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St Helens Primary Care Trust A PROTOCOL FOR PRESCRIBING

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					      St Helens Primary Care Trust




A PROTOCOL FOR PRESCRIBING AND
 WITHDRAWING BENZODIAZEPINES




                 A RESOURCE FOR
              GENERAL PRACTITIONERS




                        CSM ADVICE1,2
 Benzodiazepines are indicated for the short-term relief (two to four
 weeks only) for anxiety that is severe, disabling or subjecting the
 individual to unacceptable distress, occurring alone or in
 association with insomnia or short-term psychosomatic, organic or
 psychotic illness.

 The use of benzodiazepines to treat short-term ‘mild’ anxiety is
 inappropriate and unsuitable.

 Benzodiazepines should be used to treat insomnia only when it is
 severe, disabling, or subjecting the individual to extreme distress.
                                         Contents
                                                                              Page
Protocol for Benzodiazepine Prescribing for Anxiety and Insomnia in Primary    1
Care

Zopiclone, Zolpidem, Zaleplon                                                  2

Buspirone                                                                      2

Absolute Indications for use of Benzodiazepines                                3

Benzodiazepines – no effectiveness                                             3

Special Considerations – Elderly, Pregnancy & Lactation                        4

Advice on Withdrawing Benzodiazepines in Primary Care                          5

Benzodiazepine Withdrawal – equivalent doses                                   6

‘Z’ Drug Withdrawal                                                            7

Audit Information – Targeting Patients                                         8

Troubleshooting, Summary                                                       9

PCT Contact Information                                                        10

Appendices
Appendix 1 – Resources for GPs

·   Case Histories                                                             11
·   Sleep Diary                                                                14
·   Anxiety Diary                                                              15
·   Letter to a patient about the short term use of benzodiazepines            16
·   Letter to a patient encouraging withdrawal from benzodiazepines            17
·   Referral to Reduction Counsellor                                           18
·   LCS Referral Guidelines & Referral Form                                    19

Appendix 2 – Patient Information Leaflets

·   Reducing your Benzodiazepines/Advice for Patients                          25
·   Help with Sleep                                                            26
·   The Good Sleep Guide                                                       27
·   The Good Relaxation Guide                                                  28
·   Patients’ Comments                                                         29

Appendix 3 – Self Help Groups                                                  30

Appendix 4 – References                                                        33

    1
    Protocol for Benzodiazepine Prescribing for Primary Care3
q Must do
§ Should do

New prescriptions for benzodiazepines (inc. zopiclone/zolpidem/zaleplon)

q     Only use for the short-term treatment of severe anxiety or insomnia (anxiety
      maximum of 4 weeks, insomnia maximum of 10 nights). Duration should be as
      short as possible. The risk of dependence increases with dose and duration.4,5,6

q     Ensure all new prescriptions are NOT entered onto repeat prescribing systems.
      Discharge medication from hospital must NOT be repeated, unless the patient
      was previously receiving benzodiazepines.

q     Record annually that a patient receiving a prescription for a benzodiazepine has
      been advised on non-drug therapies for anxiety or insomnia. Non-drug strategies
      can be effective in the management of anxiety and insomnia and may address the
      underlying cause, rather than just relieving symptoms.7

q     Record that the patient has been given appropriate advice on the risks of
      treatment, including potential for addiction. Chronic use may lead to the
      development of physical and psychological dependence. Supplement with sleep
      guides, diaries and leaflets eg: self-help for anxiety (see Appendix 1 and 2).

q     Exclude co-existing physical/mental illness if symptoms persist.


Long term users

q     Record annually the prescribed indication and that advice has been given on non-
      drug therapies for anxiety and insomnia.

q     Document that advice has been given on the risks, including potential for
      dependence, drowsiness, falls, reduction of coping skills, promotion of sick role,
      impairment of judgement and dexterity.7,8

q     There is a statistically increased risk of involvement in a road traffic accident, due
      to impairment of driving. Cognitive impairment may be persistent and includes
      visuospatial and attention difficulties.9

q     Patients must be reviewed regularly, at least 3 monthly. Response to treatment
      should be assessed and non-drug treatment(s) re-enforced.

§    Chronic users (4-8 weeks or longer) should be identified and encouraged to
     reduce. There should be a structured programme for identifying long-term users
     along with a suitable strategy for gradual withdrawal of benzodiazepines in those
     who are suitable and agreeable to withdraw.

§    As diazepam has a long half-life with different strengths available, patients on
     benzodiazepines should be converted to an equivalent dose of diazepam before
     reducing the dose.

2
                  Zopiclone , Zolpidem and Zaleplon
All three drugs act at Benzodiazepine receptors (or sub-types) and hypnotic
dependence and loss of efficacy has been shown after a few weeks of treatment. 7
Both carry a risk of dependence and withdrawal effects, including rebound insomnia.
Hangover effects and impaired psychomotor performance similar to Temazepam and
Nitrazepam are reported with Zopiclone and Zolpidem.10 There is no significant
difference in adverse effects between benzodiazepines and Zopiclone and not enough
data to chose one over the other.10 There is no significant difference in sleep latency
between benzodiazepines and Zopiclone.10 The risk of hip fracture is as likely as with
other benzodiazepines. 8

Zopiclone has a street name ‘Zim-Zims’ indicating misuse.11

Zolpidem and Zaleplon have shorter half lives. It is 1 hour with Zaleplon. This has
potential for abuse as a ‘date rape’ drug, due to the similarity with flunitrazepam
(rohypnol) and triazolam. Further clinical experience is needed.10

Summary

§   There is no conclusive evidence that the Z drugs offer reduced abuse potential.
§   They offer no clinically significant advantages.10
§   They are up to ten times more expensive than traditional benzodiazepines and are
    not recommended as a substitute.


