Prescribing & Medicines Management
page PM3
March 2005

Features

Benzodiazepine withdrawal at a pharmacy technician-led clinic

Although prescribing of benzodiazepines in the North Eastern Derbyshire Primary Care Trust area is below the national average, there are pockets of high prescribing. Most benzodiazepine use is long-term, which poses well-documented risks to the individual and has a potentially negative effect on the PCT’s star rating (prescribing rates for drugs acting on benzodiazepine receptors are Commission for Health Improvement indicators).

Pharmacist-led benzodiazepine withdrawal schemes have been well documented but, because of their labour intensive nature, they may not always be the most cost-effective use of resources. With this in mind we decided to adopt a multidisciplinary approach to benzodiazepine withdrawal: we tried to introduce a more appropriate skill mix to the process by involving a pharmacy technician.

The pilot

The practice with the highest benzodiazepine prescribing in the PCT was approached and a meeting held between the GPs, the PCT prescribing adviser and a prescribing support technician, to discuss the logistics of a pilot scheme.

The Committee on Safety of Medicines advises that the use of benzodiazepines is only indicated for two to four weeks. We decided to target patients who had been taking benzodiazepines continually for three or more months. These patients were identified by the pharmacy technician searching the practice’s records. The list of patients was then passed to the lead GP who assessed individual patients against exclusion criteria prepared by the PCT’s medicines management team to ensure only appropriate patients were invited to participate. Exclusion criteria included patients with ongoing mental health issues, those prescribed benzodiazepines as an anticonvulsant, muscle relaxant or as part of a substance withdrawal programme and patients who were terminally ill.

Patients deemed suitable for reducing or stopping benzodiazepine use were sent a letter detailing the purpose and process of the scheme, and informed that they would receive a telephone call from the pharmacy technician within two weeks to arrange an appointment to discuss their benzodiazepine use further. It was documented in the patient’s notes that a letter had been sent.

A patient education leaflet was devised, to inform patients of the risks associated with long-term benzodiazepine use and this was sent with the letter. The leaflet included advice for good sleep hygiene and relaxation tips. To follow up the letter, the pharmacy technician telephoned each patient to arrange a clinic appointment for those who were interested. If the patient refused an appointment, this was documented in the notes.

Using a template designed by the medicines management team, the pharmacy technician gathered the relevant clinical information for each patient and determined a withdrawal plan following a standard operating procedure. The plan gave the patient the option of either reducing his or her current benzodiazepine dose or switching to the equivalent dose of diazepam, taken at night, with the dose gradually reduced as recommended in the British National Formulary. The pharmacist then verified the information gathered and agreed the withdrawal plan.

At the appointment (which took place either at the surgery or in the patient’s home) the pharmacy technician explained the potential risks of long-term benzodiazepine use to the patient and outlined the benefits of reducing the dose or stopping altogether. If the patient were willing to attempt withdrawal the options were explained — the choice of withdrawal method was left to the patient. A fortnightly follow-up (either a face-to-face meeting or a telephone consultation) with the pharmacy technician was offered as on-going support.

The pharmacy technician was authorised to amend repeat prescriptions as necessary. Prescriptions were generated when needed and passed to the GP for signing, along with a summary of the outcome of the appointment. Pill splitters were provided where needed to aid dose reduction. The outcome of the appointment was fully documented in the patient’s clinical record.

Outcomes

Over half (55 per cent) of the patients who met the eligibility criteria for the scheme declined an appointment (n=62). Eleven per cent of patients were seen and counselled but were unwilling or unable to take part in the scheme at the time. No further interventions were made with these patients. A quarter (26 per cent) of the patients were seen and counselled, but declined to take part in the scheme. However, these patients were taking benzodiazepines only when needed or expressed a wish to initiate withdrawal themselves. For this group of patients, prescriptions were amended to state “when required” and the quantity prescribed was reduced to a minimum — usually 14 tablets.

The remaining 8 per cent of patients were seen, counselled and agreed to take part in scheme. Of these, half stopped taking benzodiazepines altogether and the other half reduced their dose by at least 50 per cent.

Discussion

Although 8 per cent might not appear to be a significant success rate, it reflects the outcome of similar pharmacist-led schemes. In addition, the improvement in quality of life achieved is invaluable. This was reflected in comments from patients involved in the pilot. For example:

· “It used to take me ages to come round in a morning. I would have to have several cups of coffee and never felt like doing very much until midday. Now I can just get up and get on with things. I feel much better.”

· “I never realised the effect they were having on me until I stopped taking them. Now I feel much more alert and awake.”

· “I am a lot different, my eyes are brighter and I have more energy. I have been on sleeping tablets for 30 years. It is good to get off them.”

Feedback from the practice indicates that a number of patients who had originally declined to take part in the scheme have reduced their dose or withdrawn completely on their own, following the initial advice given.

This pilot showed that pharmacy technicians are a suitable alternative to pharmacists for conducting benzodiazepine withdrawal clinics. As a result of its success, the scheme is being offered to other high prescribing practices within the PCT and is currently under way in four practices. So far, these have yielded withdrawal rates of 16 to 32 per cent.