Benzo Prescribing

ttmd

Is there enough of a dialogue about this? I am pharmacist and it seems to me that inappropriate prescribing is causing a lot of problems.

What are peoples views?

http://www.irishtimes.com/newspaper/ireland/2011/0504/1224296002783.html

amjon.

ttmd wrote: »

Is there enough of a dialogue about this? I am pharmacist and it seems to me that inappropriate prescribing is causing a lot of problems.

What are peoples views?

http://www.irishtimes.com/newspaper/ireland/2011/0504/1224296002783.html

What sort of probelms have you seen?

ttmd

While I do not want to get too specific, the general trend I have seen is that GPs and even some Psychiatrists have prescribed them for periods that greatly exceed the recommended guidelines with seemingly no alternative plans on how to deal with the underlying problem (anxiety, difficulty sleeping etc.) on a long term basis. Frequently some of patients are started on some of the strongest members of the class.

I have found my own position on this difficult. I have tried to raise the issue with various people but have been dismissed due to commercial pressures and being seen as uppity (He is a consultant, GP etc they know the patient better than you do, we can not offend our customers by suggesting this may be unwise).

I feel it worth it is really worth reviewing if stricter controls are necessary on the class. They seem to be causing many more problems than they are solving.

Graces7

ttmd wrote: »

While I do not want to get too specific, the general trend I have seen is that GPs and even some Psychiatrists have prescribed them for periods that greatly exceed the recommended guidelines with seemingly no alternative plans on how to deal with the underlying problem (anxiety, difficulty sleeping etc.) on a long term basis. Frequently some of patients are started on some of the strongest members of the class.

I have found my own position on this difficult. I have tried to raise the issue with various people but have been dismissed due to commercial pressures and being seen as uppity (He is a consultant, GP etc they know the patient better than you do, we can not offend our customers by suggesting this may be unwise).

I feel it worth it is really worth reviewing if stricter controls are necessary on the class. They seem to be causing many more problems than they are solving.

As a former Involuntary Tranqillliser Addict ( a phrase coined in the IK) May I heartily endorse all you say? Thank you.

In my case, it was a misdiagnosis to start with. As is the danger as you see.

These drugs are seriously addictive. And side effects are little warned about and cumulative.

It took me a year to get off benzos. Without any help from any professional, I might add, because of the issues you list.

Are there any current stats re the usage in Ireland?

RobFowl

Graces7 wrote: »

Are there any current stats re the usage in Ireland?

Well done and there are, I'll root them out and post them.

RobFowl

Here are the prescribing recommendations for doctors
http://www.drugsandalcohol.ie/5349/1/1500-1388.pdf
And here are the most recent statistics released (2002 to 2007) which unfortunately show a 10% increase in prescribing levels despite strong advice to reduce or stop prescribing
http://www.imt.ie/news/public-health/2008/06/prescribing-drug-abuse.html

ttmd

Graces7 wrote: »

As a former Involuntary Tranqillliser Addict ( a phrase coined in the IK) May I heartily endorse all you say? Thank you.

In my case, it was a misdiagnosis to start with. As is the danger as you see.

These drugs are seriously addictive. And side effects are little warned about and cumulative.

It took me a year to get off benzos. Without any help from any professional, I might add, because of the issues you list.

Are there any current stats re the usage in Ireland?

I could easily see how this could happen. For some reason drugs like Xanax, Valium have relatively little stigma attached to them relative to the trouble they can cause. An interesting anecdote this evening - I heard Linda Martin joking about her and the audience needing to get some 'Valium' for the excitement surrounding Jedward- she probably would not joke about many other drugs of abuse this way.

Rob Fowl, as a GP, do you find a lot time wasted by these problems ( I do not want to put words in your mouth but I get the impression benzo addiction can be an unnecessary and time consuming problem) and would you favor some stronger protocols?

opinion guy

Interesting thread.

ttmd - how much of this do you think is happening from patients being given bzd's as inpatients, which I don't have a huge issue with since sleeping in hospital is hard and things like zopiclone don't always work (makes me high as a kite for one!!), perhaps they get discharged by intern who mistakenly continues the prescription as an outpatient which perhaps in turn gets continued by GP as it was started in hospital and patient is by that stage asking for more of it ?

