The misuse of benzodiazepines continues to be a significant issue in Irish society and doctors must accept their role in this problem, June Shannon reports
In 2002 a report compiled by the Benzodiazepine Committee found that over one in 10 GMS patients was being prescribed benzodiazepines. The prescribing and misuse of these drugs were, according to the report, “significant health issues in Ireland”.
Almost a decade later, figures suggest that prescribing frequency, use and deaths from benzodiazepine abuse have increased in Ireland.
Just last week the Minister of State Roisín Shortall announced a new initiative to tackle overprescribing of the drugs.
Benzodiazepines are one of the most commonly prescribed medications in the world. While generally considered safe and effective for short-term use in the treatment of anxiety, insomnia and seizures, the risk of overuse, abuse and dependence remains a key concern.
There are also concerns regarding the overprescribing of these drugs. According to a recent report in the Irish Examiner, figures from the Primary Care Reimbursement Service (PCRS) show the prescribing of one particular brand of benzodiazepine has increased from 283,000 prescriptions in 2005 to 382,921 in 2008.
In 2006/7 a national survey on drug prevalence examined the use of sedatives and tranquillisers in those aged between 15 and 64 in Ireland. More than one in 10 (11 per cent) of those surveyed reported having used such drugs at some point in their lives. Use was reported by a higher proportion of older adults (15 per cent) than young adults (6 per cent), and by a higher proportion of females (13 per cent) than males (8 per cent). The average age at first use was 29 years for men and 31 for women. This survey also found that well over half (57 per cent) of current users – those who had used sedatives or tranquillisers in the previous month – had taken them on a daily basis.
According to the latest statistics from the Health Research Board (HRB), there has been an increase in numbers seeking treatment for, or dying from benzodiazepine misuse in Ireland.
Published in December 2010, the HRB Trends Series 9 entitled Problem benzodiazepine use in Ireland: Treatment (2003 to 2008) and deaths (1998 to 2007), found that the annual number of cases treated for problem benzodiazepine use increased by more than 63 per cent from 1,054 in 2003 to 1,719 in 2008.
The HRB report includes data on treated problem benzodiazepine use recorded by the National Drug Treatment Reporting System (NDTRS) and poisoning deaths where a benzodiazepine was implicated as recorded by the National Drug-Related Deaths Index (NDRDI). While the number of treated cases who reported a benzodiazepine as their main problem substance was relatively small, it increased by 120 per cent, from 76 in 2003 to 167 in 2008.
The HRB report also found that the number of individuals who reported a benzodiazepine as an additional problem substance was much larger, increasing from 982 in 2003 to 1,562 in 2008.
According to the HRB, the majority of cases (78 per cent), treated for a benzodiazepine as their main problem substance also reported the use of more than one additional substance. Alcohol was the most common additional problem substance, reported by 52 per cent of cases, followed by cannabis at 43 per cent, and opiates at 40 per cent.
Meanwhile, the other main problem substances reported where a benzodiazepine was the additional substance were opiates (80 per cent), alcohol (9 per cent), cannabis (5 per cent), and cocaine (5 per cent).
The vast majority of those treated (98 per cent) reported taking benzodiazepines orally. While less than 1 per cent reported injecting the drug, the HRB noted that this may be an under-estimation as the NDTRS data only records one route of administration. Furthermore, the majority of cases (64 per cent) reported using benzodiazepines on a daily basis.
Benzodiazepines were implicated in nearly one-third of all deaths by drug poisoning between 1998 and 2007, with the annual number of deaths, rising from 65 in 1998 to 88 in 2007.
The additional substances most frequently involved in poisoning deaths where a benzodiazepine was implicated were alcohol (41 per cent) and methadone (36 per cent).
The report also found that twice as many men as women died as a result of misusing benzodiazepines and other substances between 1998 and 2007. While the proportion of male deaths was highest in the younger age groups, the number of female deaths was highest in women over 40 (54 per cent), compared to just over a quarter (27 per cent) of male deaths.
According to Dr Suzi Lyons, Senior Researcher at the HRB and one of the authors of the paper, the increase in numbers seeking treatment for, or dying as a result of, sedative misuse may reflect a combination of factors. These include: an increase in benzodiazepine use in the population, an increase in the number of available treatment places, or an increase in the number of treatment centres reporting to the HRB NDTRS.