                                  Buspirone 4.7
There is no difference in efficacy between Buspirone and benzodiazepines. Buspirone
has a slower onset of action and is not suitable for the treatment of acute anxiety.
Compared to placebo it causes more nausea, dizziness and somnolence.9 Two weeks
treatment may be necessary before an anxiolytic effect occurs. Most patients require
between 15-30mg daily. It is considerably more expensive than other anxiolytics.




3
        Absolute Indications For Use of Benzodiazepines
As per BNF 4.1 – all indications for short-term use only i.e. no more than 2-4 weeks

HYPNOTICS
Nitrazepam          Insomnia
Loprazolam          Insomnia
Lormetazepam        Insomnia
Temazepam           Insomnia & peri-operative use


Z DRUGS
Zaleplon            Insomnia
Zolpidem            Insomnia
Zopiclone           Insomnia


ANXIOLYTICS
Diazepam         Anxiety or insomnia, adjunct alcohol withdrawal,
                 status epilepticus, febrile convulsions, muscle
                 spasm, peri-operative use.
Chlordiazepoxide Anxiety, adjunct in alcohol withdrawal
Lorazepam        Insomnia, anxiety, status epilepticus, peri-operative
Oxazepam         Anxiety


OTHERS
Buspirone           Anxiety




No Effectiveness

Clinical trials have shown no effectiveness in the following conditions.12

Tinnitus
Chronic tension headache
Essential Tremor
Menieres
Post-traumatic stress disorder




4
                          Special Considerations
Patients over 65

§    Prescribing of benzodiazepines should be avoided as the increased risk of
     becoming ataxic and confused leads to falls and injuries, in particular hip
     fractures.7,8

§    Record in notes that the patient or carer has been given advice on non-drug
     therapies for anxiety and insomnia and the risks of benzodiazepine use.

§    If prescribing is considered essential, use doses less than half of those normally
     recommended.

§    The elderly are particularly vulnerable to adverse drug reactions because of the
     declining renal function, changes to hepatic metabolism and increased sensitivity
     to certain drugs. Diazepam will therefore have a longer half life.

§    Insomnia may be due to poorly controlled arthritic pain or underlying depression,
     neither of which will benefit from sleeping pills.

§    Exercise programmes are likely to be beneficial to improve sleep quality in the
     elderly. The programme may include 16 weeks of regular, moderate intensity
     exercise, four times per week.12

§    The elderly often experience problems swallowing medicines. The following are
     available in liquid format:

                    Temazpeam elixir S/F 10mgs in 5mls
                    Diazepam elixir 2mgs in 5mls


Pregnancy and Breast Feeding

§   Benzodiazepines should generally be avoided in pregnancy and lactation.2 Non
    drug treatments are preferred. Pharmacological intervention may be required in
    severe circumstances and specialist opinion should be sought.13

§   Seek specialist opinion for the management of pregnant or breast feeding patients
    who are currently taking benzodiazepines.




5
    Advice on Withdrawing Benzodiazepines and ‘Z’ Drugs2
                                  General Advice
Patients should have joint control over the programme and be offered ADVICE,
GUIDANCE and SUPPORT.

Withdrawal of a benzodiazepine should be gradual as abrupt withdrawal can cause:

§    Confusion
§    Toxic psychosis
§    Convulsions

The benzodiazepine withdrawal syndrome may not develop until 3 weeks after stopping
a long acting benzodiazepine, but may occur within a few hours of stopping a short
acting one.

Some symptoms may continue for weeks or months after stopping the drug.

Symptoms of withdrawal syndrome include:

·   Insomnia
·   Anxiety
·   Loss of appetite
·   Loss of body weight
·   Tremor
·   Perspiration
·   Tinnitus
·   Perceptual disturbances, eg: intolerance of loud noises or bright lights, experience
    numbness or pins and needles.




6
                         Benzodiazpine Withdrawal
Please also refer to the flow-chart

A suggested protocol is as follows:-

1.   Transfer patient to an equivalent daily dose of diazepam (refer to the table below),
     preferably taken at night. Diazepam are large tablets for a small dose and are flat
     and scored.
2.   They can be split in half allowing stepwise reduction. Oral solutions are also
     available as 2mg/5ml and 5mg/5ml.
3.   Reduce the diazepam dose in fortnightly steps of 2 to 2.5mg; if withdrawal
     symptoms occur maintain this dose until symptoms improve.
4.   Reduce the dose further, if necessary in smaller fortnightly steps, it is better to
     reduce too slowly than too quickly.
5.   The speed of withdrawal may be dependent on the initial dose and duration of
     treatment.
6.   The time needed for withdrawal can vary from 4 weeks to one year or more.
7.   If there are difficulties with the withdrawal, referral to the Benzodiazepine
     Reduction Counsellor may be considered. (see appendix 1 p.18 and flow chart)
8.   Support and education is needed to help the client to achieve withdrawal and this
     can be helped by the use of counselling. Spiegel suggests that there are two
     phases in helping clients withdraw from benzodiazepine use.14

     Ø    Phase one the key task is to provide clients with education about dependence
          and withdrawal.

     Ø    Phase two the key task is to help clients deal with any negative symptoms that
          they experience as the drug is reduced.

     These symptoms may affect the client both physically and psychologically, but
     anxiety and panic are the most common symptoms experienced, here the use of
     cognitive behavioural approaches are advocated.15


      Approximate Equivalent Doses of Benzodiazepines 2
Diazepam 5mg is equivalent to

15mg        chlordiazepoxide
0.5-1mg     loprazolam
0.5mg       lorazepam
0.5-1mg     lormetazepam
5mg         nitrazepam
15mg        oxazepam
10mg        temazepam




7
                             ‘Z’ Drug Withdrawal
                             ®
    Zopiclone (Zimovane) , Zolpidem (Stilnoct)® and Zaleplon (Sonata)®
There is little information available on how to withdraw patients from these hypnotics if
they have been on them long-term.
The pharmaceutical companies which produce these drugs have no specific information
on withdrawal regimes.
In the absence of specific information, we recommend the following for patients that are
considered for withdrawal.