Seems to me that part of the problem here is our rather antequated paper based prescription. People get started on things by different people and unless it is specfically stated in a letter, which often it isn't, other medical staff may not know exaclty why it was started or by whom. Electronic prescribing with integration from hospital to GP cannot come quickly enough!

RobFowl

ttmd wrote: »

Rob Fowl, as a GP, do you find a lot time wasted by these problems ( I do not want to put words in your mouth but I get the impression benzo addiction can be an unnecessary and time consuming problem) and would you favor some stronger protocols?

It's a frustrating problem but certainly not a waste of time. Helping some one get off them is a great result for Doctor and patient.
Unfortunately almost all Benzo addictions are iatrogenic or started initially at least by doctors.

Temazepam was a very heavily prescribed sleeping tablet and was made a controlled drug some years ago. This means it has to be handwritten in words and figures and cannot be given as a repeat script (each month will have to be issued separately). This reduced the amount of prescribing by a huge amount
I'd personally prefer if all benzo's were controlled drugs.

sam34

i find that benzos are readily available on the street (and i dont work in a geographical area with major drug problems, although i'm aware that everywhere has these problems to some degree). i find patients coming in who are taking up to 90mg (!!) diazepam a day that they are getting on the street, but they now want me to sanction a prescription for this so that they can get them free.

kiwipower

opinion guy wrote: »

Interesting thread.

Seems to me that part of the problem here is our rather antequated paper based prescription. People get started on things by different people and unless it is specfically stated in a letter, which often it isn't, other medical staff may not know exaclty why it was started or by whom. Electronic prescribing with integration from hospital to GP cannot come quickly enough!

While slightly off topic..
I was reading an article on the New Zealand Television Website this morning about deaths from drug over doses in an NZ Hospital http://tvnz.co.nz/national-news/nurse-in-lethal-dose-case-stood-down-4169714

The reason I am posting this here is that even with high tech security etc. mistakes around prescribing/administering can still happen.

Once instructed by the doctor and checked by a clinical pharmacist, most nurses get drugs from a machine.
They have to type in their code name, fingerprints and patient's name, at which point they can access information about what drugs were given to the patient and when.
Nurses then select the drug they want and it is dispensed. From there, it is the nurse's responsibility to administer the right quantity of the drug.
Doctor David Galler from the Health Quality and Safety Commission said the more steps in the procedure, "the more room there is for error".

opinion guy

kiwipower wrote: »

While slightly off topic..
I was reading an article on the New Zealand Television Website this morning about deaths from drug over doses in an NZ Hospital http://tvnz.co.nz/national-news/nurse-in-lethal-dose-case-stood-down-4169714

The reason I am posting this here is that even with high tech security etc. mistakes around prescribing/administering can still happen.

Well there is a difference between electronic prescribing and electronic dispensing - thou often the two do go together.

I can see that electronic dispensing can be problematic however unless they can somehow tag pills themselves at the manufacturing stage without poisoning anyone (hmm....barcodes perhaps.......hmmmmm....interesting....). So I wouldn't particulary be a fan of bringing in electronic dispensing in Ireland currently. But electronic prescribing with integration to GP's and pharmacies is a must. It would mean no more transcription errors, the ability for every doctor (GP and hospital), pharmacist and nurse that deals with a patient to see how long they were on a drug, why it was started, who started it and how long they should be on it. That can only be a good thing. Especially when it comes to benzo's (bringing things neatly back on topic.....:cool:)

ttmd

opinion guy wrote: »

Interesting thread.

ttmd - how much of this do you think is happening from patients being given bzd's as inpatients, which I don't have a huge issue with since sleeping in hospital is hard and things like zopiclone don't always work (makes me high as a kite for one!!), perhaps they get discharged by intern who mistakenly continues the prescription as an outpatient which perhaps in turn gets continued by GP as it was started in hospital and patient is by that stage asking for more of it ?

