prescribed medication
• Review need for continuing analgesia

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/ intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• May be appropriate to consider starting low dose diazepam, however this may be more appropriate once reviewed by specialist services

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Fleeting suicidal ideation, young and in high-risk group. Give suicide prevention advice and strategies. Given emergency contact numbers for support services
• Need for appropriate harm reduction strategies
• Discuss risk associated with street benzodiazepines
• Discuss risk of alcohol interaction with medication and support reduction

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• Patient advised to dispose of any unused medicines through community pharmacy
• Advised not dispose of medicine via household or water waste

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address:

Agreed plan

• Having checked his understanding of the current risks, he is offered further harm reduction advice, including avoiding buying benzodiazepines in bulk, splitting his dose and not using alone
• He has been reducing alcohol intake so advice regarding effect on mood and sleep. Safe reduction schedule discussed and aware not to stop abruptly
• Overdose effects due to polydrug use including OTC paracetamol and opioids rediscussed
• Check naloxone trained and has in-date supply – social group at higher risk of drug-related deaths due to substance use
• Give advice regarding suicide safety and a printed list of suicide counselling services in case of emergency
• He is ambivalent regarding a referral to specialist drug and alcohol services however has agreed to consider this and is willing to attend a local third sector drop in before returning for a review appointment in three days’ time
• May be appropriate to consider starting low dose diazepam, however this may be more appropriate once reviewed by specialist services
• Assess for PTSD presentation (possible complex trauma) and consider referral to Mental Health services and Psychological support when suitable to engage
• Key points from appointment are written down for him including the date and time of the next appointment

Key concepts in this case

• Initial focus on detoxification
• Reduce street benzos and over-the-counter co-codamol use
• Reduce alcohol intake but not abruptly stop
• Non-prescribed polypharmacy use – challenges in assessing possible dependency as uncertainty around dose
• Increased risks of non-fatal overdose
• Consider existing comorbidities e.g. potential liver damage, cognitive impairment
• Importance of education around effects of alcohol on mood and sleep
• Use of non-medicine interventions for sleep
• Suicide awareness and prevention
• Harm reduction with naloxone

Case study 3: Memory problems

Background (age, sex, occupation, baseline function)

• 57-year-old female
• Nursery manager

History of presentation/ reason for review

• Family and friends have commented on memory problems over last six months, for example, goes to shop and forgets what is needed. Reviewed by psychiatry, short-term memory impairment

Current medical history and relevant comorbidities

• Problems with memory for approximately six months
• Low mood – two years
• Brain injury due to road traffic accident four years ago

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• Diazepam 5mg one tablet twice daily if needed for anxiety. Ordering 56 tablets every month, but states taking as required. Prescribed for longer than two years
• Allergies: states ‘bad reaction to fluoxetine’ – unclear symptoms

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Ex-smoker
• Alcohol – approximately 10 units/week

“What matters to me” (ideas, concerns and expectations of treatment)

• Having a better memory
• Ask person to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• All blood tests within normal ranges (U&Es, LFTs, FBC, B12, folate, ferritin, TFTs, bone profile)
• Mini-Mental State Exam 26/30 – normal cognition
• Addenbrooke’s Cognitive Examination 96/100 - normal cognition

Most recent relevant consultations

Four months prior to review

• Attending physiotherapy for neck pain with good effect. Has managed to stop ibuprofen and will aim to reduce diazepam use

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems.
• Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address:

• Wants to improve memory problems
• Diazepam: minimise actual and potential medication related harms

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address:

• None

Step 3.

Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• Review need for diazepam – anxiety for more than two years. Takes 10mg daily regularly. Consider need for ongoing treatment and discuss a tapering plan, as may not be suitable to stop immediately

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/ intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• Discuss non-pharmacological methods to help mood and wellbeing
• Plan to stop diazepam which may cause/worsen memory impairment

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)
• monitoring mechanisms for high-risk drugs
• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• Diazepam – lack of efficacy? Questionable effects? May be contributing to anxiety, and causing short-term memory impairment

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• All medicines are formulary choices
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address:

Agreed plan

• Go slow and low reduction of diazepam. Planned reduction schedule discussed and agreed
• Diazepam to reduce by 1mg every four weeks with follow-up reviews as agreed and need
• Prescription to be supplied as special request (acute) with planned reduction steps recorded in clinical notes

Key concepts in this case

• Diazepam and other benzodiazepines/z-drugs can worsen memory impairment and anxiety symptoms
• Reducing long-term diazepam use and dose can help to minimize avoidable medicine related harms
• Long-term diazepam therapy may require a gradual dose reduction prior to stopping

Case study 4: Depression with anxiety

Background (age, sex, occupation, baseline function)

• 49-year-old female
• Works two part-time jobs: school cleaner and dinner lady at different schools
• Lives with adult daughter (currently pregnant) and daughter's partner
• Two adult sons, one local, one lives further away
• Very active helping others

History of presentation/ reason for review

• Contacted by the practice for review of her benzodiazepine

Current medical history and relevant comorbidities

• Mixed depression anxiety – 20 years
• Asthma – 20 years
• Dry eyes – 2 years

Current medication and drug allergies (include over the counter (OTC) preparation and herbal remedies)

