1. No category

NHS Fife
Guidelines for Benzodiazepine Prescribing in
Benzodiazepine Dependence
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
1
Contents Flowchart for Benzodiazepine Withdrawal ……………………………………………………………3
Establishing type of dependence.
........................................................................................... 4
Assessment of Benzodiazepine Dependence.............................................................................. 5
Management of dependence in therapeutic dose users............................................................ 6
Management of dependence in prescribed high dose users. ................................................... 7
Management of dependence in illicit and recreational users. .................................................. 8
Psychological support. ................................................................................................................. 9
Pharmacological support............................................................................................................ 10
Appendices Appendix 1
Example Patient Letter (regular user)................................................. 11
Appendix 2
Information leaflets and advice from the internet................................ 13
Appendix 3
DRUG DIARY..................................................................................... 14
Appendix 4
Benzodiazepine conversion table....................................................... 15
Appendix 5
Withdrawal regimes for therapeutic dose users.................................. 16
Appendix 6
Withdrawal regimes for high dose users ............................................ 18
Appendix 7
Self-help guides for psychological support ......................................... 20
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
2
Flowchart for Benzodiazepine Withdrawal
Patient taking benzodiazepine
Assess.
Establish dependence and pattern of
usage
Prescribed therapeutic dose
dependence
Is minimum intervention
appropriate?
Yes
Prescribed high dose
dependence
Recreational high dose and
abuse
Complete drug diary for at 2
least weeks
Monitor benzodiazepine use for
3 months & complete at least
two drug screens. Establish
boundaries, set goals
Is patient topping up
prescription with illicitly obtained
benzodiazepine?
Patient ready to reduce usage?
No
No
Yes
Yes
Advise self-reduction of illicitly
obtained benzodiazepine to
prescribed or therapeutic level. Do not
prescribe doses of diazepam to
compensate for illicitly obtained drugs
Letter and FAQs
Brief intervention
Self-help booklet
Agree gradual dose reduction
converting to diazepam with twice daily
dosing if appropriate.
Prescribe 2mg or 5mg diazepam only
No
Continue to support reduction
using motivational interviewing.
Consider referral to
DAPL/FIRST/Psychology
Yes Patient reduced use to 30-40mg
equivalent diazepam?
No
Reduce daily dose by about
1/8th (range 1/10th to ¼) every 2
or 3 weeks
Withdrawal Symptoms?
Maintain at present dose until
symptoms improve-avoid
increasing the dosage again
Address any underlying mental
health problems offering
psychological or
pharmacological support
No
Yes
Continue reduction at agreed
rate
Renegotiate rate of reduction if
required
STOP COMPLETELY
(Time needed can vary from 4
weeks to a year or more)
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
3
Following the introduction of benzodiazepines in the 1960s as the treatment of choice for anxiety and
Fife Guidelines for Benzodiazepine Prescribing in Benzodiazepine Dependence
insomnia and their widespread use from the 1970s onwards it has been recognised that long term use
can result in physical and psychological dependence as well as tolerance to their use.
In addition to patients prescribed benzodiazepines the illicit use, particularly by opioid drug users is a
major problem for users in and out of drug treatment. High doses of prescribed and illicit
benzodiazepines are taken and users become extremely tolerant to the sedative effects.
Benzodiazepine withdrawal syndrome is characterised by insomnia, anxiety, loss of appetite and bodyweight, tremor, perspiration, tinnitus, and perceptual disturbances. Abrupt withdrawal may produce
confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. For this reason
patients exhibiting dependence should undergo gradual withdrawal of the benzodiazepine.
Establishing type of dependence.
Patients may exhibit dependency on a therapeutic dose
or non-therapeutic dose – the latter group being subdivided into “prescribed high dose dependence” and
“recreational high dose abuse and dependence” groups.
Therapeutic Dose
Dependence
Prescribed High Dose
Dependence (eg ≥30mg diazepam)
Illicit and Recreational Use
Dependence
Characteristics of Therapeutic Dose Dependence – Patient may have:
• taken benzodiazepines in prescribed low doses for months or years.
• gradually come to “need” benzodiazepines in order to carry out normal activities of daily living.
• continued to take their medication even though original indication has disappeared.
• experienced withdrawal symptoms when they try to reduce or stop the drugs.
• contacted the prescriber frequently to request repeat prescriptions.
• experienced anxiety if there is a delay to the next prescription.
• increased the dosage since the original prescription
• experienced anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical
symptoms despite continuing to take benzodiazepines.
