Benzodiazepines - Use & Abuse
A GUIDE FOR PRESCRIBERS
Prepared for the Drugs Advisory Committee
by Dr Anne E Smith, MB, ChB, MRNZCGP
ISSN 0111-624X
Department of Health
PO Box 5013
Wellington
New Zealand
15 March 1989
To Medical Practitioners
(Copy to Proprietors of Retail Pharmacies)
THERAPEUTIC NOTES NO. 207
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Summary
Benzodiazepines have been prescribed freely for many years but only recently have the dangers of dependence been understood. Short term treatment may be beneficial but longer term use, more than four weeks, could well be harmful to the patient. Appropriate use of benzodiazepines is described, a summary of side effects is presented and strategies to withdraw from medication are outlined.
Introduction
Benzodiazepines have been available and widely prescribed for many years. Prescribing reached its peak in the 1970s and has only slowly declined as the dangers of long term use have been recognised.
Sales of benzodiazepines to retail pharmacies in 1979 were 54,380,000 capsules/tablets and in 1984 were 41,660,000 (source IMS).
There is increasing concern about the potential for dependency on benzodiazepines, this dependency occurring very quickly and being very difficult to withdraw from.
Use of Benzodiazepines
Anxiety reducing
Hypnotic
Anticonvulsant
Muscle relaxant
Anaesthesia
Efficacy
There is little evidence to support the idea of benzodiazepines being effective in long term use, when used as an anxiolytic or hypnotic. The anxiolytic effect does not seem to last beyond 4 months' use, and the hypnotic effect has much less duration, no more than 14 days of continuous use.
Side Effects
Amnesia is frequently a real side effect of benzodiazepines and not just a symptom of an underlying emotional disturbance for which the drug may have been prescribed. The effect may prevent a rational response to an acute stress situation as relevant factors may be forgotten.
The normal grief response in bereavement may be inhibited, prolonging the grief process and leading to inadequate psychological adjustment.
There is considerable concern that many patients are at risk of car accidents whilst taking these drugs. Benzodiazepines impair psychomotor and cognitive skills that are needed for safe car driving or working with machinery. High doses and longer acting compounds produce more risk, as side effects of accumulation include dysarthria, ataxia and diplopia.
Patients with personality disorders may show disinhibition, with exaggeration of suicidal or aggressive tendencies. This is obviously counterproductive.
Long term use may blunt appropriate emotional responses, reduce the ability to cope with stressful situations and "dull" the patient's intellect.
The ability to encode given information is impaired, resulting in poor memory.
Withdrawal
This can be very difficult, and is more so with the short acting benzodiazepines.
Withdrawal symptoms include anxiety, tremor, confusion, insomnia, perceptual disorders, fits, depression, gastrointestinal and other somatic symptoms. It can be seen that these symptoms may be the same or very similar to the original symptoms for which the drug was prescribed and lead to the patient restarting the drug or increasing the dose again. The vicious circle continues.
Whilst the shorter duration of action helps to prevent a hangover effect, the rapid elimination of short acting benzodiazepines from the body causes a relatively steep fall in blood concentrations - the steeper the fall, the more severe the withdrawal effect. Lorazepam is particularly bad in this respect.
Anxiety Reducing Effect
Drug treatment may be recommended if the anxiety is disabling, severe or subjecting the individual to unacceptable stress. In most cases the treatment should be for no longer than 3-4 weeks. Benzodiazepines taken in an intermittent dosage, (on a prn basis up to an agreed maximum) are more appropriate than a fixed schedule (tds or qds).
Remember that short acting benzodiazepines are more difficult to withdraw from but long acting ones may accumulate.
Benzodiazepines should not be used for mild anxiety symptoms or for trivial non-specific symptoms. Alternative strategies may be employed:
Information to the patient about the self limiting nature of the anxiety
Education about the dangers of "tranquillisers"
Sharing of problems with a friend or relative
Relaxation exercises and tapes
Yoga or meditation
Counselling
Sleep Inducing Effects
Hypnotics are appropriate if the insomnia is disabling, severe or subjecting the individual to extreme stress. In the past it has been acceptable to routinely prescribe hypnotics for any sleep disturbance (and for patients in hospital) but this practice should now be severely questioned.
Underlying causes for insomnia should be sought and dealt with before considering a drug for symptomatic treatment.
Insomnia can be divided into 3 categories:
Transient insomnia
experienced by normal sleepers
caused by acute stress such as hospitalisation, jet lag
duration of several days
Short term insomnia
caused by significant stress, e.g., associated with work/family
duration of up to 3 weeks
Long term insomnia
caused by underlying medical or psychiatric conditions:
- primary sleep disorders
- chronic alcohol abuse
- ageing processduration of months or years
If an underlying cause can be found (i.e. pain associated with arthritis, depression, cardiac disease) it is appropriate to treat that problem and avoid hypnotics.
If a hypnotic is recommended, certain dosage guidelines will minimise the risk of dependency.
Transient insomnia
Short term insomnia
Long term insomnia
maximum of 1-3 nights of the smallest effective dose of short acting benzodiazepine.
maximum of 3-4 weeks of the smallest effective dose of short acting benzodiazepine given in intermittent use. The patient is instructed to skip the nightly dose after 1 or 2 nights of good sleep.
may require full specialist evaluation maximum of 3-4 months of intermittent use (1 night in 3) of a benzodiazepine - short or long acting depending on the need for daytime sedation.