Seems to me that part of the problem here is our rather antequated paper based prescription. People get started on things by different people and unless it is specfically stated in a letter, which often it isn't, other medical staff may not know exaclty why it was started or by whom. Electronic prescribing with integration from hospital to GP cannot come quickly enough!

To answer your question - I honestly do not know. It would be interesting to find how the majority of long term users start on the drug, though.

On the electronic prescribing- i totally agree. I find the co ordination between hospitals and GPs surgeries poor, people cannot understand what patients are on and why. In general I think the standard of IT in healthcare relative to other industries in this day and age absolutely appalling, (information should be much easier to obtain and manage) but that is a topic for another thread.

ttmd

RobFowl wrote: »

It's a frustrating problem but certainly not a waste of time. Helping some one get off them is a great result for Doctor and patient.
Unfortunately almost all Benzo addictions are iatrogenic or started initially at least by doctors.

Temazepam was a very heavily prescribed sleeping tablet and was made a controlled drug some years ago. This means it has to be handwritten in words and figures and cannot be given as a repeat script (each month will have to be issued separately). This reduced the amount of prescribing by a huge amount
I'd personally prefer if all benzo's were controlled drugs.

Thanks for the reply Rob. I certainly enjoy helping people with their problems, but I thought it may be frustrating in that it is an avoidable problem, and that time could be used helping other people.

ttmd

sam34 wrote: »

i find that benzos are readily available on the street (and i dont work in a geographical area with major drug problems, although i'm aware that everywhere has these problems to some degree). i find patients coming in who are taking up to 90mg (!!) diazepam a day that they are getting on the street, but they now want me to sanction a prescription for this so that they can get them free.

While I agree with your sentiment, I have to play devils advocate somewhat!

You probably cant take a lot of these patients off benzos and moving the drugs up a schedule may (possibly) cause an administrative burden that is very difficult to cope with.

The amounts that are leaking onto the streets are crazy though - I heard 90mg could be low relative to some other people use.

SomeDose

opinion guy wrote: »

Interesting thread.

ttmd - how much of this do you think is happening from patients being given bzd's as inpatients, which I don't have a huge issue with since sleeping in hospital is hard and things like zopiclone don't always work (makes me high as a kite for one!!), perhaps they get discharged by intern who mistakenly continues the prescription as an outpatient which perhaps in turn gets continued by GP as it was started in hospital and patient is by that stage asking for more of it ?

Seems to me that part of the problem here is our rather antequated paper based prescription. People get started on things by different people and unless it is specfically stated in a letter, which often it isn't, other medical staff may not know exaclty why it was started or by whom. Electronic prescribing with integration from hospital to GP cannot come quickly enough!

Speaking as a clinical pharmacist in a large UK hospital that has used electronic prescribing for a number of years, I agree that it is a significant improvement over a paper-based system. However, it is far from a panacea in terms of medicines reconcilliation and should not be relied on as the sole source of a patient's medication record. And as for eliminating transcription errors - I wish! Personally, I always annotate electronic disharges when there is changes to patient's meds or if we want their GP to review/stop/titrate dosage etc. Putting myself in a GP's shoes, I couldn't imagine anything more frustrating than a patient having their meds altered with no clear reason stated and then trying to second guess why, ringing hospitals, digging through notes etc.

Regarding benzos specifically, I would almost never allow a patient to be discharged on them if they were newly initiated in hospital. Some patients ask for them but we make it clear that they should see their GP if they've got ongoing sleep or anxiety problems. The vast majority of our medics are on the ball in this respect anyway so the issue only crops up infrequently, and if it does any pharmacist worth their salt should be making an intervention.

Now if only I could achieve the same success with getting newly-started PPIs stopped on discharge....

RobFowl

sam34 wrote: »

i find that benzos are readily available on the street (and i dont work in a geographical area with major drug problems, although i'm aware that everywhere has these problems to some degree). i find patients coming in who are taking up to 90mg (!!) diazepam a day that they are getting on the street, but they now want me to sanction a prescription for this so that they can get them free.

ttmd wrote: »

While I agree with your sentiment, I have to play devils advocate somewhat!

