hypnotics & anxiolytics practice guide by ken nazareth ... · hypnotics & anxiolytics...

Hypnotics & Anxiolytics Practice Guide

By Ken Nazareth & Dr Kurt Burkhardt


This guidance has resulted in very few new patients being prescribed long-term benzodiazepines by general practitioners.

The prescribing by general practitioners of hypnotics and anxiolytics is being monitored by the All Wales Medicines Strategy Group on behalf of the Minister for Health & Social Services. This is because there are disproportionately more hypnotics and anxiolytics prescribed in Wales compared to England.

The prescribing data in Wales shows that there has been an approximate 8% reduction in the number of prescriptions and the quantity of benzodiazepines being prescribed over the last 2 years.

There still remain a large number of patients on regular repeat prescriptions of benzodiazepines which were initiated several years ago.

This practice guide is hoped to provide practices with a practical approach on how the number of patients on inappropriate long-term benzodiazepines can be reduced. The methods described in this guide have been developed from the approaches that have been used in the tLHB supported pharmacist and GP led reduction clinics. These have been undertaken in various practices in Rhondda Cynon Taff and Caerphilly.

IntroductionIt is now well recognised that the long-term use of hypnotics and anxiolytics by the majority of patients in general practice is not appropriate. The Committee on Safety of Medicines issued guidance in 1988 about the risks of the long-term use of benzodiazepines.


Hypnotics and AnxiolyticsBenzodiazepinesMechanism of ActionAll benzodiazepines act by enhancing the actions of a natural brain chemical, GABA (gamma-aminobutyric acid). GABA is a neurotransmitter, an agent which transmits messages from one brain cell (neuron) to another. The message that GABA transmits is an inhibitory one: it tells the neurons that it contacts to slow down or stop firing. Since about 40% of the millions of neurons all over the brain respond to GABA, this means that GABA has a general quietening influence on the brain: it is in some ways the body’s natural hypnotic and tranquilliser.

A brief understanding of the mechanism of action is important to explain to patients the effect on the brain of taking this medication on a long-term basis.

Difference between benzodiazepinesBenzodiazepines with high potency and short elimination half-lives are more likely to lead to problems with dependence e.g. lorazepam, oxazepam and loprazolam.

Those with long half-lives can lead to residual effects into the following day e.g. nitrazepam.

Those with an intermediate half life cause least problems when used for a short period.

The effects of long-term use can:- Cause drowsiness and falls.- Reduce a persons own coping skills.- Impair judgement and dexterity.- Increase the risk of experiencing a road traffic

accident.- Cause other effects include forgetfulness,

confusion, depression, irritability, aggression, impulsivity and digestive problems.

- Result in dependence.

Benzodiazepine dependence is often demonstrated in a number of patients by the following characteristics:- They have taken benzodiazepines in prescribed

“therapeutic” (usually low) doses for months or years.

- They have gradually become to “need” benzodiazepines to carry out normal, day-to-day activities.

- They have continued to take benzodiazepines although the original indication for the prescription is no longer relevant.

- They have difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms.

- If on short-acting benzodiazepines, they may develop anxiety symptoms between doses, or get craving for the next dose.

- They contact their doctor regularly to obtain repeat prescriptions.

- They become anxious if the next prescription is not readily available; they may carry their tablets around with them and may take an extra dose before an anticipated stressful event or a night in a strange bed.

- They may have increased the dosage since the original prescription.

- They may have anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.


Medication Usual Dose Half-life (hrs)[active metabolite]

