Please be aware that this will be a protocol of my research.
Hypnotic Audit & Review 2014/15 X Surgery
Practice prescribing of hypnotics & benzodiazepines is measured and compared at a local (prescribing performance) and a national (QIPP indicator) level.
* Continuing concern over long term use (1)
* Taking a benzodiazepine and/or hypnotic was associated with double the risk of death from any cause compared with no prescription for these drugs. Dose-response associations were found and there were approximately 4 excess deaths linked to these drugs per 100 people followed for an average of 7.6 years after their first prescription. (2)
* Driving whilst under the influence of drugs is a significant cause of injuries and deaths on the road. (3)
* Patients are not always given appropriate information and advice on the risks associated with long term use (4):
* Tolerance & addiction
* Drowsiness, clumsiness, forgetfulness, confusion, impaired judgement
* Falls & fractures – in people older than 60 years, these drugs are associated with an increased risk of falling of between 50-70% in relative terms. (5)
* Association with increased risk of dementia and increased cancer incidence in those prescribed high doses (6)
How is usage measured? Hypnotic ADQ per STAR PU – This is a measure of the total quantity of Benzodiazepines and Z-drugs prescribed, weighted for age and sex of a practice’s population.
At the start of the project x Surgery was the 4th highest prescriber out of 50 East Berkshire practices. x Surgery Q2 (Oct-Nov 13) 2013/14 ADQ 461
What action was taken in X Surgery?
1. Practice meeting to agree course of action with all prescribers. A consistent message is vital for success and helps to prevent patients pressurising or singling out a particular GP.
2. Search – patients prescribed these drugs during April – July 2013.
* Exclusion criteria: Housebound, care/nursing home (reviewed separately by care home pharmacist & responsible GP) and palliative care patients; one off supplies e.g. for back spasm, fear of flying and for epilepsy treatment.
3. Analysis consistently shows that a simple letter intervention reduces benzodiazepine use in patients who have been using them long-term (7). Letter sent to remaining patients to:
* Explain concern over the patient’s long-term use of named hypnotic/s
* Highlight potential side effects when taken over a prolonged period.
* Ask the patient to consider a reduction in their use. – Include advice on how to gradually reduce or cease use in a manner that is feasible and will decrease the likelihood of withdrawal symptoms.
* Invite the patient to discuss the issue further with own GP or by booking into pharmacist led clinic.
4. For those receiving a letter, these drugs were moved from repeat to acute and limited to 56 days supply.
5. A 2nd short reminder letter sent to non responders 3 months after the initial letter, also informing the patient that the maximum length of supply was now 30 days in line with CD regulations (June 2014).
6. Posters advertising clinics and detailing risks of long term use put up in waiting rooms
7. Agree initiation & prescribing policy for new prescribing – support leaflet supplied
8. Full range of support leaflets and reduction schedules available in all consulting rooms.
9. Monthly pharmacist (independent prescriber) led clinics offering 20 minute appointments. Scope of practice demonstrated by Benzodiazepines learning module via MHRA Training and Continuing Professional Development (CPD) and personal CPD records.
10. Reception staff / prescription clerks’ informed.
11. Raised awareness with local community pharmacies by providing self help leaflets & posters
Main audit observations
107 patients with fall/fell in consultation, recording total of 238 falls, often leading to GP appointments, OOH/MIU/A&E attendances & hospital admissions. This included 14 fractures, 54 A&E/admitted and at least 3 road traffic accidents. There was occasional documentation of addiction & tolerance discussions.
Clinic ProtocolIdentify & address any underlying cause of insomnia, anxiety & depression
Promote non drug therapies such as sleep hygiene methods and relaxation techniques using diaries & self help leaflets.
Where complete withdrawal may not be an achievable goal there is still benefit to be gained in reducing use to the minimum effective dose. (Ref BNF).
What were the potential barriers to success?
* Not perceived to be a problem
* Cheap drugs – budget not affected
* Time & impact required
* More commonly used Z drugs are perceived to be safer than temazepam
* Patient resistance
* Limited support programmes available within mental health services
After the conclusion of the project, X surgery (Q2 2014/15) moved from 4th highest hypnotic ADQ per STAR PU prescribers to 29th out of 50 practices and below England average.
The inclusion of this prescribing performance indicator meant that all 50 practices received a consistent message regarding harms of long term use together with the offer of additional support material. A decrease can be seen by a large number of practices.