Speaking at the launch of the report Dr Lyons said: While they [benzodiaepines] are considered safe for short-term use, the risk of overuse, abuse and dependence is well documented. Prescribers and users need to be more aware of the potentially fatal effects of benzodiazepines when they are used with other substances”.
The HRB report concluded that identifying and controlling possible illicit sources of benzodiazepines is also necessary, but it is equally important to revisit the good practice and prescribing guidelines for doctors.”
While the HRB report was published just last year, currently the only official Irish prescribing guidelines for benzodiazepines available to doctors are contained in a report that is now almost 10 years old.
In 2000, the then Minister for Health Micheál Martin, established the Benzodiazepine Committee charged with examining the current prescribing and use of benzodiazepines. The Committee was charged with considering recommendations on good prescribing and dispensing practice, paying particular attention to the management of drug misusers; and was asked to make recommendations as appropriate.
The Committee published its report in 2002 and made a total of 24 recommendations. It also published a prescribing guide for doctors entitled Good Practice Guidelines on Benzodiazepines for Clinicians.
One of the report’s main recommendations was that the guidelines be “disseminated to all practitioners including hospital practitioners and implemented in full. Where possible, alternative therapies to the prescribing of benzodiazepines should be considered by clinicians.”
“With regard to good practice, the Committee recommends that clinicians adhere to the Good Practice Guidelines on Benzodiazepines for Clinicians with particular emphasis on the following: practitioners should critically and urgently review their current level of benzodiazepine prescribing and in many cases this should lead to considerable reduction; prescribing benzodiazepines to opioid users (and other drug users) should be seen as an exceptional rather than a routine clinical decision; patients dependent on opioids should be advised that the concurrent taking of benzodiazepines can greatly increase the risk of overdose. This message should be conveyed as a matter of routine by all those who have contact with drug misusers,” the report read.
As part of its work the Benzodiazepine Committee also carried out a number of unique research studies in an effort to determine the prevalence of benzodiazepine use in Ireland. Based on data from the GMS, the first study looked at benzodiazepine use throughout the country, a second examined benzodiazepine use in the GMS population within the Eastern Regional Health Authority area, while a third analysed the use and prescribing of benzodiazepines in the drug misusing population.
The Committee’s report concluded that the studies “suggest that benzodiazepine prescribing and misuse of these drugs, particularly amongst the drug misusing population, are significant health issues in Ireland, with approximately one in 10 persons in the GMS population being prescribed these drugs. Diazepam is the drug preferentially misused and is the most widely prescribed in the medical card services scheme.”
The HRB figures quoted above, coupled with the latest data from the National Drug Treatment Centre, suggest that problem benzodiazepine use in Ireland remains a serious problem and one that continues to rise.
According to the National Drug Treatment Centre (NDTC), the number of benzodiazepine positive samples detected in the centre’s laboratory has increased over recent years.
Dr John O’ Connor, Clinical Director of the NDTC said that over the past number of years he has expressed “grave concern regarding the level of abuse of benzodiazepines.”
Prof Colin Bradley, Professor of General Practice at UCC, was a member of the 2002 Benzodiazepine Committee.
Speaking to the Medical Independent Prof Bradley said that the overprescribing of benzodiazepines continues to be a concern and that there has been a lack of attention to the issue since the Benzodiazepine Committee published its report. He also added that the issue seems to have slipped down the list of priorities for the health service.
According to the UCC professor, the only area where the issue has had any real attention has been in the number of complaints relating to benzodiazepine prescribing reported to the Medical Council and the subsequent Fitness to Practise inquiries. Prof Bradley said that this is “better than nothing” but he said that this attention proves that the issue is still a problem about which a lot more could be done.
Latest figures from the Medical Council reveal that it received 22 complaints regarding alcohol, drug abuse and irresponsible prescribing in 2008, eight in 2009 and 10 in 2010.
