Diazepam for Fear of Flying, and other requests (including scans, minor surgery and dental appointments)

Practice Policy for Woosehill Medical Practice

Background

Benzodiazepines (including diazepam, lorazepam, temazepam, clonazepam) are medicines that have been in use since the 1960s for a wide range of conditions, such as alcohol withdrawal, epilepsy, and muscle spasms. They are strongly sedating drugs that have negative effects on memory, coordination, concentration, and reaction times. They are addictive and withdrawal can lead to seizures, hallucinations, agitation, and confusion.

Unfortunately, benzodiazepines have widely become drugs of abuse, and as a result they are controlled in the UK as Class C, Schedule 4 drugs. This means there are restrictions on when and how much can be prescribed under the Controlled Substances Act, and inappropriate use, supply or possession of these medications is illegal in the UK under the Misuse of Drugs Act.

Many people approach their GP practice asking for diazepam to help with fear of flying, or to sleep during a flight. There are several good reasons why prescribing diazepam is not recommended, and as a result we will no longer prescribe diazepam for patients who wish to use this for a fear of flying.

Reasons

• The national prescribing guidelines followed by GPs (the British National Formulary – BNF) states that all benzodiazepines are ‘contraindicated’ (not allowed) in treatment of phobias (fear conditions, such as fear of flying). It also states that the use of benzodiazepines to treat short-term anxiety is ‘inappropriate’. Benzodiazepines are only licensed for short-term use in a generalised anxiety crisis – but if this is the case for you, you should seek proper care and support for your mental health, and it would not be advisable to go on a flight. Your GP would be taking a significant legal risk by prescribing against these national guidelines.

• Diazepam is a sedative, so it makes you sleepier. If an emergency occurred during the flight, this could impair your ability to concentrate, follow instructions, or react to the situation. This could seriously affect the safety of you and the people around you. Such incidents are rare but they do occur, and it can be fatal if you are unable to evacuate the plane properly (an example event is flight BA28M, where 55 people sadly died while the plane burned while sat on Manchester Airport runway, and the official AAIB incident report specifically commented on evacuation delays contributing to the deaths). No-one else on board a plane will evacuate for you – the cabin crew are there to guide an evacuation, but you need to be responsible for yourself. As a result, many airlines consider sedative medications as a reason why someone would not be allowed on a plane, in a similar way that someone who has consumed excessive alcohol may be removed from a plane.

• Sedative drugs can make you fall asleep; however, the sleep is an unnatural non-REM sleep. Your movements during this type of sleep are reduced and this can place you at an even higher risk of developing blood clots in the legs (deep vein thrombosis – a DVT) or lungs (pulmonary embolism – a PE). These blood clots are very dangerous and can even be fatal. This risk further increases if your flight is over 4 hours long.

• Going on an aeroplane normally involves your blood oxygen levels decreasing from around 98% to as low as 90%, due to the air pressure decrease at cruising altitudes. Normally your body compensates for this by altering the rate and depth of your breathing. However, benzodiazepines work to depress your breathing and this can put you at risk of hypoxia (excessively low blood oxygen), especially if you have lung problems already, which can be very dangerous.

• Most people feel sleepy when they take diazepam, but a small proportion of people experience the opposite effect and can become aggressive. This is called a paradoxical effect, and it can be unexpectedly inconsistent, even if diazepam has been used in the past. Alongside aggression and agitation, this response can cause disinhibition and make you behave in ways you normally wouldn’t. This could also impact on your safety and the safety of your fellow passengers or could lead you to get in trouble with the law. Recently, a passenger in this situation was detained by the aircrew, arrested after an emergency landing, given jail time, and was also fined for the costs of redirecting the plane.

• In several countries, diazepam and similar drugs are illegal (Greece, Japan, and many Middle Eastern countries including the UAE are just some examples). They would be confiscated, and you might find yourself in trouble with the police for being in control of an illegal substance, even if it has been prescribed by a doctor in the UK. This has led to people spending time in a jail a foreign country.

• Diazepam has a long half-life, which means it stays in your system for a significant time. If your job requires you to submit random drug testing, you may fail these tests.

• There is a possible link between occasional use of benzodiazepines and earlier onset of dementia in later life.

What you can do

A fear of flying is frightening and can be debilitating. However, there are much better and effective ways of tackling the problem. We recommend you tackle your problem with a Fear of Flying Course, which are aviation-industry approved and are run by several airlines. These courses are far more effective than diazepam and have none of the undesirable effects. Also, the positive effects of the courses continue after the courses have been completed.

Easy Jet: www.fearlessflyer.easyjet.com Tel: 0203 813 1644

British Airways: flyingwithconfidence.com/courses/venues Tel: 01252 793 250

Virgin Atlantic: https://flyingwithoutfear.co.uk/collections Tel: 01423 714 900

Fly And Be Calm is an instant download audio course which includes instructions, a fear removal tool and two hypnotic tracks. You can find this at: https://flyandbecalm.co.uk/

Alternatively, you could contact your local psychology therapy provider to consider having Cognitive Behavioural Therapy (CBT). Details of the local Healthy Minds service for Oldham can be found here: https://www.penninecare.nhs.uk/healthymindsoldham

Ultimately, if you still feel unable to fly, then it may be appropriate to consider alternative routes of transport.

If you still wish to consider diazepam for fear of flying, we suggest consulting with a private GP or a private travel clinic, who may be able to help you further. These services are private and not offered by the NHS. The private clinics may then liaise with the airlines directly to arrange a medically-trained escort for a passenger who is taking sedative medications, which can be expensive.

Other situations – scans, minor surgeries including cataract surgery, dental appointments etc.

We do not provide sedative medications such as diazepam for use in other situations, such as for dental/hospital procedures or scans. The Royal College of Radiologists sets out clear guidance for sedation in hospital radiology departments (https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr182_safe_sedation.pdf) which states “Sedation and analgesia should be administered by a competent and well-trained sedation and oversight provided by a sedation committee within the institution”.

The Intercollegiate Advisory Committee for Sedation in Dentistry has a similar guideline (https://www.saad.org.uk/IACSD%202020.pdf) which states “The monitoring and discharge requirements for oral sedation are the same as for intravenous sedation. Oral sedation must only be administered in the place where the dental treatment is provided and must only be carried out by practitioners who are already competent in intravenous sedation.”

As a result and keeping in with good medical practice, responsibility for this type of treatment or any treatment that your consultant or dentist feels is necessary for your treatment, lies with them, and not your GP. If you feel this is required, we suggest consulting with your dentist or the hospital teams in good time before any scans or treatments occur.