Quality prescribing for Benzodiazepines and z-drugs: guide for improvement 2024 to 2027

Summary of recommendations

• People prescribed benzodiazepines or z-drugs (B-Z) are encouraged to initiate discussions regarding the appropriateness of treatment, including recommended duration and need for continuation, reduction or discontinuation of B-Z [see Recommendations].
• In the short-term (e.g. less than two weeks) B-Z can provide some benefits for insomnia, and some anxiety disorders.
• B-Z use is associated with tolerance, dependence and avoidable medicine related harms.
• Studies have reported a higher risk of mortality associated with B-Z use in a range of populations e.g. people with schizophrenia.
• B-Z are associated with an increased incidence of depressive symptoms.
• B-Z may limit the efficacy of psychological therapies such as Cognitive Behavioural Therapy (CBT) due to their negative effects on cognitive function.
• B-Z use is associated with the use of selective serotonin re-uptake inhibitors (SSRIs), and higher SSRI doses for the treatment of depression.

Healthcare professionals should:

• Consider non-pharmacological options, including psychosocial or psychological interventions where appropriate.
• Recognise that the use of benzodiazepines is not recommended for the management of muscle spasm associated with acute low back pain or in the treatment of sciatica.
• Collaboratively develop a clear management plan with the individual, or carers where appropriate.
• Limit treatment duration to, for example, less than two weeks on an ‘as required’ basis when prescribed for the short-term treatment of insomnia or anxiety disorders.
• Record the indication for B-Z in clinical records [see Recommendations].
• Consider the ‘benzo-burden’ – the total benzodiazepine-type medicine load prescribed per day. Benzodiazepines, z-drugs and gabapentinoids provide synergistic effects such as sedation and respiratory depression.
• Only prescribe B-Z and opioids together if there is no alternative and closely monitor individuals for signs of respiratory depression.
• Proactively review the need for B-Z when individuals are stable and well, to minimise avoidable medicine related harms and optimise care.
• Prescribe multiples of 2mg tablets as the preferred choice where diazepam treatment is required.
• Utilise the 7-Steps review process to ensure person-centred reviews. See List 2 for those who may be prioritised for proactive reviews [see Targeting reviews].
• Apply a multidisciplinary whole system approach, including reception staff, pharmacy teams, practice nurses and GPs, to identify people for review.
• Use different strategies for reducing and stopping B-Z, depending on the individual’s preferences and needs [see Reducing and stopping].
• Use clinical systems such as the Scottish Therapeutics Utility (STU) available within all GP practices in Scotland to help identify individuals for review.

NHS Boards and Health and Social Care Partnerships (HSCPs) should:

• Consider the prescribing advice within this guide to plan, resource and drive quality improvement and prescribing initiatives.
• Consider and engage a whole system approach to delivering quality improvements in prescribing.
• Recognise the significant influence of secondary care in prescribing behaviour.
• Ensure primary and secondary care are informed about the guide, to support continuity of care and the overall goals of reviewing and minimising inappropriate prescribing.
• Nominate local leads/champions to support implementation of the guidance.
• Work with third sector and services to develop and support the capacity for self-management and access to non-pharmacological treatment options.
• Work with hospitals to review B-Z before discharge, to discontinue therapy or communicate a reduction plan for any B-Z prescriptions started in hospital.
• Support care homes to ensure any B-Z prescribed have an appropriate indication and are prescribed at the lowest therapeutic dose to achieve the desired effect and reduce risk of harm.
• Enable general practice clusters and local prescribing support teams to improve the quality of prescribing, through promotion and use of local and national measures, datasets and tools.
• Implement and use this guidance to improve care, clinical outcomes and minimise avoidable medicine-related harm from B-Z.