Clarification – benzodiazepine prescribing

Barb Krahn CPSA, Messenger, Prescribing Corner Leave a Comment

A recent Messenger article on benzodiazepine prescribing (June 2015) drew valuable feedback, providing a good reminder that prescribing is a fine art.

The article outlined guidelines for benzodiazepine prescribing,provided resources to reflect on prescribing practices and tools to address issues that may surround the use of benzodiazepines in practice.

The article should also have acknowledged that some physicians with highly specialized practices treat very challenging patients who, after careful consideration of their needs, require treatments that may not always align with commonly accepted guidelines.

In July, the Triplicate Prescription Program began monitoring benzodiazepine prescriptions. This information will help the College’s Physician Prescribing Practices Program (P4) ensure the prescribing of these medications is supported by evidence and good practice.

The College is supportive of physicians who provide information that validates their prescribing practice for their patients. The P4 will respond with educational resources and advice when review of a physician’s prescribing practice suggests opportunities to improve. The intent is to ensure all physicians reflect on their prescribing and practise good medicine.

With this in mind, here is a recap of the guidelines for benzodiazepine prescribing.

Benzodiazepines are generally:

  • not appropriate for treating short term mild anxiety or insomnia; non- pharmacological treatments
  • should be offered first when treating these conditions
  • not appropriate for patients with known substance abuse issues
  • not recommended for the elderly – delirium, falls, hip fractures and cognitive impairment have all been associated with use in this population
  • not recommended for children or adolescents

When prescribing benzodiazepines:

  • Prescribe the lowest dose necessary to control symptoms
  • Limit prescription to two to four weeks
  • Assess efficacy early and review regularly
  • Assess the need for more than one benzodiazepine (including the use of Z-drugs, such as Zopiclone) rigorously and often
  • Consider increased risks associated with use in combination with other medications (eg. Methadone
  • Be alert to the development of dependence. Tolerance to the effects of benzodiazepines develops quickly (within weeks) and more of the drug is needed to achieve the same effect. Dependence can develop after only three to six weeks at prescribed doses.
  • Slow taper: Withdrawal symptoms can occur after a few months of using therapeutic doses on a daily basis. Gradual withdrawal is recommended to minimize symptoms and may take months to complete.

Resources

  • Guideline for Adult Insomnia – TOP ( Towards Optimized Practice)
  • Canadian Guidelines to Safe and Effective Use of Opioids in Chronic Pain, Appendix B-6:
  • Benzodiazepine Tapering
  • Benzodiazepines, When to Prescribe – South Australia Health (website)
  • Prescribing Drugs of Dependence in General Practice, Part B – Royal Australian College of General Practitioners

Questions? Email info@cpsa.ab.ca