Cost per 28 daysMay 2008

Dose equivalence to 5mg of diazepam

Diazepam 5mg 20-100 [36-200] 61p 5mg

Buspirone 5-10mg 2-11 £34.52-£128.10 5mg

Chlordiazepoxide caps 5-10mg 5-30 [36-200] 99p-£1.98 15mg

Clonazepam 0.5-2mg 18-50 £109-£146 0.5mg

Loprazolam 1-2mg 6-12 £8.87-£17.74 0.5-1mg

Lorazepam 1-2.5mg 10-20 £11.11-£20.08 0.5mg

Lormetazepam 0.5-1mg 10-12 £79.65-£97.81 0.5-1mg

Nitrazepam 5mg 15-38 72p 5mg

Oxazepam 10-15mg 4-15 £6.44-£6.94 15mg

Temazepam 10-20mg 8-22 £2.97-£5.94 10mg

Zaleplon (Sonata) 5-10mg 2 £3.12-£3.76 10mg

Zolpidem (Stilnoct) 5-10mg 2-4 £1.83-£2.44 10mg

Zopiclone (Zimovane) 3.75-7.5mg 5-6 £1.93-£1.71 3.75mg

Table1: Characteristics of Different Benzodiazepines and Similar Medication


Protocol to review patients on long-term hypnotics or anxiolytics• Determine the patients to be reviewed

• Initial computer search of all patients receiving prescriptions of hypnotics and anxiolytics for more than 6 months

• Lead GP to audit all patients highlighted by the search

Patients suitable for managed withdrawale.g. - unintentional

long-term use - patients discharged and continued

in primary care

Patients with potential for dose reduction or stopping hypnotic or

anxiolytic

Monitor patient’s progress through regular 6-12 monthly medication

reviewsTry maintaining on

minimal dose

Consider referral to substance misuse service

or Monitor patients under

CDAT service

Contact managing psychiatrist seek guidance

on possible withdrawal

Patients who may need to remain on small doses e.g. -terminal illness

- serious physical illness - epilepsy

Potential substance misusers

Patients with severe mental health problems

Patients managed by CDAT

Split patients into 2 groups

See managed withdrawalprogram

Medication Review Policy for Hypnotics and Anxiolytics All medication reviews for patients taking long-term hypnotics and anxiolytics should include a discussion on the potential problems and available support if a patient would like to stop. This regular reminder of the potential problems and of support available may help patients to make the decision to reduce or stop this medication.


Systematic approach to reducing the number of patients in a practice on long-term hypnotics and anxiolyticsCan it be done?It is relatively straightforward to withdraw many patients from long-term hypnotic and anxiolytics if the problems linked to their long-term use are explained to them and they feel that they will be supported through the withdrawal process.

A number of studies have shown that between 40 to 80% of patients can discontinue the benzodiazepine they have been taking for more than a year through a managed process. 1. A practice should organise a practice meeting for

all staff to discuss the initial review completed by the lead GP. The practice should try to invite the local community pharmacists to this meeting so that they are informed of the practices review and to help support the practice provide a consistent message to patients. The meeting should be used to inform all staff about;

- The issues relating to hypnotics and anxiolytics.- The approach the practice will be employing.- Gaining everybody’s agreement of how to

manage these long-term patients. - Identifying the lead people in practice to discuss

any issues that may arise.- The patients that have been identified by the

audit to be included in the practices reduction program.

This will allow a consistent message to be given to patients once the practice’s process and policy is put in place.

2. Every prescription of the target group of patients should have attached an information

sheet containing:

- The practices concerns about hypnotics and anxiolytics.

- Information about the need for gradual withdrawal.

- The practices intention to invite patients to discuss a withdrawal program from this medication; (see appendix 1)

Leaflets about self-help techniques should also be provided e.g. ‘Good Sleep Guide’ (Appendix 2) and ‘Good Relaxation Guide’ (Appendix 3).

This allows patients to be informed about the issues and allows them to start preparing for the proposed appointment. A copy of all this information should be given to each local community pharmacy in the area so that they are aware of the information patients may want to discuss.

3. A letter should be sent or given to each patient inviting them to an appointment to discuss their hypnotic and / or anxiolytic medication. The letter should contain similar information as the initial information sheet. (see appendix 4)

There are a number of approaches a practice can undertake to review these patients;

- If there are a large number of patents that need to be reviewed than it may be appropriate to organise a separate clinic.

- By adding one of the patients to be reviewed at the end of each of the doctor’s normal sessions. They will need a 15 minute appointment. This may be useful in practices with a number of GPs, so that they could all be involved.

- By having the number of authorisations for repeat prescriptions of hypnotics and anxiolytics reduced to one or two months then asked to make an appointment to review only this medication.

