Benzodiazepine prescribing: The role of community pharmacists in Ireland
C.A. Cadogan, S.A. Ryder
The Benzodiazepine Committee was established in 2000 to investigate benzodiazepine prescribing and use in Ireland, and to develop good practice guidelines. It has been widely documented that benzodiazepines are often inappropriately prescribed and/or misused. However, little research has been published on community pharmacists’ role in benzodiazepine supply. The main aims of this study were to assess the attitudes, experiences and knowledge of community pharmacists regarding current benzodiazepine policy and practices, and to explore their views on dosage reduction/discontinuation. Ethical approval was granted by the Faculty of Health Sciences Research Ethics Committee, Trinity College Dublin. The study comprised an anonymous, self-administered, cross-sectional, postal questionnaire, which was distributed to half the community pharmacies registered in Ireland (sample size 857). Pharmacies were selected from the Pharmaceutical Society of Ireland’s community pharmacy register using geographically stratified random sampling. A reminder was issued five weeks after distribution. All viable data were coded and entered into PASW Statistics 18.0 for analysis. The response rate was 38% (322). It was found that awareness among community pharmacists of official sources of benzodiazepine guidelines is low (33%, 103), but that the vast majority (93%, 287) agree that such guidelines are relevant to them. A large minority of pharmacists (47%, 148) agree they have a professional responsibility to facilitate compliance with relevant prescribing guidelines. Long-term benzodiazepine use, in contravention of prescribing guidelines, was reported to be widespread. In most respondents’ pharmacies benzodiazepine prescriptions were presented at least once daily (23%, 71) or several times daily (65%, 206) and only 38% (118) of respondents estimated that the most common benzodiazepine prescription duration was shorter than 28 days. When asked to estimate the proportion of their patients using benzodiazepines long-term the mean reported figure was 50.4% (std. dev. ± 31.1). Half of the respondents (n = 156) reported that none of their long-term patients had undergone dosage reduction/discontinuation in the last six months. A majority (53%, 166) stated they had not contacted a prescriber about a patient’s benzodiazepine use in the six months before the questionnaire; however a positive association was found between the proportion of patients reported to have undergone gradual dosage reduction and contact by community pharmacists with prescribers concerning patients’ benzodiazepine use (p = 0.005, χ2-test). Community pharmacists agreed (83%, 258) that they would be willing to play an active role in facilitating patient initiation in benzodiazepine discontinuation/dosage reduction programmes. The findings indicate that anticipated outcomes of the Benzodiazepine Committee’s report have not been achieved, as long-term benzodiazepine prescribing and use is still perceived as common. The Committee recommended that all dependent patients should be encouraged to withdraw, and should regularly (at least annually) be offered detoxification. Community pharmacists believe in prescribers’ professional autonomy (fewer than half feel obliged to facilitate prescribing guideline compliance as an abstract concept, perhaps believing justifiable exceptions to the guidelines may be common) but this does not detract from their willingness to facilitate dosage reduction/discontinuation where inappropriate benzodiazepine use has clearly developed. Furthermore, guideline awareness was low; greater education on the Committee’s recommendations might lead to greater appreciation of their worth and motivation to enforce them proactively. This study’s findings have led to a multifaceted intervention (currently underway) entailing the collaboration of community pharmacists and general practitioners in identifying suitable patients who are willing to attempt benzodiazepine dose reduction/discontinuation and implementing a structured reduction/withdrawal programme.