Follow a person-centred approach to initiating and limiting B-Z supply

Discuss individual and prescriber’s expectations before initiation of new prescribing. Review medication using the 7-Steps process. Consider stepped-care and watchful-waiting for common mental health conditions. Highlight effective non-pharmacological interventions where appropriate (e.g. physical activity, self-help). Outline drug limitations e.g. marginal effects during crises but adverse effects are common.

Provide appropriate information about the condition (NHS Inform website), B-Ztreatment and stopping. The Choice and Medications website contains a variety of information and leaflets which may be helpful.

Plan and agree follow-up in relation to the condition being treated.

Review effectiveness, tolerability and adherence on an ongoing basis, and where appropriate reduce the number and doses of medicines to minimise avoidable adverse effects and optimise adherence.

The majority of studies have been for treatment of seven days or less of therapy. The effects were small, with an increased risk of adverse effects; the number needed to treat (NNT)  for improved sleep quality was 13 and the number needed to harm (NNH) for any adverse event was 6, see the figure below.⁵⁷

Adverse events were defined as cognitive (memory loss, confusion, disorientation); psychomotor (reports of dizziness, loss of balance, or falls); and morning hangover effects (residual morning sedation).

Numbers needed to treat and harm

Note: Population: adults (≥60 years old) prescribed a benzodiazepine or z-drug for insomnia; 18 (75%) of studies meeting inclusion criteria were for ≤14 days of treatment.⁵⁷

Benzodiazepines are not recommended for the routine treatment of general anxiety disorder (GAD), panic disorder, post-traumatic stress disorder (PTSD) or panic disorder.^14,15,58

A stepped-care approach including psychological treatment and/or self-help is advised. Pharmacological treatment, if assessed as being appropriate, should be with a selective serotonin re-uptake inhibitor e.g. GAD: step 3 where there is marked functional impairment, or that has not improved after step 2.^14,15,58

B-Z are not recommended for the treatment of depression⁵⁹ or the treatment of general anxiety disorder.¹⁵

It is known that regular B-Z use is associated with reducing the effectiveness of psychological therapies (interfering with new memory formation), worsening depressive symptoms, and cognitive dysfunction which may prolong symptoms and slow recovery.^12,20,22

It is advised that co-prescribing B-Z with antidepressants should be avoided wherever possible. A recent Cochrane Review indicated that the evidence for benefit was marginal and there was no difference in dropouts due to any reason, between combined therapy (antidepressant plus B-Z) and antidepressants alone in the first two weeks of treatment.⁶⁰

NICE recommends ‘do not offer gabapentinoids, other antiepileptics, oral corticosteroids or benzodiazepines for management of sciatica, as there is no overall evidence of benefit and there is evidence of harm’.²⁴

NICE recommends ‘do not initiate benzodiazepines to manage chronic primary pain in people aged 16 years and over’.⁶¹