JAMA network - Patterns in Outpatient Benzodiazepine Prescribing in the U.S.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2722576 (January 25, 2019) I haven't read this yet, but it coincided with another article I was reading today in Medscape: https://www.medscape.com/viewarticle/908269?src=wnl_edit_tpal&uac=234089MJ&impID=1868804&faf=1

 

In Medscape: Benzodiazepines "can be effective medications when used in appropriate patients for short-term use. But I fear that we're seeing a lot of chronic use, even though there isn't much evidence supporting its use past 8 or 10 weeks. In these patients, we should broach the idea of deprescribing with slow tapers," said Agarwal.

 

Where in the world did they get the idea that use up to 8-10 weeks is okay??? They still aren't getting this right.  :'(

Interesting.  Thanks for posting, Terry.  As is pointed out, there are very few guidelines and I've actually seen varying recommendations for the duration of use too, usually dependent on condition being treated.  I've most often seen 2-4 weeks but I've also seen 4-6 weeks.  I think maybe 6-8 weeks too but not very often.  This is the first time I've seen 8-10 weeks.

 

One of the surprising things to me was that half the benzo prescriptions were from primary care physicians.

Yes, I saw that, too, seltzerer. GPs, I have a feeling, are very naive about benzo prescriptions. I often think that with the shortened time of seeing patients, they just figure that a quick solution to various problems is to prescribe a benzo. They, it seems likely, don't go into the side effects and dependence. Bad all the way around.

 

And I certainly don't know where they came up with 8-10 weeks! Someone would surely be dependent by that time, on the way to tolerance. NOT okay.

I used to work for a pharma company that was developing an extended release alprazolam tablet in the early 2000s. You take one tablet in the morning and it works all day.  The tablet was supposed to treat chronic anxiety. I can't remember how the anxiety was measured in patients in clinical trials. Probably self-reported on a scale is my guess.

 

When the phase 3 clinical results were unblinded, it was found that alprazolam was no better than a placebo for treating chronic anxiety.

 

I knew this, yet I still started taking alprazolam for chronic anxiety after my cancer. I could just kick myself.

HopeToDoThis, we ALL have deep regrets. I can't tell you how many times I've gone over the past and wished I'd done something different. But I didn't. What's done is done and cannot be redone. Don't put yourself down anymore about this. It can't be helped. But at least you're on a micro-taper and are slowly getting off the benzo. That's progress right there!!  :thumbsup:

 

If we added up all our regrets, over the span of people being on BB from way back, they'd probably reach the moon or far surpass it!! Regretting is one of the benzo symptoms that just keeps hammering away at us, an intrusive thought that I wish would leave.

Thanks Terry38! That makes me feel better. I've been having a lot of regrets lately. I need to remember they are intrusive thoughts.

Yes, they are. They're intrusive hammering thoughts. It's awful to go through that, and I wish you well!!

Here's an NPR story about this study.

 

https://www.npr.org/sections/health-shots/2019/01/25/688287824/steep-climb-in-benzodiazepine-prescribing-by-primary-care-doctors

Thanks so much for this, seltzerer!!

 

I find this particularly telling: Lembke notes that the biggest rise in outpatient visits that led to benzodiazepine prescriptions were from primary care physicians and not psychiatrists.

 

"I think the big message here is that primary care doctors are really left with burden of dealing, not only with chronic pain and opioid prescription, but also benzodiazepine prescriptions," she says.

 

The trends, she adds, reflect "the incredible burden of care on primary care physicians, who are given little time, or resources" to handle a high volume of pain patients with complex conditions.

 

PCPs don't have adequate benzo training. That's where a large portion of benzo prescriptions are coming from.

 

This is so very important: Physicians who want to move patients off their long-term use of benzodiazepines should do it slowly over time, Starrels cautions. "It has to be slow and medically monitored over time," she says, because "sudden withdrawal can be fatal."

 

But the problem is that there's absolutely no consensus on this. I'm hoping that the Benzo Coalition and other benzo sites can be instrumental in schooling these people so that we don't have a rash of patients being yanked off their pills (there already is!). What doctors may think is slow certainly doesn't bode well for patients.