1. The patient IS NOT converted to diazepam. There is no dosage equivalent
   available.

2. Dosage should be withdrawn gradually on an individual patient basis.

3. Dose reductions should be made at not less than 2 week intervals.

4. If the patient suffers from withdrawal symptoms/problems maintain their current
   dose until symptoms improve. Then continue the withdrawal regime - in smaller
   steps if necessary.

An example of a withdrawal regime

A patient on zopiclone 15mg at night :

Week 1         Zopiclone 7.5mg tablets one at night AND Zopiclone 3.75mg tablet
Week 2         one at night

Week 3         Zopiclone 7.5mg tablets one at night
Week 4

Week 5         Zopiclone 3.75mg tablets one at night
Week 6

Week 7         Possibly then could have 3.75mg alternate nights
Week 8




8
                  Audit Information - Targeting patients
Where to start?
Decide on the most appropriate treatment group to start with for your practice, for
example:

§    All patients taking one particular benzodiazepine.
§    Those patients in one particular age bracket eg: 50-60.
§    Those on a long acting benzodiazepine.
§    Patients receiving other sedative agents.
§    Patients receiving high doses of temazepam (>20mg per day).
§    Young people whose dependance may impair aspects of ‘normal daily life’ eg:
     driving and operating machinery.
§    Recent chronic users.

Groups to avoid:-
§     Patients with serious mental illness.
§     Polydrug users already being seen by a drug dependency unit.
§     Elderly patients taking benzodiazepines for many years and are stable. Refer to
      Consultant Psychiatrists for the Elderly if necessary.
§     Terminally ill patients.
§     Epileptic patients requiring benzodiazepines as part of their anticonvulsant
      therapy.

Strategies for withdrawal:-
Please refer to the flow chart.

1.     Minimal Intervention
      Use of a standard letter (see Appendix 1 p.17)16
      Standard letter sent to patients identified by means of a computer search. If a
      letter is sent this should be recorded in the patient’s notes. There is evidence that
      this alone may achieve a success rate of 20-40%17

2.     A longer consultation 18
      Those patients responding to the above approach or those attending the surgery
      for some other reason may be identified and invited to attend for a review
      consultation.

3.    Non-Drug methods19
      Relaxation therapy, tapes and leaflets may help (see Appendix 2). Kava, exercise
      programmes may help as a substitute for drug treatment of insomnia.12

4.    Referral to Benzodiazepine Reduction Counsellor
      Consider referral to this service provided by Locality Counselling if you have
      attempted withdrawal and there have been difficulties with this and the patient has
      mild to moderate mental health difficulties. The patient may require further
      psychological help with the withdrawal (see Appendix 1 p18).



9
                        Other tips/Troubleshooting
§    Treat any symptoms of depression.20
§    Advise patient to avoid or reduce stimulants, eg: caffeine, alcohol.19
§    Advise patient that insomnia will pass. Plan for this and offer practical advice
     (Good Sleep Guide).
§    Teach the patient about the reflex action of adrenaline, to help understanding of
     symptoms of withdrawal. The patient will then be less afraid, leading to less
     adrenaline production and will be familiar with the reflex action.
§    Encourage the patient to use adrenaline for its purpose ie: exercise.21


                             Anxiety Summary 22
·    Anxiety may be a normal response to stressful situations, but may occur as a
     symptom of another syndrome, eg: depression.

·    Treatment is only required if the anxiety is considered to be pathological.
     Attempts to reduce the normal anxiety response may impair performance.

·    Behaviour therapy is the treatment of choice for phobias, whereas CBT is effective
     in the management of panic and generalised anxiety disorder. (See Anxiety Care
     Pathway).

·    Antidepressants are also useful adjuncts, and are significantly better than
     tranquillisers in the management of anxiety. Depressive illness is frequently
     misdiagnosed as anxiety neurosis.

·    The prevalence of anxiety disorder in general practice is second to depressive
     illness and adjustment reactions.


                            Insomnia Summary 12
·    Primary insomnia is a chronic and relapsing condition.

·    The aetiology of insomnia is uncertain. Prevalence increases with age, with an
     estimate of up to 45% in people over the age of 65.

·    Risk factors in all age groups include hyperarousal, chronic stress and daytime
     napping.




10
                                        Contacts
For further help and advice contact:-

Dr Laura Pogue, Mental Health Specialist in Primary Care
Tel No: (01744) 457317

Ms Lynn Marsden, Mental Health Co-ordinator
Tel No: (01744) 457354


Primary Care Pharmacists
St Helens North Locality

Margaret Geoghegan         Tel No: (01744) 457241
Nicola Cartwright          Tel No: (01744) 457242
Jason Farrow               Tel No: (01744) 457337
Renee Ashcroft             Tel No: (01744) 457200


St Helens South Locality

Helen Potter               Tel No: (01744) 458364
Louise Dawson              Tel No: (01744) 458295
Andrea Giles               Tel No: (01744) 458364
                           Tel No: (01744) 458295
Lesley Grimes              Tel No: (01744) 458295
Rachel MacDonald           Tel No: (01744) 458295


Newton & Haydock Locality

Nigel Cosford              Tel No: (01925) 222722
Anna Rawson                Tel No: (01925) 222722


Locality Counselling Service
The Mulberry Centre, Whiston Hospital

Dave Scott                 Tel No: (0151 430 1707)



Millennium Centre (Walk-In Centre)
Bickerstaffe Street, St Helens

Tel No: (01744) 627400




11
Case Histories
A
55 year old lady with intermittent anxiety symptoms. She has regularly taken Diazepam 2mgs
for many years. She admits to only using them infrequently.
Discussion
During the history taking establish if there are any symptoms suggestive of mild depression or
generalised anxiety disorder. Exclude physical illness such as thyrotoxicosis or an arrhythmia.
Options include:
     ·   Reduction of the amount available on each monthly script & monitoring.
     ·   Advise regarding addiction and side effects.
     ·   Self-help material on ways to cope with the symptoms, alternative methods.
     ·   Review & see if further intervention or referral is needed.


