Reducing the use of benzodiazepines
in general practice
J W Tiller
British Medical Journal
1994; 309:3-4 (2 July)
Editorials
Benzodiazepines are the most commonly used psychotropic drugs.(1,2) When introduced they were embraced with enthusiasm by the medical profession and public alike, although since then a backlash has developed against them, which has culminated in legal actions against their manufacturers. The use of benzodiazepines has fallen steadily since the 1970s.(3) Adverse effects have been highlighted, including the chance of a discontinuation syndrome after patients stop taking the drugs.(4)
Doctors have been exhorted not to prescribe these drugs and to try to stop their long term use.5 The exhortations have worked: a community survey in this week's journal does not confirm earlier popular notions of long term use of benzodiazepines [p27].(6) Benzodiazepines are now often regarded as suitable only for short term use, if they have a use at all. (This ignores their appropriate longer term use by some patients.(7) The development of newer anxiolytics and hypnotics and roles for some newer antidepressants as anxiolytics may further alter patterns of use of benzodiazepines.
Educating the public about the risks and benefits of these drugs is the key to reducing their use. Educational programmes can be supplemented by written material and counselling during medical consultations. An educational programme directed at prescribers, people providing care, and patients (who also received training in relaxation) halved long term use of benzodiazepines among elderly residents in care.(8) A study of 200 long term users found that more than half were using benzodiazepines as hypnotics and had done so for a median of 15 years. Use fell by almost a third after a simple mailing encouraged patients slowly to reduce then stop their drugs.(3) Some of the patients may have been receiving the wrong treatment - insomnia may be a symptom of depression, which is better treated with antidepressants than benzodiazepines.
The appropriate use of benzodiazepines depends on a careful diagnosis and clear instructions regarding the drugs’ use.(9) For may patients general health advice; supportive counselling; and information on sleep, relaxation, and behavioural strategies, including cognitive behavioural therapy may suffice. These techniques can be learnt, and every practitioner should be able to provide them. They do not necessarily require long consultations and may be used over several brief consultations. Active participation in treatment reinforces the patients' responsibility for their health. Patients should be told which benzodiazepines to use and why, whether to take them short term or intermittently, and what effects (including adverse effects) to expect. The likely duration of use should be explained before the first dose is taken. If, on starting treatment, patients expect that it will be of short duration they find it easier to reduce the dose later and then to stop the treatment.(10)
Patients using benzodiazepines long term should be reviewed to see whether they continue to need them. When no justification exists patients should be introduced to the idea of stopping the drug. Do not threaten patients with abrupt cessation of a drug that they associate with keeping them well: explain that the original need for treatment may no longer apply; recommend slow reduction; and explain the possibility of a short term, self limiting, discontinuation syndrome. This avoids such symptoms being prematurely misinterpreted as indicating a return of prior insomnia or anxiety.
General practitioners should be aware of the negative effects of not prescribing benzodiazepines. Sedative tricyclic antidepressants, antihistamines, and neuroleptics are more toxic. Untreated, or inadequately treated, patients remain chronically disabled. Furthermore, they may try to relieve persisting distress with alcohol or other agents that have worse short and long term adverse effects.
Some people seek benzodiazepines for non-medical purposes - last week's letters pages provide several examples [p1709].(11) Such behaviour should be recognised and strategies adopted for the safe use of prescribed drugs. Doctors should not prescribe benzodiazepines for patients they don't know unless genuine clinical indications exist - in which case only small amounts should be prescribed. Alternative to drugs should be offered.(12)
Doctors should avoid stigmatising people with mental illness by implying that everybody should be able to overcome mental distress without the need for drugs. The principles for reducing use of benzodiazepines in general practice apply to drugs for any condition; this is not exclusively an issue for people with psychiatric problems.
References
Tyrer P, Murphy S. The place of benzodiazepines in psychiatric practice. Br J Psychiatry 1987;151:719-23.
Salzman C, Watsky E. Rational prescribing of benzodiazepines. In: Hallström C, ed. Benzodiazepine dependence. Oxford: Oxford University Press, 1993:13-27.
Cormack MA, Sweeny KG, Hughes-Jones H, Foot GA. Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice. Br J Gen Pract 1994;44:5-8.
American Psychiatric Association. Benzodiazepine dependency, toxicity and abuse. Washington, DC:APA, 1990.
National Health and Medical Research Council. Guidelines for the prevention and management of benzodiazepine dependence. Canberra: NHMRC, 1991. (Monograph series No 3.)
Wright N, Caplan R, Payne S. Community survey of long term daytime use of benzodiazepines. BMJ 1994;309:27-8.
Romach MK, Somer GR, Sobell LC, Sobell MB, Kaplan HL, Sellers EM. Characteristics of long-term alprazolam users in the community. J Clin Psychopharmacol 1992;12:316-21.
Gilbert A, Innes JM, Owen N, Sansom L. Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Aust NA J Med 1993;23:343-7.
Shader RI, Greenblatt DJ. Use of benzodiazepines in anxiety disorders. N Engl J Med 1993;328:1398-405.
Clift A. Dependence on hypnotics. In: Hallström C, ed. Benzodiazepine dependence. Oxford: Oxford University Press, 1993:203-19.
Correspondence. Misuse of benzodiazepines. BMJ 1994;308:1709-10.
Victorian Medical Postgraduate Foundation. Drug seeking for benzodiazepines: the recognition and management of patients seeking benzodiazepines for non-medical purposes. Melbourne: VMPF, 1994.
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