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Addiction by Prescription

Why are we still getting caught
in the old tranquillizer trap?

Victoria Times Colonist
BC, Canada
February 1, 2002
by Quade Hermann

'I went to the doctor because I had very tight chest muscles from water skiing. He gave me Ativan and told me it was a muscle relaxant. That's all he said," says Kimberly Kern, a statistical manager at an Alberta insurance company. "Not that it was an anxiety drug, or potentially addictive. I didn't know anything about it."

With annual prescriptions for benzodizepines in Canada standing in at more than 16 million, Kern is among the many Canadians who have become addicted by prescription. Like so many of them, she just didn't know it.

That's ironic, because since Valium was introduced by Swiss drug maker Roche Labs in 1963 and became the drug of choice for anxious and sleepless middle-class North American women, the perils of benzodiazepines have been well known, especially to the medical community.

One health agency warns that addiction can begin in as little as two weeks.

What's less known are the numbers of Canadians addicted to the drugs but studies show that between 50 and 100 per cent of long-term users experience withdrawal symptoms when they stop using the drug.

According to B.C.'s ministry of health services, benzodiazepines round out the top five list of drugs used by those entering provincial addiction treatment programs in 2000.

But people entering treatment programs are only the tip of the iceberg. It's believed few people suffering from withdrawal seek help through programs.

"It's generally recognized as a problem that there are more people on benzodiazepines than there should be," according to Dr. Brenda Osmond, deputy registrar of the B.C. College of Pharmacists. "In working with patient profiles in a number of capacities we see there are people who use these drugs for longer than they should."

The B.C. Women's Hospital just received a $10,000 grant from the Canadian Institute of Health Research to develop a plan to research how our health care system can more effectively respond to the problem of benzodiazepine dependence among Canadians.

"We're just really starting to investigate this area thoroughly," says Renee Cormier, principal investigator.

"We know how many prescriptions go out and roughly to which age group they're going, but we're really lacking descriptive statistics as to the extent of the problem."

As for Kern, she didn't know what was wrong with her after six months of taking benzodiazepines.

"Every time I went to the doctor, they told me to keep taking [Ativan] because it would help my stomach relax."

But thanks to a well-informed health food store clerk, Kern learned she was suffering between-dose withdrawal, a common problem for those taking benzodiazepines over the long term.

It took four harrowing months of withdrawal to taper herself off the drug. Now two years since her last dose, Kern says she's still feeling the effects.

Kern is typical of many who become unwittingly addicted to prescription drugs. She's a middle-class, well-educated professional with no history of drug abuse. And she always put her faith in doctors.

"Before this happened I trusted my doctor," she says. "Now I don't even have a regular doctor. I'm too leery."

That attitude doesn't surprise Dr. Nancy Hall.

"I've been worried about it as a public health issue for eight years," says Hall, former B.C. provincial mental health advocate and now Director of Health Promotion at the B.C. Women's Hospital in Vancouver. "I keep writing reports, we have media coverage, but basically, the government doesn't go anywhere with it."

Health Canada recommends daily use of the drug be limited to four weeks, but the Centre for Addiction and Mental Health at the University of Toronto cautions that dependency can begin in as few as two weeks, depending on the dosage and frequency, the type of benzodiazepine, and the psychological and physiological makeup of the patient.

Pharmacia Corporation, manufacturer of the benzodiazepine Xanax, admits that, "withdrawal symptoms, including seizures, have been reported after only brief therapy at doses within recommended range for the treatment of anxiety."

And yet the drugs are still "frequently over-prescribed" according to a recent study co-funded by the Canadian Pharmaceutical Association and the Canadian Medical Association. Despite there being "virtually no evidence to support the chronic use of benzodiazepines" to treat, in the case of the study, insomnia.

Sixteen benzodiazepines are available by prescription in Canada. The powerful central nervous system depressants act as tranquillizers and sleep aids and are marketed under brand names such as Ativan, Xanax, Restoril, Serax, Valium and Rohypnol (the so-called "date rape drug" because it has been used to sedate and block the memories of unwitting women prior to their dates raping them).

In small doses and for short periods of time, they are considered safe and extremely effective for treating bouts of high anxiety, insomnia and muscle spasm. They're also used as sedatives during surgical procedures, and to ease detoxification from alcohol and other drugs.

Potency among benzodiazepines varies, depending on how quickly they are designed to leave the body.