B
A 31 year old lady has been taking Temazepam 10mg for 2 years following a mild depression
associated with sleep disturbance. Her depression has resolved but she continues with the
tablets. At her annual medication review you discuss the need for further scripts.
Discussion
The patient may be concerned that she cannot do without them. Support and reinforce a
suggestion of slow withdrawal with:
     ·   Good Sleep Guide.
     ·   Documentation of your discussion and the addictive nature of the medication
         and its side effects.
     ·   Discussion of alternative methods.
     ·   Advice about withdrawal. Suggest a gradual tapered reduction.
     ·   Arrange a follow up consultation.


C
A new male patient 26 years complains of tiredness and early insomnia. He has many worries
and ‘stresses’ following moving house and starting a new job. He works long hours and finds it
difficult to ‘relax’.
Discussion
Exclude in the history how long the symptoms have been going on for. Ask about anxiety
symptoms and depression. Take a sleep history. What self-help methods has he tried?
Supportive advice and other questions include:
     · Exclude physical illness.
     · What are his caffeine levels?
     · Promote sleep hygiene and offer support with the Good Sleep Guide.
     · This is likely to be temporary, if no previous history.
     · If he has had sleep deprivation present for a few weeks, a short prescription
       of a hypnotic may help (5-7 days). Advise that it is a short course only and
       no further scripts (document!).
     · If symptoms continue, referral for relaxation therapy (to either Locality
       Counselling Service or the Community Mental Health Team for a ‘Stress Pak’)
       may be required.




12
D
A 40 year old man who has a long history of a generalised anxiety disorder (GAD). In
the past he has had psychological therapy for traumas suffered in childhood. He has
had an admission to the psychiatric unit with Depression and Anxiety in 1997. He has
received your letter suggesting reduction of medication and has come in for advice.
Currently he takes diazepam 5mgs qds. What are the options and how do you go
about it?

Discussion
MUST DO’S
·   Advise on the long-term effects.
·   Discuss dependency and addiction.
·   Advise on alternative & non-drug therapies.

OPTIONS
·   Assess current mental health. Does he require a psychiatric review/out patient
    appointment?
·   Offer a gradual reduction programme. This could entail regular appointments with
    the GP for support. Reduction should occur slowly at 2mgs per 2-week period, or
    at a slower rate eg 1mg per 2 week.
·   Support with information leaflets on possible withdrawal effects and how to cope.
·   Consider further support from counselling or psychological services for the GAD.
·   If the process fails, or if the patient decides he doesn’t wish to continue, this will
    require documenting and further reviews on a regular basis.
·   Consider referral to the Benzodiazepine Reduction Counsellor.

E
A 75 year old man has been taking 5mgs Nitrazepam a day on a regular basis for at
least 30 years. He is worried that from your letter you will stop this medication. He has
no problems and this keeps his ‘nerves’ at bay. He feels rotten if he doesn’t take it.
What are the options here?

Discussion
MUST DO’S
·   Advise on the long term effects.
·   Discuss dependency and addiction.
·   Advice on alternative and non-drug therapies (can include here switching the
    nitrazepam to diazepam, which is considered safer).

SHOULD DO
·  Advise on particular risks for the elderly: cognitive problems, risk of falls.
·  Encourage to reduce.

OPTIONS
·   If the patient agrees to a reduction, switch to 5mgs diazepam and then taper and
    reduce as above.
·   It is often considered reasonable practice for the stable, elderly patient on low
    doses of hypnotics or benzodiazepines to continue on them, as long as they are
    monitored and reviewed.




13
F
A 17 year old girl arrives in your surgery late Friday evening demanding an urgent
appointment. She says that her Auntie is ill in hospital with cancer and she has come
to visit. She is requesting some dihydrocodeine for her back pain and some sleeping
pills, because she is unable sleep due to the worry. She cannot remember the name of
her GP, but says that her GP is marvellous and always gives her sleepers (but can’t
remember the name). It is 6.00 pm and the patient appears agitated and continues to
embellish the ‘story’. What do you do?

·    Attempt to contact patient’s GP, if known, to clarify the situation.
·    You are not duty bound to do what another doctor does.
·    Suggest that you would want to speak to the patient’s doctor before prescribing
     such medication and that this is the ‘practice policy’.
·    Advise that in the short term you are willing to prescribe simple analgesics only.
·    If the patient becomes threatening, explain that your practice doesn’t tolerate such
     behaviour and that you are not responsible for their actions.
·    If you feel it is appropriate to prescribe hypnotics eg: if you were able to contact
     GP then do daily prescriptions for small amounts (temazepam 10mg at night for
     three nights only – Friday, Saturday and Sunday).




14
15
16
    Dear

    You have been prescribed …………………………………………………..,, one
    of a group of medicines known as the benzodiazepines. This medicine can
    help you cope with a short period of severe stress; it is not intended for
    long-term treatment and can be habit forming.

    If you are being treated for sleeplessness you will be given tablets for up to 10
    nights only. Treatment for longer often makes sleep difficulties worse and may
    even make it difficult to stop the drug, so please do not ask for further supplies
    when these run out. Try to do without a sleeping tablet 1, 2 or 3 nights a week.
    Avoid drinks such as coffee, tea and cola after 3.00 pm; these contain caffeine,
    which can keep you awake. Avoid late-night exercise and mental stimulation.