Other strategies may include:
Information about the problem and the self limiting nature of the condition.
Information about the body's requirements for sleep and that a few nights' less sleep is not harmful.
Education about self help measures:
vigorous exercise (like running) in the late afternoon stimulates production of a hormone which helps you sleep.
develop a routine and always go to bed and settle to sleep at the same time each night.
avoid coffee or strong tea after 4 p.m.
drink very little alcohol before bedtime as it often wakes you up after a few hours' sleep.
a glass of hot milk taken before settling for the night may help.
reading or listening to the radio may help.
arrange to wake the same time each day and avoid sleeping in.
avoid mental stimulation just before bedtime.
Avoid pressure by the patients with minor problems to prescribe hypnotics. Education of the patient does take time but can be rewarding and may save time in the long run if difficult dependency problems are avoided.
Special Problems in the Elderly
The elderly experience more frequent and severe side effects and generally need lower doses. They are more likely to be on benzodiazepines as a result of the prescribing practices of the 1970s and are the most difficult group to get off these drugs.
They often present with the symptoms suitable for benzodiazepines and may be less amenable to alternative strategies.
Even small doses may produce drowsiness, incoordination and ataxia (resulting in falls and fractures) and acute confusion.
Small doses may disinhibit behaviour and worsen anti-social behaviours of Alzheimer's disease.
Thioridizine and chlorpromazine are more useful drugs for elderly patients with behaviour problems.
Medico-Legal Aspects
Disinhibition of behaviour, combined with memory loss and confusion, may lead patients, even on low doses, to commit a variety of anti-social acts, such as shoplifting. Doctors may be required to give evidence in such cases where patients claim diminished responsibility due to prescribed drugs.
Recent evidence suggests a specific benzodiazepine teratogenicity, similar to foetal alcohol syndrome, and, if substantiated, may open the way for litigation.
Many patients are now questioning the wisdom of their doctors in initiating benzodiazepine use without warning of the possible dangers and in agreeing to repeat prescriptions without reassessment. Publicity about the dangers of benzodiazepines is sufficient to make any patients angry with their doctors. A real possibility is that patients may begin taking legal action against drug companies marketing benzodiazepines and doctors prescribing them long term.
Whatever the arguments about this, the body of evidence is such that the dangers of benzodiazepines are now well known, and doctors should hesitate before prescribing these drugs for more than a week or two.
Strategies for Withdrawal
Prevention of dependency
- obviously the ideal. Avoid dangerous prescribing.Information and education of the individual to understand the dependency problem and the need to come off these drugs.
Gaining co-operation of the individual for the withdrawal programme. An explanation of the withdrawal symptoms will be required to facilitate the patients complying with the withdrawal procedure.
Reduce the daily dosage VERY slowly, perhaps over several months in long term users.
Consider changing a short term benzodiazepine to a long term one initially and then withdrawing that slowly.
Consider changing hypnotics to a tricyclic antidepressant at night. Sometimes a tricyclic is more appropriate anyway, but will be easier to withdraw. Beware in a patient with overdose risk, as toxicity is much greater in tricyclic antidepressants.
If withdrawal fails, do not give up but try again later when conditions may be better for a successful outcome.
Avoid repeat prescriptions without seeing the patient to discuss the issues. Repeated discussions may be needed before a patient agrees to withdraw from the drugs.
Consider counselling and/or treatment programmes for drug withdrawal.
Abuse
Abuse of these drugs is common and flunitrazepam (Rohypnol) is particularly sought after by drug seekers. It is recommended that benzodiazepines are not prescribed to people unknown to the doctor if they present as casual patients as the likelihood of drug abuse is high.
Expert Help
This is available at most drug treatment centres if a patient wishes to withdraw from benzodiazepines but is unable to do so or if the doctor does not feel sufficiently confident to assist the patient. Assistance is also offered through some psychiatric hospitals in the form of group discussions.
References
Petursson, H., and Lader, M.H. Benzodiazepine dependence. Brit.J. Addict. 1981; 76:133-45.
Lader, M H, and Petursson, H. and Benzodiazepine derivatives - side effects and dangers. Biol. Psychiatry. 1981; 16:1195.
Skegg, D. C. G., Richards, S. M. and Doll, R. Minor tranquillisers and road accidents. Brit. Med. J. 1979; 2:917-919.
The Pharmacological Basis of Therapeutics. Goodman Gillman, A. 1980; 391-447, MacMillan.
Laegreid, L., et al. Abnormalities in children exposed to benzodiazepines in utero. Lancet 1987; 108-109.
Australasian Journal of the Medical Defence Union. Autumn, 1988.
JAMA. 1984; 251:2410-2414.
Tyrer, J. Anxiety disorders. Prescribers Journal. 1987; 27, No. 6: 1-7.
Murphy, E. Drug treatment of behaviour problems in the elderly: 20-23.
Bulletin of the Royal College of Psychiatrists Vol.12, March, 1988; 107-108.
G. R. Boyd
Manager
Primary Health Care Programme
An invited contribution. Opinions expressed in the Therapeutic Notes series are those of the author, and do not necessarily reflect the views of the Department of Health. The author should receive copies of all correspondence relating to this article.
Australia & New Zealand Information
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