Benzodiazepines: the end of a dream
Andrew Byrne MB, BS (Sydney)
Australian Family Physician
Vol 23 No 8: 1584-1585
August 1994
• It is suggested that the medical profession needs to reassess the current use of benzodiazepines in light of new evidence of habituation and side effects. We should encourage patients with insomnia and anxiety to persevere with non drug treatments. Before prescribing, we must inform patients of the addictive potential of the drug.
The good name of the medical profession will be permanently tarnished unless we address 'the benzodiazepine question' promptly and adroitly. Litigation has already occurred over inappropriate use of these drugs, and lawyers have medical practice in their sights. Doctors still unaware of such eventualities may be most at risk.
Benzodiazepine tranquillisers were introduced in 1960 after brief clinical tests at the University of Texas in 1959. Controlled trials were not required for evaluation and 'efficacy' was demonstrated by anecdotes and testimonials. If introduced today they would probably only be approved for limited indications.
A generation of doctors has presided over a massive expansion of benzodiazepine use for insomnia and anxiety. With new, narrower indications for tranquilliser use, we find ourselves in the uncomfortable position of treating some patients who might be better off without them. We now know that these drugs induce tolerance in most subjects at recommended doses. This develops within two weeks, and applies to all their effects and side-effects, with the exception of amnesia. Some critical authors have suggested that the medical profession and drug companies have been guilty of knowingly ignoring the dangers of tranquillisers.
The three common defences for continuing to prescribe as before are:
"This drug is safer than the alternative, barbiturates."
"If I do not prescribe them, the patient will get them somewhere else."
"You cannot overdose on benzodiazepines."
These are all spurious, and do not stand up to cross-examination.
To protect ourselves and those in our care, all clinical decisions must be based on sound practice principles. In fact, prescribing habits are changing.
There are further compelling reasons for us to modify our prescribing habits. Both the cost of the drug and consultation fees are partially government-funded, and are therefore subject to public account. Is there value being had? Around 4000kg of benzodiazepine base is consumed annually in Australia, and virtually all is imported.
Side-effects, including instability and falls in the elderly, memory disturbance, abnormal sleep patterns, sexual disturbance, depression, fatigue and habituation are all well documented. As the elderly are at substantially greater risk they stand to gain more from dose reductions and drug withdrawal. It has been shown that the risk of hip fracture increases threefold in those taking temazepam.
Use of these drugs for minor complains, or as first line of management is no longer justified. A comparison might be the use of morphine for tension headache or osteoarthritis. It may help the pain, but the treatment would prove more troublesome than the disease.
For new patients, the advice is relatively straightforward: follow the drug companies' recommendations, which are now surprisingly frank about the indications, precautions and contraindications. Some manufacturers have begun circulating information in 'plain English' and in large print. This entreats us to avoid benzodiazepines in long and medium-term conditions, and to use only with caution in those with addictive or unreliable tendencies.
Although slower to act, non drug treatment can be as effective as tranquillisers in cases of severe anxiety. These may include counselling, exercise and other physical therapies, diets and vitamin advice, relaxation treatment and acupuncture.
For existing patients the position is complicated by established habituation both physical and psychological. We should inform our patients in a non alarmist way that the drug they are taking is not as harmless as was once believed. As with all medications, we must weigh the benefits with the known dangers, and correlate these with the natural history of the symptoms being treated. We each need to develop a compassionate strategy consistent with good medical practice. We must tread the delicate path between the ideal of abstinence and the reality of maintenance.
The decision to withdraw from these medications should come from the patient. At this point, we should offer our support and suggest a plan for gradual reductions. Any medication that the patient is unable to break in half should be replaced with scored tablets to allow dose titration. Gel-capsules should no longer be used. Short acting forms may be replaced with the longer acting drugs such as diazepam.
Some patients can withdraw from these drugs rapidly without great trouble. For others it is a long, harrowing experience. Several useful self-help books are available to assist patients and self- help groups have been set up in most States.
The dream of the perfect sedative has not come true. For some, it has become a recurrent nightmare. Chloral, bromides, barbiturates, meprobamate and even heroin were all touted in their turn as the ideal, non-addictive calming agents. There is still no perfect drug for primary insomnia or anxiety. Benzodiazepines are a limited tool in the pharmacopoeia, but not the panacea once thought. ‡
References:
Harris TH. Methamindiazepoxide. JAMA March 1960; 172:1162-1163.
Lucki, I., Rickels, K., & Geller AM. Chronic use of benzodiazepines and psychomotor and cognitive test performance. Psychopharmacology, (Berlin) 1986; 88(4), 426-433.
Faust B. Benzo Junkie, Ringwood, Vic: Viking Press, 1993, 43.
Statistics on drug abuse in Australia 1992. Dept. of Health, Housing Community Services, Australian Government Printing Service, Canberra.
Cumming R, Klineberg R. Psychotropics, thiazide diuretics and hip fractures in the elderly. Med J Aust 1993; 158(6):414-417.
Rickels K. Treatment of benzodiazepine dependence. (Letter); Med J Aust 1987; 146(2):112.
Trickett, S. Coming Off tranquillizers and sleeping pills. Willingborough, England: Thorsons Publishing Group, 1991.
Jerome J. The Lost Years. Virgin Books, 1991.
C.O.P.E. Program (Coming off Pills entirely) Woden Valley Hospital, ACT and contact D&A Advisory Services in other States.
Andrew Byrne MB, BS (Sydney)
General Practice · Drug & Alcohol
75 Redfern Street, Redfern
NSW, Australia, 2016
Phone: 9319 5524
Facsimile: 9318 0631
Email: ajbyrne@ozemail.com.au
• Benzodiazepine Dependence by Dr Andrew Byrne, 1997.
