BENZO/OPIOID POLICY | Castlereagh Medical

PRESCRIPTIONS

Benzodiazepine and Opioid Policy

All patients taking medicines that can affect awareness and skilled activities, should be aware of their obligations to the DVLNI and driving laws: see here.

OPIOIDS LIKE CODEINE, TRAMADOL, MORPHINE

Pain that lasts for more than 3 months is known as chronic or persistent pain. It is common and affects between 3 and 5 in every 10 people. Pain is complex and many factors can affect or be affected by the pain, including your work and leisure time, relationships with family and friends, and sleep. Management of chronic pain would be individualised to each individual with a focus on self-management, and maintaining daily function and quality of life despite ongoing pain.

Many of our patients require strong, potentially addictive medication to help manage their pain condition(s). Of concern are the opioid medications which can cause dependence and addiction, particularly when these are prescribed on an ongoing basis. Evidence has shown that opioid medications (e.g. codeine, tramadol, morphine) have very little benefit in the management of chronic pain and often the risks associated with treatment would outweigh any potential benefit.

Unless you are prescribed specific medications by a pain specialist, we only prescribe short courses of opioid medication for acute pain. Current guidelines in the UK that we are bound by do not support the use of opioids in chronic pain and limit their use to acute pain (short term) and cancer pain.

OPIOID PRESCRIPTIONS

Opioid prescriptions will not be added to your repeat medication list
Sometimes, your medicine will be dispensed at shorter time periods
Lost prescription or medication requested early is only done in truly exceptional circumstances
All opioid prescriptions will include full directions wherever possible and should not be used more than that
Opioid medication (e.g. codeine, tramadol, morphine, buprenorphine, fentanyl) will not be initiated for chronic primary pain, unless there are other underlying conditions that warrant the use of these medications.
Co-codamol will be stopped in all patients. This will be replaced with codeine only tablets. In this form it will give greater flexibility with dosing as codeine on its own is available in various doses. We will be weaning people off the codeine and stopping gradually. Patients can purchase the paracetamol separately to take with the codeine if they wish.

REVIEW OF OPIOID PRESCRIPTIONS

We know there are patients who have been taking these medications for a number of years. We will need to review these patients and discuss slowly weaning off their opioid medication. This will be done either with their usual doctor or with our in-house pharmacist.

We appreciate that for a patient who has been taking opioids for a number of years, there may be a sense that they won’t be able to cope without them. Evidence does show that we can reduce withdrawal symptoms by reducing the dose of the opioid medication slowly. The reduction schedule would be individualised for each patient.

The ‘My Live Well With Pain’ website (https://my.livewellwithpain.co.uk) has a range of useful resources to help you learn the skills you need to become an effective self-manager of your pain. If you have any concerns or would like to discuss your conditions/medications, please do speak to the GP or pharmacist.

You should also review our pain management resources, here.

BENZODIAZEPINES LIKE DIAZEPAM, TEMAZEPAM, NITRAZEPAM

Diazepam for Fear of Flying, and other requests (including scans and dental appointments)
Background

Benzodiazepines (including diazepam, lorazepam, temazepam, clonazepam) are medicines that have been in use since the 1960s for a wide range of conditions, such as alcohol withdrawal, epilepsy, and muscle spasms. They are strongly sedating drugs that have negative effects on memory, coordination, concentration, and reaction times. They are addictive and withdrawal can lead to seizures, hallucinations, agitation, and confusion.

Unfortunately, benzodiazepines have widely become drugs of abuse, and as a result they are controlled in the UK as Class C, Schedule 4 drugs. This means there are restrictions on when and how much can be prescribed under the Controlled Substances Act, and inappropriate use, supply or possession of these medications is illegal in the UK under the Misuse of Drugs Act.

Many people approach their GP practice asking for diazepam to help with fear of flying, or to sleep during a flight. There are several good reasons why prescribing diazepam is not recommended, and as a result we will no longer prescribe diazepam for patients who wish to use this for a fear of flying.

