Guidelines on the Use of Benzodiazepines and Related Medicine

In accordance with the opinions of the Fellows of Hong Kong College of Psychiatrists as expressed in the Annual General Meeting of the College in December 1995, the Council of the College set up an Ad Hoc Committee to draft its guidelines on the use of benzodiazepines and related medicine. Members of the Committee were Prof. C.N Chen, Dr Barry Connell, Dr Benjamin Lai, Dr. S.P. Leung and Dr. Y.K. Wing. References were made to the various documents. These included the Use of Benzodiazepines of the World Psychiatric Association, Guidelines on the Use of Benzodiazepines by the Royal College of Psychiatrists of the United Kingdom, and Guideline on the Use of Benzodiazepines of New Zealand. Opinions and comments had also been received from various Fellows and Members of the College at various stages of development of the guidelines. Draft on the guidelines was discussed by the Council of the College and modified according to the views of the Council. The Guidelines was formally adopted by the College Council in March 1996 as presented below.

INTRODUCTION

Benzodiazepines are useful and effective pharmacological agents when they are used for the right indications with treatment properly supervised, dosage appropriately chosen and adjusted, and used for an appropriate period of time. They are used in the pharmacological aspect of the overall management of patients with anxiety and insomnia. Some benzodiazepines are also used in other conditions, like in the use as an anti-epileptic agent and as a muscle relaxant. However they pose the risk of abuse, acute or chronic intoxication, and dependence in addition to the adverse effects of slowing of reaction time, impairment of memory, mood changes, and paradoxical effects of excitation and aggressiveness. The likelihood of dependence increases with increasing dose and increasing duration of treatment. Withdrawal symptoms have been reported with benzodiazepines following therapeutic doses given even for a short period of time. Short and intermediate half-life hypnotics, like triazolam and medazepam, are said to be more likely to lead to withdrawal symptoms. Dependence may also be more likely with a benzodiazepine of higher potency, like flunitrazepam.

Anxiety and insomnia are often symptoms of an underlying psychiatric illness. They often indicate the presence of psychosocial stresses affecting a patient who is having an underlying psychopathology. The management of the patient requires a proper and comprehensive psychiatric assessment and biopsychosocial management. The risks and benefits of treatment with benzodiazepines must be discussed with the patient. The progress of the patient must be reviewed regularly and the management adjusted appropriately.

GUIDELINES OF GOOD CLINICAL PRACTICE IN USE OF BENZODIAZEPINES

The following serves as guidelines of good clinical practice in the use of benzodiazepines as a pharmacological agent in the following uses.

USES AS ANXIOLYTICS:

Benzodiazepines are indicated as a pharmacological agent in the overall psychosocial management of a patient with anxiety that is severe, disabling or subjecting the individual to unacceptable distress. The anxiety may occur alone or in association with insomnia or short-term psychosomatic, organic or psychotic illnesses. The use of the agent should in general be for short term use.

USES AS HYPNOTICS:

Benzodiazepines should be used as a pharmacological agent in the overall management of a patient with insomnia only when it is severe, disabling or subjecting the individual to extreme distress. The use of the agent should in general be of short duration.

DOSES:

I. The lowest dose which can control the symptoms should be used.
II. Long-term chronic use is in general not recommended.
III. Treatment should always be tapered off gradually.
IV. The total amount of medicine supplied or prescribed to a patient at any single clinical consultation should be limited to avoid any stocking by the patient, resale, inappropriate or illicit usage

PRECAUTIONS:

I. Benzodiazepines should not be used alone to treat depression. They are in general ineffective. Disinhibiting effects including suicidal behaviour may be precipitated.
II. Patients should be warned of psychomotor impairment related to benzodiazepines which could affect driving and working with machinery.
III. Extra cautions should be exercised in prescribing benzodiazepines in patients with personality disorder.
IV. Because of pharmacokinetic and pharmacodynamic changes with aging, the frequent presence of multiple medical problems, polypharmacy, and other issues associated with aging, benzodiazepines must be used with special care in the elderly.
V. In patients expressing symptoms of excitement, agitation and severe psychotic disturbance benzodiazepines should be prescribed only on specialist advice and for a short period. They are usually not used for the treatment of chronic psychosis

INDIVIDUAL BENZODIAZEPINE:

The pharmacological properties of the individual benzodiazepine used by a medical practitioner should always be read. Appropriate uses, dosage and duration of use, cautions, adverse reactions and drug interaction of the benzodiazepine should always be noted and observed. The medical practitioner should keep updated with the scientific information about the various aspects of the clinical use of the benzodiazepine.

ASSOCIATED MEDICINE:

Some medicines, like buspirone, zopiclone, and zolpidem, are used as anxiolytics and hypnotics but they do not belong to the group of benzodiazepines. Their use should also desirably follow the guidelines for benzodiazepines as above.

MANAGEMENT OF PATIENTS WITH DEPENDENCE ON BENZODIAZEPINE AND RELATED MEDICINE:

Dependence on benzodiazepine and related medicine often indicates psychosocial problems in a person. The patient needs to have individualised and comprehensive psychiatric assessment and appropriate biopsychosocial management. Detoxification is only part of the overall management. In general the longer acting benzodiazepine should be used as the pharmacological agent in the detoxification of benzodiazepine dependence. There is usually no such role of using benzodiazepine as long term maintenance treatment of patients with benzodiazepine dependence. Whenever necessary, a second opinion from an expert should be sought.

ACKNOWLEDGMENT

The enthusiastic participation, differing opinions and frank discussions of members of the Ad Hoc Committee, members of the College Council, and other members of the College have to be acknowledged.

Dr. Benjamin Lai
Chairman, Ad Hoc Committee on Guidelines on Use of Benzodiazepines Hong Kong College of Psychiatrists

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