Long-acting ones store up in our fatty tissues, causing withdrawal symptoms (from mild headaches and muscle tension, to seizures and suicidal impulses) to continue for weeks or even months. Short-acting ones may clear the system in as few as four hours so that once tolerance develops, users begin to suffer withdrawal between regularly prescribed doses.

In most cases, the withdrawal symptoms mirror the complaints for which the drug was initially prescribed, which can lead to a misdiagnosis of symptoms as chronic disorders.

"Most of [the doctors] were telling me that I didn't take enough to be effective," says Jean-Pierre Ergan, an economist in Montreal who was prescribed benzodiazepines for insomnia. He weaned himself off the drug with the help of an on-line support group after five years of suffering the peaks and valleys of between-dose withdrawal. "In their mind, I would have to take a lot more to be in such a state. I know now they were not aware of the symptoms."

Depressive disorders are now the second most often cited reason Canadians visit their doctors. An estimated five million visits in 2000 were for anxiety and nearly eight million were for depression.

Though the use of benzodiazepines declined in the 1990s after the introduction of non-addictive anti-depression drugs like Paxil and Prozac, they're still widely used.

They're part of a class of drugs called psychotherapeutics, which were the third most prescribed drugs in Canada in 1999.

In B.C. in 2000, psychotherapeutics topped the list of most frequently prescribed drugs. About 1.5 million benzodiazepine prescriptions, many of them refills, were written for B.C. residents that year.

IMS Canada, a pharmaceutical market research firm, estimates that in 2000, Canadians were given nearly 16 million prescriptions for tranquillizers, up almost five per cent from 1999.

Use is no less prevalent on the other side of the border and in other countries. The National Institute for Health Care Management in the U.S. estimates 800 million prescriptions where written for anti-anxiety drugs in 2000. A large number of those prescriptions would be benzodiazepines. Other studies estimate two per cent of Americans, or about four million people, have been using benzodiazepines regularly for five or more years, a figure matched in the UK and Europe, according to Dr. Heather Ashton.

Research also shows that benzodiazepines are more frequently prescribed to the elderly (in whom they are believed to be the cause of increased falls and fractures), and to women.

"Back in the 1970s, the makers of Valium had an ad in medical journals," says Christine Kitteringham, clinical manager of the Aurora Centre, an addiction treatment facility in the B.C. Women's Hospital. "It was a woman standing in front of a sink in curlers, and there are bars across the picture. It said: 'You can't set her free, but you can help her cope.' The image now may be the woman behind the executive desk with incoming emails and faxes, but it's the same message."

Studies show that between 50 and 100 per cent of long-term users experience withdrawal symptoms when they stop using the drug. But the point at which therapy turns the corner into addiction varies among individuals, which makes for a wide margin of error in assessing dependency. Many claim they had no idea they were hooked until they tried to stop.

"There's no point at which you can see it happening," says Eve Norman, a nurse and former college professor from Vernon who took Valium for 30 years to manage chronic back pain. "Your thinking is hijacked. It changes slowly and gradually until you're at the mercy of these things. Until even if you do have them, they're never enough."

Advocates say most people dependent on the drug don't seek treatment at detox centres. Nor do they fit the stereotype of a drug addict.

"There is a small group of benzodiazepine users - the street users - who abuse them," says Janet Currie of the Benzodiazepine Awareness Network. "But the vast majority of benzo users are not street users but are simply following their doctor's prescription. Most benzo users are obedient patients. That's part of the problem. They take what they're told to."

Despite the dangers, physicians still telling patients to use benzodiazepines because they work.

"You could be in a complete state of panic and one Ativan and, bang, you feel better," says Wanda Crouse, a psychiatrist who runs a Victoria clinic specializing in anxiety disorders. Crouse prefers to treat patients with the newer anti-depression drugs, but they can take up to six weeks to take full effect. She uses benzodiazepines to help people cope in the meantime.

"Some people are in such a bad state when you finally get your hands on them," she says, "that they can't do any kind of work with you. They've done well just to get to your office."

It's when that quick fix prescription becomes a long term panacea that the problems start. Given what's known about benzodiazepines, how that still happens is a perplexing question.

According to Warren Bell, a family physician in Salmon Arm B.C., the answer is in the cultural biases that crowd into the examining room alongside doctors and patients.

"Benzodiazepine abuse is part of a social context that is awash with drugs and the promotion of drugs," he says. "The idea 'a pill for every ill' is still the dominant model."

It's an attitude that he says has warped the way our health care system responds to the kind of anxiety-related disorders for which benzodiazepines are typically prescribed.

