Medication Information and Guidance
Amitriptyline
Amitriptyline: why we are reviewing your prescription
If you take amitriptyline, you may be invited to a medication review with one of our clinicians over. This summary below explains why, and what it could mean for you.
Amitriptyline was first developed as an antidepressant. Today, however, it is mostly prescribed at low doses, usually 10mg, to help with long-term nerve pain, atypical pain, irritable bowel syndrome, to prevent migraines, and sometimes to help with sleep. For some people it works well. For many others the benefit is small, and the side effects can build up over time, particularly as we get older.
Our aim is simple: to make sure everyone taking amitriptyline is still getting a real benefit from it, and that the benefit outweighs the risks.
What is anticholinergic burden?
Acetylcholine is a chemical messenger that helps control memory, attention, muscle movement, bladder and bowel function. Some medicines block it. These are called anticholinergic medicines, and amitriptyline is one of the strongest of these types of medicines.
Doctors and pharmacists use a scoring system called the Anticholinergic Burden (ACB) score to rate medicines from 1 (mild effect) to 3 (strong effect). Amitriptyline scores 3. Your total burden is the sum of the scores of everything you take, so it rises quickly when several medicines that block acetylcholine are combined. Common examples include some bladder medicines, some antihistamines and some medicines for mental health.
Common anticholinergic side effects include:
• dry mouth and blurred vision
• constipation
• difficulty passing urine
• drowsiness and dizziness
• confusion and poor concentration
Why it matters more after 60
As we age, our bodies process medicines more slowly and become more sensitive to their effects. A dose that suited you at 50 may affect you differently at 70. For older adults, a high anticholinergic burden is linked to:
• Falls and fractures, because drowsiness, dizziness and blurred vision affect balance
• Confusion and memory problems, which can be mistaken for other conditions
• Long-term effects on the brain: research has linked long-term use of strongly anticholinergic medicines with a slightly higher risk of dementia
A fall can mean a hip fracture, a hospital stay and a loss of independence. Reducing medicines that affect balance is one of the most practical ways to lower that risk.
Evidence shows limited benefit
The evidence for benefit is also more modest than many people expect. A Cochrane Review found the evidence for amitriptyline in nerve pain is limited. It estimated that about one in four people will get meaningful pain relief compared with a dummy (placebo) tablet, and about one in four will have a side effect.
The picture in Devon
NHS Devon’s medicines optimisation team has shared prescribing data with every practice in the county. It shows:
• Amitriptyline is the single biggest contributor to anticholinergic burden in Devon, with over 102,000 items prescribed in three months in 2025
• About three quarters of that is the 10mg tablet, and 97% of patients on 10mg take no other strength
• 55% of Devon patients prescribed amitriptyline 10mg are over 60
• Practices in Devon prescribe amitriptyline at a greater frequency compared to the average prescribing in the whole of England.
These figures do not mean anyone has been prescribed amitriptyline wrongly. Many people started it years ago for good reasons. But circumstances change, and regular review is good practice.
What a review involves
We are prioritising patients aged 60 and over and those taking other anticholinergic medicines. You may receive a text, email, call or letter inviting you to book a telephone medication review. Any decision will be made together with you. Nobody will have their medicine stopped without a conversation first.
In your review we will talk about:
• why you started amitriptyline and whether it is still helping
• any side effects, such as constipation, dry mouth, drowsiness or unsteadiness
• your other medicines and your overall anticholinergic burden
• whether a trial without it, or a lower dose, might suit you
NICE guidance advises against using antidepressants such as low-dose amitriptyline solely to treat sleep problems. If you take it mainly for sleep, we can talk about other approaches that are often more effective long term, such as cognitive behavioural therapy for insomnia (CBT-I).
Please do not stop amitriptyline suddenly on your own. Some people notice withdrawal effects within about five days of stopping, such as nausea, headache or poor sleep. These are usually mild and short-lived, but we may suggest reducing gradually, for example taking it every other day for a period. If you have any concerns, contact the surgery.
Further information
• NHS: Amitriptyline for pain and migraine
• NICE CG173: Neuropathic pain in adults
• NICE NG215: Medicines associated with dependence or withdrawal symptoms
• MHRA Yellow Card scheme: report any side effect you think may be linked to a medicine
Data source: NHS Devon Medicines Optimisation Scheme 2026/27 data pack (ePACT2, October to December 2025).