Characteristics of Prescribed High Dose Dependence – patient requiring ever larger doses may:
• try to persuade doctor to escalate doses and/or number of tablets on the prescription.
• present at hospital or register at further practices to obtain more tablets
• combine benzodiazepine misuse with excessive alcohol consumption or other sedative drugs
• be highly anxious, depressed or have personality disorder
• tend not to use illicit drugs, but may obtain benzodiazepines from relatives or acquaintances.
Characteristics of Recreational High Dose Abuse & Dependence –
• Often develops as polydrug abusers attempt to enhance the effect of opioids or to “come down” from
stimulants.
• A very high tolerance develops making it difficult to detect the actual scale of drug consumption.
• Users may be taking well in excess of 100mg daily in a single dose to maximise the effect.
• There may be a concurrent alcohol problem and the user may have been introduced to
benzodiazepines during previous alcohol detoxification
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
4
Assessment of Benzodiazepine Dependence
1.
Establish PATTERN of benzodiazepine usage
Benzodiazepines used ……………………………….
2. Establish DEPENDENCE if 3 or more or the following are present in the
same 12-month period:
3 to 5 indicators – mild to moderate dependence
5 to 7 indicators – moderate to severe dependence
Average daily dose and dose intervals ……………..
i) Tolerance – a need for increased amounts to achieve desired effect
- diminished effect with continued use of same amount
Date of onset of usage ………………………………
OR
ii) Withdrawal – previous attempts to cut down result in withdrawal symptoms OR
- substance is taken to prevent withdrawal symptoms
Previous successful withdrawal from use? …………
If yes, longest period of abstinence? ………………
iii) Substance taken in larger amounts or over longer period than originally intended
Any other drug or alcohol used?..............................
iv) Persistent desire or unsuccessful effort to cut down or control use
v) Great deal of time spent obtaining substance or recovering from its effects
vi) Important activities (social, work related or recreational) given up or reduced
vii) Continued use of drug despite clear evidence of harmful effects
4. Establish CATEGORY of dependence:
DSM-IV Diagnostic Criteria for Substance Dependence
Therapeutic Dose Dependence
Started for a reason and continued
3. Additional considerations (to inform but not prevent detox):
High Dose Dependence
Started as a prescription and then escalated
No other drug or alcohol problems
Concomitant severe medical or psychiatric illness
History of severe withdrawal (including PROVEN history of seizures)
Recreational High Dose Abuse & Dependence
Used and abused by people who use drugs:
illicit, POM or OTC and/or alcohol
Completion of drug diary (for at least 2 weeks, up to 3 months may be appropriate)
Confirmation of dependence by drug screening (urine but consider oral fluid)
See page 4 for more detail
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Level of motivation to change
Issued: April 2013
Review Date: April 2016
Date June 2013
5
Management of dependence in therapeutic dose users
Management can include minimal interventions, gradual dose reduction and gradual dose reduction with
additional psychological support.
Minimal interventions (1 and 2 below) are suitable in early/mild dependence.
1. Write to the patient: explain problems associated with long-term benzodiazepine use and the
need to reduce their prescription encouraging a gradual reduction or cessation if possible. (appx 1)
2. Brief Intervention: Simple advice and provision of information leaflets and other materials.
(appx 2)
3. Gradual Dose Reduction
Gradual dose reduction is preferable to abrupt discontinuation of benzodiazepine. There are two
methods of achieving a reduction
3A. Dosage reduction of currently
prescribed benzodiazepine
Dose reduction schedules frequently last
several weeks and may last for over a year.
For a selection of different schedules refer to
“Benzodiazepines: How They Work & How
to Withdraw”. Prof CH Ashton available at
www.benzo.org.uk
Be Aware
If withdrawal symptoms occur maintain
present dose until symptoms improve – but
avoid increasing the dosage again.
Consider adding psychological therapies.
Plan reduction schedule with patient but
review and be prepared to adjust
according to circumstances – the end
goal, however, is completely stopping.
3B. Switching to a long-acting benzodiazepine.
Switching to diazepam to aid withdrawal may be
useful if:
• reduction of short half-life benzodiazepines
(loprazolam, lorazepam, lormetazepam,
temazepam) causes problematic withdrawal
symptoms.
• On potent benzodiazepines that do not easily
allow for small reductions in dose (as above
plus alprazolam)
• Long duration of treatment, high doses and
history of anxiety problems indicate likely
difficulty in withdrawing.