No other practice achieved the same magnitude of reduction as X surgery (as seen in Graph 1 below), who had received a higher level of support in terms of education, letters sent to patients and pharmacist led clinics over this time period. (Latest epact data available Q2 14/15)
Graph 1 – highlighting X Surgery
Medication Results: [12 month time period Oct12 – Nov13 vs Oct13 – Nov 14 (ePACT)]
The number of items dispensed decreased by 572, despite changing prescriptions to 30 days supply and thereby potentially increasing the number of items ordered.
The annual cost of hypnotic and benzodiazepine prescriptions reduced by £8,744.35, despite temazepam price fluctuations.
January 2013: Temazepam 10mg £4.23/28,
August 2013: Temazepam 10mg £27.08/28,
November 2014: Temazepam 10mg £19.77/28,
Table 1. Change in X SURGERY prescribing of hypnotics
X Surgery Previous 12 Months Current 12 Months
Chemical Substance Items Cost Items Cost
Temazepam 415 £13,186.81 205 £6,554.73
Zopiclone 1,023 £1,894.21 842 £1,232.56
Lorazepam 230 £1,096.01 209 £787.14
Oxazepam 147 £545.84 98 £238.27
Nitrazepam 93 £500.10 46 £138.81
Zolpidem Tartrate 175 £457.69 153 £279.15
Lormetazepam 6 £397.92 4 £234.14
Clonazepam 84 £239.44 44 £108.87
TOTAL 2173 £18,318.02 1601 £9,573.67
Melatonin prescribing remained stable, indicating patients had not been switched to melatonin as a non hypnotic alternative.
OUTCOMES – Benefit to individual, practice and wider public health agenda
* Keeping patients from harm by reducing exposure to side effects
* Patient in control, involved in own healthcare decisions & empowered to manage their medicines
* Prescriber education promotes consistent patient experience and raised awareness of potential serious side effects for patient and prescriber.
* Improved patient access to healthcare in convenient location with choice of provider
* Vulnerable or complex patients linked into other support agencies
* Opportunity to discuss other medication, helping patients to get the most from their medicines.
The final word – What particularly went well and what was hard?
Practice engagement over the course of the project was superb. It was well supported from the outset with the delivery of a consistent message, and patients actively encouraged to attend the pharmacist led clinic. GPs held steadfast regarding keeping supply on acute rather than repeat, at least until the patient had received the relevant support information. Initially, pressure on GPs time was high. Inevitably, this quickly decreased, but was time consuming on top of the usual high work load.
(1) NICE also confirms that there is no compelling evidence of a clinically useful difference between ‘Z drugs’ and benzodiazepine hypnotics from the point of view of their effectiveness, adverse effects, or potential for dependence or abuse. There is no evidence to suggest that if patients do not respond to one of these hypnotic drugs, they are likely to respond to another. Despite these national safety warnings and guidance, overall prescribing of hypnotics is not decreasing.
(2) BMJ 2014;348:g1996(published 19 March 2014)Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study. After an average of 7.6 years, prescription of an anxiolytic, a hypnotic or both was associated with double the risk of death from any cause compared with no prescription for these drugs, after accounting for pre-existing psychiatric disorders, other diseases and other prescribed drugs.
(3) Report of the Review of Drink and Drug Driving Law, Sir Peter North, June 2010; Some evidence suggests drug driving is a much bigger road safety and may be a factor in 200 road deaths per year. A large study of drivers prescribed sleeping tablets in the previous 7 days had double the risk of road traffic accidents compared with those who did not take them.
(4) PMID:15203405 Aging Ment Health. 2004 May;8(3):242-8.Attitudes to long-term use of benzodiazepine hypnotics by older people in general practice: findings from interviews with service users and providers.
5) Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. 2009;169(21):1952-1960. doi:10.1001/archinternmed.2009.357.
(6) BMJ 2014;349:g5205 doi: 10.1136/bmj.g5205 (Published 9 September 2014) Benzodiazepine use and risk of Alzheimer’s disease:case-control study
(7) Vicens C, Bejarano F, Sempere E, et al. Comparative efficacy of two interventions to discontinue long-term benzodiazepine use: cluster randomised controlled trial in primary care. Br J Psychiatry. 2014 Feb 13 and Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2011; DOI: 10.3399/bjgp11X593857.
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