Benzodiazepines and z-drugs: Quality prescribing - a guide for improvement
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 co-morbidities
- No mental or physical health comorbidities
Current medication and drug allergies (include 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 (including 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” (patient 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
- No recent bloods or tests
Most recent relevant consultations
- None
7 Steps: Person specific issues to address for case study
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
- Ask individual to complete Patient Reported Outcomes Measures (PROMS) before the review
Person specific actions
- 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
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions
- Drugs to prevent rapid symptomatic decline
* with advice from healthcare professional with specialist interest
Person specific actions
- No essential medicines prescribed
3. Does the patient 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 actions
- No current prescribed medication
- Review need for continuing analgesia
4. Effectiveness: Are therapeutic objectives being achieved?
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 actions
- May be appropriate to consider starting low dose diazepam, however this may be more appropriate once reviewed by specialist services
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- 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
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- 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
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
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 actions
- Patient advised to dispose of any unused medicines through community pharmacy
- Advised not dispose of medicine via household or water waste
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
- Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place
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 individual to complete post-review PROMS questions after their review
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
Click on the table image to view a PDF version of the full 7 steps table for sleep management case study.