Approximate equivalent doses are available in the
BNF section 4.1 Hypnotics and Anxiolytics:
dependence and withdrawal. (appx 4)
For switching and dose reduction schedules see
appx 5.
Only prescribe 2mg or 5 mg diazepam tablets
10mg tablets have a higher street value and may
be diverted.
4. Additional Psychological Support
See page 9 of guidelines
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
6
Management of dependence in prescribed high dose users
This group of patients will have increased their use of benzodiazepines to above a therapeutic dose, e.g. a
dose equal to or greater than 30mg diazepam or equivalent. This dose may be entirely prescribed or their
prescription topped up with illicitly obtained benzodiazepines or Z-drugs.
1. Assessment
Undertake an assessment of dependence (see page 5 of guidance) including the completion of a drug
diary by the patient for at least 2 weeks (appx 3).
Nb. Patients taking high doses of benzodiazepines in binges are not necessarily dependent.
2. Planning
Education and motivational techniques are important to ensure patient is willing to embark on
detoxification.
Set realistic goals – disagreement with the pace of reduction is likely to end in a poor outcome.
Allow for some periods of stabilisation of dose if withdrawal symptoms occur but avoid increasing the
dosage again.
Patients topping up their prescription with illicitly obtained medication should reduce their
daily dose until taking their prescribed medication only. They may choose to do this by gradual
reduction (see schedules at appx 6). However, doses greater than 30mg diazepam are rarely
necessary as this is sufficient to prevent benzodiazepine withdrawal symptoms (including withdrawal
seizures) in very high-dose benzodiazepine users.
It is not helpful to prescribe additional doses of diazepam to compensate for illicitly obtained
drugs.
3. Convert to diazepam
Benzodiazepines should be converted to diazepam using the approximate equivalent doses available
in the BNF section 4.1 Hypnotics and Anxiolytics: dependence and withdrawal. (appx 4)
Substitute one dose of current benzodiazepine to diazepam at a time, usually starting with the evening
or night-time dose. Replace the other doses, one by one, at intervals of a few days or a week until the
total approximate equivalent dose is reached before starting the reduction.
Once on diazepam the long half-life should enable the patient to take a single dose at night or a twice
daily dose at most.
Prescribe 5mg or 2 mg diazepam tablets only. 10mg tablets have a higher street value and may be
diverted.
4. Dose Reduction
The daily dose can be reduced in steps of about one-eighth (range one-tenth to one-quarter).
Initially the dose can be reduced every 2 to 3 weeks: if withdrawal symptoms occur maintain the
current dose until symptoms improve – do not increase the dose again.
At a dose of 20mg diazepam the dose may need to be reduced in smaller steps over a longer period
of time – it is better to reduce too slowly than too quickly.
The aim is to stop completely and the period needed will vary from individual to individual: anything
from about 4 weeks to a year or more.
For a variety of schedules see appendices 5 & 6
5. Psychological and/or pharmacological support
See page 9 & 10 of guidelines
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
7
Management of dependence in illicit and recreational users
Be Aware
Maintenance prescribing in illicit drug users cannot be recommended on the basis of existing
evidence.
Doses greater than 30mg diazepam are rarely necessary as this is sufficient to prevent
withdrawal seizures even in very high-dose benzodiazepine users .
Always prescribe 5mg or 2mg diazepam tablets as there is risk of diversion of 10mg diazepam
tablets.
Dispensing should be daily (especially at start) and always in line with collection of any opiate
substitute prescription. Consider supervision if diversion is suspected.
1. Before prescribing:
Education and motivational techniques are important to ensure patient is willing to embark on
detoxification.
Undertake extended assessment of use (up to 3 months), establish firm boundaries, set specific goals
and consider written contract.
Patients on methadone or buprenorphine should keep their dose stable during detoxification.
Patients taking high doses of illicit benzodiazepines must evidence self-reduction to near therapeutic
level (less than 50mg of street diazepam) by means of drug diary (appx 3). Self -reduction regimes
available appendix 6.
At least two drug screens should be completed (consider oral fluid testing).
• Any negative to benzodiazepine would indicate non dependence
• Illicit opioids would indicate instability if on opioid substitute treatment
• Stimulant (and alcohol) use needs to be addressed before any detoxification
Liaise with other involved professionals to establish history of benzodiazepine prescribing, other
prescribed medication, potential use of other illicit drugs and to inform them of proposed plan.
2. Convert to diazepam:
Benzodiazepines should be converted to diazepam using the approximate equivalent doses available
in the BNF section 4.1 Hypnotics and Anxiolytics: dependence and withdrawal. (appx 4)
Do not prescribe combination benzodiazepines e.g. nitrazepam and diazepam
Starting dose should not exceed 30mg to 40mg.
