1 benzodiazepine reduction in general practice. it’s easy! viggo kragh jørgensen specialist in...

1

Benzodiazepine reduction in Benzodiazepine reduction in general practice. general practice.

It’s easy!It’s easy!

Viggo Kragh JørgensenSpecialist in General Practice

Medical Advisor

Medicine Team Region Midtjylland

General Practitioner

Thyborøn, Denmark

2

Benzodiazepines

3

Benzodiazepines

Cyclopyrrolones

4

Benzodiazepines

Cyclopyrrolones

Hypnotics (sleeping pills)

5

Benzodiazepines

Cyclopyrrolones

Hypnotics (sleeping pills)Flunitrazepam (Rohypnol)

6

Benzodiazepines

Cyclopyrrolones


Anxiolytics (anxiety reducing agents)

7

Benzodiazepines

Cyclopyrrolones


Anxiolytics (anxiety reducing agents)Diazepam (Valium)

8

Benzodiazepines

Cyclopyrrolones



Hypnotics (sleeping pills)

9

Benzodiazepines

Cyclopyrrolones



Hypnotics (sleeping pills)Zopiclone (Imovane, Zimovane and Zopinox)

10

Benzodiazepines in 1969!

11Benzodiazepines in 2009…

12

Adverse effectsAdverse effectsDependence

– Physical– Psychological– Tolerance– Rebound-effect (symptoms

amplified by the end)

13

Adverse effectsAdverse effectsConfusionDizzinessDrowsinessTendency to fallLoss of memory

14

Adverse effectsAdverse effects

Emotional bluntnessAffects learningAffects memoryMotor co-ordination

15

Adverse effectsAdverse effects

Summary–Memory–Concentration

16

Withdrawal symptomsWithdrawal symptoms Fear Panic Excitability Phobias Irritability Depression Sleep disorders Hallucinations Paranoid thoughts Restlessness Concentration difficulty Tremor Dizziness Muscle cramps

Twitch Aggressiveness Hypersensitivity

– Sight – Hearing – Taste – Touch

Headache Paresthesia Sweat Nausea Gastrointestinal symptoms Influenza Symptoms Chest Pain Tinnitus

17

Common withdrawal Common withdrawal symptomssymptoms::

AgitationAnxietyInsomniaSweatingTremor Restlessness

CNS Drugs 2007

18

The positive The positive effect decrease

The hypnotic effect is gone after a few weeks

19



The anxiolytic effect is gone after a few months •BMJ 1980

•Cochrane 2005•Gerlach 2003

20



The anxiolytic effect is gone after a few month

Subsequently there are only side effects and withdrawal symptoms

•BMJ 1980•Cochrane 2005•Gerlach 2003

21

Thyboron-projectThyboron-project

Thyborøn Medical Center

Doctor Viggo Kragh Jørgensen Doctor Hans Holmsgaard In collaboration with

Medical public health officer Børge SommerPharmacist Birgit Toft, Medicine Unit Doctor Max Fogh, Medicine Unit

22

Basic Attitude

Normal people should not be prescribed benzodiazepines or cyclopyrrolones for a longer period of time.

23

InstrumentsInstruments

The elimination of telephone prescriptions

Prescription only following personal consultation

Prescription for a single month only

ExceptionsNursing HomesTerminal PatientsPsychiatric patients

24


This leads to a discussion at each consultation regarding future treatment requirements as well as a possible phased reduction of treatments.

25


Articles for the press Booklet for patients Guidance for staff

26

ThyborønThyborøn Medical Centre Medical Centre results over 2 ½ yearsresults over 2 ½ years

0

500

1000

1500

2000

2500

3000

DD

D_S

TD

Before 2153 2260 319

After 548 279 61

NO5BA NO5CF NO5CD

-75 % -88 % -81 %

Pharmacy Practice 2008

Anxiolyticsbenzodiazepines

Hypnotics cyclopyrrolones

Hypnotics benzodiazepines

27

Thyborøn Medical Centre Thyborøn Medical Centre results over 3 ¼ yearsresults over 3 ¼ years

-85 % -91% -83%

Siic may 2009

28

Thyborøn Medical Centre Thyborøn Medical Centre Distribution groupingDistribution grouping

29

Thyborøn Medical Centre Thyborøn Medical Centre Age groupingAge grouping

30

ThyborønThyborøn Medical Centre Medical Centre results over 3 yearsresults over 3 years

-

Antidepressiva

Accepted Ugeskrift for Læger 2009

8.6 %

31

ThyborønThyborøn Medical Centre Medical Centre results over 3 yearsresults over 3 years

-

Antipsychotics

Editorial process Ugeskrift for Læger

3,7 %

32

Does the model works on a Does the model works on a large scale?large scale?