- As part of their usual medication review. This can be difficult as they may be on a number of medications which will all need time to be discussed. It may be an opportunity to give written information for a patient to take home and to then organise another appointment to discuss a reduction program.

Initial Appointment- Explain the reasons for the appointment;

o That long-term use of this medication is no longer recommended.

o Tolerance can develop.o Risk of rebound insomnia and withdrawal

effects if stopped abruptly.o Risk of over-sedation and cognitive impairment

seen as confusion and falls.o Risk of CNS depression.o Risk of physical and/or psychological

dependence.

- The need to address the cause of sleep disturbance.

o Poor sleep hygiene. o Minor anxiety.o Pain control.o Depression.o Anxiety /panic attacks.

If at this initial appointment it is not appropriate to reduce their medication, the patient’s prescription should be re-authorised for a period of 6-12 months when another review can take place.

Reduction Protocols for Hypnotics to Support Withdrawal - Standard reduction protocols often recommend

converting patients medication to an equivalent dose of diazepam. Experience locally from clinicians and practices that have successfully reviewed patients on long-term hypnotics and anxiolytics is that the vast majority of patients can be withdrawn using the medication they are already taking.

- Patients prefer to try reducing their current medication rather than changing to another medication. Many patients link “valium” to being a dangerous medication.

- Patients on lorazepam and oxazepam may need to be converted to diazepam at some stage during the withdrawal process, as their short half-lives make withdrawal effects more pronounced and more difficult to cope with. The initial reduction should be attempted using their current medication. (see table 1 for dose equivalences to diazepam)

Patients on high doses of hypnotics of hypnotics or anxiolytics can usually be reduced to a standard dose within a month or two as tolerance is usually well developed. Reductions to standard doses do not result in withdrawal symptoms or major change in sleep patterns.

Patients on high strength tablets will need to be prescribed their current dose of medication in the lowest available tablet strength.e.g. • 20mg - 40mg temazepam convert to 2-4 x 10mg tabs

• 1mg lormetazepam convert to 2 x 500micrograms tabs

• 7.5mg-15mg zopiclone convert to 2-4 x 3.75mg tabs

- At this stage and throughout the process it is important to provide advice on good sleep hygiene and basic support to reduce anxiety.

(see appendix 2 and 3)

- It is advisable to see these high dose patients once more during the reduction programme. This will be an opportunity to offer any additional support whilst on the final part of their reduction protocol. (see Other Treatment Options for Insomnia / Anxiety section)

- For patients on standard doses of hypnotics or anxiolytics a 3 month reduction schedule is normally slow enough to prevent withdrawal effects and for patients to get used to not taking any medication at night.

- A copy of the protocol should be given to the patient, the patient’s pharmacy and a copy needs to be kept in the practice’s patient records.

All the protocols are available electronically. Please follow the link from the Teaching LHB website: www.teachinglhb.co.uk(See examples of the protocols appendix 5)


Reduction Protocols for Anxiolytics Patients on Diazepam

• All patients should be converted to 2mg tablets. The reduction protocols will reduce their dose by 1mg or 2mg per month.

• Patients on doses up to 5mg day will be given monthly repeat prescriptions.

• Patients on higher doses will need to be given fortnightly or weekly scripts in the first few months due to the quantity of tablets prescribed.

• It is advisable to see these patients monthly, or every 2 months initially, to offer advice or any additional support.

(See other treatment options section)• The reduction protocols last between 4 and 12

months to allow gradual withdrawal. • The protocols can be individualised to meet

patient’s response.• A copy of the protocol should be given to the

patient, the patient’s pharmacy and a copy needs to be kept in the practice’s patient records.

• The reduction protocols for different doses are available electronically via the Teaching LHB web site www.teachinglhb.co.uk (See examples of the protocols in appendix 6)

• Throughout the process it is important to provide advice on good sleep hygiene and basic support to reduce anxiety (see appendix 2 and 3) as well as any additional support.