The patient should take a single daily dose (or a twice daily dose at most)
3. Reduction:
Starting at 30-40mg the dose may be reduced by 5mg every one to two weeks until 20mg daily. At a
dose of 20mg reduction may be slowed to 2mg every one to two weeks.
This rate of withdrawal is relatively rapid and should be tailored to suit the individual. In particular
patients showing clear signs of withdrawal symptoms on assessment may benefit from slower
reduction rate.
Patients who fail to cope with reduction may have underlying mental health problems that need
addressing. Reductions may be halted for 2 to 4 weeks, but the dose should not be increased.
For a variety of schedules see appendix 5
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
8
Psychological support
1.
Written support
4. Psychological
and/or pharmacological support
See page 6 of guidelines
Patients may find the self help guides available at www.moodjuice.scot.nhs.uk and
www.moodcafe.co.uk useful sources of support and advice about anxiety management, panic attacks,
depression, sleep problems and relaxation training (appx 7). These may be printed from the internet in
booklet form.
2. Internet support
There is a wealth of information and support available on the internet. Apart from two websites set up
locally - www.moodjuice.scot.nhs.uk and/or www.moodcafe.co.uk there is also information at
www.patient.co.uk/health/stopping-benzodiazepines-and-z-drugs
www.benzo.org.uk specialises in support and information on benzodiazepine withdrawal.
3. Counselling and relapse prevention
Fife wide voluntary organisations FIRST and DAPL offer one to one support. Patients may be referred
or self-refer. Contact the organisations for further information.
Fife Intensive Rehabilitation
& Substance Misuse Team
3 Fergus Place,
Kirkcaldy, KY1 1YA
01592 585960
www.firstforfife.co.uk
FIRST provides a Fife-wide rehabilitation
service to individuals with Substance
Misuse problems via one to one sessions,
group work and volunteer support.
Drug and Alcohol Project
Limited
2 Parkdale, Park Drive
Leven, KY8 5AO
01333 422277
www.dapl.net
DAPL offers one to one counselling,
support, information and advice to
individuals and families who are affected by
substance use and live within Fife.
4. NHS Fife Adult Mental Health Services
NHS Fife Adult Mental Health Services run a six session evening class entitled “Step Forward” dealing
with different aspects of stress and the skills required to fight it. Participants will also be given
handouts, diaries and a relaxation CD to enable them to continue to combat stress once the course is
completed. Contact NHS Fife Psychology Service for more information on 01383 565402.
5. NHS Fife Psychology Services
Fife NHS Addictions Clinical Psychology Service offer training, consultancy and psychological
supervision to staff (support workers, nursing staff, counsellors, therapists, rehabilitation workers etc)
delivering interventions for mild and moderate psychological problems. Phone 01383 565402 for
information.
Patients with complex psychological problems may be referred to Fife NHS Addictions Clinical
Psychology Service for direct therapeutic contact. Please note that the patient must fulfil the following
criteria:
• Current history of benzodiazepine use.
• Concurrent complex psychological problems caused by a pre-existing mental health problem
not directly attributable to the benzodiazepine misuse and hampering the patient’s treatment
progress.
• Behavioural indicators demonstrating that the benzodiazepine use is stable.
• Currently under medical supervision for their benzodiazepine use.
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
2013
Review Date: April 2016
Contact
the Clinical Psychology Addictions Service forIssued:
moreApril
information
on
01383 565402.
Approved by NHS Fife ADTC on behalf of NHS Fife
Date June 2013
9
Pharmacological support
Evidence does not support the use of adjunct drug therapy to improve the benzodiazepine withdrawal
rate or to reduce withdrawal symptoms.
However the BNF states:
“Beta-blockers should only be tried if other measures have failed; antidepressants should be used
only where depression or panic disorder co-exist or emerge; avoid antipsychotics (which may
aggravate withdrawal symptoms)”
If psychological measures are not effective enough:
• low dose of propranolol may control severe palpitations, muscle tremors or motor jerks.
• low dose of sedative tricyclic antidepressant or sedative antihistamine may help severe
insomnia
In practice additional drugs are seldom needed with very slow benzodiazepine reduction. (Ashton)
For drug users using other sedative drugs (illicit or prescribed) and/or alcohol, sedative
antidepressants and antihistamines should be used with caution as their use may contribute to
a fatal overdose.
Treatment of emerging or co-existing depression.