You probably cant take a lot of these patients off benzos and moving the drugs up a schedule may (possibly) cause an administrative burden that is very difficult to cope with.

The amounts that are leaking onto the streets are crazy though - I heard 90mg could be low relative to some other people use.

Street supply of benzo's is a big issue all right. I hear stories of children being given them for Holy Communions and other event !
The problem with street supply is largely due to poor prescribing practices leading to large amount being made available. Stories persist of pensioners selling on their valium to supplement the old age pension. Certainly I'm aware of one dealer who gets a large repeat prescription form the local psych clinic (who are among the worst offenders re prescribing in my neck of the woods).
Education of GP's seems not to be working for whatever reason. I stick by the opinion that controlled status along with formal medication reviews by GP's, pharmacists and patients should become commonplace. The emerging PCT's could be a good vehicle to deliver this.

SomeDose wrote: »

Now if only I could achieve the same success with getting newly-started PPIs stopped on discharge....

Completely agree !! The world and his wife seem to on these at the moment..

kellso81

A lot of the posts on here seem to view this problem as one which can be solved by better prescribing patterns from GPs and increased vigilance from pharmacists. Although they do have a significant role to play I think the problem runs much deeper and is much more serious. On a wider social level benzos are so commonplace that people view them as being harmless (as indicated by the poster who talked about children receiving them for holy communion days) until in many instances it is too late and people are addicted to them. In todays society it seems everyone is after a quick fix, if someone is stressed, can't sleep, going through a period of mourning, they view a quick tablet as a cure rather than addressing underlying issues and trying to resolve them by non-drug means such as counselling, exercise, relaxation methods and analysing alcohol use (which i think is a huge factor in the proliferation of benzos). Of course these alternatives cost more money or require more effort and when benzos are so cheap there's only ever going to be one winner. I think a government led educational campaign involving GPs, Pharmacists, community groups would go a long way to getting people discussing the issues involved and maybe setting the ball rolling in trying to reign back the wider social use!

ttmd

kellso81 wrote: »

A lot of the posts on here seem to view this problem as one which can be solved by better prescribing patterns from GPs and increased vigilance from pharmacists. Although they do have a significant role to play I think the problem runs much deeper and is much more serious. On a wider social level benzos are so commonplace that people view them as being harmless (as indicated by the poster who talked about children receiving them for holy communion days) until in many instances it is too late and people are addicted to them. In todays society it seems everyone is after a quick fix, if someone is stressed, can't sleep, going through a period of mourning, they view a quick tablet as a cure rather than addressing underlying issues and trying to resolve them by non-drug means such as counselling, exercise, relaxation methods and analysing alcohol use (which i think is a huge factor in the proliferation of benzos). Of course these alternatives cost more money or require more effort and when benzos are so cheap there's only ever going to be one winner. I think a government led educational campaign involving GPs, Pharmacists, community groups would go a long way to getting people discussing the issues involved and maybe setting the ball rolling in trying to reign back the wider social use !

I do actually think moving benzos to a controlled drug status would, eventually, significantly reduce the problem to a fraction of what it is presently, whatever the initial hassle involved. Of course there is going to be a lot of people who are going to be maintained on the drugs.

I view public discussions on illicit drugs as a two sided coin - I actually think when you say such a drug is bad for you, mind bending etc. a lot of people are going to ask where they can get some! Added to this, the media start stirring the s**t.

ttmd

RobFowl wrote: »

Education of GP's seems not to be working for whatever reason. I stick by the opinion that controlled status along with formal medication reviews by GP's, pharmacists and patients should become commonplace. moment..

I think the reason is that there only needs to be a few poor prescribers, I have seen experienced some physicians that addicts view as a soft touch.

Graces7

Appalled by this situation and sadly by what seems to be ignorance?

of the addictive nature of these drugs.

It took me a year to get the effects out of my body and mind and I am left with attacks of painful facial neuralgia years later.

