MH 70:41/24 Vol.

14 October 2008

All registered medical practitioners

ADMINISTRATIVE GUIDELINES ON THE PRESCRIBING OF BENZODIAZEPINES

AND OTHER HYPNOTICS

There is a need for every medical practitioner to ensure that benzodiazepines

are used appropriately. These drugs are sometimes inappropriately prescribed to
treat insomnia, anxiety and other psychiatric and medical conditions. Tolerance and
drug dependence can be the undesired result.

2 To assist medical practitioners in prescribing the benzodiazepines

appropriately, the ‘Guidelines for Prescribing Benzodiazepines’ which were
developed in 2002 to guide doctors on the proper prescribing of benzodiazepines
have been updated and revised by the Ministry of Health, which had worked in
conjunction with relevant experts and professional organisations.

3 All medical practitioners are advised to familiarise themselves with the 2008
revised guidelines on the prescribing of benzodiazepines and other hypnotics and to
comply with the guidelines.

4 In addition, all medical practitioners are requested to comply with the

administrative guidelines (enclosed as Annex A) with immediate effect for the
purpose of assisting the Ministry of Health in monitoring the appropriate use and
documentation of all benzodiazepines prescribed to each patient. Your strict co-
operation is appreciated.

5 All medical practitioners are reminded that under Regulation 19 of the Misuse
of Drugs Regulations, a medical practitioner who attends to a person whom he
considers, or has reasonable grounds to suspect, is a drug addict shall, within 7 days
of the attendance, furnish to both the Director of Medical Services and the Director of
the Central Narcotics Bureau the following particulars of that person:
(a) Name;
(b) Identity Card number;
(c) Sex;
(d) Age;
(e) Address; and
(f) The drug to which the person is believed to be addicted.

A sample of the notification form is attached as Annex B.

PROF K SATKU
DIRECTOR OF MEDICAL SERVICES
 Annex A

ADMINISTRATIVE GUIDELINES ON THE PRESCRIBING OF BENZODIAZEPINES

AND OTHER HYPNOTICS

Documentation and maintenance of patient medical records

(a) All information relating to a particular patient must be consolidated as one

medical record relating only to that patient. Such information must be
legibly documented.

(b) Each patient’s medical record must be entirely reproducible upon request
by the Ministry of Health or Singapore Medical Council.

(c) The following information must be documented in the medical record of

every patient who is prescribed with benzodiazepines/ other hypnotics:
(i) Comprehensive history, including psychosocial history and
previous use of benzodiazepines or other hypnotics;
(ii) Comprehensive physical examination findings, including evidence
of misuse of benzodiazepines or other drugs; and
(iii) Withdrawal symptoms to benzodiazepines/ other hypnotics
previously experienced by the patient, if any.

(d) The following information must be documented in the medical records of

every patient each time he/she is prescribed benzodiazepines / other
hypnotics either initially or as repeat prescriptions:

(i) The prescribed type/name of benzodiazepine/hypnotic, its dosage

and duration of use;
(ii) Indication(s) and/or justification(s) for prescribing
benzodiazepines/ other hypnotics; and
(iii) Physical signs or evidence of tolerance, physical/psychological
dependence or any illicit use or misuse of benzodiazepines or
other drugs (eg. needle tracks on skin, inappropriate lethargy).

Use of benzodiazepines

(e) Medical practitioners are strongly discouraged from prescribing highly

addictive benzodiazepines such as midazolam and nimetazepam (except
for midazolam use in surgical procedures).

(f) Benzodiazepines / other hypnotics, when used for treating insomnia,

should be prescribed for intermittent use (eg. 1 night in 2 or 3 nights) and
only when necessary.

(g) Medical practitioners should routinely warn patients about rebound

insomnia with the use of benzodiazepines and document such warning
accordingly.

(h) The dosage of benzodiazepine / other hypnotic used should be the lowest
effective dose necessary to achieve symptomatic relief.

(i) The concurrent prescribing of two or more benzodiazepines should be

avoided.
 (j) Repeat prescriptions for benzodiazepines / other hypnotics should not be
provided without a clinical review.

(k) Where there are doubts about dosage prescription or tapering of

benzodiazepines/ other hypnotics, a psychiatrist or other specialists
should be consulted.

(l) Care should be taken when prescribing benzodiazepines / other hypnotics

to avoid excessive sedation (which may pose a risk to the patient who
drives, operates heavy machinery, etc).

(m) Caution should be exercised when prescribing benzodiazepines for

patients with a history or evidence of alchohol or other substance abuse.

Specialist referrals

(n) The following categories of patients should not be further prescribed with
benzodiazepines / other hypnotics and must be referred to the appropriate
specialist for further management a :

(i) Patients who require or have been prescribed benzodiazepines /

other hypnotics beyond a cumulative period of 8 weeks;
(ii) Patients who are already on high-dose and/or long-term
benzodiazepines from their specialists or general hospitals; where
possible, these patients should be referred back to their respective
specialists for further management until they are weaned off
benzodiazepines / other hypnotics; and
(iii) Patients who are non-compliant with professional advice or
warning to reduce intake of benzodiazepines/ other hypnotics.

(o) Patients who refuse to be referred to a specialist should be counselled

appropriately. Such refusal should be documented in the patients’
medical records. Patients who refuse referrals and turn aggressive
should be reported to the police.

a An appropriate specialist refers to any SMC-registered specialist (eg. psychiatrist, rheumatologist, gastroenterologist,

neurologist, etc.) who has the necessary competence to treat the underlying condition that resulted in the patient’s persistent
use of benzodiazepines/ other hypnotics.
 Annex B

Notification to MOH and CNB * fields are mandatory

1. I, Dr _____________________________________, MCR number ______________ of

_________________________________ (clinic name) hereby certify that I am treating the

following patient for the following:

*Drug to which
the person is __________________________________
believed to be
addicted

2. The particulars of the patient is given as follows:

* Name
_________________________________
* IC Number
_________________________________
* Age
________
* Sex
Male Female
* Address
__________________________________

__________________________________

Postal Code: _______________

Please complete the form and fax one copy to MOH at fax number 6325 1744, and one
copy to CNB at fax number 6227 3978.

Incomplete form will not be entertained.