There is no comparative evidence to assist in the selection of an antidepressant for severe
depression. Both tricyclics and SSRIs have been found to be effective for severe depression during
benzodiazepine withdrawal. See Fife Joint Formulary: 4.3 Antidepressant Drugs.
Start with the lowest dose and increase slowly, maintaining the effective dose during the
benzodiazepine withdrawal before starting to withdraw antidepressant.
All SSRIs and tricyclics prolong the QT interval by varying degrees and an ECG should be considered
particularly for patients on a high dose of methadone.
References:
1. BAP Guidelines. Journal of Psycopharmacology 26(7) 899-952
2. Benzodiazepines: how they work and how to withdraw. Prof. C Heather Ashton. Available at
www.benzo.org.uk
3. Guidance on prescribing Benzodiazepines to drug users in Primary Care. SMMGP. Available at
www.smmgp.org.uk
4. BNF 4.1 Hypnotics and anxiolytics. Dependence and withdrawal. Available at
http://www.medicinescomplete.com/mc/bnf/current/PHP2093-hypnotics-and-anxiolytics.htm
5. Fife Joint Formulary: Appendix 4B - Guidance for the use of Pharmacological Agents for the
Treatment of Depression in Adults (18 years and over). Available at http://www.fifeadtc.scot.nhs.uk
6. Fife Joint Formulary: Section 4.3 Antidepressant Drugs
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
10
Appendix 1
Example Patient Letter (regular user)
Practice address
Date as postmark
Dear Patient,
In the interests of patient care, the doctors in the practice are continually reviewing their
prescribing in order to keep up with the latest developments. The practice is currently carrying out
reviews of patients who receive medicines for insomnia and management of anxiety. We are writing to
you because we notice from our records you have been taking……………………. for some time now.
There
•
•
•
•
is concern about this type of medication when taken for a long time.
The body can become used to the tablets so that they no longer work properly.
Stopping the tablets suddenly can cause unpleasant withdrawal effects
They can become addictive
They may even cause anxiety and sleeplessness.
For these reasons repeated use of the tablets over a long period of time is no longer recommended.
However you should not stop taking the tablets suddenly as you may experience some withdrawal
effects.
We are writing to offer you the opportunity to try and cut down the dose of your tablets and perhaps
stop them in the future. The best way to do this is to reduce the dose of the tablets very gradually,
for example, every 2 -4 weeks to reduce the likelihood of having withdrawal symptoms. If you would
be prepared to reduce the dose with a view to stopping your tablets in the future please phone /
contact the practice and we will advise you of how best to reduce the dose of medication. Together
we can work out a planned timetable for slowly stopping these tablets.
We attach a question and answer sheet answering some of the questions you may have and some
information about how best to improve your sleep and help relaxation.
Yours sincerely
Practice/GP
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
11
Reducing your Benzodiazepines & or Z Drugs in anxiety and insomnia
Q. What are benzodiazepines/Z Drugs?
A. These are drugs that can help with sleep problems, benzodiazepines are also used to reduce
anxiety. Both types of drugs should only be used for very short periods in patients with severe
symptoms.
Q. What are their effects?
A. Short-term:
•
•
•
Long-term:
•
•
•
•
•
•
Reduced alertness.
Drowsiness. This may affect your ability to drive or operate machinery.
Reduced tension and anxiety.
Dependence on the drug.
Reduced alertness may lead to accidents and falls.
Poorer memory.
Lack of emotion.
Tasks take longer to complete.
The short-term effects continue.
Q. What may happen when the drug is withdrawn too quickly?
•
•
•
•
•
•
•
Your muscles may ache and strange sensations may be felt on the skin.
You may feel restless and anxious.
You may feel sick and weight loss may occur.
You may sweat more than normal.
You may have difficulty sleeping.
You may feel more frightened or panicky. At first you can have a reduced ability to
cope with stress.
Eventually your anxiety will disappear and you will become more assertive.
Q. Why does this happen?
These drugs block some of your emotional responses in the brain. When you reduce the drug, your
brain becomes over-stimulated; this can magnify your feelings and senses.
This is why your doctor will very slowly reduce your medication to ease the withdrawal process.
Hopefully you won’t experience these side effects or they will be kept to a minimum.
