1. 1 Benzodiazepine reduction in general practice. It’s easy! Viggo Kragh Jørgensen Specialist in General Practice Medical Advisor Medicine Team Region Midtjylland General Practitioner Thyborøn, Denmark

2. 2 Benzodiazepines

3. 3 Cyclopyrrolones

4. 4 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills)

5. 5 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills) Flunitrazepam (Rohypnol)

6. 6 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills) Flunitrazepam (Rohypnol) Anxiolytics (anxiety reducing agents)

7. 7 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills) Flunitrazepam (Rohypnol) Anxiolytics (anxiety reducing agents) Diazepam (Valium)

8. 8 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills) Flunitrazepam (Rohypnol) Anxiolytics (anxiety reducing agents) Diazepam (Valium) Hypnotics (sleeping pills)

9. 9 Benzodiazepines Cyclopyrrolones Hypnotics (sleeping pills) Flunitrazepam (Rohypnol) Anxiolytics (anxiety reducing agents) Diazepam (Valium) Hypnotics (sleeping pills) Zopiclone (Imovane, Zimovane and Zopinox)

10. 10 Benzodiazepines in 1969!

11. 11 Benzodiazepines in 2009…

12. 12 Adverse effects Dependence – Physical – Psychological – Tolerance – Rebound-effect (symptoms amplified by the end)

13. 13 Adverse effects Confusion Dizziness Drowsiness Tendency to fall Loss of memory

14. 14 Adverse effects Emotional bluntness Affects learning Affects memory Motor co-ordination

15. 15 Adverse effects Summary – Memory – Concentration

16. 16 Withdrawal 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. 17 Common withdrawal symptoms: Agitation Anxiety Insomnia Sweating Tremor Restlessness CNS Drugs 2007

18. 18 The positive The positive effect decrease The hypnotic effect is gone after a few weeks

19. 19 The positive The positive effect decrease The hypnotic effect is gone after a few weeks The anxiolytic effect is gone after a few months BMJ 1980 Cochrane 2005 Gerlach 2003

20. 20 The positive The positive effect decrease The hypnotic effect is gone after a few weeks 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. 21 Thyboron-project Thyborøn Medical Center Doctor Viggo Kragh Jørgensen Doctor Hans Holmsgaard In collaboration with Medical public health officer Børge Sommer Pharmacist Birgit Toft, Medicine Unit Doctor Max Fogh, Medicine Unit

22. 22 Basic Attitude Normal people should not be prescribed benzodiazepines or cyclopyrrolones for a longer period of time.

23. 23 Instruments The elimination of telephone prescriptions Prescription only following personal consultation Prescription for a single month only Exceptions  Nursing Homes  Terminal Patients  Psychiatric patients

24. 24 Instruments This leads to a discussion at each consultation regarding future treatment requirements as well as a possible phased reduction of treatments.

25. 25 Instruments Articles for the press Booklet for patients Guidance for staff

26. 26 Thyborøn Medical Centre results over 2 ½ years Thyborøn Medical Centre results over 2 ½ years -75 % -88 % -81 % Pharmacy Practice 2008 Anxiolytics benzodiazepines Hypnotics cyclopyrrolones Hypnotics benzodiazepines

27. 27 Thyborøn Medical Centre results over 3 ¼ years -85 % -91%-83% Siic may 2009

28. 28 Thyborøn Medical Centre Distribution grouping

29. 29 Thyborøn Medical Centre Age grouping

30. 30 Thyborøn Medical Centre results over 3 years Thyborøn Medical Centre results over 3 years - Antidepressiva Accepted Ugeskrift for Læger 2009 8.6 %

31. 31 Thyborøn Medical Centre results over 3 years Thyborøn Medical Centre results over 3 years - Antipsychotics Editorial process Ugeskrift for Læger 3,7 %

32. 32 Does the model works on a large scale? Can you reduce the consumption of an entire city?