In its report, the Benzodiazepine Committee acknowledged concerns expressed at the time by the ICGP in relation to the implementation of the Good Practice Guidelines on Benzodiazepines for Clinicians. While the College welcomed the guidelines, it pointed to “the lack of supports such as psychologists, nurses, counsellors etc as being a barrier to their full implementation”.
In response to these concerns the Committee stated: “The Primary Healthcare Strategy which was published by the Minister for Health and Children in November 2001 recognises the need for the appointment of a range of community-based support services to support primary care practitioners”.
While the Committee was cognisant of the fact that it would “take time for these supports to come on stream”, it perhaps did not envisage just how slow the full implementation of the Primary Care Strategy would be or indeed that 10 years after its publication many of the Strategy’s recommendations in relation to psychological supports have yet to be put in force.
Prof Bradley said one of the issues is that some GPs may not necessarily view benzodiazepine addiction as a major problem compared to opiate or even alcohol addiction and that those who do can find it difficult to access support services or get prioritisation for their patients.
The Professor feels Ireland has made less progress on the issue of benzodiazepine prescribing than other comparable countries such as the UK, where the prescribing of these drugs in general practice has been substantially reduced.
He added that failing to address the issue of benzodiazepine overprescribing may also be contributing to other problems in the health service, including an increased risk of falls and fractures among the elderly population.
The Minister of State with responsibility for Primary Care Ms Roisín Shorthall last week announced her intention to introduce an initiative to tackle the issue of overprescribing of benzodiazepines in Ireland.
Speaking at the launch of a report responding to benzodiazepine use in Ballymun, Minister Shorthall said “addressing the issues associated with benzodiazepines as problem substances is a priority for me and I am currently developing proposals under the Misuse of Drugs legislation to introduce stricter controls on benzodiazepines”.
“We need to take a closer look at prescribing patterns for benzodiazepines in order to identify those areas that are out of line with best practice and I have asked the HSE to look at this and report back to me. I am hopeful that this work will get under way in the coming months and that it will have an impact on consumption levels of benzodiazepines in Ireland, which are unacceptably high.”
Speaking to the Medical Independent Minister Shorthall said that she has asked the HSE to draft a proposal on the development of the initiative, which would include compiling up to date information on prescribing habits. This data may be collated by a small group of experts who would examine information from the GMS and DPS schemes, she said.
The report responding to benzodiazepine use in Ballymun outlined the operation and development of the GP-Community Partnership Addiction Project over its first three years of implementation (September 2006-September 2009). The Project is managed by the Ballymun Family Practice and funded by the Ballymun Local Drugs Taskforce.
The main aim is to develop services for patients with benzodiazepine problems that present in primary care. The model proposed was that GPs in the practice would be supported by an addiction counsellor who would be integrated into each practice. A total of 124 patients of the Ballymun Family Practice attended the addiction counselling service during the period January 2007 to December 2010.
The report found that an addiction counselling service is an effective strategy to complement existing general practitioner practices and recommended that the delivery of a counselling service be considered as a model for future pilot projects
The project evolved from one that primarily envisaged meeting the needs of clients with a benzodiazepine addiction to one that now also has the ability to address any other addiction issues that may present.
At the launch the Minister said: “this report and the recent Health Research Board report on problem benzodiazepine use in Ireland both highlight the increase in cases of benzodiazepines as problem substances and the need to address benzodiazepine misuse issues in our society”.
“This pilot project in Ballymun, which involved local GPs working in partnership with an addiction counsellor, demonstrates how innovative approaches can be successfully adopted to address benzodiazepine problems in the primary care setting,” the Minister said.
According to Prof Bradley the use of benzodiazepines in large volumes in the community, albeit legitimately prescribed, can also feed into the illicit street use. It is important that GPs are made aware of this, he said.
“There is a certain lack of awareness in general practice about the problems that this is causing in the community. I think there is an underestimation about the harm they do to older people and there is an underestimation about the extent they leak into street usage,” Prof Bradley stated.
Large volume prescribing of benzodiazepines was also raised by the 2002 report of the Benzodiazepine Committee, which expressed concern that “the estimated standard prescription quantity for all benzodiazepine hypnotic drugs appears to be a one month supply. Since benzodiazepines are indicated for short-term relief (two to four weeks), and tolerance to their effects may develop within three to 14 days of continuous use, it would appear that in many cases the prescribing of these drugs is excessive and perhaps has become a matter of routine”.