One point here is that it would be a huge task to help folk off the addictions. I was offered no help. And when I was in hospital once, one GP ( rural hospital) said he did not like me taking so much valium so reduced that evening's dose from 20 mg to 2 mg.

By then I had read enough to know that that is not the way to do these things so I discharged myself and went home. And, with great support from internet advice groups....

The drugs were not being checked etc and the scrips were coming by post, and I was scared that if they found what I was doing and I failed, I would not get any more meds. So I simply kept getting the meds, and when I was off all of them, sent the lot to a medical mission charity.

It was a terrible experience. And maybe that is a part of the constant prescribing. It takes time and a great deal of support to wean someone off benzos

Graces7

kellso81 wrote: »

A lot of the posts on here seem to view this problem as one which can be solved by better prescribing patterns from GPs and increased vigilance from pharmacists. Although they do have a significant role to play I think the problem runs much deeper and is much more serious. On a wider social level benzos are so commonplace that people view them as being harmless (as indicated by the poster who talked about children receiving them for holy communion days) until in many instances it is too late and people are addicted to them. In todays society it seems everyone is after a quick fix, if someone is stressed, can't sleep, going through a period of mourning, they view a quick tablet as a cure rather than addressing underlying issues and trying to resolve them by non-drug means such as counselling, exercise, relaxation methods and analysing alcohol use (which i think is a huge factor in the proliferation of benzos). Of course these alternatives cost more money or require more effort and when benzos are so cheap there's only ever going to be one winner. I think a government led educational campaign involving GPs, Pharmacists, community groups would go a long way to getting people discussing the issues involved and maybe setting the ball rolling in trying to reign back the wider social use!

Bravo.. well said...

Betaketone

My clinical pharmacology is a bit rusty but isn't someone taking 90mg plus of Diazepam a day risking a massive seizure if they suddenly stop taking it?

RobFowl

Betaketone wrote: »

My clinical pharmacology is a bit rusty but isn't someone taking 90mg plus of Diazepam a day risking a massive seizure if they suddenly stop taking it?

Yes, graduated discontinuation is the recommended way to do it.

http://www.acnp.org/g4/GN401000129/Default.htm

Graces7

Betaketone wrote: »

My clinical pharmacology is a bit rusty but isn't someone taking 90mg plus of Diazepam a day risking a massive seizure if they suddenly stop taking it?

Exactly so; and that is true for lower amounts. That is what I knew from the internet when that GP said that. Clearly he did not know. Clonic seizure.

Graces7

Well, not all who are prescribed valium take it.. Long story but we needed help with a dangeroulsy thunder phobic collie and the only thing the vet suggested was a lethal injection or a drug that is banned in most countries.

We asked around and learned that a small dose of valium will work fine. So we asked around some more and obtained a bottle of 2mg valium prescribed for someone's grannie that she refused to use..... does not knock the dog out but stops the terror, and we use it very, very sparingly when there is dire need. Works out about once a month. Or less.

There were around 100 in the bottle by the way.

Which of course is how these drugs should be used; emergency only.

Wondering if the "benzo island" site is still aroumd..

sam34

SomeDose wrote: »

Speaking as a clinical pharmacist in a large UK hospital ....Regarding benzos specifically, I would almost never allow a patient to be discharged on them if they were newly initiated in hospital. Some patients ask for them but we make it clear that they should see their GP if they've got ongoing sleep or anxiety problems. The vast majority of our medics are on the ball in this respect anyway so the issue only crops up infrequently, and if it does any pharmacist worth their salt should be making an intervention.

do you mind me asking you to clarify this... as a pharmacist do you have prescribibg powers in the UK? if not, how do you mean you would "never allow" a patient to be discharged on benzos?

Odysseus

ttmd wrote: »

To answer your question - I honestly do not know. It would be interesting to find how the majority of long term users start on the drug, though.

I work for the addiction services and TBH benzos cause us more problems than heroin. With opiate users a lot start on them to enhance the effects of opiates or dissipate withdrawal, some started on them for a genuine reason, but the reason for starting can be very subjective.

