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1 Benzodiazepine reduction in general practice. It’s easy! Viggo Kragh Jørgensen Specialist in...
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Transcript of 1 Benzodiazepine reduction in general practice. It’s easy! Viggo Kragh Jørgensen Specialist in...
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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
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Benzodiazepines
Cyclopyrrolones
Hypnotics (sleeping pills)Flunitrazepam (Rohypnol)
Anxiolytics (anxiety reducing agents)
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Benzodiazepines
Cyclopyrrolones
Hypnotics (sleeping pills)Flunitrazepam (Rohypnol)
Anxiolytics (anxiety reducing agents)Diazepam (Valium)
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Benzodiazepines
Cyclopyrrolones
Hypnotics (sleeping pills)Flunitrazepam (Rohypnol)
Anxiolytics (anxiety reducing agents)Diazepam (Valium)
Hypnotics (sleeping pills)
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Benzodiazepines
Cyclopyrrolones
Hypnotics (sleeping pills)Flunitrazepam (Rohypnol)
Anxiolytics (anxiety reducing agents)Diazepam (Valium)
Hypnotics (sleeping pills)Zopiclone (Imovane, Zimovane and Zopinox)
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Adverse effectsAdverse effectsDependence
– Physical– Psychological– Tolerance– Rebound-effect (symptoms
amplified by the end)
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Adverse effectsAdverse effects
Emotional bluntnessAffects learningAffects memoryMotor co-ordination
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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
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Common withdrawal Common withdrawal symptomssymptoms::
AgitationAnxietyInsomniaSweatingTremor Restlessness
CNS Drugs 2007
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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
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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
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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
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Basic Attitude
Normal people should not be prescribed benzodiazepines or cyclopyrrolones for a longer period of time.
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InstrumentsInstruments
The elimination of telephone prescriptions
Prescription only following personal consultation
Prescription for a single month only
ExceptionsNursing HomesTerminal PatientsPsychiatric patients
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InstrumentsInstruments
This leads to a discussion at each consultation regarding future treatment requirements as well as a possible phased reduction of treatments.
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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
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Thyborøn Medical Centre Thyborøn Medical Centre results over 3 ¼ yearsresults over 3 ¼ years
-85 % -91% -83%
Siic may 2009
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ThyborønThyborøn Medical Centre Medical Centre results over 3 yearsresults over 3 years
-
Antidepressiva
Accepted Ugeskrift for Læger 2009
8.6 %
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ThyborønThyborøn Medical Centre Medical Centre results over 3 yearsresults over 3 years
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Antipsychotics
Editorial process Ugeskrift for Læger
3,7 %
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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?
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Lemvig Lemvig ((MunicipalityMunicipality))
Inhabitants:17.944
13 doctors, 8 medical centres in the city 2 medical centres in the country
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Lemvig Lemvig ((MunicipalityMunicipality))
The intervention covered approximately 900 inhabitants
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Combined results over 15 months:
Cyclopyrrolones (Hypnotics): -50,3%
Benzodiazepines (Hypnotics):-46,5%
Benzodiazepines (Anxiolytics):-41,7%
Lemvig (Municipality)Lemvig (Municipality)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
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
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Lemvig Lemvig ((MunicipalityMunicipality))
Expected workload impact of the intervention?
6,0 (12) VAS
VAS Scale, 1 (lowest) -10 (highest)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Initial consultations :
4,3 per 1000 registered patients per week
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Final consultations :
2.1 per 1000 registered patients per week
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients relocated as a consequence of the project :
2 for the entire Municipality
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients referred to psychiatrists.
5 for the entire municipality (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients hospitalized in psychiatric wards:
0 (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients hospitalized in local hospitals:
0 (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients referred to outpatient treatment at the counties addiction unit
4 (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients referred to homecare services:
0,9 per 1000 registered patients
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients referred to external cognitive-behavioral therapy :
4 (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Patients treated with cognitive-behavioral therapy by own practitioner :
2,3 per 1000 registered patients (13)
CNS Drugs 2007
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Lemvig Lemvig ((MunicipalityMunicipality))
Official complaints to the Danish Public Health Service Complaints Board, or to the Chief Medical Officer:
0 (13)
CNS Drugs 2007
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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?
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Central Denmark Region (western part)(western part)
Population: 415.000
General Practices: 270
Estimated population with intervention:20.000
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Other initiativesOther initiatives
Education seminarsSupervisory groupsPsychotherapeutic counselingMedical health officersSmaller groups using Thyborøn-model
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AnxiolyticsAnxiolytics BenzodiazepinesBenzodiazepinesDiazepam, Clonazepam, Oxazepam, Lorazepam etcDiazepam, Clonazepam, Oxazepam, Lorazepam etc..
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Hypnotics Hypnotics CyclopyrrolonesCyclopyrrolonesZopiclon, Zolpidem, ZaleplonZopiclon, Zolpidem, Zaleplon
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Hypnotics Hypnotics BenzodiazepinesBenzodiazepines Flunitrazepam, Nitrazepam, Triazolam etc.Flunitrazepam, Nitrazepam, Triazolam etc.
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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?
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The Danish National Board of Health July 2008
Communication regarding the prescription of addictive drugs
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The Danish National Board of Health July 2008
HypnoticsRe-evaluation after 1-2
weeks
AnxiolyticsRe-evaluation after 1 month
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The Danish National Board of Health July 2008
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
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It is especially thought provoking when one discovers that 80-90% of one’s prescriptions of these potentially dangerous drugs are superfluous