SMMGP has published guidance for using benzodiazepines and benzo-like drugs in primary care. It’s a comprehensive 60+ page document which covers most (but not all) of the bases and reinforces the need for caution when prescribing the drugs. The guidance is so long in coming because consensus could not be reached. Benzo prescribing is an issue where people have strong views.
The guidance sets out a major problem: that current prescribing guidance is that these drugs should not be used for more than 2-4 weeks, but in practice this is widely flouted with over one million people on these in the long term. As I say the document is comprehensive, so I’ve just picked out a few nuggets here.
Key points on insomnia and anxiety
- Address underlying issues; go for talking first
- Drugs should not be first line
- Low dose, short treatment
- Not indicated for chronic problems
- Prescribing “controversial” for those with established benzo dependence
Long term use
- Considerable, mental and social health problems can occur. Avoid long term use
- Relapse rates are low with benzos (are they seeing different clients from me?)
- Long-term use of benzodiazepines has been associated with long-term cognitive effects, memory impairment, emotional blunting, weakening of coping skills and amnesia, which gradually disappear in most people 6-12 months after stopping
- Long-term benzodiazepine users will sometimes develop depression, for the first time after prolonged use, which will resolve within 6 months or a year of stopping
- Benzodiazepines may also aggravate depression and can precipitate suicidal tendencies in depressed patients
- Use of benzodiazepine and Z-drug hypnotics is associated with an increased risk of many physical health conditions and death
- Fits are rare
The guidance is solid, based on evidence or experience and is certainly the best and most robust piece of work I have seen on the subject. Not everyone will agree with everything in the guidance, but there’s enough here to make it useful to everyone.
There were two things that put up red flags for me. The first was the reference to ‘involuntary addiction’. Sometimes called “iatrogenic”. To me this suggests a different sort of addiction; one which is materially different. Presumably this distinction means that either addiction is something that happens to you or you make a conscious choice to volunteer for addiction. I believe this adds to discrimination and stigma to start to create classes of addiction. Nobody sets out to develop all of the negative consequences of addiction. Nobody. Involuntary addiction is a term best abandoned.
Secondly, and it is by no means confined to this document, the whole thing is recovery light. How many times is recovery mentioned in the body of the document? That will be zero. What about mutual aid? Not at all. (Self-help is mentioned in terms of anxiety management).
The authors estimate that there are between half a million and a million people dependent on benzodiazepines in the UK. I have seen many, many folk who fulfil criteria for benzo dependence go on to achieve recovery with the help of community recovery resources. It seems most odd not to mention the recovery process in terms of managing a benzo dependence problem.
That said, I think most folk working in clinical settings will welcome this document on benzodiazepine guidance. Take a look here.