People can 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 1980-90s; 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 the surgery as made a decision to no longer prescribes such medications for this purpose.

There are a number of very good reasons why prescribing this drug is not recommended.

• The use of any sort of benzodiazepines causes longer reaction times & 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 clot (Deep Vein Thrombosis – DVT) in the leg or even the lungs. Blood clots are very 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 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 with the law.
• Benzodiazepine use added to alcohol consumption causes an increase in the risk posed by the points above.
• According to the prescribing guidelines doctors follow (British National Formulary) diazepam is contraindicated (not allowed) in treating phobic states.[i] It also states that “the use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.”[ii] 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[iii]. 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 the 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 time 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 (V), said that though there may be reduced anxiety in the moment, benzodiazepines cause increased long-term anxiety reactions.

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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.

1. Easy Jet www.fearlessflyer.easyjet.com Tel 0203 8131644
2. British Airways www.flyingwithconfidence.com  Tel 01252 793250
3. Virgin www.flyingwithoutfear.co.uk  Tel 01423 714900
4. https://thefearofflying.com/programs/fly-and-be-calm/
5. 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. 
6. Patients who still wish to take benzodiazepines for flight anxiety are advised to consult with a private GP or travel clinic. 
7. 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.

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For further information/References

[i] British National Formulary; Diazepam – https://bnf.nice.org.uk/drug/diazepam.html

[ii] British National Formulary; Hypnotics and anxiolytics – https://bnf.nice.org.uk/treatment-summary/hypnotics-and-anxiolytics.html

[iii] Generalised anxiety disorder and panic disorder in adults: management. NICE Clinical guideline [CG113] Published date: January 2011 Last updated: July 2019 https://www.nice.org.uk/guidance/cg113

[iv] Acute and delayed effects of Alprazolam on flight phobics during exposure. Behav Res Ther. 1997 Sep;35(9):831-41

V. https://www.psychologytoday.com/gb/blog/conquer-fear-flying/201407/anti-anxiety-medication-and-flying  Anti-Anxiety Medication and Flying | Psychology Today United Kingdom

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Other situations – scans, dental appointments etc.

After very careful consideration, Kepier Medical Practice has also decided to no longer prescribe diazepam for patients having MRI scans or other investigative procedures. This is not a decision we took lightly; we have a duty of care to provide safe, consistent, and appropriate care for our patients. We hope the reasons outlined below help to explain our main concerns.

• Small doses of benzodiazepines such at 2mg diazepam are probably sub-therapeutic for most adults for any effective sedation. Conversely anxiolytics can have an idiosyncratic response in patients, and even very small doses can cause increased agitation in some subsets of patients.
• A patient may take a sedative ‘an hour’ before their assumed procedure, to then attend the hospital to find their procedure has been delayed, therefore the timing of the anxiolytic being sub optimal.
• The Royal College of Radiologists‘ own guidelines on sedation for imaging makes no mention of GP involvement or provision of low dose anxiolytics and stresses the importance of experienced well-trained staff involved and the monitoring of sedated patients : Sedation, analgesia and anaesthesia in the radiology department, second edition. (rcr.ac.uk)
• 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, responsibility for this type of treatment lies with your dentist or hospital staff, 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.

1. Sedation, analgesia and anaesthesia in the radiology department, second edition. (rcr.ac.uk) (https://www.rcr.ac.uk/media/ch2olbds/rcr-publications_sedation-analgesia-and-anaesthesia-in-the-radiology-department-second-edition_june-2018.pdf)

• The Intercollegiate Advisory Committee for Sedation in Dentistry has a similar guideline (https://www.saad.org.uk/IACSD%202020.pdf)