(see Other Treatment Options for Insomnia / Anxiety section)

• If it is appropriate to refer a patient for psychological support, please use the standard mental health referral form so that a patients condition can be assessed as to what support will be required.

Other Anxiolytics• Attempts can be made to reduce patients on

other anxiolytics using their current medication but many may need to be converted to diazepam to overcome the withdrawal effects they experience. (See Table 1 for equivalence to diazepam)

Other Treatment Options for Insomnia / AnxietyBibliotherapyThe Book Prescription Wales scheme allows health care professionals to prescribe self-help books to patients with mild to moderate mental health problems. Book therapy has been shown to be very useful in treatment strategies for conditions such as anxiety and depression. It is recommended by NICE as part of an early intervention program. If the practice does not have a prescriber pack, please contact your LHB for information.

Counselling Services, CBT and Secondary Care ReferralPatients needing more specialised support may need to be referred to other service providers. The availability of various services will depend on the locality, please contact your LHB for more information.


External Support Agencies • Bereavement Supporto Cruse Bereavement Care. Website http: //www.crusebereavementcare.org.uk

• Domestic Abuseo Welsh Women’s Aid: 0808 8010 800

Lead Agency offering support to all Welsh women and children who are experiencing domestic abuse. Website: http://www.welshwomensaid.org

• Victim of Crime Supporto Victim Support England and Wales helps residents cope with the effects of crime. Provides confidential support and information to victims of crime and to witnesses attending local courts. Website: http://www. victimsupport.org.uk/vs_england_wales/ contact_us/wales_home.php

• Support for Veteranso Support and other web links for veterans are available through the community veterans mental health service. Website http://www. veterans-mhs-cvct.org

Appendix 1

Sleeping and Anxiety TabletsInformation for PatientsRecently family doctors and all health care professionals have been concerned about the use of this kind of sedative medication when it is taken over long periods.

Rhondda Cynon Taff Teaching Local Health Board has asked all doctors to review all patients’ prescribed sedative medication as a repeat medication.

Research work done in this field has shown that all medication used as a sedative is not recommended to be used regularly and for long periods.

Sleeping and anxiety tablets used to be commonly taken. However, they have been shown to have problems, and are now not commonly prescribed. Possible problems with these tablets include:

• Drowsiness the next day. You may not be safe to drive or to operate machinery. • Clumsiness and confusion in the night if you have to get up. For example, if you have had a sleeping

tablet, you may fall over if you get up to go to the toilet in the night. (Older people who take sleeping tablets have an increased risk of breaking their hip.)

• Tolerance to sleeping tablets may develop if you take them regularly. This means that, in time, the usual dose has no effect. You then need a higher dose to help with sleep. In time, the higher dose then has no effect, and so on.

• Developing dependence (addiction) to sleeping and anxiety tablets.• Suffering from withdrawal symptoms if the tablets are stopped suddenly so a slow withdrawal is needed.

If you would like discuss the best approach to reducing or stopping this medication please make anappointment to see the doctor.


AntidepressantsPatients with anxiety and depression may need to be started on medication during the withdrawal process.

Citalopram 10-40mg, trazodone 50-150mg and fluoxetine 20mg have all been used to good effect to control and manage symptoms. Trazadone is useful if a sedating effect is needed.

Tricyclic antidepressants, although not recommended for first-line therapy due to the high risk of cardio-vascular side-effects and the risk in overdose, may be a useful choice if a medication with a sedative side-effect is needed. Individual patients will need to be carefully assessed before starting treatment.

Treatment should be monitored every 6 months to prevent inappropriate long-term use.

Sedating AntihistaminesSedating antihistamines such as promethazine and diphenhydramine are available without a prescription for self treatment of occasional insomnia.

They have a lack of good evidence slow onset of action and long duration, and the effect may diminish after a few days treatment. Very occasionally they have been prescribed to patients during withdrawal process.

Beta BlockersPropanolol 40-120mg has been used to control the physical symptoms of anxiety which may reduce a patient’s worry and fear.

It may be worth considering in patients with pre-existing hypertension or ischaemic heart disease. Need to be aware of contra-indications, cautions and side effects before prescribing.