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
12
Appendix 2
Information leaflets and advice from the internet
The following list is comprised of a few of the very many resources available on the internet. For patients
without access to the internet some of the information is available in pdf format for ease of printing.
www.patient.co.uk/health/stopping-benzodiazepines-and-z-drugs
4 page Information leaflet for download : www.patient.co.uk/pdf/4638.pdf
www.recovery-road.org
Information leaflets for download:
http://recovery-road.org/wp-content/uploads/2010/06/Information-for-Family-Carers.pdf
http://recovery-road.org/wp-content/uploads/2010/06/Caring-for-Benzo-Users1.pdf
www.benzo.org.uk
The Ashton Manual, “Benzodiazepines: how they work and how to withdraw”
available at http://www.benzo.org.uk/manual/index.htm
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
13
Appendix 3
DRUG DIARY
DRUG DIARIES ARE USEFUL FOR THE FOLLOWING REASONS:•
IT GIVES A CLEAR PICTURE OF YOUR CURRENT BENZODIAZEPINE (AND OTHER DRUGS) USE
•
IT GIVES YOU THE OPPORTUNITY TO LOOK MORE CLOSELY AT WHAT YOU ARE TAKING AND WHY
•
THE MORE INFORMATION WE CAN GATHER, THE EASIER IT WILL BE TO PLAN “THE WAY FORWARD”
•
THIS WILL ONLY TAKE ABOUT TEN MINUTES TO COMPLETE EACH DAY
NAME……………………….………….. STARTING DATE………..
Day
Time
What did I take and how
much?
Why did I take?
How was I feeling at the
time?
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
14
Appendix 4
Benzodiazepine conversion table
This table is based on the equivalent doses published in the BNF Section 4.1 Hypnotics and Anxiolytics.
Equivalent doses do vary from source to source but, more importantly, can vary considerably between
individuals.
BENZODIAZEPINE OR
Z- DRUG
DOSE EQUIVALENT TO 5MG
DIAZEPAM
HALF-LIFE (hrs)
[active metabolite]
Alprazolam (Xanax)
0.25mg
6 -12
Chlordiazepoxide (Librium)
15mg
5 - 30 [36 -200]
Diazepam (Valium)
5mg
21-50 [36 – 200]
Flunitrazepam (Rohypnol)
0.5mg
18 – 26 [36 – 200]
Flurazepam (Dalmane)
15mg
[40 – 250]
Loprazolam (Dormanoct)
0.5 – 1mg
[10 – 20]
Lorazepam (Ativan)
0.5 – 1mg
10 - 20
Lormetazepam (Noctamid)
0.5 – 1mg
10 - 12
Nitrazepam (Mogadon)
5mg
15 - 38
Oxazepam (Serax)
15mg
4 – 15
Temazepam (Normison)
10mg
8 - 22
Triazepam (Halcion)
0.25
2
Zaleplon (Sonata)
10
2
Zolpidem (Stilnoct)
10
2
Zopiclone (Zimovane)
7.5
5-6
In the list of drugs above the original brand names are stated in brackets even though many of the branded
drugs are no longer available. Service users may refer to a drug by its original brand name.
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
15
Appendix 5
Withdrawal regimes for therapeutic dose users
BNF 4.1 Hypnotics and anxiolytics – Dependence and Withdrawal:
A benzodiazepine can be withdrawn in steps of about one-eighth (range one-tenth to one-quarter) of the
daily dose every fortnight.
The following examples are variations from those available at www.benzo.org “Benzodiazepines: How they
work and how to withdraw”, Chapter II: Slow withdrawal schedules. Professor C Heather Ashton.