Plus the services available for helping a person who is only using benzos are very poor. I'm a therapist not a doctor, but I can find it very difficult to get the person seen medically if they are only using street benzos. If their GP is unwilling to get involved in scripting a detox, often the person has to arrange their own detox, sadly the addiction services is from a medical viewpoint only interested in treating opiate addiction; whereas within the same service I supply psychological treatment for everything from cannabis to OTC codeine.

SomeDose

sam34 wrote: »

do you mind me asking you to clarify this... as a pharmacist do you have prescribibg powers in the UK? if not, how do you mean you would "never allow" a patient to be discharged on benzos?

Pharmacist prescribing does exist in the UK (not me personally), although that is irrelevant to the point above. Every discharge prescription needs to be screened and signed off by a pharmacist - if it's a patient on my ward or area who I'm familiar with and has been initiated on a benzo or Z-drug for no other reason than for peri-op anxiety or as a sleep aid, then I will liaise with the relevant prescriber and remove it from the discharge letter. Ditto for alcoholic patients started on benzos or librium for AWS during their hospital stay, or IVDUs (no methadone on discharge).

There are rare exceptions to this, such as those patients under psyche referral for other issues.

sam34

SomeDose wrote: »

Pharmacist prescribing does exist in the UK (not me personally), although that is irrelevant to the point above. Every discharge prescription needs to be screened and signed off by a pharmacist - if it's a patient on my ward or area who I'm familiar with and has been initiated on a benzo or Z-drug for no other reason than for peri-op anxiety or as a sleep aid, then I will liaise with the relevant prescriber and remove it from the discharge letter. Ditto for alcoholic patients started on benzos or librium for AWS during their hospital stay, or IVDUs (no methadone on discharge).

There are rare exceptions to this, such as those patients under psyche referral for other issues.

that's a very practical system, am not aware of any hospital here doing it, more's the pity. the discharge scripts aren't seen by pharmacists, afaik.

my mother went into hospital a few years back for a few investigations, 2 night stay, and came home on dalmane 15mg! she never questioned it, just kept taking it at home until i realised it.

Graces7

Odysseus wrote: »

I work for the addiction services and TBH benzos cause us more problems than heroin. With opiate users a lot start on them to enhance the effects of opiates or dissipate withdrawal, some started on them for a genuine reason, but the reason for starting can be very subjective.

Plus the services available for helping a person who is only using benzos are very poor. I'm a therapist not a doctor, but I can find it very difficult to get the person seen medically if they are only using street benzos. If their GP is unwilling to get involved in scripting a detox, often the person has to arrange their own detox, sadly the addiction services is from a medical viewpoint only interested in treating opiate addiction; whereas within the same service I supply psychological treatment for everything from cannabis to OTC codeine.

Someone we knew went into John of God for detox from benzos. he was there months. A year later he was taking some prescribed painkillers that were also addictive... No one warned him of that.

In my case the reason for being prescribed was a misadiagnosis; it is easy to give these drugs as a fast "cure".

ZYX

ttmd wrote: »

While I agree with your sentiment, I have to play devils advocate somewhat!

You probably cant take a lot of these patients off benzos and moving the drugs up a schedule may (possibly) cause an administrative burden that is very difficult to cope with.

The amounts that are leaking onto the streets are crazy though - I heard 90mg could be low relative to some other people use.

The important thing though is not to prescribe them for people simply because they are hooked on them from street use already. Patients do say things like "well if you don't prescribe them for me I will go out on the street and buy them". The answer to that is to simply tell them to go and do that.

Some mention has been made of the risk of suddenly stopping benzos. While this risk may be real, I have always felt it is more theoretical than real. I have never seen or heard of any first hand accounts of someone coming to serious harm from stopping benzos (as distinct from alcohol withdrawal where probably every doctor has seen major problems with withdrawal).

