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GHA tightens controls on sedative prescriptions

The Gibraltar Health Authority is putting in place tighter controls on the prescription of certain types of powerful, highly-addictive sedatives.

The sedatives, from a family of drugs called benzodiazepines, have been prescribed as a matter of routine to hundreds of patients in Gibraltar for years.

But when a manufacturer raised concerns about the amount of product that was being shipped to Gibraltar, the GHA conducted an audit and, shocked by the scale of consumption, is putting in place a protocol for existing and future patients.

The aim is to wean patients on long-term prescriptions off the drugs in a phased and structured manner overseen by doctors.

New patients, in the meantime, will be offered alternative, less addictive drugs, with benzodiazepines reserved for short-term, carefully-controlled use.

There are over 20 different types of benzodiazepines currently authorised for prescription under GHA guidelines, but a new protocol has been drafted to tackle the issue in line with the UK standards.

Under NHS guidelines in the UK, only 12 kinds of benzodiazepines are authorised for prescription. Now, Gibraltar is looking to follow the UK’s lead.

The audit was triggered after American pharmaceutical company Pfizer questioned why Gibraltar was buying large amounts of Xanax, a drug that is available in the UK from private practitioners but is blacklisted for prescription under the NHS.

The initial audit uncovered that 930 patients in Gibraltar with a median age of 67 years were regularly prescribed sedatives such as Xanax and other brands.

Further research into the issue found that the number is in fact higher, with some 1,300 local patients prescribed these types of drugs.

Medical Director Dr Daniel Cassaglia and Dr Chimene Taylor, who works closely the Drug and Alcohol Awareness and Rehabilitation Services, told the Chronicle that patients taking the sedatives should continue to do so until they have discussed their prescription with their GP.

The doctors said that patients who use any type of benzodiazepines daily, in particular Xanax, should continue to take their medication.

They stressed repeatedly that reducing the intake of these types of drugs must be done under the guidance and supervision of medical professionals.

The medications include Lorazepam, Clonazepam, Temazepam, Nitrazepam, Diazepam and Xanax, including its generic version Alprazolam.

These drugs are often prescribed for anxiety and other health concerns but are generally inappropriate for use beyond four weeks.

Dr Cassaglia and Dr Taylor admitted there have been cases where patients in Gibraltar had been prescribed these drugs for years.

Asked how these medications continued to be prescribed well over the guidelines, Dr Taylor said it was “an element of culture”.

Dr Cassaglia outlined that many of these were legacy prescriptions and that addictions services were now coming to the fore.

He described how an overall audit would have been difficult without the new GHA digital infrastructure that has allowed doctors to investigation the issue.

“We now have more resources in this area so we are now able to help people get off [the sedatives],” Dr Cassaglia said.

“We incorporated digital systems relatively recently and to do an audit of this type [in the past] would have involved a manual exercise, which would have taken a huge amount of man power.”

“Now we have a few years’ worth of prescribing behaviour which we can access.”

Patients who have used benzodiazepines for years will have to be weaned off the drug slowly.

“In those patients it will take some time and there will be patients where we will not be able to take them off it, but we can keep working with them to try and reduce it very slowly,” Dr Taylor said.

She added: “Those that will be dependent on it would have been using every day and on higher dose and they will take much longer to get off it. By longer I don’t mean weeks, I mean months and years.”

Patients with prolonged daily use should not attempt to quit or wean themselves off the benzodiazepines as this could cause withdrawal symptoms such as anxiety episodes, confusion, lack of reality and in extreme cases seizures.

Dr Cassaglia said that the patients will be weaned off gradually and will not notice any difference.

Dr Taylor described how prolonged used benzodiazepines can result in side effects such as addiction, memory loss and dementia-like symptoms.

“There is a place for benzodiazepines in acute crisis,” Dr Taylor said.

“They can be used short term and the recommendations are no longer than two to four weeks, for severe acute anxiety.”

“They are not recommended to be prescribed long term, every month for years. What we need to work through is stopping that long term prescribing.”

Dr Cassaglia added that benzodiazepines would only be used to treat anxiety for short periods of time such as for people who have had a bereavement or shock, as people can become dependent “quite easily”.

The GHA is reviewing its practice with an aim to blacklist Xanax and other strong sedatives, much as the NHS has done.

The plan is for no new prescriptions of certain types of benzodiazepines in line with UK standards.

The GHA is also working with the importer of Pfizer products and is looking in detail at how many sedatives have been imported into Gibraltar.

This information will be contrasted with GHA data to find out how much is being prescribed in the private sector.

The GHA protocol outlines that patients taking these drugs could be offered doctors’ appointments, self-help guides, counselling, and as a last resort would be referred to the Substance Misuse Services.

In lieu of sedatives prescribed for anxiety Dr Taylor added that in severe cases the GHA would now look at prescribing anti-depressants instead.
“A lot of anti-depressants are licenced just for anxiety,” Dr Taylor said.

“There are other mediations, like everything in medicine.”

Affected patients can arrange an appointment at the Primary Care Centre on tel: 20052441.