Review, Mar/21: Best practices in benzo prescribing & management in primary care

The full title of this American review is "Best practices in benzodiazepine prescribing and management in primary care".

https://journals.lww.com/tnpj/Fulltext/2021/03000/Best_practices_in_benzodiazepine_prescribing_and.7.aspx

Excerpt (see link above for full review):

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade. This article reviews best practices regarding primary care benzodiazepine prescriptions and how providers can best prevent and treat benzodiazepine use disorder and other harmful effects.

Benzodiazepines (BZDs) are a class of central nervous system (CNS) depressants with anxiolytic, hypnotic, muscle relaxant, anticonvulsant, and amnesic effects.1 They are approved for several conditions, including anxiety, insomnia, seizures, and alcohol withdrawal.2,3 While BZDs are relatively safe for short-term use (that is, 2 to 4 weeks) or for acute as-needed use (that is, panic attacks), their prolonged use has been associated with dependence, use disorder, and death.2 More than half of the patients who take a BZD for over 1 month develop dependence.4 Many are unable to discontinue use without significant withdrawal symptoms.5

Despite these concerns, BZD prescriptions have increased 2.5% annually between 1996 and 2013, with 5.6% of US adults receiving a prescription in 2013, up from 4.1% in 1996.6 Additionally, the quantity per prescription tripled during this period.6 “Drug overdose deaths involving BZDs rose from 1,135 in 1999 to 11,537 in 2017” in the US.

The purpose of this article is to review best practices regarding BZD prescriptions in primary care and highlight how primary care providers can best prevent and treat dependence and other harmful effects associated with BZD use.

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade.

This sentence is really annoying because the ambiguous phrasing makes it possible to read it as there being a lack of evidence of their potential harmful effects. I know that's not true and can guess from the context that it isn't the intended meaning... but it's lazy and it bugs me, because it's important to get the right message across. 

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade.

 

This sentence is really annoying because the ambiguous phrasing makes it possible to read it as there being a lack of evidence of their potential harmful effects. I know that's not true and can guess from the context that it isn't the intended meaning... but it's lazy and it bugs me, because it's important to get the right message across. 

I have to agree. But I also think that there are few, if any, studies that show exactly what happens in the human body beyond a rather short period of time on benzos. The kinds of studies that need to be done would be considered unethical, e.g. do testing on people, then put them on benzos for four, five, six months, or even several years (like many BBs), and then do more testing and follow-up to see what happened over time. You can't control for the other variables that are involved over these long time periods. So, while you and I and other people who have taken benzos for long periods of time know that there are long-term effects, there are no randomized control trials that document these things in a detailed manner. There are definitely papers, reviews and studies (many of which I've posted here) on benzodiazepines, but again, it's the before/during/after studies of long-term use which could document changes in a detailed manner that are missing.

Well, that's my take on it anyway. It is my understanding that Drs. Ashton and Lader wanted to do certain kinds of research all those years ago (1980s?), but they were denied the funding necessary to carry it out.  Lost opportunities there.

Having said that, I've also come across -- and posted -- many studies on the falls, fractures and motor vehicle accidents that can result from taking benzos. And there are lots on seniors whose cognition, balance, reflexes, coordination, etc. are negatively affected by ongoing benzodiazepine use. There are many references to the BEERS list of medications that seniors should not be taking, and, of course, benzos are on that list.

Despite the lack of evidence on the long-term effectiveness of benzodiazepines and their potential harmful effects, prescriptions of the drug have significantly increased in the US over the past decade.

 

This sentence is really annoying because the ambiguous phrasing makes it possible to read it as there being a lack of evidence of their potential harmful effects. I know that's not true and can guess from the context that it isn't the intended meaning... but it's lazy and it bugs me, because it's important to get the right message across. 

 

I have to agree. But I also think that there are few, if any, studies that show exactly what happens in the human body beyond a rather short period of time on benzos. The kinds of studies that need to be done would be considered unethical, e.g. do testing on people, then put them on benzos for four, five, six months, or even several years (like many BBs), and then do more testing and follow-up to see what happened over time. You can't control for the other variables that are involved over these long time periods. So, while you and I and other people who have taken benzos for long periods of time know that there are long-term effects, there are no randomized control trials that document these things in a detailed manner. There are definitely papers, reviews and studies (many of which I've posted here) on benzodiazepines, but again, it's the before/during/after studies of long-term use which could document changes in a detailed manner that are missing.

 

Well, that's my take on it anyway. It is my understanding that Drs. Ashton and Lader wanted to do certain kinds of research all those years ago (1980s?), but they were denied the funding necessary to carry it out.  Lost opportunities there.

 

Having said that, I've also come across -- and posted -- many studies on the falls, fractures and motor vehicle accidents that can result from taking benzos. And there are lots on seniors whose cognition, balance, reflexes, coordination, etc. are negatively affected by ongoing benzodiazepine use. There are many references to the BEERS list of medications that seniors should not be taking, and, of course, benzos are on that list.

Lapis, although I'm unaware of human subject studies that tested their functionality before, after long-term use of benzodiazepines and then subsequent withdrawal, detailed studies of human subjects have been conducted that document their functionality while using and then post withdrawal from benzodiazepines. As I've noted in the past and point to again, this follow up meta analysis: "The Residual Medium and Long-term Cognitive Effects of Benzodiazepine Use: An Updated Meta-analysis:

Simon F Crowe,  Elizabeth K Stranks

https://academic.oup.com/acn/article/33/7/901/4734935

This follow up meta analysis which included 19 separate studies states:

"In conclusion, the results of this meta-analytic study are important in that they corroborate the mounting evidence that a range of neuropsychological functions are impaired as a result of long-term benzodiazepine use, and that these are likely to persist even following withdrawal. Furthermore, the findings highlight the problems associated with long-term benzodiazepine therapy as well as the important clinical implications of these results. More specifically, it is clear that the residual neuropsychological sequelae must be considered when making treatment decisions for these patients."

I highlighted parts from the conclusion of that meta analysis because I believe with all my heart, soul and mind that it is very important that post withdrawal residual neuropsychological sequelae treatment decisions should be considered by patients and their prescribing physicians BEFORE considering withdrawal from long-term use of benzodiazepines.

Yes, thank you, Fi. I've seen this one. Still, we haven't seen the studies of before, during and after long-term use that could really give us the kind of information that I'm talking about. They can't happen, because it would be unethical to do them.

It's as if we've all been mice and guinea pigs in a large experiment, and we each, individually, have had to draw our own conclusions about whether benzos have been helpful or hurtful to us over the long term.