Fear of Flying
After very careful consideration Primrose Hill Surgery have reviewed our benzodiazepine prescribing and established out new policy not to prescribe benzodiazepines or sedatives (such as diazepam) to patients for fear of flying. Many other GP practices have a similar policy.
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 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 & as 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 cot (Deep Vein Thrombosis- DVT) in the leg or even in the lungs. Blood clots are every dangerous and can even prove fatal. This risk is even greater if your flight is greater than 4 hours.
- Whilst most people find benzodiazepines like diazepam sedating, a small number have a paradoxical agitation and in 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 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 use of benzodiazepines stops the normal adjustment response that would gradually lessen anxiety over tune 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 Het fearlessflyer.easyjet.com Tel 02023 8131644
- British Airways flyingwithconfidence.com Tel 01252 793250
- Virgin flyingwithoutfeat.co.uk Tel 01423 714900
- https://thefeariffking.com/programs/fly-and-be-calm/
- 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.
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 not the responsibility of the Practice.
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 he 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.
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 phobics 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.
Private Prescriptions
Below you will find some frequently asked questions by patients who have been seen by a private doctor. The responses are supported by North Central London Integrated Care Board (NCL ICB) who are responsible for allocation NHS budget and commissioning services in our local area.
Can I get my private prescription transferred to an NHS prescription?
If you see a private doctor or specialist and they recommend a particular medication or treatment for you, this will be a private prescription. The GP practice will not usually be able to transfer a private prescription onto a NHS prescription.
What happens when I continue the treatment on the NHS?
If you ask your GP to take over prescribing of a medication or treatment recommended by the private doctor or specialist, they will need to be satisfied that prescribing is appropriate, responsible and what they would prescribe for other NHS patients with the same diagnosis/ condition. Your GP may not prescribe the particular medication suggested by a private doctor in the following circumstances:
The medication is generally not prescribed on the NHS.
- The medication is not licensed in the UK or is being used for a purpose not included in its UK licence.
- Normally, NHS specialists and not GPs, would prescribe the medicine. So, GPs may be unfamiliar with the medicine and how it should be prescribed and reviewed. GPs would not normally prescribe these medicines on NHS prescription.
The use of the medication is not compatible with national or local prescribing guidelines.
- For example, in our local area the medicine may not be included in the normal NHS treatment for your condition or would not normally be prescribed first, therefore it would not normally be recommended on an NHS prescription.
The GP does not believe the medication is appropriate or necessary for you.
If your GP is unable to prescribe the medication suggested by the private doctor, they may give you the option of having a different but equally effective medication prescribed on the NHS. Alternatively, if you prefer, you can pay for your private prescription through your private doctor. This will not affect any other medications, which are currently prescribed for you by your GP.
I cannot afford to pay for the treatment privately, what can I do?
It is important to consider all potential costs when using a private consultant and this includes medicine costs. If your GP is unbale to prescribe the medicine on an NHS prescription for one of the reasons documented above. You should speak to the clinician that issued you with the private prescription to discuss what to do next. This may include them recommending an alternative less costly medicine or one which may be prescribed by your GP on an NHS prescription.