The following is a bit of a vent but there doesn't seem to be a unified message from the BIC or other benzo advocacy sites either, that I can see.  What is it?  2-4 weeks only?  Never long-term?  What about patients who've been on long-term?  What's the unified deprescribing message?  Should there be one?  What happens with patients who can't get off or don't want to?  There's some efforts on informed consent and language about patient-controlled tapers but there doesn't seem to be general consensus.  Even patients who've been harmed by benzos as a group have several different opinions.  Calling for more training and education for doctors makes sense but is it reasonable to expect we would see results?  Doctors are overwhelmed with all their responsibilities as it is now.

 

My opinion is that we need a clinical group to stand up and outline guidelines (perhaps building on the work of Dr. Ashton?) and legislation to protect patients from the lack of guidelines and the pharmaceutical companies that are just making money off this mess.  We need advocates to support their efforts and to educate the public, doctors, and patients.

They just can’t get off of how benzodiazepines are “addictive” to explore the more troubling aspect of benzodiazepines, their physiologically destructive nature.

 

As soon as I see the statement that the problem is they are addictive, I feel completely let down and like all hope is lost, yet again, and that no doctor will drop this language in favor of revealing the deeper and more accurate truth about these drugs. That addicted or not, you may find yourself in a place where you can’t stop taking them... not because of an inherently addictive nature of the drugs or the person being suceptible to addiction, but because the pharmaceutical industry has made a demon drug that completely alters the brain and probably other organs and systems as well.

 

All they can ever say is “addiction, addictive.” So sickening. I think and feel the world will end before enough doctors are brave enough to actually admit the truth. It’s been 60yrs. or whatever... hopeless.

 

I agree, we need advocates and a thorough, consistent and unified message. What about patient rights advocates, where do they fit?

 

Ugh... it all feels like a totally hopeless and forever lost cause. Probably even the as “As Prescribed,” documentary will focus on addiction. That’s how freaking hopeless this all feels to me. No one has truthful language for any of it.

I don't get about why these drugs are prescribed for pain at such a high rate. If that's true at all.

 

If I were to assume that is not the cause, I would think that the economic decline, stress and hardship have a lot to do with this.

 

I agree about 'addictive'. Don't get me started ... but basically, benzodiazepines cause iatrogenic harm. And doctors, those noble creatures who have intrinsic healing abilities, do not harm their patients !!!! One could easily make the cause that long term prescribing is a matter of making medical errors !

 

Just like everyone else, they rationalize their actions. Most of our actions are determined by our subconsciousness.

The following is a bit of a vent but there doesn't seem to be a unified message from the BIC or other benzo advocacy sites either, that I can see.  What is it?  2-4 weeks only?  Never long-term?  What about patients who've been on long-term?  What's the unified deprescribing message?  Should there be one?  What happens with patients who can't get off or don't want to?  There's some efforts on informed consent and language about patient-controlled tapers but there doesn't seem to be general consensus.  Even patients who've been harmed by benzos as a group have several different opinions.  Calling for more training and education for doctors makes sense but is it reasonable to expect we would see results?  Doctors are overwhelmed with all their responsibilities as it is now.

 

My opinion is that we need a clinical group to stand up and outline guidelines (perhaps building on the work of Dr. Ashton?) and legislation to protect patients from the lack of guidelines and the pharmaceutical companies that are just making money off this mess.  We need advocates to support their efforts and to educate the public, doctors, and patients.

 

I agree, there is no consensus on a stopping date. It seems the 2-4 weeks is popular, but even within that time, some people are dependent. I would like it less than that, personally. Someone within that time is in a "honeymoon phase" and thinks the benzo is the best thing they've had in years. That brings up another point: Informed consent, which is sorely lacking. Explaining that these drugs may be wonderful at the outset but may turn on a person quickly with little a few warnings here and there. Explaining it all out to the patient, having them think twice about taking these.

 

I think you have a really good idea, seltzerer. Have advocates doctors can call upon to help someone plan a taper. An advocate needs to be well-versed on tapering methods, however. Advocates would be strongly needed in the medical groups. It seems that's the only way to turn this terrible mess around. When I was on Ativan, I always feared something would happen to them or they would somehow be taken away. This ISN'T to say that I or someone else is an "addict," like so many doctors like to chalk it all up to. These drugs are so powerful and some of them so short-acting that it's almost inevitable that sensitive people would reach tolerance. Do doctors understand that?? I doubt it. It's too easy to classify someone as an addict. That way they can walk away from the situation free and clear.

