Benefits to the individual

This quality prescribing guide is intended to encourage supportive and constructive discussions between individuals and prescribers, to enable shared decision-making when reviewing B-Z and consider the fears and apprehensions associated with reducing or stopping B-Z, tailoring treatment plans to the needs of the individual.

This guidance focuses on quality prescribing to result in improvements in care. The 7-Steps medication review process promotes a shared decision-making approach to medicine reviews and places the individual at the centre, to ensure prescribing is effective and appropriate for them. People will be encouraged to self-manage their condition where appropriate and be asked ‘what matters to you?’⁴ to support a holistic approach in line with the Scottish Government’s polypharmacy guidance.³

To ensure outcomes from medication are optimised, and prescribing is appropriate and safe, the 7-Steps medication review process provides a clear structure for both the initiation of new and the review of existing treatments, and places an emphasis on ‘what matters to the individual’? A polypharmacy review (following the 7-Steps approach) should ensure optimal management of conditions. It should include addressing aggravating lifestyle factors and consideration of the most appropriate medication at the right dose, with regular review. 

It is important to routinely and proactively monitor and review the ongoing need for B-Z. While the prescribing of B-Z has steadily declined over the last 30 years, and continues to decrease, 1 in 15 (6.8%) adults (≥18 years), and 1 in 11 (8.9%) older adults (≥65 years) in Scotland were prescribed a B-Z in 2020/21.¹

The majority of B-Z are prescribed by general practitioners (GPs) in primary care, however some of these prescriptions are initiated and continued on the advice of neurologists, psychiatrists and other specialists, and may result in deliberate or inadvertent long-term use.^5-8

For a very small minority of people long-term (≥8weeks) B-Z use may be considered appropriate, for example, in Parkinson’s disease or epilepsy.^9,10 For the vast majority, long-term use of B-Z raises the risk of harm and runs contrary to current clinical guidelines and drug licensing, as B-Z are licensed for a maximum of four weeks duration.^1,11-13,15 B-Z also demonstrate limited therapeutic effects for the short-term (e.g. less than two weeks) treatment of insomnia and some anxiety disorders (e.g. generalised anxiety disorder, panic disorder).^13-15

B-Z use is associated with tolerance, dependence and avoidable drug-related harms. These harms include but are not limited to:

• cognitive dysfunction (confusion, impaired concentration, memory impairment, impaired ability to drive and increased accidents)
• falls, and associated increased risk of hip fractures
• depressive symptoms
• paradoxical effects i.e. disinhibition, anxiety and impulsivity.^12-16

More recently studies have reported increased mortality associated with B-Z use in a range of populations.^17-19

In the short-term (e.g. less than two weeks) B-Z can provide some benefits for insomnia, and some anxiety disorders.^14-15 However, they are associated with reducing the effectiveness of psychological therapies and worsening depressive symptoms, causing cognitive dysfunction which may prolong symptoms and slow recovery.^12,20-22

The use of benzodiazepines is not recommended for the management of muscle spasm associated with acute low back pain.²³ Benzodiazepines should also not be used in the treatment of sciatica.²⁴ It is acknowledged that they are used as muscle relaxants in other causes, such as managing muscle spasm pain in palliative care.^25-26

B-Z are also associated with a 60-80% increased risk of road traffic accidents,^27-28 which led the Department of Transport in 2015 to make it ‘illegal in England, Scotland and Wales to drive with legal drugs in your body if it impairs your driving’.²⁹

There are concerns regarding the role of B-Z in drug-related deaths.^19,30 This is complicated by more than one drug being used (polydrug use), the use of high B-Z doses (‘mega-dose’) and ageing populations.

There is a lack of evidence that B-Z are routinely diverted from primary care prescriptions. Although small quantities of B-Z have previously been diverted by some individuals, the greater use of instalment dispensing and supervised consumptions can help to reduce this. The electronic transfer of prescriptions in Scotland also reduces the risk of prescriptions being forged or amended. While these methods have been successful in restricting licensed B-Z, it is harder to restrict access to internet and ‘street’ sources of benzodiazepines such as phenazepam, etizolam, alongside those licensed outside of the UK, or other street preparations with varying concentrations of diazepam.^19,31

While we are limited in the ability to minimise the use of unlicensed and illegally sourced B-Z, proactively reviewing prescribed B-Z use will help to minimise avoidable drug-related harms and optimise an individual’s care.