Example 1 – Diazepam 10mg three times daily reducing by approx. one-tenth every 2 weeks
Starting dose
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Stage 7
Stage 8
Stage 9
Stage 10
Stage 11
Stage 12
Stage 13
Stage 14
Stage 15
Stage 16
Stage 17
Stage 18
Stage 19
Stage 20
Stage 21
Morning
10mg
10mg
10mg
10mg
10mg
10mg
8mg
8mg
6mg
5mg
4mg
3mg
2mg
1mg
-
Afternoon
10mg
8mg
6mg
4mg
2mg
-
Night
10mg
10mg
10mg
10mg
10mg
10mg
10mg
8mg
8mg
8mg
8mg
8mg
8mg
8mg
8mg
7mg
6mg
5mg
4mg
3mg
2mg
1mg
Total daily dose
30mg
28mg
26mg
24mg
22mg
20mg
18mg
16mg
14mg
13mg
12mg
11mg
10mg
9mg
8mg
7mg
6mg
5mg
4mg
3mg
2mg
1mg
Example 2 – Diazepam 10mg three times daily reducing by approx. one-tenth every 2 weeks
Morning
10mg
Starting dose
Stage 1
10mg
Stage 2
8mg
Stage 3
8mg
Stage 4
8mg
Stage 5
6mg
Stage 6
6mg
Stage 7
6mg
Stage 8
4mg
Stage 9
4mg
Stage 10
4mg
Stage 11
3mg
Stage 12
3mg
Stage 13
2mg
Stage 14
2mg
Stage 15
2mg
Stage
16
1mg
Appendix 7
Stage 17
1mg
Stage
18
1mg Addiction Services
Dr. A. Baldacchino, Liz. Hutchings,
Approved
by NHS Fife ADTC -on behalf of NHS Fife
Stage
19
Afternoon
Night
Total daily dose
10mg
10mg
30mg
8mg
10mg
28mg
8mg
10mg
26mg
8mg
8mg
24mg
6mg
8mg
22mg
6mg
8mg
20mg
6mg
6mg
18mg
4mg
6mg
16mg
4mg
6mg
14mg
4mg
4mg
12mg
2mg
4mg
10mg
2mg
4mg
9mg
2mg
3mg
8mg
2mg
3mg
7mg
2mg
2mg
6mg
1mg
2mg
5mg
1mg
2mg
4mg dose users
Withdrawal regimes for non therapeutic
1mg
1mg
3mg
1mg
2mg
Issued: April 2013
Review Date: April 2016
16
Date June 2013 1mg
1mg
Example 3 – Withdrawal from lorazepam 3mg daily with diazepam substitution
Starting dose
Stage 1
Afternoon
Night
lorazepam 1mg
lorazepam 1mg
lorazepam 1mg
lorazepam 1mg
lorazepam 1mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
Stop lorazepam
diazepam 10mg
Stage 2
Stage 3
Stage 4
Stage 5
Stage 6
Daily diazepam
equivalent
Morning
diazepam 10mg
lorazepam 1mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
Stop lorazepam
diazepam 10mg
30mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
lorazepam 0.5mg
diazepam 5mg
Stop lorazepam
diazepam 10mg
30mg
30mg
30mg
30mg
diazepam 10mg
30mg
diazepam 10mg
30mg
Continue reducing diazepam using example 1 or 2 above
Example 4 - Withdrawal from zopiclone 15mg with diazepam substitution
Night time
Starting dosage
Daily diazepam equivalent
zopiclone 15mg
Stage 1 (1 week)
10mg
zopliclone 7.5mg
diazepam 5mg
Stop zopiclone
diazepam 10mg
Stage 2 (1 week)
Stage 3 (1-2 weeks)
Stage 4 (1-2 weeks)
10mg
10mg
diazepam 9mg
9mg
diazepam 8mg
8mg
Continue reducing by 1mg every 1 – 2 weeks as in example 1 above
Some notes for patients:
•
The first stages of a reduction schedule may be manageable with one week between
reductions but the later stages are better taken over at least 2 weeks.
•
A mixture of 5mg and 2mg tablets will be required. For reductions of 1mg the scored 2mg
tablet may be halved.
•
This is intended to be a slow process. Do not try to speed it up in any way.
•
If you are struggling, take an extra week to complete a stage rather than going backwards by
increasing a dose.
•
Tell a friend or a partner what you are aiming for so they can encourage and support you.
•
Consult your GP regularly. Especially if experiencing any fainting, fits, depression or panic
attacks.
•
Access self-help information and booklets at www.moodjuice.scot.nhs.uk &
www.moodcafe.co.uk
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
17
Appendix 6
Withdrawal regimes for high dose users
Example 1 – recommended reducing regime from 80mg to 30mg
DIAZEPAM REDUCING REGIME: STARTING AT 80MG DAILY
SOME GROUND RULES:
• The following reducing plan is to help you reduce your own benzodiazepine use
•
It is unlikely that these doses will be prescribed for you
•
It is intended to be a slow process. Do not try to speed it up in any way
•
If you are struggling, take an extra week to complete a stage rather than going backwards by
increasing the dose.
