A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by the government because of the potential for abuse or addiction. Such drugs include those classified as narcotics, stimulants, depressants, hallucinogens, and cannabis.
A list of the most commonly encountered controlled drugs can be found at:
https://www.gov.uk/government/publications/controlled-drugs-list–2
Some patients require strong, potentially addictive medication to help manage their condition(s). Of concern are ‘drugs of dependence’ (e.g. opioid medications, benzodiazepines and Z-drugs), particularly when these are prescribed on an on-going basis.
Due to increasing reports of abuse of prescription drugs and patient behavioural problems, Clifton Court Medical Practice has established a policy to ensure adequate treatment, while reducing the risk of problems with drug prescriptions.
New Patients to the practice who have been prescribed Benzodiazepines/Z drugs by a previous care provider.
Patients New to the practice:
- It may take time to get accurate medical information about new patients. Until such information is available, GP’s may choose not to prescribe any medication. It is our policy that GPs do not prescribe drugs of dependence until they have a full clinical picture.
- GP’s may decide not to continue prescribing a benzodiazepine or Z-drug previously prescribed for patients. It may be determined that such a medication is not suitable. It is our policy that GPs do not prescribe drugs of dependence if they feel that previous prescriptions were inappropriate.
- GP’s will evaluate patients’ conditions and only prescribe a benzodiazepine or Z-drug of the lowest strength for the shortest time necessary. This may be different to the drug prescribed for a patient at a previous GP Practice.
General practice standards:
- If the decision to prescribe is taken after a shared discussion of goals, plans, risks and benefits, patients may be required to confirm consent in writing.
- Patients may be asked to complete a withdrawal programme and sign a withdrawal contract which details our practice’s expectations when prescribing drugs of dependence. This agreement details the patients’ responsibilities as a patient taking a drug of dependence; any prescriptions issues; advice on taking medications; how we will monitor care; and the standards of behaviour that are expected.
- Patients may need to acknowledge that their care requirements may be complex, and that referral for on-going care for all or part of their healthcare may be required. It is our practice policy that patient care is matched with the level of complexity.
- Patients should be reminded that we have a zero tolerance on issues relating to staff abuse.
Sedative prescription requests for fear of flying
The surgery has a practice policy that we do not issue sedative prescriptions, such as diazepam, chlordiazepoxide or zopiclone to alleviate symptoms that patients may experience relating to a fear of flying.
This decision has been made by all of our GP partners; our main reasons are listed below:
- The use of any sedating drug causes longer reaction times and slower thinking which during a flight may put the patient and or other passengers at significant risk of not being able to act in a manner which could save life in the event of an emergency.
- The use of any CNS depressant has the potential to increase the risk of Deep Vein Thrombosis (DVT).
- For some countries it is illegal to import these drugs.
- National guidelines advise that medication should not be used for mild and self-limiting mental health disorders and/or phobias.
- Use of these medications increases the risks of falls and accidents.
What to discuss with the patient when considering use of a benzodiazepine or Z-drug
Ensure the patient is aware that the medication is for short-term use alongside self-care.
Ensure patients are aware of the risks of treatment including Central Nervous System (CNS) depressant effects, including ‘hangover’ effects, unsteadiness, reduced alertness and impaired memory, tolerance, dependence, and withdrawal.
The long-term use of benzodiazepines or Z-drugs is associated with a number of health conditions and an increased risk of death:
- Over-sedation from long-term use can increase the risk of falls and accidents on the road and in the home.
- Poisoning from overdose may contribute to increased mortality risk.
- Long-term use of benzodiazepines or Z-drugs (usually more than 4 weeks) may be associated with:
- Tolerance — a higher dose is required to obtain the initial effect.
- Dependence — the person feels they need the medication to carry out day-to-day activities, and/or withdrawal symptoms occur upon stopping or dose reduction.
- Other effects of long-term use of benzodiazepines include:
- Cognitive effects, anxiety, agoraphobia, emotional blunting, reduced coping skills, and amnesia.
- Reduced social functioning due to effects on memory, reduced ability to remember new people, appointments etc.
- Depression, either for the first time, or aggravation of pre-exisiting depression with possible precipitation of suicidal tendencies.