Appendix 2

The Good Sleep GuideDuring the Evening• Put the day to rest. Think it through. Tie up “loose ends” in your mind and plan ahead. A notebook may help.• Take some light exercise early in the evening. Generally try to keep yourself fit.• Wind down during the course of the evening. Do not do anything that is mentally demanding within 90 minutes

of bedtime.• Do not sleep or snooze in the armchair. Keep your sleep for bedtime.• Do not drink too much coffee or tea and only have a light snack for supper. Do not drink alcohol to aid your

sleep – it usually upsets sleep.• Make sure your bed and bedroom are comfortable – not too cold and not too warm.

At Bedtime• Go to bed when you are “sleepy tired” and not before.• Do not read or watch TV in bed. Keep these activities for another room.• Set the alarm for the same time every day – 7 days a week, at least until your sleep pattern settles down.• Put the light out when you get into bed.• Let yourself relax and tell yourself that “sleep will come when it’s ready”. Enjoy relaxing even if you don’t at first

fall asleep.• Do not try to fall asleep. Sleep is not something you can switch on deliberately but if you try to switch it on you

can switch it off!

If you have Problems getting to Sleep• Remember that sleep problems are quite common and they are not as damaging as you might think. Try not to

get upset or frustrated.• If you are awake in bed for more than 20 minutes then get up and go into another room.• Do something relaxing for a while and don’t worry about tomorrow. People usually cope quite well even after a

sleepless night. Go back to bed when you feel “sleepy tired”.• A good sleep pattern may take a number of weeks to establish. Be confident that you will achieve this in the

end of the end by working through the “GOOD SLEEP GUIDE”.

This guide has been adapted from material originally prepared by Dr Colin Espie.


Appendix 3

The Good Relaxation GuideDealing with Physical Tension• Value times of relaxation. Think of them as essentials not extras. Give relaxation some of your time not just

what’s left over.• Build relaxing things into your lifestyle every day and take your time. Don’t rush. Don’t try too hard.• Learn a relaxation routine, but don’t expect to learn without practice.• There may be relaxation routines available, especially in audio format. These help you to reduce muscle tension

and to learn how to use your breathing to help you relax.• Tension can show in many different ways – aches, stiffness, heart racing, perspiration, stomach churning, etc.

Don’t be worried about this.• Keep fit. Physical exercise, such as a regular brisk walk or a swim, can help to relieve tension.

Dealing with Worry• Accept that worry can be normal and that it can be useful. Some people worry more than others but everyone worries sometimes.• Write down your concerns. Decide which ones are more important by rating each out of ten.• Work out a plan of action for each problem.• Share your worries. Your friends or your general practitioner can give you helpful advice.• 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.• Practice enjoying quiet moments, e.g. sitting listening to relaxing music. Allow your mind to wander and try to

picture yourself in pleasant, enjoyable situations.

Dealing with Difficult Situations• Try to build your confidence. Try not to avoid circumstances where you feel more anxious. A step by step

approach is best to help you face things and places which make you feel tense. Regular practice will help you overcome your anxiety.

• Make a written plan and decide how you are going to deal with difficult situations.• Reward yourself for your successes. Tell others. We all need encouragement.• Your symptoms may reduce as you face up to difficult situations. Keep trying and they should become less

troublesome as your confidence grows.• Everyone has good and bad days. Expect to have more good days as time goes on.• Try to put together a programme based on all the 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 has been adapted from material originally prepared by Dr Colin Espie.


Appendix 4

Practice Name and Address

Dear ………………………

I am writing to you because I note from our records that you have been taking …………………………... tablets for some time now. Recently family doctors have been concerned about the use of this kind of sedative medication when it is taken over long periods.

Research work done in this field has shown that all medication used as a sedative is not recommended to be used regularly and for long periods.

Sleeping and anxiety tablets used to be commonly taken. However, they have been shown to cause problems, and are now not commonly prescribed. Possible problems with these tablets include:

• Drowsiness the next day. You may not be safe to drive or to operate machinery.