These concerns lead to the Committee making a recommendation that the issue “should be raised with the Irish Medicines Board (IMB) with a view to reducing pack sizes”.
The Medical Independent contacted the IMB in an effort to ascertain if this issue was indeed raised with the Board as recommended by the 2002 report, and what efforts, if any, have been made to reduce pack sizes.
Interestingly the IMB stated that far from reducing pack sizes, the number of packs of benzodiazepines containing 30 tablets has “increased considerably over the years”.
“The IMB and the Department of Health and Children are in regular communication on issues relating to medicines and their regulation. In relation to reduction in pack sizes of benzodiazepines, the number of packs containing 30 tablets/capsules has increased considerably over the years. These products are dispensed according to the doctor’s prescription. Pack sizes of 30 can be broken to accommodate smaller courses of treatment as specified by the doctor,” the IMB advised.
“All benzodiazepines are subject to prescription control. Generally, they are presented in blister packs of 30 tablets. They are dispensed by a pharmacist in accordance with a prescription written by a doctor. Pack sizes greater than 30 tablets are used by pharmacists for dispensing purposes and are more likely to be used by pharmacists in a hospital setting. In relation to the product information, a harmonised Summary of Product Characteristics (SmPC) was introduced across Europe in 1994, which recommends short-term use, regular reassessment and assessment of the need for continued treatment of patients with benzodiazepines. The SmPCs for benzodiazepines authorised in Ireland are available on the Irish Medicines Board website,” the board added.
The IMB plays an important role in protecting public health through the regulation of medicines, medical devices and healthcare products in Ireland and key to this role is the ongoing work of the Board’s Enforcement Section.
In 2009 this Section initiated 3,729 enforcement cases involving breaches of medicinal product legislation – up 19 per cent on 2008. The vast majority of these breaches related to mail order importations of prescription only medicinal products.
The latest figures from the IMB suggest that the quantities of benzodiazepines being brought into the country illegally is on the rise. Between 2008 and 2011 (up to May 18th) the Board seized more than a quarter of a million illegal benzodiazepine type drugs.
In 2008 a total of 5,350 tablets of this type were seized, while a year later this number had increased almost tenfold to 55,086. In 2010 this figure more than doubled to 137,722, while to date in 2011 the IMB has seized a total of 70,663 benzodiazepine type drugs.
The surge in online pharmacies and the relative ease with which people can purchase benzodiazepines and other prescription only drugs illicitly online, has also had an impact on the increased use of benzodiazepines here.
This increase in the number of people accessing benzodiazepines online was raised by a number of the experts contacted by the Medical Independent including Mr Tony Geoghegan, the CEO of Merchants Quay Ireland, which provides homeless and drug support services in Dublin. According to Mr Geoghegan, the Internet has played a part in the increasing misuse of benzodiazepines with a lot of people accessing these drugs as well as other synthetic opiates online.
The Merchants Quay Ireland CEO was also a member of the Benzodiazepine Committee. He believes that, as a result of the 2002 report and its subsequent prescribing guidelines, many GPs have become more cautious and stringent in their prescribing practices. However he added that there are “always people who are outside of that net.”
Mr Geoghegan advised that benzodiazepine abuse has been an ongoing issue for a number of years.
He felt that part of the difficulty lies in the fact that while people who are engaged with drug treatment services will have their main treatment provided through a HSE clinic, they can still attend a GP as a private patient and receive a prescription for benzodiazepines, some of which they use and the remainder they then sell on the street to supplement their income.
“They are very prevalent and are sold quite openly on the street. [They are] often used to spread out the methadone or to enhance the effect of methadone,” he explained.
Like Mr Geoghegan, Dr Hugh Gallagher, GP Coordinator in the HSE Dublin North addiction service and Detox Director and attending GP at Toranfield House, a residential addiction treatment centre in Enniskerry, County Wicklow, also sees the harm caused by the long term effects of benzodiazepine use and addiction on a daily basis.