    If you are being treated for anxiety you will be given a supply of medicine for a
    short period.

    Avoid alcoholic drinks when taking a benzodiazepine, particularly when first
    starting treatment.

    Do not drive or operate machinery while under the effects of these drugs.

    Yours sincerely




    Dr ………………….




Taken from the report of the Scottish National Medical Advisory Committee on the management of anxiety and
insomnia. This may be adapted, and/or reproduced for local use, and are not bound by copyright. You might,
for example, wish to keep a master copy on a word-processor and fill in the appropriate details as required.




    17
     Dear

     I am writing to you because I note from our records that you have been
     taking ……………………………………….. for some time now. Recently,
     family doctors have become concerned about this kind of tranquillising
     medication when it is taken over long periods. Our concern is that the
     body can get used to these tablets so that they no longer work properly. If
     you stop taking the tablets suddenly, you may experience unpleasant
     withdrawal effects. For these reasons, repeated use of the tablets over a
     long time is no longer recommended. More importantly, these tablets may
     actually cause anxiety and sleeplessness and they can be addictive.

     I am writing to ask you to consider cutting down on your dose of these tablets
     and perhaps stopping them at some time in the future. The best way to do this is
     to take the tablets only when you feel they are absolutely necessary. In this way
     you might be able to make a prescription last longer.

     Once you have begun to cut down, you might be able to think about stopping
     them altogether. It would be best to cut down very gradually and then you will be
     less likely to have withdrawal symptoms.

     If you would like to talk to me personally about this, I would be delighted to see
     you in the surgery whenever it is convenient for you to attend.

     Yours sincerely




     Dr ………………….




Taken from the report of the Scottish National Medical Advisory Committee on the management of anxiety and
insomnia. This may be adapted, and/or reproduced for local use, and are not bound by copyright. You might,
for example, wish to keep a master copy on a word-processor and fill in the appropriate details as required.




     18
                                   St Helens and Knowsley Hospitals
                                   NHS Trust
                                                                                      NHS
Our Ref:      SS/                  LOCALITY COUNSELLING SERVICE
Your Ref:
                                   The Mulberry Centre
                                   Whiston Hospital
When telephoning please ask for:   Sandra Stock                               Prescot, Merseyside
Direct telephone line:             0151 430 1707                                         L35 5DR
                                                                               Tel: 0151 430 1707
email address:                                                                Fax: 0151 430 1397



      01.07.03


      The Locality Counselling Service (LCS) has provided counselling since 1998, for the
      clients, of Central and South Knowsley, who experience common mental health
      problems.

      The LCS has now developed its service for this group of clients, to include, a
      Benzodiazepines reduction clinic, with close liaison with primary care and the GP,
      which follows the identified protocol.

      Referrals in relation to the reduction programme will be sent to the LCS, which has its
      central base at the Mulberry centre, Whiston. Please state on the form that you have
      seen your client and they are willing to discuss or participate in the reduction
      programme.

      The current LCS referral form will still be used, which already has a place identifying
      client’s prescribed medication. It is necessary to state hear clearly the name and
      dosage of the prescribed medication, also the planned reduction so far.

      We have two sessions allocated for the GPs of St.Helens (which are also being shared
      with 3 practices in Newton le Willows) this is provided by an experienced counsellor
      (Dave Scott). The work will include 1.1 assessment, 1.1 counselling, relaxation and
      stress management, and education re healthy life styles.

      This work will be provided from the Millennium Centre (01744 627400) on a
      Wednesday, in which the GP can liaise with the counsellor and discuss any referral
      about to be referred to the programme.

      The model of therapy used will have a Cognitive Behavioural Approach, which is
      supported by research and the outcomes and data analysis will be collected and
      reported on at regular intervals to the Primary Care Trust.


      Sandra Stock
      Operational Co-ordinator
      Locality Counselling Service




      19
Created 16.12.97                    Policy no - 3




                            Locality Counselling Service

                  Guidelines for making referrals to the service

· The Service will accept referrals of all patients of GPs attached to one of the four
  localities, Central and South Knowsley, St Helens North and St Helens South.

· The remit for referral to the Locality Counselling Service is for those clients who have
  mild to moderate mental health problems and therefore are more likely to respond
  to briefer intervention by a single practitioner.

· The problems covered by the service include the following:

     -   Mild to moderate anxiety and stress reactions
     -   Stress related physical conditions
     -   The acute effects of psychological and physical trauma, not complex
     -   Mild to moderate reactive depression
     -   Difficulty coping with life events
     -   Relationship problems which are recent in origin
     -   Grief reaction
     -   Low self esteem

The service is available to patients of age 16 years plus.

· Referrals should be made using the special referral pack provided comprising a GP
  referral form, a patient confirmation form, a reply-paid envelope and a client
  information booklet.

· When it has been agreed with your patient to refer him/her to the service, an
  information booklet, confirmation form and pre-addressed envelope should be
  supplied for the patient to fill in and send direct to our service. An appointment is
  sent to the patient as soon as we receive your referral and the confirmation form.
  This system aims to cut down on failures to keep initial appointments by ensuring
  that patients understand the nature of counselling and wish to use the service.
  Appointment letter states, that missed appointments with no contact to the service
  within 48 hours, results in the client being discharged from the service.

· The confirmation forms also provide us with essential information about a patient’s
  preferences e.g. gender of counsellor, times available for appointments and mode of
  transport available and whether the patient is happy for us to phone him or her at
  home.



20
· Please use the referral forms provided rather than standard GP forms or letters - this
  will avoid delay by ensuring that your referral does not get passed to the CMHT in
  error and also enables the clients needs to be assessed more fully at the screening
  process, by the Operational Co-ordinator.