 

The burden is on doctors, particularly PCPs. But they have way too much to do in a short visit. I agree, there need to be advocates within the medical group to assist patients in getting off these horrible medications.

They just can’t get off of how benzodiazepines are “addictive” to explore the more troubling aspect of benzodiazepines, their physiologically destructive nature.

 

As soon as I see the statement that the problem is they are addictive, I feel completely let down and like all hope is lost, yet again, and that no doctor will drop this language in favor of revealing the deeper and more accurate truth about these drugs. That addicted or not, you may find yourself in a place where you can’t stop taking them... not because of an inherently addictive nature of the drugs or the person being suceptible to addiction, but because the pharmaceutical industry has made a demon drug that completely alters the brain and probably other organs and systems as well.

 

All they can ever say is “addiction, addictive.” So sickening. I think and feel the world will end before enough doctors are brave enough to actually admit the truth. It’s been 60yrs. or whatever... hopeless.

 

I agree, we need advocates and a thorough, consistent and unified message. What about patient rights advocates, where do they fit?

 

Ugh... it all feels like a totally hopeless and forever lost cause. Probably even the as “As Prescribed,” documentary will focus on addiction. That’s how freaking hopeless this all feels to me. No one has truthful language for any of it.

 

I'm with you, mon pilote. The word "addiction" ends all conversation. Doctors spend so much time focusing on that that the real issue is submerged: Sensitive people who took them iatrogenically, following the doctor's orders, STILL can become dependent.

 

It seems hopeless to me, too. That's all I see in articles is the word "addiction." But doctors don't want to face the idea that they themselves are the cause of this. (1) There is no informed consent. I doubt if many doctors even say ANYTHING to their patients about benzos, which is a travesty and is going against "do no harm." (2) They are not versed in benzos. They don't know (or care to know) about all the nerve damage benzos can cause. They tend to spout off words such as "the drug is out of the body in four weeks, so that should be the end of it." Huh??? (3) They don't have the time to counsel their patients, which is the fault of insurance companies who want to pack more patients in within a particular time. I'm sure there are many other reason. This topic could go on and on.

 

I don't call myself an addict with benzos!! I just wanted to get off the damned pills. But I followed the advice of pharmacists that I called and got poor advice, followed it, and was in a world of trouble. How many of us have done that? Further exacerbating the CNS. But I never concluded that I was an "addict" just because I tried that and failed. Would doctors have told me I'm an addict because I was dependent?

I don't get about why these drugs are prescribed for pain at such a high rate. If that's true at all.

 

If I were to assume that is not the cause, I would think that the economic decline, stress and hardship have a lot to do with this.

 

I agree about 'addictive'. Don't get me started ... but basically, benzodiazepines cause iatrogenic harm. And doctors, those noble creatures who have intrinsic healing abilities, do not harm their patients !!!! One could easily make the cause that long term prescribing is a matter of making medical errors !

 

Just like everyone else, they rationalize their actions. Most of our actions are determined by our subconsciousness.

 

I agree with everything you say, liberty. Maybe doctors are substituting benzos for opiates to relieve pain?? Or instead of giving patients more opiates, they used benzos on top of them once upon a time, thinking benzos less troublesome? Or maybe some pharma rep told them something. Why they would even believe in pharma reps is a mystery to me. They have no medical background usually and have been taught what to say. OMG in that case!

 

I agree that long-term benzo usage is a matter of making medical errors. That ought to be a sound basis for a lawsuit. Where does it say that benzos ought to be taken indefinitely??? This is from the FDA: The effectiveness of Ativan (lorazepam) in long-term use, that is, more than 4 months, has not been assessed by systematic clinical studies. The physician should periodically reassess the usefulness of the drug for the individual patient.

 

4 months??? In my mind this is very shady information and leaves the doctor in an open-ended situation. This is NOT good practice. They need to change that ASAP.

 

Yes, doctors do rationalize their actions. And if other doctors agree with them, there is a consensus. And that could be at the core of the problem. They've all drunk the Kool-Aid when it comes to benzos.