• Clumsiness and confusion in the night if you have to get up. For example, if you have had a sleeping tablet, you may fall over if you get up to go to the toilet in the night. (Older people who take sleeping tablets have an increased risk of breaking their hip.)

• Tolerance to sleeping tablets may develop if you take them regularly. This means that, in time, the usual dose has no effect. You then need a higher dose to help with sleep. In time, the higher dose then has no effect, and so on.

• Developing dependence (addiction) to sleep and anxiety tablets. Suffering from withdrawal symptoms if the tablets are stopped suddenly so a slow withdrawal is needed.

Our aim is to change your medication over the next few months to gradually withdraw you from it. This will reduce the risk of you taking the tablets regularly. We will also monitor your progress as part of the practice’s medication review process.

The practice is setting up a clinic for patients to discuss the long-term use of sleeping tablets.................................................. will be running the clinic. I have made an appointment for you to see them on the ………………… at ………………… If this is inconvenient please telephone the practice to re-arrange your appointment.

Yours sincerelyDr


Appendix 5

Local Health Board

Reducing and stopping your sleeping tablets: Information for patientsThe table below advises how you should take your next supply of Temazepam tablets. The prescription supply of 45 tablets is sufficient to reduce and finally stop your dose of Temazepam over the next 12 weeks.

To use the table, write down in the brackets the day of the week that you start on Day 1, and then write down the remaining days of the week.

Temazepam 10mg dose reduction timetable

Day 1 Start

( Mon)

Day 2

( Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

( Fri)

Day 6

(Sat)

Day 7

(Sun)

Day 1 Start

(Mon)

Day 2

(Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

(Fri)

Day 6

(Sat)

Day 7

(Sun)

1st week 1 tablet 1 1 none 1 1 1

2nd week 1 1 1 none 1 1 1

For example:

When you have completed the 1st week of the table put a line through that week, to avoid confusion and repeating the same week….do the same with remaining weeks once they have been completed.

For example:


Your Personal Table

Day 1 Start ( ) Day 2 ( ) Day 3 ( ) Day 4 ( ) Day 5 ( ) Day 6 ( ) Day 7 ( )

1st week 1 1 1 ½ 1 1 1

2nd week ½ 1 1 1 ½ 1 1

3rd week ½ 1 1 ½ 1 1 ½

4th week 1 ½ 1 ½ 1 ½ ½

5th week 1 ½ ½ 1 ½ ½ ½

6th week ½ ½ ½ ½ ½ 1 ½

7th week ½ ½ ½ ½ ½ ½ ½

8th week ½ ½ ½ 0 ½ ½ ½

9th week ½ ½ 0 ½ 0 ½ ½

10th week ½ 0 ½ 0 ½ 0 ½

11th week ½ 0 ½ 0 0 ½ 0

12th week 0 ½ 0 0 ½ 0 0

13th week Stop temazepam


Local Health Board

Reducing and stopping your sleeping tablets: Information for patientsIn here we would write temazepam 20mg or zopiclone 7.5mg tablets, and an explanation that the dose will be supplied as 10mg temazepam tablets or 3.75mg zopliclone tablets.

The table below advises how you should take your future supplies of sleeping tablets.

Firstly your sleeping tablets will be removed from your repeat prescription on the practice computer, and over the few months, you will be issued with 4 separate prescriptions to cover the reduction and cessation of your sleeping tablets.

How to use the table:To use the table overleaf, write in the brackets the day of the week that you start the reduction, e.g. if you start on a Monday, then write Mon in the Day 1 brackets, and then write the remaining days of the week.

Day 1 Start

( Mon)

Day 2

( Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

( Fri)

Day 6

(Sat)

Day 7

(Sun)

Day 1 Start

(Mon)

Day 2

(Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

(Fri)

Day 6

(Sat)

Day 7

(Sun)



For example:

When you have completed the 1st week of the table put a line through that week, to avoid confusion and repeating the same week…. do the same with remaining weeks once they have been completed.