     Information on the referral form should include, (within the appropriate section
     provided):

     -   A brief description of reason for referral to counselling.
     -   Any risk issues, (those clients who pose a moderate to severe degree of risk
         should be referred to the CMHT and not the LCS.
     -   Any other health/care workers who may be involved with the patient
     -   Any relevant medication

· Please send the referral direct to the Locality Counselling Service, based at the
  Mulberry Centre, Whiston Hospital. Please do not send referrals to the Community
  Mental Health Teams or the medical records department.

· Length of wait times varries, dependant on the Counsellors through put, rate of
  referrals, DNA rate. All efforts are made by the service to keep wait times down and
  these are constantly monitored.

· A copy of the assessment report by the counsellor will be sent within two weeks of
  the initial appointment. You will also be informed when the case is closed.

· Please address any queries or concerns related to the counselling service to:

Sandra Stock Operational Co-Ordinator, Locality Counselling Service or John
Traverse, Manager, Psychological Therapies Service, The Mulberry Centre,
Whiston Hospital. Tel: 0151 430 1707/1321.




sc/ c:\my documents\sandra\gp guidelines 5.01.01/Created: Reviewed: 06.12.02:
Expires 06.12.




21
                             Locality Counselling Service
                                The Mulberry Centre
                              Whiston Hospital
                                        Prescot
                                       Merseyside
                                        L35 5DR

                                GP Referral Form
In order for the service to assess accurately the needs of clients and to process the
referral more quickly please provide as much information as possible.
Thank you (PLEASE PRINT CLEARLY)

Clients Name…………………………………….. Male / Female

Address      ……………………………………………
             ………..…………………………………..

DOB          …………………………………………….

Telephone ……………….……………………………

GP Name   ….…………………………………………
Telephone ………….…………………………………

Practice     ………………………………………………………
             ………………………………………………………

Date ………………………………                         Signature ……………………………

i.    REASON FOR REFERRAL:
ii.   Please give brief history and state the length of time the client has experienced this
      problem. (If the referral is urgent please consider risk element and make referral to
      CMHT)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

22
Is the client's daily living affected ?     YES     r           NO    r
Comment……………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Risk Factors ( Please Tick )

To self             r               Loss of carer                        r
To others           r               Disabilities                         r
Suicidal ideas      r                Homeless or risk of losing home     r
Self Neglect        r
Comment………………………………………………………………………………

…………………………………………………………………………………………

  ii.     Has the client been given a patient confirmation letter to return to the
          Locality Counselling Service ?

  YES     r      NO   r


  Has the client been referred to any other service ?
  YES r       NO    r
  If the answer is yes please state which one
  …………………………………………………………………………………..
  …………………………………………………………………………………




23
 Current Medication

 Anti-depressants   r
 Benzodiazapines    r
 Any other medication? ……………………………………………………….

 How long has the medication been prescribed ?

 .……………………………………………………………………………………




24
                                       Locality Counselling Service
                                             Client Confirmation Letter
                                                                                                       The Mulberry Centre
                                                                                                  Whiston Hospital
                                                                                                                            Prescot
                                                                                                  Merseyside               L35 5DR

My doctor has referred me to the Counselling Service for help. I confirm that I have
read the explanatory booklet and that I do / do not * wish to be seen for counselling.
(* Please delete as appropriate).

Name:................................................................................................................

Date of Birth:                .........................................................       Gender: Male/Female*

Address:            …….......................................................................................................
                    ...............................................................................................................

Postcode:           …………....................................

Day Tel: ...........................................................
(Please tick boxes as appropriate)
I am happy to be contacted by telephone                                                          Yes r                 Nor
I would prefer to be seen                                     day r eveningr
(Evening appointments are limited so you may have to wait longer for your
appointment. Please choose this option only if you really need to).

Please state any days or times that you cannot
attend……………………………………….
I would prefer to be seen by a:                                          Male counsellor                             r
                                                                         Female counsellor                           r
                                               Either                                                                r
Do you have any disabilities that we need to consider when allocating your
appointment? e.g., you may be unable to climb stairs.
…………………………………………………………………………………………………

How will you be travelling                 by public transport                      r by car r                or walking r

Are you currently being seen by any other counsellor / therapist or any other support
worker (if yes please state name………………                                              Yes       r            No     r
Signed ....................................................... Date ....................................

Please sign this letter and return it to the Mulberry Centre in the reply-paid envelope
provided. If you have any queries please telephone 0151 430 1707. Thank you.

25
                  Reducing your Benzodiazepines

                                ADVICE FOR PATIENTS


What are benzodiazepines?

Benzodiazepines are drugs that can reduce anxiety and help sleep problems. They
should only be used for very short periods in patients with severe symptoms.

What are the effects?
Short term:

Ø     Reduced alertness.
Ø     Drowsiness. This may effect your ability to drive or operate machinery.
Ø     Reduced tension and anxiety.

Long term:

Ø     Dependence on the drug.
Ø     Reduced alertness may lead to accidents or falls.
Ø     Poorer memory.
Ø     Lack of emotion.
Ø     Tasks take longer to complete.
Ø     The short-term effects continue.

What may happen when the drug is withdrawn?
Ø     Your muscles may ache and strange sensations may be felt on the skin.
Ø     You may feel restless and anxious.
Ø     You may feel sick and weight loss may occur.
Ø     You may sweat more than normal.
Ø     You may have difficulty sleeping.
Ø     You may feel more frightened or panicky. At first you can have a reduced ability
      to cope with stress.
Ø     Eventually your anxiety will disappear and you will become more assertive.

Why does this happen?
Benzodiazepines in the brain block your emotional responses. When you reduce the
drug, your brain becomes over-stimulated again. This can magnify your feelings and
senses.