Reasons

The national prescribing guidelines followed by GPs (the British National Formulary – BNF) states that all benzodiazepines are ‘contraindicated’ (not allowed) in treatment of phobias (fear conditions, such as fear of flying).
Diazepam is a sedative, so it makes you sleepier. If an emergency occurred during the flight, this could impair your ability to concentrate, follow instructions, or react to the situation. This could seriously affect the safety of you and the people around you.
Sedative drugs can make you fall asleep; however, the sleep is an unnatural non-REM sleep. Your movements during this type of sleep are reduced and this can place you at an even higher risk of developing blood clots in the legs (deep vein thrombosis – a DVT) or lungs (pulmonary embolism – a PE). These blood clots are very dangerous and can even be fatal. This risk further increases if your flight is over 4 hours long.
Going on an aeroplane normally involves your blood oxygen levels decreasing from around 98% to as low as 90%, due to the air pressure decrease at cruising altitudes. Normally your body compensates for this by altering the rate and depth of your breathing. However, benzodiazepines work to depress your breathing and this can put you at risk of hypoxia (excessively low blood oxygen), especially if you have lung problems already, which can be very dangerous.
Most people feel sleepy when they take diazepam, but a small proportion of people experience the opposite effect and can become aggressive. This is called a paradoxical effect, and it can be unexpectedly inconsistent, even if diazepam has been used in the past. Alongside aggression and agitation, this response can cause disinhibition and make you behave in ways you normally wouldn’t. This could also impact on your safety and the safety of your fellow passengers or could lead you to get in trouble with the law.
In several countries, diazepam and similar drugs are illegal (Greece, Japan, and many Middle Eastern countries including the UAE are just some examples). They would be confiscated, and you might find yourself in trouble with the police for being in control of an illegal substance, even if it has been prescribed by a doctor in the UK. This has led to people spending time in a jail a foreign country.
Diazepam has a long half-life, which means it stays in your system for a significant time. If your job requires you to submit random drug testing, you may fail these tests.
There is a possible link between occasional use of benzodiazepines and earlier onset of dementia in later life.

What you can do

A fear of flying is frightening and can be debilitating. However, there are much better and effective ways of tackling the problem. We recommend you tackle your problem with a Fear of Flying Course, which are aviation-industry approved and are run by several airlines. These courses are far more effective than diazepam and have none of the undesirable effects. Also, the positive effects of the courses continue after the courses have been completed.

Easy Jet : www.fearlessflyer.easyjet.com Tel: 0203 813 1644

British Airways: http://flyingwithconfidence.com/courses/venues Tel: 01252 793 250

Virgin Atlantic: https://flyingwithoutfear.co.uk/collections Tel: 01423 714 900

Fly And Be Calm is an instant download audio course which includes instructions, a fear removal tool and two hypnotic tracks. You can find this at: https://flyandbecalm.co.uk/

Alternatively, you could contact your local psychology therapy provider to consider having Cognitive Behavioural Therapy (CBT).

Ultimately, if you still feel unable to fly, then it may be appropriate to consider alternative routes of transport.

If you still wish to consider diazepam for fear of flying, we suggest consulting with a private GP or a private travel clinic, who may be able to help you further. These services are private and not offered by the NHS. The private clinics may then liaise with the airlines directly to arrange a medically-trained escort for a passenger who is taking sedative medications, which can be expensive.

Other situations – scans, dental appointments etc.

We do not provide sedative medications such as diazepam for use in other situations, such as for dental/hospital procedures or scans.

The Royal College of Radiologists sets out clear guidance for sedation in hospital radiology departments: here. This states “Sedation and analgesia should be administered by a competent and well-trained sedation and oversight provided by a sedation committee within the institution”.

The Intercollegiate Advisory Committee for Sedation in Dentistry has a similar guideline here which states “The monitoring and discharge requirements for oral sedation are the same as for intravenous sedation. Oral sedation must only be administered in the place where the dental treatment is provided and must only be carried out by practitioners who are already competent in intravenous sedation.”

As a result, responsibility for this type of treatment lies with your dentist or hospital staff, and not your GP. If you feel this is required, we suggest consulting with your dentist or the hospital teams in good time before any scans or treatments occur.