For example:


Your Personal Table


1st prescription to be issued

Date Your 1st prescription will include the 1st four weeks supply of tablets (i.e. 43 tablets)

1st week 2 1 ½ 2 1 ½ 2 1 ½ 2

2nd week 1 ½ 2 1 ½ 2 1 ½ 2 1 ½

3rd week 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1

4th week 1 1 ½ 1 1 ½ 1 1 ½ 1

New prescription due

Date Your 2nd prescription will include weeks 5-8 of your supply of tablets (i.e. 26 tablets)

5th week 1 ½ 1 1 ½ 1 1 ½ 1 1

6th week 1 1 1 ½ 1 1 1

7th week ½ 1 1 ½ ½ 1 1

8th week ½ 1 1 ½ 1 1 ½


Date Your 3rd prescription will include weeks 9-12 of your supply of tablets (i.e. 19 tablets)

9th week 1 ½ 1 ½ 1 ½ ½

10th week 1 ½ ½ 1 ½ ½ ½

11th week ½ ½ ½ ½ ½ 1 ½

12th week ½ ½ ½ ½ ½ ½ ½


Date Your 4th and final prescription will include weeks 13- 16 of your supply of tablets (i.e. 9 tablets)

13th week ½ ½ ½ 0 ½ ½ ½

14th week ½ ½ 0 ½ ½ ½ ½

15th week ½ 0 ½ 0 ½ 0 ½

16th week ½ 0 ½ 0 0 ½ 0

17th week 0 0 0 0 0 0 0


Appendix 6

Local Health Board

Reducing and stopping your Diazepam tablets: Information for patientsThe table below advises how you should take your future supplies of diazepam tablets.

Firstly your DIAZEPAM tablets will be removed from your repeat prescription on the practice computer, and over the coming months, you will be issued with 5 separate prescriptions to cover the reduction and cessation of your DIAZEPAM tablets.

How to use the table:To use the table overleaf, write in the brackets the day of the week that you start the reduction, e.g. if you start on a Monday, then write Mon in the Day 1 brackets, and then write down the remaining days of the week.

Day 1 Start

( Mon)

Day 2

( Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

( Fri)

Day 6

(Sat)

Day 7

(Sun)

Day 1 Start

(Mon)

Day 2

(Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

(Fri)

Day 6

(Sat)

Day 7

(Sun)



For example:


For example:

As you are currently using a total daily dose of 5mg DIAZEPAM, further prescriptions will use a 2mg strength tablet to facilitate the dose reduction and eventual cessation of your DIAZEPAM.

Diazepam 5mg dose reduction timetable


Your Personal Table



Date Your 1st prescription will include the 1st four weeks supply of tablets (i.e. 56 tablets x2mg)

1st week 2 2 2 2 2 2 2

2nd week 2 2 2 2 2 2 2

3rd week 2 2 2 2 2 2 2

4th week 2 2 2 2 2 2 2


Date Your 2nd prescription will include weeks 5-8 of your supply of tablets (i.e. 42 tablets x 2mg)

5th week 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½

6th week 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½

7th week 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½

8th week 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½ 1 ½


Date Your 3rd prescription will include weeks 9-12 of your supply of tablets (i.e. 28 tablets x2mg)

9th week 1 1 1 1 1 1 1

10th week 1 1 1 1 1 1 1

11th week 1 1 1 1 1 1 1

12th week 1 1 1 1 1 1 1


Date Your 4th prescription will include weeks 13- 16 of your supply of tablets (i.e. 16 tablets x2mg)

13th week ½ 1 ½ 1 ½ 1 1

14th week ½ 1 ½ 1 ½ 1 ½

15th week ½ ½ ½ ½ ½ ½ ½

16th week ½ 0 ½ 0 ½ 0 0


Date Your 5th prescription will include weeks 17-18 of your supply of tablets (i.e. 2 tablets x2mg)

17th week 0 ½ 0 0 ½ 0 0

18th week 0 0 0 0 0 ½ 0


Appendix 6

Local Health Board

Reducing and stopping your Diazepam tablets: Information for patientsThe table below advises how you should take your future supplies of diazepam tablets.

Firstly your DIAZEPAM tablets will be removed from your repeat prescription on the practice computer, and over the coming months, you will be issued with 9 separate prescriptions to cover the reduction and cessation of your DIAZEPAM tablets.