- Older people are more vulnerable to the CNS depressant effects of benzodiazepines, possibly leading to confusion, night wandering, amnesia, ataxia, and hangover effects. Impaired cognitive function and memory may be wrongly diagnosed as dementia. In the UK, it has been estimated that older adults receive 80% of all prescriptions written for benzodiazepine hypnotics.
- Provide advice related to driving whilst taking the medication
- Warn of potential serious adverse effects if alcohol and other sedative substances are used with the medication.
Benzodiazepine/Z-drug Policy – Issuing Prescriptions
- All new benzodiazepines and Z-drugs will be issued as acute prescriptions.
- Wherever possible, patients will see the same Prescriber for review of the initial prescription.
- Where benzodiazepines and Z-drugs are initiated by an external provider the Practice will only take over prescribing once a written request has been received. GPs are under no obligation to prescribe on the advice or recommendation of an external provider and are reminded that they take on prescribing responsibility if they choose to prescribe. Where the GP chooses to accept this, the remainder of this policy applies, especially with regard to duration and review.
- Where patients are discharged from hospital on Benzodiazepines or Z Drugs the Practice should not automatically add these to the patients’ medications. Patients should be reviewed by the GP prior to any further issue.
- All patients will be reviewed within 2- 4 weeks of initiation of a benzodiazepine/Z-drugs prescription.
- Patients on long-term benzodiazepines/Z-drugs will be reviewed every 6 months.
- All benzodiazepines and Z-drugs will be issued on prescriptions with a maximum duration of 1 month.
- All benzodiazepines and Z-drugs prescriptions will include full directions wherever possible and use of PRN or MDU directions will be avoided.
Practice procedure for lost/stolen Controlled Drug Prescriptions
The loss or theft of a controlled drug prescription must be recorded in the patients’ medical record and a READ code added to enable the Practice to monitor/audit.
If the prescription is stolen, the patient or the Practice must report the incident to the police and obtain a crime number.
The loss or theft of a controlled drug or prescription must be reported to the CD Accountable Officer via cdreporting.co.uk
If Practices need to send out an alert regarding lost or stolen prescriptions, this can be done by sending an alert template to: [email protected].
The Practice must review the patient’s records when considering if it is appropriate to re-issue a prescription. Notes should be assessed to identify if there is a pattern of regularly requesting additional prescriptions. Practices may consider reviewing ordering patterns for immediate family and household members when considering patterns of behaviour. If a pattern is identified this could indicate an underlying problem such as abuse, diversion or a safeguarding issue, report via cdreporting.co.uk and refer as appropriate.
The patient should be invited in for review and the appropriate steps taken.
Practices may issue a small supply of medication to cover the period until the patient attends.
At the review, Practices should review the appropriateness of the current prescription and steps that can be taken to support the patient such as:
- Reducing and withdrawing medication.
- Reducing script duration e.g. weekly prescriptions.
- Discussion about future action should there be further issues.
- Working with the community pharmacy e.g., if prescriptions are being stolen could the pharmacy collect prescriptions on the patient’s behalf, use of EPS.
Existing patients with a regular prescription for Benzodiazepines or Z Drugs.
Patients registered at the Practice who are already receiving regular prescriptions for Benzo’s and Z Drugs will be systematically reviewed.
The pharmacist or GP will identify and audit patients who require review and make appropriate recommendations which may include a reduction to stop regime.
The Practice will support the Patient to reduce and stop Benzo and Z drug medication by following the recommendations, the timely issue of prescriptions as per the reduction plan and adhering to the Practice Policy.
Where a patients’ circumstances are such that a reduction regime would cause undue distress or anxiety at the given time, they will be informed that further attempts will be made to reduce and stop at 6 monthly intervals.
For any patients who repeatedly fail to engage in a reduction plan without appropriate clinical reason, the GP may cease to prescribe, after taking appropriate specialist advice.
Summary of relevant NICE Guidance
Medicines Optimisation Key Therapeutic Topic – Hypnotics (KTT6)
Only use hypnotics if insomnia is severe, using the lowest dose that controls symptoms for the shortest period of time.
Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (TA77)
Z-drugs and the shorter-acting benzodiazepine hypnotics should only be considered for severe insomnia interfering with normal daily life.
They should be prescribed for short periods of time only, in strict accordance with their licensed indications.
There is no compelling evidence to distinguish between zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics.
Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others (switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent).
NICE CKS Insomnia
If a hypnotic is required for insomnia the recommended choices are:
- Non-benzodiazepines (the ‘z-drugs’) – zopiclone, zolpidem, and zaleplon (all are short acting).
- Short-acting benzodiazepines – temazepam, loprazolam, lormetazepam.
- Diazepam is not generally recommended, but it can be useful if insomnia is associated with daytime anxiety,prescribe 5 – 15 mg at bedtime.
- Use the lowest effective dose for the shortest period possible.
Treatment should not continue for longer than 2 weeks.
Sedative drugs other than hypnotics (such as antidepressants, antihistamines, choral hydrate, clomethiazole, and barbiturates) are not recommended for the management of insomnia. Expert opinion from reviews suggests that there is insufficient evidence to support their use, and that the potential for adverse effects is significant.
Generalised anxiety disorder and panic disorder in adults: management (CG113)
Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Benzodiazepines are associated with a less good outcome in the long term.
Benzodiazepines should not be prescribed for the treatment of individuals with panic disorder.
NICE CKS Anxiety
If a benzodiazepine is required for anxiety the recommended choice is diazepam:
- For anxiety, prescribe 2 mg three times a day.
- If needed, the dose can be increased to 15–30 mg daily in 3 divided doses (half the dose should be prescribed in elderly or debilitated people).
- Caution in the elderly, due to the increased risk of falls — the manufacturer advises halving the recommended doses.
- Prescribe the lowest possible dose for the shortest period of time and review the patient regularly.
Treatment should not exceed 2–4 weeks.
Depression in adults: recognition and management (CG90) and Depression in adults with a chronic physical health problem: recognition and management (CG91)
Benzodiazepines are only to be considered as an option if a person with depression prescribed an SSRI develops the side effects of anxiety, agitation and/or insomnia early in antidepressant treatment and symptoms are problematic.
In this case short-term concomitant treatment with a benzodiazepine is one of several options that can be considered.
If a benzodiazepine is prescribed this should be for no longer than 2 weeks in order to prevent the development of dependence.
Benzodiazepines should not be used in people with chronic symptoms of anxiety.
Benzodiazepines should be used with caution in patients at risk of falls
Social anxiety disorder: recognition, assessment and treatment (CG159)
Do not routinely offer benzodiazepines to treat social anxiety disorder in adults.
Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG 31)
Anxiolytics should not normally be used to treat OCD or BDD without comorbidity except cautiously for short periods to counter the early activation of SSRIs.
Post-traumatic stress disorder (ng116)
Do not offer drug treatments, including benzodiazepines, to prevent PTSD in adults
Antenatal and postnatal mental health: clinical management and service guidance (CG192)
Do not offer benzodiazepines to women in pregnancy and the postnatal period except for the short‑term treatment of severe anxiety and agitation.
Consider gradually stopping benzodiazepines in women who are planning a pregnancy, pregnant or considering breastfeeding.
NICE CKS BPSD
If challenging behaviour requires urgent treatment (when the person is a danger to themselves or others) and underlying causes (such as discomfort, thirst, or the need for the toilet) have been addressed, advise moving the person to a safe, low-stimulation environment (such as a quiet room) away from others and use of verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, pictures, and symbols).
If these measures fail, seek advice from an elderly care psychiatrist, the challenging behaviour team, or an elderly care physician.
Depending on the specific situation, short-term (off-label) use of drugs for behavioural control (such as haloperidol or lorazepam) may be suggested.
Lorazepam (off-label) for the treatment of challenging behaviour associated with dementia should only be used on the advice of a specialist who should specify dose and duration of treatment.
Short-term treatment with lorazepam (off-label use) may be suggested for immediate management of violence, aggression, or extreme agitation in people with dementia when non-pharmacological measures have failed and the person poses a risk to themselves or others. The aim of the treatment is to calm the person and reduce agitation or aggression, not to sedate.
Treatment should start at the lowest possible dose (500 microgram) orally and be titrated slowly in increments, if necessary, to a maximum of 1 mg daily (2 mg daily in exceptional circumstances). One-to-one care of the person should be available while the dose is titrated in a controlled and safe manner.
The person should be reviewed regularly, and lorazepam discontinued as soon as possible.