Insomnia
Trouble sleeping? Help and support for insomnia
*Resources for Insomnia and mental health support can be found towards the end of this page*
Poor sleep is very common, and most short spells settle by themselves within a few weeks. Insomnia means difficulty falling asleep, waking often in the night, or waking too early, despite a reasonable opportunity to sleep, and this affecting how you feel the next day. Most adults need seven to nine hours, but this varies, and it is normal to wake briefly during the night.
What helps most?
Changing sleep habits works better in the long run than sleeping tablets. Small, consistent changes are the place to start. Sometimes this is referred to as “sleep hygiene”.
Build a steady routine
– Getup at roughly the same time every day, including weekends, even after a bad night
– Only go to bed when you feel sleepy, not simply because it is late
– If you are awake and frustrated after about 20 minutes, get up, do something quiet in dim light, and return when sleepy
– Avoid daytime naps, or keep them short and early
Look at your day routine, not just your night
– Get outside in natural daylight, particularly in the morning, exposure to daylight (luxe) helps your bodies inner body clock
– Be active during the day, but not vigorously in the last couple of hours before bed
– Cut caffeine after early afternoon. Tea, fizzy carbonate drinks, energy drinks and chocolate all contain caffeine.
– Reduce alcohol. Whilst alcohol may help you drop off, it fragments sleep and worsens early waking
– Avoid smoking or vaping close to bedtime, as nicotine is a stimulant
Protect the bedroom
– Keep it dark, quiet, cool and comfortable
– Keep the bed for sleep and sex only, not for work, television or scrolling
– Leave phones and tablets outside the bedroom, and stop screens an hour before bed
– Avoid clock-watching, which fuels anxiety about sleep
Deal with a busy mind
– Write worries and tomorrow’s to-do list down earlier in the evening, rather than at 2am
– Try a wind-down routine: a warm bath, reading, gentle stretching or a relaxation exercise, mindfulness exercises can be helpful.
Cognitive behavioural therapy for insomnia (CBT-I)
If poor sleep has lasted more than a few weeks, the recommended treatment is not a tablet. NICE and the Devon Formulary recommend cognitive behavioural therapy for insomnia (CBT-I) as the first-line treatment for long-term insomnia. It is a structured, practical programme that tackles the habits and thoughts keeping the problem going, and its benefits last after the course ends. You do not need a GP appointment to start.
- TALKWORKS, Devon’s free NHS talking therapies service, runs a two-hour Improving Sleep workshop alongside one-to-one CBT, group courses and online self-help for adults aged 18 and over living in Devon.
You can Refer yourself via: 🌐 https://www.talkworks.dpt.nhs.uk/self-refer or call 📞 0300 555 3344.
🌐 https://www.talkworks.dpt.nhs.uk/sleep-workshop
- Sleepstation, an NHS-commissioned online CBT-I programme with sleep coach support. 🌐 https://www.sleepstation.org.uk/request-nhs-access/check-availability/
- Sleepio – is a six-week sleep improvement program. It has been designed by sleep expert Prof Colin Espie and features the latest cognitive and behavioural techniques. It is clinically proven to help a person fall asleep faster, stay asleep through the night and feel better during the day – whether they’ve had poor sleep for weeks, months or even years. The whole course takes place online via a computer, tablet or mobile app. 🌐 io
- A podcast on Sleep: 🌐 How to Get a Good Night’s Sleep: The Very Best Tips on Sleep
- Some medications for insomnia such as dariodorexant require patients to have completed a CBT-I course and found now benefit before they can be trialled.
Why we try to avoid sleeping tablets
Sleeping tablets, mainly the “z-drugs” (zopiclone, zolpidem) and benzodiazepines (such as diazepam), can help very briefly, but they carry real risks:
– Only around 1 in 13 people will get benefit from them and that benefit is small (an additional 25minutes of sleep), and yet they carry significant risks and side effects
– The body adapts within days to weeks, so the same dose stops working
– They cause dependence and difficult withdrawal, which can leave sleep worse than before
– They cause next-day drowsiness, poor concentration and memory problems
– They increase the risk of falls and fractures, particularly in older people
– Driving while affected is an offence, and you must tell the DVLA if sleepiness is likely to affect your driving.
In January 2026 the Medicine health regulator – MHRA strengthened the addiction and dependence warnings on the packaging and patient leaflets for benzodiazepines and z-drugs, following a review by the Commission on Human Medicines.
Where a clinician does think medication is appropriate, it will normally be the lowest effective dose for a very short course, typically three to seven days, with a stopping plan agreed at the outset and a review booked if needed.