"In general, the [fee] system is structured against counseling and the majority of practitioners are reluctant to speak at length with people about their personal distresses. And then you add in the all-pervasive presence of the pharmaceutical industry and the fact that as a culture we are habituated to drug taking for mood alteration."

It adds up to the problem, according to John Cook, of the magic bullet. "Once people have a pill that gives them immediate short-term results, they're going to be less inclined to put in several months on therapy."

Still, a quick fix is the most reasonable solution if you're too anxious or exhausted to work or take care of your kids.

"It's the same thing that happens with chronic pain," says Dr. Crouse. "They are truly suffering and they know and believe that what they need to control their pain is a narcotic. It's true, it works; though the downside far outweighs the benefits. All you can do is present the information and try to get them to ally themselves with you."

Though we rely on physicians for their expertise, in reality, our expectations often play a huge role in their decisions.

"Patients, consciously or unconsciously, put pressure on doctors," says Dr. Bell. "But I think that's where the moral integrity of the practitioner comes in. How willing are you to swim upstream and say, 'I know this is what you think is the best solution, but here's why it's not.' ''

The B.C. College of Physicians and Surgeons has elected to monitor benzodiazepine prescriptions (as does the province's Pharmacare program) to ensure its 8,000 members are prescribing them properly.

Results of the monitoring program are confidential, but Dr. Brian Taylor, registrar of the College, says there have been cases in which "high prescribers" have been contacted for "collegial discussions" about their prescribing practices.

Usually educating the doctor is considered the best remedy. Thanks to patient advocates, the College now hands out what's known as the "Ashton Manual," a primer on benzodiazepine addiction and the complicated process of safe withdrawal, written by Dr. Heather Ashton, an internationally recognized expert on the drug from the University of Newcastle upon Tyne.

In a 1998 study reported on by the British Medical Association, fear of jeopardizing the doctor-patient relationship "greatly influenced" physician's prescribing practices.

And there are other influences. "A lot of doctors are afraid to open up and talk," says David Rosen, a family practitioner in Mississauga, Ont. "What are they going to do if they find some disturbing information? Maybe they won't know what to do, or have the skills to handle it."

When faced with someone they believe is addicted to benzodiazepines, doctors have two choices: refuse to refill the prescription which will, if the patient doesn't simply go to another physician, send them into withdrawal. Or write another, and try to get them some help.

"We know that doctors and other health care professionals can't provide the constant reassurance that people need coming off benzos," says Janet Currie, of Victoria, who through the Benzodiazepine Awareness Network followed the course of nearly 400 cases of withdrawal last year. "When I get a call from someone in B.C., I just don't know where to refer them to."

"We do have some gaps in service," according to Christine Kitteringham of the Aurora Centre. "Often women will go through a short term withdrawal and then really all they have is the option of a support recovery program setting, which may have some programming, but there isn't that specialized knowledge that really helps women manage their symptoms and emotions."

The Medical Services Plan of British Columbia pays family physicians for only four counselling sessions (presumed to be longer than the average visit) per year for each patient. Any additional sessions are paid at the rate of a standard medical consultation.

Those limits help fuel the popular perception that doctors simply can't afford to do much more than diagnose a problem and write a prescription. "Doctors aren't really paid for counselling," says Kitteringham. "They need to have a turnover of patients every 10 minutes to meet their overheads."

"That's complete nonsense," according to Dr. Bell. "The excuse is I don't have time to do it, but I think the real reason is they just don't want to, because the physicians who want to, do it. You just earn a little bit less, or work a little more per hour. "

In fact, given all these pressures, the willingness, and ability, of doctors and patients to communicate may be our only real insurance against the tranquillizer trap.

A 1999 study headed by King's College in England found that misunderstandings between doctor and patient resulted in inappropriate prescriptions in 80 per cent of the routine visits studied. Patients either received unwanted prescriptions, or didn't receive prescriptions when they expected them.

Lack of information or conflicting information about patient health or history; lack of patient understanding of the doctor's diagnosis or decisions; and inaccurate guesses and assumptions on the part of either, or both, doctor and patient were cited as the most frequent problems.

Much of this can be remedied, according to Dr. Rosen, by asking better questions.

He says we need to improve diagnostic exams, sets of questions that doctors can use to help patients give them accurate and helpful information, and that patients can use to help doctors find the root of their maladies.

"Ninety per cent of medicine is diagnosis, which is history taking," he says. "There are about 10 questions to ask and you can learn a lot from 10 questions. I think a lot of us are just not asking the right questions."

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