The biggest source of benzos in Ireland is still from doctors and considering the massive problem we have in Ireland this is a pretty poor indictment of Irish doctors. Some things that would help improve the situation:

1. Never prescribe to a patient you do not know.
2. Never prescribe more than seven days supply at one time.
3. Never resupply within that time even if meds are "lost"unless you have a seriously good reason.
4. Know why you are prescribing the medication.
5. If starting the medication are you certain the benefits outweigh the risks?
6. Psychiatrists should never prescribe benzos unless patient is an inpatient. They should write letter to GP for him/her to prescribe instead. Patients use this as a way of getting 2 scripts.
7. If prescribing benzos as part of alcohol withdrawal supply should be daily and preferrably taken infront of doctor. Alcoholics selling benzos to get money to buy alcohol is really common.
8. Anyone on benzos should have the consequences explianed to them and some form of detox discussed.

ttmd

ZYX wrote: »

The important thing though is not to prescribe them for people simply because they are hooked on them from street use already. Patients do say things like "well if you don't prescribe them for me I will go out on the street and buy them". The answer to that is to simply tell them to go and do that.

Some mention has been made of the risk of suddenly stopping benzos. While this risk may be real, I have always felt it is more theoretical than real. I have never seen or heard of any first hand accounts of someone coming to serious harm from stopping benzos (as distinct from alcohol withdrawal where probably every doctor has seen major problems with withdrawal).


The biggest source of benzos in Ireland is still from doctors and considering the massive problem we have in Ireland this is a pretty poor indictment of Irish doctors. Some things that would help improve the situation:

1. Never prescribe to a patient you do not know.
2. Never prescribe more than seven days supply at one time.
3. Never resupply within that time even if meds are "lost"unless you have a seriously good reason.
4. Know why you are prescribing the medication.
5. If starting the medication are you certain the benefits outweigh the risks?
6. Psychiatrists should never prescribe benzos unless patient is an inpatient. They should write letter to GP for him/her to prescribe instead. Patients use this as a way of getting 2 scripts.
7. If prescribing benzos as part of alcohol withdrawal supply should be daily and preferrably taken infront of doctor. Alcoholics selling benzos to get money to buy alcohol is really common.
8. Anyone on benzos should have the consequences explianed to them and some form of detox discussed.

While these are all good pieces of advice, and sorry to be glib, some people entrenched in their ways will still ignore the advice. The lowest common denominator will only change if they are forced to.

Also, you may well be correct that stopping suddenly has a more theroretical than real risk, but I would for one would not want to run the risk of being wrong!

I have to update my own knowledge on the drugs in light of the available literature, I have been searching a bit but I have been busy during the past few weeks. Also I dont have access to pubmed etc.

I want to know more about risks pertaining to chronic use especially and anything further to what ZYX said about sudden discontinuation? If anyone has links to some good studies could they post them here?

RobFowl

ttmd wrote: »

I want to know more about risks pertaining to chronic use especially and anything further to what ZYX said about sudden discontinuation? If anyone has links to some good studies could they post them here?

I work in the addiction services part-time and we see withdrawal seizures not uncommonly. They tend to result with sudden stopping of massive doses but I have come across 4 people who had them in the past 2 years.
Long term benzo use is associated with pyscho motor slowing, reduction in ability to concentrate, memory problems and depression among others.
I've posted a link already but will look for a few more.

ttmd

RobFowl wrote: »

I work in the addiction services part-time and we see withdrawal seizures not uncommonly. They tend to result with sudden stopping of massive doses but I have come across 4 people who had them in the past 2 years.
Long term benzo use is associated with pyscho motor slowing, reduction in ability to concentrate, memory problems and depression among others.
I've posted a link already but will look for a few more.

I am chiding myself for appearing a bit ignorant but I saw some comments by David Nutt of ACMD fame questioning the damages of long term use, and thought i better question my own predjuices.

I knew about the above, but this came from usual textbooks, medical reference materials and what I have seen on the job, and I have not looked at enough big studies to the relative prevalence of different problems related to benzo use.

I am going to do a bit of reading!