Over-the-counter sleep aids sold in pharmacies – usually sedating antihistamines, are not recommended for regular use and commonly cause next-day grogginess. Melatonin is prescription-only in the UK and is used in specific, limited circumstances.
When to contact the surgery
Please contact the surgery for a review if:
– Poor sleep has lasted more than four weeks despite trying the measures above and completing CBT-I course
– You snore heavily, gasp or stop breathing in your sleep, or feel very sleepy during the day, which can suggest sleep apnoea
– You have uncomfortable, restless legs in the evening
– Low mood, anxiety, pain, the menopause or another health problem seems to be driving it
– You want help to reduce or stop a sleeping tablet
Further resources on sleep
– NHS: Insomnia – 🌐 https://www.nhs.uk/conditions/insomnia/
– NHS: Sleep and tiredness – 🌐 https://www.nhs.uk/live-well/sleep-and-tiredness/
– Sleeping Problems: NHS self-help guide -https://www.selfhelpguides.ntw.nhs.uk/devon/leaflets/selfhelp/Sleeping%20Problems.pdf
– The Sleep Charity – 🌐 https://thesleepcharity.org.uk/
– Mind: tips to improve your sleep – 🌐 https://www.mind.org.uk/information-support/types-of-mental-health-problems/sleep-problems/tips-to-improve-your-sleep/
– Choice and Medication: insomnia- 🌐https://www.choiceandmedication.org/devon/condition/insomnia/
– Reading Well: Books on Prescription – 🌐 https://reading-well.org.uk/
– Free self-help books through your local library
Urgent help and General help for Mental health and wellbeing
Sometimes insomnia is a symptom of mental health struggles with mood, anxiety or other mental health condition.
For urgent help in a crisis Click HERE or 📞 ring 111
- If you or a loved one are struggling to cope or feel you are unable to keep yourself safe, you can call NHS 111 and select the mental health option for Devon’s 24/7 First Response crisis Service.
- The Samaritans are available day and night on 📞 116 123, or 📞 text SHOUT to 85258.
- If needing immediate help in an emergency, 📞 call 999.
General Help for mental health and wellbeing
TALKWORKS (Talking Therapies, Cognitive Behavioral Therapies)
Trained practitioners to help you understand and find ways of tackling, coping and working out life’s problems, including stress, anxiety, panic attacks, depression, obsessions, anger, difficulty coping, relationship difficulties, loss and bereavement. They can also help with long term physical health conditions. A range of options include individual or group sessions, workshops and interactive computer programmes.
📞 0300 555 3344
🌐 self refer here https://www.talkworks.dpt.nhs.uk/#get-help
Reading Well – Books on Prescription
Self-help books for managing common conditions. Please visit your local library or visit the website below.
Mindfulness
Meditation exercises to enable you to pay attention to the present moment, helping you become more aware of your thoughts & feelings. Proven to help stress, anxiety, depression, fatigue & sleep problems, addictions, relationship problems, and even physical problems like heart disease, hypertension and chronic pain.
🌐 https://www.bemindfulonline.com/
🌐 http://www.freemindfulness.org/download
Mind
Provide advice and support to empower anyone experiencing a mental health problem
📞 0300 123 3393 🌐 www.mind.org.uk
Mental Health Crisis
For support in a mental health crisis and to prevent self-harm or suicide (in an emergency call 999 or 111)
🌐 www.maytree.org.uk 📞 020 7263 7070
App https://www.prevent-suicide.org.uk/find-help-now/stay-alive-app/
SHOUT
What is Shout: 24/7 text service, Support to take you from a hot moment to feeling calmer, A safe space where you’re listened to by a trained Crisis Volunteer, Our service is based on a tried and tested model of crisis support, 24/7 anonymous free conversation that won’t show on your phone bill, Professional support creating a simple plan of action to manage your crisis.
🌐 https://www.giveusashout.org/get-help/
Text For support in a crisis, Text Shout to 85258
Relate
Counselling, support and information for all relationships
📞 0300 100 1234 🌐www.relate.org.uk
Samaritans
Someone who will listen to you and will help you talk through your concerns, worries and troubles
📞 116 123 🌐www.samaritans.org
Cruse Bereavement Care
Provide support and care after a bereavement
📞 0808 808 1677 🌐www.cruse.org.uk
Citizens Advice
Offer free, independent, confidential and impartial advice to help people resolve numerous issues that may be affecting your mental wellbeing, including advices on benefits, work, finance, consumer, relationship, housing, discrimination, tax, education, healthcare and legal issues.