Can you reduce the consumption of an entire city?

33

Lemvig Lemvig ((MunicipalityMunicipality))

Inhabitants:17.944

13 doctors, 8 medical centres in the city 2 medical centres in the country

34


The intervention covered approximately 900 inhabitants

35


The intervention was over 15 months

36

Combined results over 15 months:

Cyclopyrrolones (Hypnotics): -50,3%

Benzodiazepines (Hypnotics):-46,5%

Benzodiazepines (Anxiolytics):-41,7%

Lemvig (Municipality)Lemvig (Municipality)

CNS Drugs 2007

37


QuestionnaireQuestionnaire

38


Actual workload impact of the intervention ?:

3,6 (13) VAS

Visual Analogue Scale where 1 (lowest) -10 (highest) is a measure of workload impact.

CNS Drugs 2007

39


Expected workload impact of the intervention?

6,0 (12) VAS

VAS Scale, 1 (lowest) -10 (highest)

CNS Drugs 2007

40


Initial consultations :

4,3 per 1000 registered patients per week

CNS Drugs 2007

41


Final consultations :

2.1 per 1000 registered patients per week

CNS Drugs 2007

42


Patients relocated as a consequence of the project :

2 for the entire Municipality

CNS Drugs 2007

43


Patients referred to psychiatrists.

5 for the entire municipality (13)

CNS Drugs 2007

44


Patients hospitalized in psychiatric wards:

0 (13)

CNS Drugs 2007

45


Patients hospitalized in local hospitals:

0 (13)

CNS Drugs 2007

46


Patients referred to outpatient treatment at the counties addiction unit

4 (13)

CNS Drugs 2007

47


Patients referred to homecare services:

0,9 per 1000 registered patients

CNS Drugs 2007

48


Tentamen suicidi or suicidi :

0 (13)

CNS Drugs 2007

49


Patients referred to external cognitive-behavioral therapy :

4 (13)

CNS Drugs 2007

50


Patients treated with cognitive-behavioral therapy by own practitioner :

2,3 per 1000 registered patients (13)

CNS Drugs 2007

51


Official complaints to the Danish Public Health Service Complaints Board, or to the Chief Medical Officer:

0 (13)

CNS Drugs 2007

52

Does the model work on a Does the model work on a larger scale?larger scale?

Can you reduce the consumption of an entire region?

53

Central Denmark Region (Region Midtjylland)

Denmark

Population: 1.2 million

54

Central Denmark Region (western part)(western part)

Population: 415.000

General Practices: 270

Estimated population with intervention:20.000

55

Other initiativesOther initiatives

Education seminarsSupervisory groupsPsychotherapeutic counselingMedical health officersSmaller groups using Thyborøn-model

56

AnxiolyticsAnxiolytics BenzodiazepinesBenzodiazepinesDiazepam, Clonazepam, Oxazepam, Lorazepam etcDiazepam, Clonazepam, Oxazepam, Lorazepam etc..

57

Hypnotics Hypnotics CyclopyrrolonesCyclopyrrolonesZopiclon, Zolpidem, ZaleplonZopiclon, Zolpidem, Zaleplon

58

Hypnotics Hypnotics BenzodiazepinesBenzodiazepines Flunitrazepam, Nitrazepam, Triazolam etc.Flunitrazepam, Nitrazepam, Triazolam etc.

59

Does the model work on a Does the model work on a larger scale?larger scale?

Can you reduce the consumption of an entire country?

60

The Danish National Board of Health July 2008

Communication regarding the prescription of addictive drugs

61


HypnoticsRe-evaluation after 1-2

weeks

AnxiolyticsRe-evaluation after 1 month

62


Only prescriptions following personal consultation

Extended treatment is not allowedFocus on road safetyNo prescriptions to the elderly or senilePsychiatrists may not end treatments for

benzodiazepine-prescribed patients

63

It is especially thought provoking when one discovers that 80-90% of one’s prescriptions of these potentially dangerous drugs are superfluous

64

Doctors' prejudice is the biggest problem facing benzodiazepine reduction in general practice

1 benzodiazepine reduction in general practice. it’s easy! viggo kragh jørgensen specialist in...

Documents

weeksthe anxiolytic

agentsdiazepam valiumhypnotics

viggo kragh jrgensenspecialist

withdrawal symptomsbmj

prescribed benzodiazepines

pharmacy practice

benzodiazepine reduction

medicine unitdoctor