• Carbomer eye gel - as required
• Clenil® (beclomethasone) 200 microgram MDI - two puffs twice daily
• Hypromellose eye drops - as required
• Diazepam 5mg tablets - two tablets three times a day
• Paracetamol 500mg tablets - two tablets four times a day if needed
• Salbutamol 100microgram MDI - one to two puffs four times a day if needed
• Temazepam 20mg tablets – one tablet at night
• Venlafaxine 150mg modified-release (MR) capsules – one capsule daily (prescribed for three years)

Lifestyle and current function (include frailty score for >65yrs), alcohol, smoking, diet, physical activity

• Walks between jobs, does not drive
• Smoker - 10 cigarettes per day
• No alcohol
• Number of episodes of deliberate self-harm, last overdose five years ago

“What matters to me” (ideas, concerns and expectations of treatment)

• Main focus is being there for and able to help her family
• At review agrees to reduce diazepam but not temazepam
• Managing well with other medicines, reports:
  • Asthma well controlled (Has ordered two salbutamol reliever inhalers over last 12 months). Demonstrates good inhaler technique
  • Depression and anxiety mood stable, less depression symptoms over the last two to three years. PHQ-9 score 8 (mild depression). Denies thoughts of self-harm or suicide
• Ask person to complete questions to prepare for the review (PROMs)

Results e.g. biochemistry, other relevant investigations or monitoring

Note: local lab reference ranges may vary

• Weight 52kg, height 1.6m, BMI 20 kg/m2
• BP 134/84 mmHg
• Normal blood results previously, including thyroid function tests

Most recent relevant consultations

• Rarely attends GP. Last consultation 18 months ago for dry eyes

Step 1.

Aims

What matters to the individual about their condition(s)?

Process:

Review diagnoses and consider:

• Therapeutic objectives of drug therapy
• Management of existing health problems.
• Prevention of future health issues, including lifestyle advice

Ask person to complete PROMs (questions to prepare for my review) before their review

Person specific issues to address:

• Wishes to maintain good control of depression and anxiety
• Wondering what drops to use for her dry eyes

Step 2.

Need

Identify essential drug therapy

Process:

Identify essential drugs (not to be stopped without specialist advice)

• Drugs that have essential replacement functions (e.g. levothyroxine)
• Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure)

Person specific issues to address:

• Asthma: Clenil® and salbutamol. Check inhaler technique and adherence to preventative therapy
• Venlafaxine - mood currently stable

Step 3.

Does the individual take unnecessary drug therapy?

Process:

Identify and review the continued need for drugs

• what is medication for?
• with temporary indications
• with higher than usual maintenance doses
• with limited benefit/evidence for use
• with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address:

• Currently on hypromellose and carbomer for dry eyes. Prefers carbomer. Stop hypromellose
• Paracetamol – uses irregularly
• Diazepam and temazepam prescribed for longer than four weeks and may worsen depression/anxiety symptoms

Step 4.

Effectiveness

Are therapeutic objectives being achieved?

Process:

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

• to achieve symptom control
• to achieve biochemical/clinical targets
• to prevent disease progression/exacerbation
• is there a more appropriate medication to achieve goals?

Person specific issues to address:

• Total daily diazepam equivalent dose is 40mg. Diazepam reduction agreed

Step 5.

Safety

Does the individual have or is at risk of ADR/ Side effects?

Does the person know what to do if they’re ill?

Process:

Identify individual safety risks by checking for

• appropriate individual targets e.g. HbA1c, BP
• drug-disease interactions
• drug-drug interactions (see ADR table)

monitoring mechanisms for high-risk drugs

• risk of accidental overdosing

Identify adverse drug effects by checking for

• specific symptoms/laboratory markers (e.g. hypokalaemia)
• cumulative adverse drug effects (see ADR table)
• drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address:

• No clear indication for long-term diazepam and temazepam
• Previous history of self-harm

Step 6.

Sustainability

Is drug therapy cost-effective and environmentally sustainable?

Process:

Identify unnecessarily costly drug therapy by

• considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

• inhaler use
• single use plastics
• medicines waste
• water pollution

Person specific issues to address:

• All medicines are local formulary choices
• Prescribe carbomer in line with health board formulary
• Venlafaxine MR to standard release considered inappropriate
• Good asthma control, appropriate salbutamol use
• Patient advised to dispose of medicines through community pharmacy
• Advised patient to only order what is needed, do not stockpile medicines

Step 7.

Person-centredness

Is the person willing and able to take drug therapy as intended?

Process:

Does the person understand the outcomes of the review?

• Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

• is the medication in a form they can take?
• is the dosing schedule convenient?
• what assistance is needed?
• are they able to take medicines as intended?

Agree and communicate plan

• discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
• include lifestyle and holistic management goals
• inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete the post-review PROMs questions after their review

Person specific issues to address:

Agreed plan

• Low and slow reduction of benzodiazepines. Start to reduce diazepam dose as per table below. At third review agrees to reduce temazepam
• Follow-up agreed at a suitable time by phone between jobs e.g. between 2-3pm weekdays
• Prescription changed to acute issue rather than on repeat

Key concepts in this case

• Shared approach to reducing benzodiazepines, engaging with people and their willingness to reduce. After initial diazepam dose reduction went well, individual was content to attempt reduction of temazepam therapy
• Rationalisation of preparations for dry eyes