    This is why your doctor will very slowly reduce your medication to
    ease the withdrawal process. Hopefully these side effects will be
                           kept to a minimum



26
                                                           St Helens
                                                        Primary Care Trust




Information for carers

·    Older people need less sleep at night, particularly if they doze during the day

·    It is important to have a set time for getting up. The time for going to bed can be
     more flexible

·    It is normal for older people to awaken several times during the night. This isn’t
     harmful. Being awake does not necessarily mean that the individual is distressed.
     Resting in bed can be as good as sleeping.

·    A good night’s sleep may follow a sleepless night, without the need to resort to a
     sleeping pill.

· Physical symptoms, especially pain, which disturb sleep should be treated in their
     own right.

·    The doctor should be alerted to symptoms of depression or anxiety.

·    A range of activities should be encouraged in order to have an interest and
     alertness in life.

·    Sleeping pills are addictive. They should only be used for a few days when they
     are really needed.

·    Sleeping pills can have ‘hangover’ effects the next day causing difficulty with
     concentration, dizziness, drowsiness and falls.

·    As a carer, you should feel able to discuss your own feelings with the doctor. You
     are entitled to periods of respite care to enable you to have a much needed break!




27
                                                             St Helens
                                                           Primary Care Trust




            The following tips should help you get into a good sleep pattern


               1.    Put the day to rest. Tie up loose ends in your mind.
                     A notebook may help.
               2.    Take some light exercise in the early evening.
During         3.    Wind down in the course of the evening. Try and avoid
  the                anything mentally demanding within 90 minutes of bedtime.
Evening        4.    Don’t sleep or doze on the sofa.
               5.    Avoid drinks such as coffee/tea/cola after 6pm. These
                     contain caffeine and can keep you awake.
               6.    Make your bedroom comfortable. Not too cold or hot.

                       .
                1.   Go to bed when you are “sleepy tired”.
                2.   Do not watch TV in bed.                                           At
                3.   Set the alarm for the same time every day until your sleep      Bedtime
                     pattern settles down.
                4.   Put the lights out when you get into bed.
                5.   Try a relaxing drink such as camomile, horlicks or ovaltine.
                6.   Enjoy relaxing even if at first you don’t fall asleep.


                1. Sleep problems are common and not as damaging as you
                   might think.
  If you        2. If you are awake for more than 20 minutes then get up and
   have            go into another room.
Problems        3. Do something relaxing and don’t worry about tomorrow.
                   People usually cope quite well after a restless night. Try
                   reading something like Hello or OK! Magazine.
                4. Go back to bed when you are “sleepy tired”.
                5. Remember the tips from the above section.
                6. A good sleep pattern may take a number of weeks to
                   establish. If you have had problems for years then it will
                   take longer. Be confident that you will get there in the end!

     This guide was prepared with help from Dr Colin Espie who is an international authority
                           on sleep problems and their treatment.



     28
                                                                                 St Helens
                                                                               Primary Care Trust




                The following tips should help towards better relaxation

                       1.    Value times of relaxation. Think of them as essentials not extras. Give
                             relaxation some of your best time not just what’s left over.
Dealing                2.    Build relaxing things into your lifestyle every day and take your time. Don’t
  with                       rush. Don’t try too hard.
Physical               3.    Learn a relaxation routine, but don’t expect to learn without practice.
Tension                4.    There are many relaxation routines available, especially on audio tape.
                             These may help you to reduce muscle tension and to learn how to use
                             your breathing to help you relax.
                       5.    Tension can show in many ways – aches, stiffness, heart racing,
                             perspiration, stomach churning etc. Don’t be worried about this.
                       6.    Keep fit. Physical exercise, such as a regular brisk walk or a swim, can
                             help to relieve tension.

                       1.    Accept that worry can be normal and that it can be useful. Some people
                             worry more than others but everyone worries sometimes.
                       2.    Write down your concerns. Decide which ones are more important by
                             rating each of them out of ten.                                                 Dealing
                       3.    Work out a plan of action for each problem.                                      With
                       4.    Share your worries. Your friends or your general practitioner can give you       Worry
                             helpful advice.
                       5.    Doing crosswords, reading, taking up a hobby or an interest can all keep
                             your mind active and positive. You can block out worrying thoughts by
                             mentally repeating a comforting phrase.
                       6.    Practice enjoying quiet moments, eg sitting, listening to relaxing music.
                             Allow your mind to wander and try to picture yourself in pleasant,
                             enjoyable situations.

                       1.  Try to build up your confidence. Try not to avoid circumstances where you
                           feel more anxious. A step by step approach is best to help you face things
  Dealing
                           and places which make you feel tense. Regular practice will help you
    with                   overcome your anxiety.
  Difficult           2.   Make a written plan and decide how you are going to deal with difficult
Situations                 situations.
                      3.   Reward yourself for your successes.          Tell others.     We all need
                           encouragement.
                      4.   Your symptoms may return as you face up to difficult situations. Keep
                           trying and they should become less troublesome as your confidence grows.
                      5.    Everyone has good days and bad days. Expect to have more good days as
                            time goes on.
                      6.    Try to put together a programme based on all elements in ‘The Good
                            Relaxation Guide’ that will meet the needs of your particular situation.
                            Remember that expert guidance and advice is available if you need further
                            help.
         This guide was prepared with help from Dr Colin Espie who is an international authority on sleep problems
                                                   and their treatment




           29
                              Patients’ Comments
Withdrawal Effects
“Whenever I tried to cut out or reduce the dosage completely, I became extremely
anxious, had hot sweats, was very irritable and couldn’t sleep or relax. I then went
back on medication.”


Effects following a gradual withdrawal schedule
“I do not feel as drugged up and am much more alert in the mornings.”

“Mentally and physically I feel much better. My temperament is much better, before I
felt edgy and moody in the mornings.”

“I am learning to overcome a few poor nights sleep. I find by having a positive attitude I
am able to settle back into a good sleeping pattern without being obsessed with sleep.”