33. 33 Lemvig ( Municipality ) Inhabitants:17.944 13 doctors, 8 medical centres in the city 2 medical centres in the country

34. 34 Lemvig ( Municipality ) The intervention covered approximately 900 inhabitants

35. 35 Lemvig ( Municipality ) The intervention was over 15 months

36. 36 Combined results over 15 months: Cyclopyrrolones (Hypnotics): -50,3% Benzodiazepines (Hypnotics):-46,5% Benzodiazepines (Anxiolytics):-41,7% Lemvig (Municipality) CNS Drugs 2007

37. 37 Lemvig ( Municipality ) Questionnaire

38. 38 Lemvig ( Municipality ) 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. 39 Lemvig ( Municipality ) Expected workload impact of the intervention ? 6,0 (12) VAS VAS Scale, 1 (lowest) -10 (highest) CNS Drugs 2007

40. 40 Lemvig ( Municipality ) Initial consultations : 4,3 per 1000 registered patients per week CNS Drugs 2007

41. 41 Lemvig ( Municipality ) Final consultations : 2.1 per 1000 registered patients per week CNS Drugs 2007

42. 42 Lemvig ( Municipality ) Patients relocated as a consequence of the project : 2 for the entire Municipality CNS Drugs 2007

43. 43 Lemvig ( Municipality ) Patients referred to psychiatrists. 5 for the entire municipality (13) CNS Drugs 2007

44. 44 Lemvig ( Municipality ) Patients hospitalized in psychiatric wards : 0 (13) CNS Drugs 2007

45. 45 Lemvig ( Municipality ) Patients hospitalized in local hospitals: 0 (13) CNS Drugs 2007

46. 46 Lemvig ( Municipality ) Patients referred to outpatient treatment at the counties addiction unit 4 (13) CNS Drugs 2007

47. 47 Lemvig ( Municipality ) Patients referred to homecare services: 0,9 per 1000 registered patients CNS Drugs 2007

48. 48 Lemvig ( Municipality ) Tentamen suicidi or suicidi : 0 (13) CNS Drugs 2007

49. 49 Lemvig ( Municipality ) Patients referred to external cognitive- behavioral therapy : 4 (13) CNS Drugs 2007

50. 50 Lemvig ( Municipality ) Patients treated with cognitive-behavioral therapy by own practitioner : 2,3 per 1000 registered patients (13) CNS Drugs 2007

51. 51 Lemvig ( Municipality ) Official complaints to the Danish Public Health Service Complaints Board, or to the Chief Medical Officer: 0 (13) CNS Drugs 2007

52. 52 Does the model work on a larger scale? Can you reduce the consumption of an entire region?

53. 53 Central Denmark Region (Region Midtjylland) Denmark Population: 1.2 million

54. 54 (western part) Central Denmark Region (western part) Population: 415.000 General Practices: 270 Estimated population with intervention: 20.000

55. 55 Other initiatives Education seminars Supervisory groups Psychotherapeutic counseling Medical health officers Smaller groups using Thyborøn-model

56. 56 Anxiolytics Benzodiazepines Diazepam, Clonazepam, Oxazepam, Lorazepam etc.

57. 57 Hypnotics Cyclopyrrolones Zopiclon, Zolpidem, Zaleplon

58. 58 Hypnotics Benzodiazepines Flunitrazepam, Nitrazepam, Triazolam etc.

59. 59 Does the model work on a larger scale? Can you reduce the consumption of an entire country?

60. 60 The Danish National Board of Health July 2008 Communication regarding the prescription of addictive drugs

61. 61 The Danish National Board of Health July 2008 Hypnotics Re-evaluation after 1-2 weeks Anxiolytics Re-evaluation after 1 month

62. 62 The Danish National Board of Health July 2008 Only prescriptions following personal consultation Extended treatment is not allowed Focus on road safety No prescriptions to the elderly or senile Psychiatrists may not end treatments for benzodiazepine-prescribed patients

63. 63 It is especially thought provoking when one discovers that 80-90% of one’s prescriptions of these potentially dangerous drugs are superfluous

64. 64 Doctors' prejudice is the biggest problem facing benzodiazepine reduction in general practice