“It is still a major problem out there… We would see a lot of our users presenting with benzodiazepine addiction or benzodiazepine use sourced mostly on the street, some from GPs. It is something which I feel has a major negative impact on rehabilitation and recovery in addiction.”
Coupled with the abuse of benzodiazepines, Dr Gallagher also warned that the misuse of the sleeping tablet zopiclone is also a very significant problem in the community, particularly within the drug using population.
“These tablets are coming from somewhere. There are drugs labelled as benzodiazepines or sleeping tablets, particularly zopiclone, being sourced over the internet, but… a significant amount of them are being prescribed legitimately by GPs,” Dr Gallagher added.
According to Dr Gallagher, doctors are trained and equipped with excellent skills in communication, and employing those skills would be particularly beneficial in helping people who may pressurise them into prescribing benzodiazepines.
These skills would also help GPs to eliminate prescribing in those who have an established addiction to benzodiazepines, he added.
In terms of detoxing people who are on long-term maintenance benzodiazepines, Dr Gallagher advised that these patients should be prescribed just one long-acting benzodiazepine – such as diazepam – and that this should then be reduced to as low as 1mg a month.
However he said it is important to note that this process requires a lot of psychological and/or social support.
Dr Gallagher feels there is no rationale for the prescribing of benzodiazepines in community medicine at all. “I don’t believe that they achieve any benefit,” he said.
“Realistically of course people are going to be pressurised and benzodiazepines are going to be prescribed but my belief is that it should be as a last resort and it should be at the lowest possible dose for the shortest possible time”.
In concordance with Dr Gallagher, Prof Colin Bradley stated that the use of benzodiazepines as the major stratagem in the management of anxiety and/or insomnia should be viewed “as old fashioned medicine”.
While he agrees that benzodiazepines relieve symptoms of acute stress in the short term, ultimately, he believes, that they disempowered people and reduced their chances to make a more comprehensive recovery.
“If it is pure anxiety the best stratagem does seem to be various forms of counselling. There is an evidence base accruing around various forms of cognitive-based therapy and structured psychological interventions but again we would know in general practice that these people don’t always come with just pure anxiety; there may be mixed anxiety and depression… It is a more complicated strategy involving the use of medication and counselling, but with the medication being targeted more at the depression rather than the anxiety,” Dr Gallagher said.
Some key recommendations from the 2002 report of the Benzodiazepine Committee
1. The General Medical Services (Payments) Board should review and report at regular intervals on the prescription and use of benzodiazepines on the basis of the claims for reimbursement which are submitted to it every month.
2. Reports should be prepared by the GMS (Payments) Board and provided to GP / Primary Care Units and as appropriate to individual practitioners, particularly where there may be concerns arising from the continuous use by patients of benzodiazepines.
3. The GMS (Payments) Board should also be requested to take whatever steps are necessary to ensure that “repeat prescription forms”, and the repeat prescription facilities that are currently installed on some of the computer software in use for the writing of GP prescriptions, are not available or used for the issue of multiple prescriptions for benzodiazepines in the course of a single consultation.
4. Reporting of drug-related deaths should be improved so that statistical information clearly identifies whether drug dependence and/or misuse were the actual cause of death.
5. Ongoing evaluation and monitoring should be carried out into the use and misuse of benzodiazepines in Ireland, particularly in the private sector and among older people.
6. Patient packs that are being made available to the market for many benzodiazepine products are for a month’s supply: this issue should be raised with the Irish Medicines Board with a view to reducing pack sizes.
7. Ireland should take into account Resolution 44/13 of the Commission on Narcotic Drugs in the development of policies for the appropriate use of benzodiazepines.
8. Good Practice Guidelines on Benzodiazepines for Clinicians should be disseminated to all practitioners including hospital practitioners and implemented in full. Where possible, alternative therapies to the prescribing of benzodiazepines should be considered by clinicians.
9. The provision of details of a client’s GP should be part of the contract between a client and a health board clinic for the treatment of drug misuse.
10. Clinic doctors should communicate with clients’ GPs involved in the treatment of drug misusers regarding the prescribing of benzodiazepines. In most cases the clinic should, with the agreement of the GP, take responsibility for the prescribing of benzodiazepines and so prevent double or multi-prescribing to known drug users.