•
Tell a friend or partner what you are aiming for so that they can encourage and support you
•
Access self-help information and booklets at www.moodjuice.scot.nhs.uk & www.moodcafe.co.uk
Starting dose
Stage
2 weeks
1
Morning
Midday
Afternoon
Night
20mg
20mg
20mg
20mg
Total for the
day
80mg
20mg
20mg
15mg
20mg
75mg
2
2 weeks
20mg
15mg
15mg
20mg
70mg
3
2 weeks
15mg
15mg
15mg
20mg
65mg
4
2 weeks
15mg
15mg
10mg
20mg
60mg
5
2 weeks
15mg
10mg
10mg
20mg
55mg
6
2 weeks
10mg
10mg
10mg
20mg
50mg
7
2 weeks
10mg
10mg
5mg
20mg
45mg
8
2 weeks
10mg
10mg
stop
20mg
40mg
9
2 weeks
10mg
10mg
-
15mg
35mg
10
2 weeks
10mg
5mg
-
15mg
30mg
11
2 weeks
10mg
stop
-
15mg
25mg
12
2 weeks
10mg
-
-
10mg
20mg
Total = at least
24 weeks
WELL DONE. NOW FOLLOW SLOWER REDUCTION SCHEDULE FROM 20mg
BY HALVING 5mg TABLETS OR QUARTERING 10mg TABLETS
13
2-4 weeks
7.5mg
-
-
10mg
17.5mg
14
2-4 weeks
7.5mg
-
-
7.5mg
15mg
15
2-4 weeks
5mg
-
-
7.5mg
12.5mg
16
2-4 weeks
2.5mg
-
-
7.5mg
10mg
17
2-4 weeks
Stop
-
-
7.5mg
7.5mg
18
2-4 weeks
-
-
-
5mg
5mg
19
2-4 weeks
-
-
-
2.5mg
2.5mg
20
2-4 weeks
-
-
-
STOP
-
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
18
Example 2 – recommended reducing regime from 200mg to 80mg
DIAZEPAM REDUCING REGIME: STARTING AT 200MG DAILY
SOME GROUND RULES:
• The following reducing plan is to help you reduce your own benzodiazepine use
•
It is unlikely that these doses will be prescribed for you
•
It is intended to be a slow process. Do not try to speed it up in any way
•
If you are struggling take an extra week to complete a stage rather than going backwards by
increasing the dose.
•
Tell a friend or partner what you are aiming for so that they can encourage and support you
•
Access self-help information and booklets at www.moodjuice.scot.nhs.uk & www.moodcafe.co.uk
Starting dose
Stage
2 weeks
1
Morning
Midday
Afternoon
Night
50mg
50mg
50mg
50mg
Total for the
day
200mg
50mg
40mg
40mg
50mg
180mg
2
2 weeks
40mg
40mg
30mg
50mg
160mg
3
2 weeks
40mg
30mg
30mg
40mg
140mg
4
2 weeks
30mg
30mg
20mg
40mg
120mg
5
2 weeks
30mg
20mg
20mg
40mg
110mg
6
2 weeks
30mg
20mg
20mg
30mg
100mg
7
2 weeks
20mg
20mg
20mg
30mg
90mg
8
2 weeks
20mg
20mg
20mg
20mg
80mg
Total = at least
16 weeks
WELL DONE. NOW FOLLOW SLOWER REDUCTION SCHEDULE FROM 80mg
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
19
Appendix 7
Self-help guides for psychological support
SUBJECT
WEB ADDRESS
http://www.moodcafe.co.uk/article/uploaded/UnderstandingAnxietyportrait_2.pdf
http://www.moodcafe.co.uk/article/uploaded/dealingwithworry_1.pdf
ANXIETY
http://www.moodjuice.scot.nhs.uk/anxiety.asp
http://www.moodjuice.scot.nhs.uk/stress.asp
http://www.moodcafe.co.uk/article/uploaded/Panic-Aselfhelpguide.pdf
PANIC
http://www.moodcafe.co.uk/article/uploaded/GeneralisedAnxietyandPanicAttacks.pdf
http://www.moodjuice.scot.nhs.uk/panic.asp
http://www.moodcafe.co.uk/article/uploaded/Copingwithdepression-NHSFife.pdf
DEPRESSION
http://www.moodjuice.scot.nhs.uk/Depression.asp
http://www.moodcafe.co.uk/article/uploaded/TipsforBetterSleep_2.pdf
SLEEP
PROBLEMS
http://www.moodjuice.scot.nhs.uk/sleepproblems.asp
http://www.moodcafe.co.uk/article/uploaded/guidetorelaxation_1.pdf
RELAXATION http://www.moodjuice.scot.nhs.uk/mildmoderate/Relaxation.asp
http://www.moodjuice.scot.nhs.uk/relaxationsearch.asp
Dr. A. Baldacchino, Liz. Hutchings, Addiction Services
Approved by NHS Fife ADTC on behalf of NHS Fife
Issued: April 2013
Review Date: April 2016
Date June 2013
20