📞03444 111 444 (National) 🌐 https://www.citizensadvice.org.uk/
Clarity
Mental health charity based in Barnstaple, Devon providing services and support to people experiencing mental health and emotional issues. Monday – Thursday
📞 01271 267474
Devon Together Drug and Alcohol Service
📞 0800 233 5444
Kingscare Newton Abbot memory cafe
Third Thursday of the month – 2pm – 3:45pm – The Avenue Church, Newton Abbot, TQ12 2BY. £3 Per Person or £5 if accompanied by someone
📞 07557 275324 Email jayne.edwards16@nhs.net
🌐 https://kingscare.co.uk/what-we-do/memory-cafes/newton-abbot-memory-cafe/
https://dmcc.org.uk/newton-abbot/
The Moorings at Torquay, Exeter or Barnstaple
Offers out of hours mental health support to anyone over 16years. No appointment or referral needed. Open 4pm-10pm, Monday to Sunday.
📞 07483 991 848 🌐 https://www.mhm.org.uk/moorings-torquay https://www.mhm.org.uk/the-moorings-devon
Other Resources
🌐 https://www.anxietyuk.org.uk/
🌐 https://www.beatingtheblues.co.uk/
🌐 https://www.nhs.uk/mental-health/
Opioids and prescribing
Opioid painkillers, including codeine: what has changed and why?
You may notice that we now prescribe opioid painkillers in smaller quantities and for shorter periods, and if you take one regularly, we may invite you for a medication review. This is not about doubting your pain. It is about making sure the medicines you take are genuinely the right medications for you, and are not quietly doing you harm.
What we mean by opioids
Opioids are morphine-based painkillers: codeine and co-codamol (codeine combined with paracetamol), dihydrocodeine and co-dydramol, tramadol, and stronger drugs such as morphine and oxycodone. Codeine-containing medicines are by far the most commonly prescribed opioids in Devon.
Good for short-term pain, poor for long-term pain
Opioids are the strongest painkillers available and can be very effective for severe, short-lived pain: after surgery, after an injury such as a broken bone, or as part of cancer care. Used briefly, at the lowest effective dose, they are usually safe.
For pain lasting more than about three months, the evidence points the other way.
- When you start an opioid, or increase the dose, pain usually settles for a few days or weeks. Your body then adapts and the pain returns to roughly where it was, but you are now on a higher dose with more side effects. This is called tolerance.
- Opioids can also make you more sensitive to pain, at any dose. This is called opioid-induced hyperalgesia. The medicine can end up causing some of the pain it was meant to treat.
- Codeine is converted into morphine by the body, and people vary a great deal in how fast they do this. Around three in every hundred convert it very quickly, so a routine codeine dose can act like a much larger dose of morphine.
- The National Institute of Clinical Excellent (NICE), which sets NHS treatment standards, found no good evidence that opioids help chronic primary pain and advises against their use in chronic pain or starting them for it.
(NG193: https://www.nice.org.uk/guidance/ng193 )
Its guidance on low back pain and sciatica takes a similar
(NG59: https://www.nice.org.uk/guidance/ng59 )
- The Faculty of Pain Medicine puts it plainly in its ‘Opioids Aware guidance’ : if you are taking an opioid and are still in pain, the opioid is not working and should be stopped, even if nothing else is available to replace it.
(https://fpm.ac.uk/opioids-aware/information-patients )
- The MHRA, the UK medicines regulator, warned in 2020 that using opioids for more than three months for non-cancer pain significantly increases the risk of dependence and addiction. Opioid packs now carry an addiction warning for this reason.
The risks around opioid use
Common side effects include constipation, nausea, drowsiness, dizziness, itching, weight gain, low sex drive and reduced fertility. The more serious risks include:
– Falls and fractures – Older people taking opioids are around twice as likely to have a fall.
– Dependence and addiction – Uncommon after a short course, much more likely with continued use over weeks to a few months.
– Breathing problems – particularly at night and especially if you have sleep apnoea.
– Dangerous combinations – Risks rise sharply when opioids are taken with alcohol, benzodiazepines such as diazepam, or gabapentin and pregabalin.
– Medication overuse headache – Taking painkillers on more than about ten days a month can start to cause headaches in itself.
– Driving and heavy machinery use – You may drive on prescribed opioids if you follow your prescriber’s instructions, but it is illegal to drive if you are impaired. Take particular care in the days after starting or changing a dose.