Comments on short term prescribing & preventing chronic usage
“My previous medication (Nitrazepam) which I initially took for a sleep disorder,
became a quick fix……was masking anxiousness or other problems that came along,
and unfortunately became an addiction”

“ I am grateful to leave behind a dark cloud”

“As a long term user my memory is very poor. Before it was excellent.”

“I get hyperactive rather than drowsy.”

“ In a stressful situation I still get sweaty tense and have a panic attack.”

“My sleep pattern hasn’t improved. It takes a few hours before I sleep.”

“ I can honestly say that there has been no improvement in sleep pattern for 12 years.”




30
                         SELF HELP GROUPS
Anxiety, Panic & Phobias

No Panic (local groups)
93 Brands Farm Way, Telford, TF3 2JQ.

Information Line:   0800 783 1531        10.00 am to 10.00 pm

Helpline, information booklets and local self-help groups for people with anxiety,
phobias, obsessions, panic.


MIND
15-19 Broadway, London, E15 4BQ.

Helpline:           02085192122          9.15 am to 5.15 pm

Information, literature and follow-on contact numbers (as required), given to people with
anxiety, depression, post-natal depression, stress, stress at work, emotional problems,
drug related mental health problems.


Triumph Over Phobia (TOP UK) (local groups)
PO Box 1831, Bath, BA2 4YW.

Office:             01225 330353

Structured self-help groups for those suffering from phobias or obsessive compulsive
disorder. Each group has a volunteer leader and four or five supporters. Average
recovery rate is five months.




31
Drug Dependence

Narcotics Anonymous
0207 730 0009


National Drugs Helpline
Health Wise Help Line Ltd, 85-89 Duke Street, Liverpool, L1 5AP.
(formerly 1st Floor, Cavern Court, 8 Mathew Street, Liverpool, L2 6RE).

Helpline:                 0800 776600 – 24 hours a day, 7 days a week
For foreign speakers:     0800 9176650
                          6.00 pm to 10.00 pm, Monday to Friday

General overall advice, information and support for drug users and concerned family
members, friends etc of drug users. Literature of all ranges available as required.


Release
388 Old Street, London, EC1V 9LT.

Helpline:                 02077299904
                          10.00 am to 10.00 pm Monday to Friday
                          8.00 am to 12.00 midnight at weekends

General and legal advice given to drug users and concerned family members, friends
etc of drug users. Leaflets available as required.




32
Bereavement

Cruse Bereavement Care (local groups)
126 Sheen Road, Richmond, Surrey, TW9 1UR.

                     02089404818
National Helpline:   0245585565

Help for bereaved people and those caring for bereaved people.


Foundation for the Study of Infant Deaths (FSID) (local groups)
14 Halkin Street, London, SW1X 7DP.

Helpline:            02072332090 – 24 hours
Enquiries:           02072350965

National helpline, local parent groups and befrienders.


Still Birth and Neonatal Death Society (SANDS)
28 Portland Place, London, W1N 4DE.

                     02074365881
Administration:      02074367940

Support for parents whose baby is stillborn or dies within 28 days of birth.


Compassionate Friends
53 North Street, Bristol, BS3 1EN.

Helpline:            0117 953 9639 – 9.30 am to 5.00 pm

National organisation of bereaved parents offering friendship and understanding to
other bereaved parents.




33
                                      References
1.   Anon. Benzodiazepines, dependence and withdrawal symptoms. CSM Current Problems
     1988 No 21.

2.   British National Formulary (Number 42) London. The Pharmaceutical Press. September
     2001.

3.   Adapted from, Shaw E, Baker R. Audit protocol: Benzodiazepine prescribing in primary
     care. Journal Clinical Governance 2001 (9): 45-50.

4.   Bazire S. Psychotropic Drug Directory 2001/2002.

5.   Ashton HC, Report to Health Committee of House of Commons 1999.

6.   Committee Safety of Medicines, Report by Royal College Physicians 1998.

7.   Clinical Evidence BMJ Publishing Group (4): 503-506.

8.   Wang PS, Bohn RL, Glyn RJ American Journal Psychiatry 2001 (158) 88-89.

9.   National Prescribing Centre NHS, October 2001.

10. Zopiclone and Zolpidem. MeReC Bulletin 1995; Vol 6, No 11: 41-44.

11. Clee WB, McBride AJ, Sullivan G, Addiction 1996. ‘1389-90’.

12. Clinical Evidence BMJ Publishing Group 2003 (9): 110, 269, 267, 102, 211, 362.

13. Anne Lee, Sally Inch & David Finnigan.       Therapeutics in Pregnancy and Lactation.
    Radcliffe Medical Press, 2000.

14. Speigal D. Psychological Strategies for Discontinuing benzodiazepine treatment. Journal
    of Clinical Psychopharmacology. 1999. Vol 19.6

15. Otto et al. Discontinuation of Benzodiazepines – CBT. American Journal of Psychiatry
    1993. 1485-1490.

16. Management of Anxiety and Insomnia. MeReC Bulletin 1995; Vol 6, No 10: 37-40.

17. Educating patients reduces benzodiazepine prescribing costs. Primary Care Pharmacy
    June 2001 (2): 56.

18. Cormack MA, Sweeney KG, Hughes-Jones H, Foot GA. Evaluation of an easy, cost
    effective strategy for cutting benzodiazepine use in General Practice. British Journal
    General Practice 1994 (44): 5-8.

19. WHO Guide to Mental Health in Primary Care. The Royal Society of Medicine Press
    Limited. 2000.

20. Martinez-Cano H Addiction 1999 Jan 94 (1): 97-107.

21. Withdrawal Protocol.   Council for Involuntary Tranquiliser Addiction (CITA) Information
    Pack. January 2001.

22. Patricia Casey. A Guide to Psychiatry in Primary Care. Wrightson Biomedical Publishing
    Limited 1997.


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