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Benzodiazepine Guidance

Posted · 9 Comments
Diazepam-3

Diazepam

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.

Recovery-lightRed Flags

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.

    9 Responses to "Benzodiazepine Guidance"
    1. Peter Sheath says:

      I’ve not seen the paper yet but I get a real flavour of it from your blog. Benzos are, and always have been, very difficult to deal with on almost every level of substance misuse treatment. From a supply perspective there seems to be an almost limitless availability. In my experience most, on the street, Benzos are diverted from GP/mental health/substance misuse services prescribing and cost 50p-£1.00 for 10mgs Diazepam tablets.

      Most people using them illicitly, again in my experience, binge on them according to availability and funding. They are often used to enhance the effect of other drugs such as opiates and/or alcohol and to quickly reduce the wired effect of stimulants and/or hallucinogens. Availability over the internet is growing pretty rapidly often through next day delivery via off shore sources such as Mexico and India.

      One of my main worries is that the substitute prescribing model, when applied to Benzos, may transfer occasional, binge use to daily dependent use and we may be leaving ourselves wide open to litigation. I know that I have seen some medics proposing and advocating for maintenance Benzo prescribing fairly recently, I’m not sure that this is a good and effective way forward.

      I’ve worked with hundreds, perhaps thousands of benzo users and had lots of issues with them myself, rarely have I found people who use them as prescribed. I’ve worked with people, coming into residential detox, who were adamant that they were taking 40mgs daily, backed up by their key worker and prescribing Doctor. It became really obvious on the first dose of 10mgs that this was not so and, on further investigation, they revealed that they were selling nearly all of them and only taking half a tablet when they knew they were due a urine screen.

      There are lots of ways of helping people manage Benzo misuse, giving someone a script for two weeks supply of 40mgs a day in 10mgs tablets probably isn’t one of them.

      • djmac says:

        I share quite a lot of your experience and all of your concerns; I think these sorts of issues are the ones we struggle to get right.

    2. detox nurse says:

      In relation to your first red flag, I think they’ve conflated the term ‘addiction’ (i.e. continued use despite negative consequences) with physical dependence. While the two often occur together, I think they can also be mutually exclusive – you can become phsycially dependent on benzos (often due to mismanagement by prescibers) without being ‘addicted’ them.

      • djmac says:

        I see where you are coming from and that makes a bit more sense, though I do wonder how many ‘involuntary addicts’ might fulfil the criteria for a DSM-IV or ICD-10 diagnosis.

        • detox nurse says:

          I think there’d definitely be a proportion of ‘involuntary addicts’ who would meet the criteria for a dependence disorder, but Ive met enough people (colleagues even) who’ve been physically dependent on benzos or Z drugs and who haven’t exhibited any of the other features of addiction.

        • detox nurse says:

          Also interesting is the DVLA’s position on benzos and driving…even in the context of dependence. I frequently have difficult discussions with alcohol/opiate dependent patients informing them of their responsibility to inform the DVLA. Looks like double standards.

          • djmac says:

            It’s always tricky. I don’t find those discussions easy either and part of the reason is that the attempt to make simple, logical guidelines does not allow for complex, multi-nuanced human beings with a variety of responses to illicit, prescribed and legal drugs.

    3. abstinought says:

      Benzo are an underestimated and extremely dangerous group of chemicals. Not so much in their own right, addictive yes but it’s the choices people make under their influence that really concern me, I’ve seen rational methodical individuals become nr sociopathic, at worse benzos potentiate addiction, drive overdose by removing empathy and installing narcissism. They are subtle but their use and hard users are out of control.

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