How is Devon doing with opioid prescribing?
Recent prescribing data reviewed by NHS Devon shows that Devon is an outlier compared to the national average of opioid prescribing:
– People in Devon are about 10% more likely to be prescribed an opioid than the England average (5.7% of the population against 5.2%).
– Nearly two thirds of Devon patients on an opioid are given a codeine-containing medicine, more than all other opioids put together.
- Around three quarters had been receiving it for at least 6-9 months, pointing to long-term rather than short-term use, which is not advised by guidelines
- More than half of those long-term users are 65 or over, the group most vulnerable to falls.
How we will prescribe opioids at Albany?
All practices in Devon and across the England, are being advised to prescribe opioids less and reduce patients who have been on them for a long time or for chronic pain off of them, in line with guidance.
To keep prescribing safe and consistent, we are adopting the following approach:
– Short, defined courses – New opioid prescriptions will be for small quantities and a set number of days, typically a 2 week course, with a clear plan for stopping, and issued as one-off acute prescriptions rather than added to your repeat list.
– Lower strengths and doses – Where codeine or an opioid is still needed, we will aim for the lowest strength and smallest quantity that keeps your pain manageable and reduces the risks of addiction and side effects.
– Separate paracetamol and codeine prescriptions – Where appropriate we may change co-codamol to separate tablets, so the codeine dose can be adjusted on its own. Most people then take less of it while keeping the same pain control.
– Regular review – Repeat prescriptions will be reviewed by our practice pharmacist or GP at set intervals to check the medicine is helping and is still safe and to review and institute step wise reductions.
– Early or excess requests – If prescriptions are requested ahead of schedule or are taken in larger quantities than agreed, we may decline the request, future date the prescription for when it would have been due and arrange a medication review before more is issued/or to discuss future issues. This is a safety check, not a punishment.
– Prescribing agreements – For some patients we may put a written agreement in place setting out what will be prescribed, how often, and who will review it, so everyone has the same understanding.
– Lost or stolen medications – due to the risky nature of these medications and because some opioids are controlled drugs, secure storage of these is vital for safety. If you lose your opioids medication or it is stolen, we may ask for a police crime number, if this happened recurrently we may decline to issue more.
If your opioid medication dose is being reduced
Please do not stop suddenly, stopping abruptly can be unpleasant and, in some cases, unsafe, in most cases a gradual reduction and withdrawal of medication is the best approach.
We will gradually be arranging for patients, who have been taking opioid medications for longer than 3 months, or who have no clear indication/reason for being on them or who are on them for chronic pain/back pain, to have a medication review with our practice pharmacist or GP. Together you and clinician will discuss the risks and benefits and arrange a gradual reduction in medication dose/strength. Reductions go at a pace you can manage, and can be paused, It can take many months, sometimes up to 2 years to come off of these medications, fortunately many people, who reduce gradually find their pain is no worse, and once off of them often get better response to opioids medications of needed as an acute short course in the future.
The local pain team recommends reducing by around 10% every week, with a pause of about a month after every 30% reduction. At that pace most people get no withdrawal symptoms and only small, short-lived flares in pain with each step down.
Specialists are clear that gradual withdrawal is safe and generally does not make pain worse. Most people who reduce carefully find that after a few weeks their pain is no worse than before, their head is clearer, and they feel less tired and muddled. Our local NHS pain service also asks that opioid reduction is underway or complete before they take on a referral, because opioids can mask what is really driving the pain.
Please do be aware that if you request your medication early or have taken more than is advised on your prescription, you may be switched to shorter duration issues of your medication eg 7 or 14 days, this is part of safe prescribing procedure and not a judgement on you. From time-to-time patients may also be asked to sign a prescribing agreement, that explains the risks of the medication and how often it will be issued and in what circumstances it will not be issued.
What other measures can help?
