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

3. Which groups of people should be targeted for review?

A multidisciplinary whole system approach, including reception staff, pharmacy teams, practice nurses and GPs, should be used to identify people for review.

List 2: Groups of people that receive B-Z who could be prioritised for a proactive medicines review

• People recently discharged from hospital on new B-Z
• People receiving long-term (≥8 weeks) treatment
• Older adults (≥65 years)
• People with dementia and/or receiving other medicines that may cause cognitive dysfunction e.g. anticholinergic medicines
• Care home residents
• People receiving polypharmacy
• Higher risk of falls
• People receiving B-Z and opioids e.g. oxycodone, morphine, tramadol etc.
• People receiving other psychotropic medicines e.g. antidepressants, antipsychotics, gabapentinoids etc.
• People receiving high dose B-Z combinations: >30mg per day diazepam equivalent
• People receiving diazepam 10mg tablets – ‘blues’
• People who report/present with street/non-prescribed B-Z use

People recently discharged from hospital

Some people may be initiated on B-Z in hospital as part of crises management in line with guidelines, however others may be initiated on such medicines due to environmental factors which cause insomnia e.g. busy noisy wards. Studies relating to psychiatric admission have shown that up to one in three individuals are discharged on a B-Z, with one in five continuing long-term treatment for 12 months.^7,[65],[66] Proactively reviewing and stopping B-Z therefore, should be considered to reduce avoidable medication related harms.^{12,17, [67]} Where appropriate, hospitals should establish and communicate a reduction plan for all B-Z prescriptions initiated in hospital or develop a ‘no hypnotic on discharge policy’.

People receiving long-term treatment (≥8weeks)

B-Z are only licensed for 28 days maximum use. Most studies are for short-term use (e.g. 7-14 days or less)^13,57 and guidelines only recommend their use for management of short-term crises.^14,15,58,59

A very small minority of people may be considered appropriate for longer-term (≥8weeks) treatment e.g., some people with Parkinson’s disease or multiple sclerosis, or as part of harm reduction strategies.^9,10 However, long-term use is inappropriate for the large majority of people.

Older adults or frail people: avoidable adverse drug events/harms and polypharmacy

It is known that up to one in eight older adults in Scotland receive one or more B-Z prescriptions annually, and care home residents are twice as likely to receive these medicines than non-care home residents.¹⁰

Older adults and frail people are more susceptible to the adverse effects and harms of B-Z: cognitive dysfunction (i.e. confusion, impaired concentration, memory impairment, impaired ability to drive and increased accidents); falls, and associated increased risk of hip fractures; depressive symptoms; and paradoxical effects i.e. disinhibition, anxiety and impulsivity.^12,16 They may also experience liver impairment or reduced kidney function which can reduce B-Z excretion, increasing the risk of adverse effects.^[68],[69] Proactively reviewing, reducing and stopping B-Z will help to reduce avoidable B-Z-related harms.^[70],[71]

People receiving combination treatment

Prescribers should consider the ‘benzo-burden’ – the total benzodiazepine-type medicine load prescribed per day – as benzodiazepines, z-drugs and gabapentinoids provide synergistic effects such as sedation and respiratory depression.¹³ All may interact with the individual's conditions to cause more adverse effects and avoidable drug-related harms e.g. increased breathlessness, fatigue, respiratory depression, which can be potentially fatal.

Opioids

The effects of B-Z and the ‘benzo-burden’ can be further exacerbated by the addition of a range of opioids, and even reduce the protective ceiling effects of buprenorphine.^[72] In line with the Medicines and Healthcare products Regulatory Agency advice, only prescribe B-Z and opioids together if there is no alternative and closely monitor individuals for signs of respiratory depression.

Non-prescribed B-Z

People who report street/non-prescribed B-Z use, often within the context of polysubstance use, are arguably at greatest risk of combination effects. To respond to what is recognised as a public health crisis, recent guidance, including key principles of care, are outlined in the Scottish Drug Deaths Taskforce and Public Health Scotland’s Medication Assisted Treatment (MAT) standards informed response for benzodiazepine harm reduction.^[73]

The MAT standards highlight that we all have a responsibility to respond to B-Z-related harms which is underpinned by a willingness to have supportive, collaborative conversations regarding B-Z. This guidance supports a comprehensive, holistic assessment of need, to inform highly intensive, flexible and individualised care plans. This may include prescribing interventions (e.g. a small minority of individuals may require longer-term B-Z treatment to optimise care and minimise street B-Z use). This is in addition to psychological components of care to support harm reduction and stabilisation.

Again for this patient group, the 7-Steps process should be used to determine the appropriateness of prescribing medication and to minimise harm. This allows consideration of the risks and benefits of treatment, in particular at point of initiation.

Antidepressants

B-Z use is associated with the use of selective serotonin re-uptake inhibitors (SSRIs), and the use of higher SSRI doses for the treatment of depression.^[74],[75] In part this may be due to higher SSRI doses causing more avoidable adverse effects such as anxiety, agitation and insomnia.^{[76],[77],[78]} However, B-Z are also associated with an increased incidence of depressive symptoms.^20,21 Therefore, person-centred review and reducing B-Z using the 7-Steps process may help to optimise care and recovery.

Antipsychotics

B-Z use is associated with a higher mortality risk for people with schizophrenia.18 Although some have argued that B-Z provide antipsychotic sparing effects,^[79] this is not supported by current evidence.^[80]

Psychological therapies

B-Z may limit the efficacy of psychological therapies such as CBT due to negative effects on cognitive function; impairing memory function and amnesia.²²

High dose combination B-Z use

As highlighted above the use of more than one B-Z will increase the ‘benzo-burden’ and provide synergistic effects which may lead to avoidable adverse effects and harms. Minimising the use of such combinations and high doses of B-Z will help to minimise adverse drug effects, see Reduction schedules. It is important to consider if benzodiazepines are being bought alongside those that are being prescribed.

Diazepam 10mg tablets

Historically these have enabled people to take higher doses with fewer tablets and have been desirable for those using substances illicitly.¹⁹ Due in part to these issues, where diazepam is required, multiples of 2mg tablets should be prescribed as the preferred choice.^[81]

Potential exclusions and cautions

It has already been acknowledged that a small minority of individuals may require long-term treatment. However, it would be good practice to routinely review ongoing need, e.g. as part of their routine annual medicines review.

It may be appropriate to consider excluding some people from proactive B-Z reduction reviews for example, in palliative care, people under the care of drug treatment services or those with intractable epilepsy. However, closer working with specialist services may in some cases support the appropriate use and reduction of B-Z, such as linking with community mental health teams to minimise B-Z use in people with schizophrenia, where there is an association with increased mortality risk.67 For those presenting at greatest risk of harm from street B-Z use, both psychosocial and prescribing interventions may support harm reduction and establish stability with regular monitoring and review.^[82]