How to use the table:To use the table overleaf, write in the brackets the day of the week that you start the reduction, e.g. if you start on a Monday, then write Mon in the Day 1 brackets, and then write down the remaining days of the week.

Day 1 Start

( Mon)

Day 2

( Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

( Fri)

Day 6

(Sat)

Day 7

(Sun)

Day 1 Start

(Mon)

Day 2

(Tues)

Day 3

(Wed)

Day 4

(Thurs)

Day 5

(Fri)

Day 6

(Sat)

Day 7

(Sun)



For example:


For example:

As you are currently using a total daily dose of 10mg DIAZEPAM, further prescriptions will use a 2mg strength tablet to facilitate the dose reduction and eventual cessation of your DIAZEPAM.

Diazepam 10mg dose reduction timetable


Your Personal Table



Date Your 1st prescription will include the 1st two weeks supply of tablets (i.e. 56 tablets x 2mg)

1st week 4 tablets 4 4 4 4 4 4

2nd week 4 4 4 4 4 4 4


Date Your 2nd prescription will include weeks 3-4 supply of your tablets (i.e. 56 tablets)

3rd week 4 4 4 4 4 4 4

4th week 2 4 4 4 4 4 4


Date Your 3rd prescription will include weeks 5-6 of your supply of tablets (i.e. 42tablets x 2mg)

5th week 3 3 3 3 3 3 3

6th week 3 3 3 3 3 3 3


Date Your 4th prescription will include weeks 7-8 of your supply of tablets (i.e. 42 tablets x 2mg)

7th week 3 3 3 3 3 3 3

8th week 3 3 3 3 3 3 3



9th week 2 2 2 2 2 2 2

10th week 2 2 2 2 2 2 2

11th week 2 2 2 2 2 2 2

12th week 2 2 2 2 2 2 2



13th week 1½ 1½ 1½ 1½ 1½ 1½ 1½

14th week 1½ 1½ 1½ 1½ 1½ 1½ 1½

15th week 1½ 1½ 1½ 1½ 1½ 1½ 1½

16th week 1½ 1½ 1½ 1½ 1½ 1½ 1½Continued overleaf

References:Ashton H. Benzodiazepines: How they work and how to withdraw. School of NeurosciencesDivision of Psychiatry The Royal Victoria Infirmary Newcastle upon Tyne August 2002.Primary Care Guidelines for Medicines Liable to Misuse. Bridgend, Neath Port Talbot and Swansea Local Health Board 2002. Drug and Therapeutics Bulletin. What’s wrong with prescribing hypnotics? DTB 2004; 42(112): 89-93.National Institute for Health and Clinical Excellence (NICE). Anxiety Full Guidance. Clinical Guideline (22) 2008.Clinical Knowledge Summaries Benzodiazepines /Z drug Withdrawal National Library for Health June 2006 http://cks.library.nhs.uk/home.




17th week 1 1 1 1 1 1 1

18th week 1 1 1 1 1 1 1

19th week 1 1 1 1 1 1 1

20th week 1 1 1 1 1 1 1


Date Your 8th prescription due will include weeks 21- 24 of your supply of tablets (i.e. 16 tablets x2 mg)

21st week ½ 1 ½ 1 ½ 1 1

22nd week ½ 1 ½ 1 ½ 1 ½

23rd week ½ ½ ½ ½ ½ ½ ½

24th week ½ 0 ½ 0 ½ 0 ½


Date Your 9th prescription due will include weeks 25- 26 of your supply of tablets (i.e. 2 tablets x2mg)

25th week 0 0 ½ 0 0 ½ 0

26th week 0 ½ 0 0 ½ 0 0

AcknowledgmentsThe tLHB would like to thank the following contributors for their assistance in the preparation of this booklet. The staff and patients in the following practices: St Johns Medical Practice, Aberdare; Abercwmboi Medical Centre, Abercwmboi, Aberdare; Park Surgery, Trecynon, Aberdare, The Pharmacy Team, RCT tLHB.


www.wales.nhs.uk/tlhb


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