Long-term pain is rarely fixed by a tablet, in fact there is no single painkiller shown to help chronic pain in every case, which is why guidance advises against opioids for this. Stress, poor sleep, low mood, past trauma and worries about money or housing all feed into how much pain you feel, and addressing them often helps more than medication. Discussing how best to address these with your GP can be helpful. These resources are also worth exploring:
– ReConnect2Life – the local NHS pain rehabilitation programme
🌐 https://www.torbayandsouthdevon.nhs.uk/services/pain-service/reconnect2life/
– Opioids Aware: information for patients
🌐 https://fpm.ac.uk/opioids-aware/information-patients
– Live Well With Pain
🌐 https://livewellwithpain.co.uk/
– Tame The Beast
🌐 https://www.tamethebeast.org/
– TALKWORKS – free NHS talking therapies you can refer yourself to
🌐 https://www.talkworks.dpt.nhs.uk/
– NHS guidance on opioid medicines and the risk of addiction
🌐 https://www.gov.uk/guidance/opioid-medicines-and-the-risk-of-addiction
Prescribing of Diazepam for Medical Procedures and Fear of Flying
After very careful consideration Albany Surgery has reviewed our benzodiazepine (diazepam/lorazepam etc) prescribing and established our new policy not to prescribe benzodiazepines or sedatives (such as diazepam) to patients for medical procedures or fear of flying. This is in line with up to date guidance and other GP practices.
Medical Procedures
The Practice has made the decision not to prescribe Diazepam, or any sedation, for MRI scans or any other medical procedures, including dental procedures.
Some people find scans daunting and in the past, you may have received a prescription from your GP for a sedative such as Diazepam to help with claustrophobia or anxiety during such procedures. Such prescribing is no longer considered safe.
This will no longer be possible for the reasons detailed below.
For most cases we, as your GP Practice, do not request MRI scans. These are almost always requested by hospital clinicians. If you feel too anxious to undergo an MRI scan, please speak to the requesting team to discuss your options as this is the responsibility of the specialist requesting the scan.
There are several reasons why we do not prescribe these medicines for procedures:
- GPs are not trained to provide the correct level of sedation for a procedure / scan. Providing too little sedation will not help you, providing too much sedation can make you too sleepy, which could lead to the procedure being cancelled. Too much sedation can dangerously affect your breathing. After taking a sedative for a procedure or scan, you will need to be closely monitored to keep you safe.
- Although Diazepam makes most people who take it sleepy, in some rare situations it can have an opposite effect and make people aggressive or agitated.
- Scans and hospital procedures are often delayed, therefore the team performing the procedure or scan should provide the sedation, to ensure you become sleepy and relaxed at the right time.
The Royal College of Radiologists have strict guidance on the safe sedation of patients during investigations such as CT and MRI scans. It would be unsafe for us to prescribe a sedative that we unable to monitor. If you were to become unwell during a scan after taking a sedative that the Radiology team did not know about, this could be very dangerous.
Again, if you have concerns about anxiety of claustrophobia with regards to a scan, please contact the Department who requested the scan or the Radiology department, as they are responsible for providing this if they feel it is clinically necessary. It is not the responsibility of the Practice, and we will not prescribe for these reasons.
Finally, for procedures such as cataract operations or dental procedures it is the responsibility of the Surgeon or Dentist to prescribe any sedation, if they feel you require it. Requests to the Practice for such reasons will always be declined.
Fear of Flying
People often come to us requesting that we prescribe diazepam for fear of flying or to assist with sleep during flights.
Initially in the 1960s benzodiazepines including Diazepam (also known as ‘Valium’) were hailed as a wonder drug, However, it became increasingly clear that, as well as having short term deleterious effects on memory, co-ordination, concentration, and reaction times, they were also addictive, with withdrawal leading to fits, hallucinations, agitation, and confusion. Furthermore, they were found to have long term effects on cognition/memory and balance. Unfortunately, benzodiazepines have also become a widely used drug of abuse since they first came on the market. Because of these reasons the use of benzodiazepines has been a lot more controlled around the world since the 1980s-90s; especially in the UK.
Diazepam in the UK is a Class C/ Schedule IV controlled drug.
The following short guide outlines the issues surrounding its use with regards to flying and why our practice no longer prescribes such medications for this purpose.
There are several very good reasons why prescribing this drug is not recommended.
- The use of any sort of benzodiazepines causes longer reaction times and slowed thinking, which during a flight will put the passenger at significant risk of not being able to act in a manner which could save their life, or that of a loved one or co-passenger, in the event of a safety critical incident. Incapacitation from benzodiazepines is a risk to the lives of all on board the aircraft in the event of an emergency requiring evacuation.
- The use of such sedative drugs can make you fall asleep, however when you do sleep it is an unnatural non-REM sleep. This means you won’t move around as much as during natural sleep; this can cause you to be at an increased risk of developing a blood clot (Deep Vein Thrombosis- DVT) in the leg or even in the lungs. Blood clots are every dangerous and can even prove fatal.
