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Drug Watch-Benzodiazepines

Effective reduction in benzodiazepine use in general practice

The size of the problem

Benzodiazepine prescribing in the UK has been falling, but the number of prescriptions is still large. In 1989 there were 21 million prescriptions for hypnotics, sedatives and tranquillisers - the vast majority being benzodiazepines. Of these prescriptions, 9 million prescriptions for sedatives and 12 million prescriptions for hypnotics were issued from family health services at a total cost of some £34 million, with about £27 million of this being for benzodiazepines.

The nature of the problem

GPs have received clear advice about problems associated with prescribing benzodiazepines. Benzodiazepines impair performance (including driving), they affect memory, and have adverse cognitive effects. The British National Formulary states that benzodiazepines should be avoided in elderly people because of risks of ataxia and confusion.

The study

Small studies have shown that a letter from a GP could be as effective as interviews with the GP or a group run by a psychologist in reducing benzodiazepine use. This has now been tested in a randomised controlled trial.

Patients taking benzodiazepines (more than 6 months) were identified from the lists of 10 GPs from three group practices - all of which had a policy of trying to reduce benzodiazepine prescribing in existence. 209 patients were identified, with ages from 34 to 102 years (median 71); the ratio of women to men was 4:1, and the median duration of benzodiazepine use was 15 years (1-29 years). Patients taking benzodiazepines for certain defined conditions (like current psychosis or dementia) were not included.

These patients were randomly allocated to one of three groups:
  • No intervention.
  • Received a letter from the GP asking them to try to reduce or stop their medication, and explaining how to do this.
  • Received the same letter, together with four information sheets at monthly intervals.
Patients use of benzodiazepines was monitored for one year before the intervention, and for six months afterwards, by analysis of repeat prescriptions.

And the results

Patients in the two intervention groups reduced their consumption of benzodiazepines by at least 30% compared with the control group, which was highly statistically significant. There was no difference between the two interventions, of letter only or letter plus follow-up information.

Combining the two intervention groups, about a fifth of patients stopped taking benzodiazepines (compared with 6% in the control group) and over 40% reduced their consumption by half (more than twice that seen in the control group). It has to be recognised that these results were obtained in practices which had positive policies to reduce benzodiazepine prescribing.

Cost effective?

The letter patients received is reproduced in the article, and on average each GP sent out 20 letters - not overly demanding nor expensive. Nationally the effect could be savings of over £4 million on the drugs budget at 1989 prices. This is about £100,000 per million population. There might well be fewer confused elderly patients around, with a positive effect on general levels of health.

Reference:

Cormack et al, British Journal of General Practice 1994 44: 5-8.
Questions to be Answered
Q: What need is met by this?
A: Reduction in consumption of benzodiazepines, mainly by elderly patients.
Q: Is quality increased?
A:Yes - there will be fewer unwanted effects in patients who reduce their use of benzodiazepines.
Q: What is the cost of this intervention?
A: Effectively nothing.
Q: Can cost savings be made?
A: Yes - savings of at least £100,000 per million population could be expected if this process was followed by GPs nationally.
Advice to Health Authorities and GPFHs
Will increase quality and effectiveness.
Will decrease total cost of care.

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