- Whilst most people find benzodiazepines like diazepam sedating, a small number have the opposite: agitation and aggression. They can also cause disinhibition and lead you to behave in a way that you would not normally. This could impact on your safety as well as that of other passengers and could also get you into trouble in law.
- Benzodiazepine use added to alcohol consumption causes an increase in the risk posed by the points above.
- According to prescribing guidelines doctors follow (British National Formulary) diazepam is contraindicated (not allowed) in treating phobic states. It also states that the use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate. Your doctor would be taking a significant legal risk by prescribing against these guidelines. (They are only licensed short term for a crisis in generalised anxiety. If this is the case, you should be getting proper care and support for your mental health and not going on a flight; benzodiazepine doses used for flying previously are not likely to control an acute crisis in generalised anxiety disorder).
- NICE guidelines suggest that medication should not be used for mild and self- limiting mental health disorders. In more significant anxiety related states, benzodiazepines, sedating antihistamines, or antipsychotics should not be prescribed.
- In some countries it is illegal to import these drugs, e.g., in the Middle East, and so the passenger will need to use a different strategy for the homeward bound journey and / or any subsequent legs of journey; they may be confiscated, or you may find yourself in trouble with the police. The passenger may also need to use a different strategy for the homeward bound journey and/ or other legs of the journey.
- Diazepam stays in your system for quite a while. If your job requires you to submit to random drug testing, you may fail this having taken diazepam.
- Benzodiazepines have been linked to the onset of dementia.
- A study published in 1997 from the Stanford University School of Medicine (iv) showed that there is evidence that use of benzodiazepines stops the normal adjustment response that would gradually lessen anxiety over time and therefore perpetuates and may increase anxiety in the long term, especially if used repeatedly. In an article in Clinical Psychiatry News, Shanna Treworgy. Psy.D of the Dartmouth Geisel Medical School, said that though there may be reduced anxiety in the moment, benzodiazepines caused increased long-term anxiety reactions.
Given the above we will no longer be providing Diazepam for flight anxiety and instead suggest the below aviation industry recommended flight anxiety courses which are easily accessible for those who wish to fly & conquer their fear of flying, e.g.
- Easy Jet easyjet.comTel 02023 8131644
- British Airways comTel 01252 793250
- Virgin co.ukTel 01423 714900
- Flight anxiety does not come under the remit of General Medical Services as defined in the GP contract and so we are not obliged to prescribe for this.
- Patients who still wish to take benzodiazepines for flight anxiety are advised to consult with a private GP or travel clinic.
- It is important to declare all medical conditions and medications you take to your travel insurer. If not, there is a risk of nullifying any insurance policy you may have.
Further information
www.nhs.uk/medicines/diazepam/about-diazepam
For further information/References:
- British National Formulary; Diazepam
https://bnf.nice.org.uk/drug/diazepam.html
- British National Formulary: Hypnotics and anxiolytics
https://bnf.nice.org.uk/treatment-summary/hypnotics-and-anxiolytics.html
- Generalised anxiety disorder and panic disorder in adults: management. NICE Clinical guideline (CG113) Published date: January 2911 Last updated: July 2019 https://www.nice.org.uk/guidance/cg113
- Acute and delayed effects of Alprazolam on flight phobias during exposure. Behav Res Ther. 1997 Sep; 35 (9): 831-41
- Travel Health Pro; Medicines and Travel; Carrying medication abroad and advice regarding falsified medication.
Sleeping tablets and Sedatives
Sleeping tablets and sedatives: why we are prescribing them less?
You may have heard that GP practices across Devon are reducing how often they prescribe medicines like, zopiclone, zolpidem, diazepam, lorazepam, temazepam and nitrazepam. Albany Surgery is one of them. This page explains what these medicines are, why the evidence has changed, and what it means if you are taking one now.
What are these medicines?
Benzodiazepines – diazepam, lorazepam, temazepam, clonazepam, midazolam are sedatives. They can help for a few days with severe anxiety, muscle spasm, seizures or alcohol withdrawal and in end of life care.
“Z-drugs” – zopiclone, zolpidem are sleeping tablets. They are not benzodiazepines, but they act on the brain in a very similar way and carry the same problems with long-term use.
Both are controlled drugs and both are licensed for short-term use only, usually no more than two to four weeks, which includes the time it takes to come off them.
Why we are changing how we prescribe?
- Local data shows that Devon as a whole is a national outlier, with 1.22% of the population prescribed one of these medicines compared with 0.80% nationally.
- We are not alone in tackling this, all practices across Devon have been tasked to reduce their prescribing of these medications to improve safety.
- The honest answer is that the benefit is smaller than most people expect, and the risks are larger.
Research on Z drugs summarised by the NHS puts it like this. Imagine 13 people aged 60 or over with insomnia are all take a sleeping tablet for at least five nights:
– Of these 13 people about 1 person sleeps better. On average they get just an extra 25 minutes’ sleep a night, and wake once less often every other night.
– About 2 people get side effects that they would not have had otherwise: drowsiness, headache, nightmares, nausea or stomach upset.
– The other 10 people get no benefit at all, compared with a placebo tablet.
Z-drugs and benzodiazepines also carry some significant harms:
– Falls and fractures – These medicines roughly double the risk of falls in older adults.
– Dependence/Addiction – The Royal College of Psychiatrists estimates that around 4 in every 10 people, who take them daily for more than six weeks will become dependent/addicted.
– Tolerance – Over months the same dose stops working, so the medicine keeps being taken without it helping.
– Memory, mood and thinking – Long-term use is linked to poor concentration, low mood and memory problems that can be mistaken for dementia.
– Increased risks/side effects in combination with other medications – The MHRA, the UK medicines safety regulator, warns that benzodiazepines and Z-drugs when taken with opioid painkillers (codeine, morphine, tramadol) can cause breathing to slow, which can be fatal in some instances. The two should only be taken together where there is no alternative.
When we might still prescribe a short course
After a discussion with your GP, and once other options have been tried, a short course of a few days of benzodiazepine or zopiclone may occasionally be appropriate for:
– Severe insomnia, after sleep hygiene advice, online cognitive behavioural advice CBT and other treatments have been explored (such as daridorexant, melatonin and so on).
– Muscle spasm in back pain (3-5 day course), if this has genuinely helped before
– An acute crisis, for example bereavement
These will be issued as, one-off acute prescriptions with a clear end date and at the lowest dose (eg 2mg for diazepam and 3.75mg for Zopiclone). They will not be added to your repeat list and will not be for recurrent issue.
When we will not prescribe
– Fear of flying. Sedatives slow your reaction times in an emergency, increase the risk of blood clots on long flights, and are illegal to carry into some countries. Airline-run courses have far better results. See flyingwithconfidence.com.
– MRI scans, hospital procedures or dental work. The team carrying out the procedure is responsible for any sedation, and is trained to monitor you safely. Please contact them directly.
– Ongoing anxiety. The National Institute of Clinical Evidence (NICE) advises against benzodiazepines for generalised anxiety and panic disorder, because outcomes are worse in the long run. We will talk to you about other treatments that work better.
If you are already taking one of these medicines
Please do not stop suddenly, stopping abruptly can be unpleasant and, in some cases, unsafe, in most cases a gradual reduction and withdrawal of medication is the best approach.
We will gradually be arranging for patients on long-term prescriptions to have a medication review with our practice pharmacist or GP. Together you and clinician will discuss the risks and benefits and arrange a gradual reduction in medication dose/strength. Reductions go at a pace you can manage, and can be paused, It can take many months, sometimes up to 18months to come off of these medications, fortunately many people who reduce gradually find they sleep no worse, and often feel sharper during the day.
Please do be aware that if you request your medication early or have taken more than is advised on your prescription, you may be switched to shorter duration issues of your medication eg 7 or 14 days, this is part of safe prescribing procedure and not a judgement on you. From time to time patients may also be asked to sign a prescribing agreement, that explains the risks of the medication and how often it will be issued and in what circumstances it will not be issued.
Driving and/or operating heavy machinery whilst taking these medications
Diazepam, lorazepam, temazepam, oxazepam, clonazepam and flunitrazepam are named in drug-driving law, which sets blood limits. If you take your medicine exactly as prescribed and your driving is not impaired, you have a medical defence. It remains an offence to drive while impaired by any medicine. Zolpidem’s product information advises not driving for at least eight hours after a dose. If you are unsure, speak to us or to your pharmacist.
Where to find out more
For further advice and a list of resources that can support you with insomnia and mental health please click here to access our page on insomnia resources:
– Patient.info: Benzodiazepines and Z-drugs:
https://patient.info/mental-health/insomnia-poor-sleep/benzodiazepines-and-z-drugs)
– Mind: Sleeping pills and minor tranquillisers
– Talk to FRANK: Benzodiazepines
https://www.talktofrank.com/drug/benzodiazepines
– NICE guideline NG215: Medicines associated with dependence or withdrawal symptoms