ZYX

RobFowl wrote: »

I work in the addiction services part-time and we see withdrawal seizures not uncommonly. They tend to result with sudden stopping of massive doses but I have come across 4 people who had them in the past 2 years.
.

Did any of them come to any serious harm though? I used to work for addiction services but again never saw anyone coming to serious harm. Seizures affect up to 2% of the population at some stage of their lives if memory serves me correctly. I wouldn't necessarily count a seizure as "serious harm".

RobFowl

ZYX wrote: »

Did any of them come to any serious harm though? I used to work for addiction services but again never saw anyone coming to serious harm. Seizures affect up to 2% of the population at some stage of their lives if memory serves me correctly. I wouldn't necessarily count a seizure as "serious harm".

Mostly no.
Contributed to one death of someone I knew though.

opinion guy

ZYX wrote: »

I wouldn't necessarily count a seizure as "serious harm".

I wouldn't necessarily NOT count a seizure as "serious harm" either.

resus

Many Doctors prescribe out of fear, as highlighted in recent court cases.

Malmedicine

Ok I know what I've taught up to this point is any patient started on librium for AWS and is being discharged is always discharged on a decreasing dose.

For hospital scripts I think the max they are valid for is 7 days.

SomeDose

Malmedicine wrote: »

Ok I know what I've taught up to this point is any patient started on librium for AWS and is being discharged is always discharged on a decreasing dose.

For hospital scripts I think the max they are valid for is 7 days.

We would of course initiate a reducing regime of librium where appropriate for inpatients, but would never discharge an alcoholic patient with a supply of it. From a risk management point of view, we cannot vouch for their bona fides after discharge and there's a very real possibility that they may continue to drink heavily whilst taking a CNS depressant. Rather, the patients are encouraged to liaise with a community alcohol team / GP who are in a better position to safely manage their detox.

NOELER

I have to update my own knowledge on the drugs in light of the available literature, I have been searching a bit but I have been busy during the past few weeks. Also I dont have access to pubmed etc.

I want to know more about risks pertaining to chronic use especially and anything further to what ZYX said about sudden discontinuation? If anyone has links to some good studies could they post them here?[/QUOTE]

You will find some info on bzo use/misue here;
[url
http://benzo.org.uk/[/url]

NOELER

Hi
An interesting topic;
I would not agree with all BZO drugs being classified as controlled, From a drug administration point of view it would be a nightmare under current MDA record keeping, like giving methadone. Most of the drugs i use in work are BZO family, and I don't think the patients would be very safe without them.
There are many issues to consider in BZO prescription ,dispensing, administration and monitoring. I think they are safe when used correctly. I have seen people abusing 300 to 450 mg of diaz/day. Thay would be the exception, but plenty on 100- 300mg valium/day. I would not fancy being the patient if a pharmacist decide to stop this or refuse the script. I think previous discussion re GP's allegedly over prescribing is a complex one. No they ought not to be prescribed for >30 days, but if people are dependant on BZO meds, then I wonder if it is ethical not to manage that reality? It is not really a medically safe option to simply stop BZO's abruptly due to risks that would entail (seizures and associated injuries, other morbidities),is it? It is ethically questionable also to put a patient through the sever discomfort, or trauma of sudden withdrawal. I'n my own experience, it matters little of the whys of how people get dependant on medication, more important would be, the how's of how to stop, then how to maintain this. I posted it before, but found this site good for bzo info.
http://www.benzo.org.uk/index.htm
http://www.benzo.org.uk/manual/

amjon.

This forum is also pretty intersting:

http://www.drugs-forum.com/index.php

It's a pretty good resource for almost any drug anyone would ever consider abusing. There are extensive threads on benzos that I have never even heard off. Some pretty harrowing stories on it too.

daithi1986

I spend a lot of my time working with older people, some who have behavioural problems related to dementia and a lot of them with sleep disturbance.

Definitely the GP's that I work with are very careful with prescribing of Benzodiazepines. The rule of thumb generally in our area is benzodiazepines are usually only commenced when a person is dying i.e Alprazolam for anxiety. The drug of choice for behavioural problems now seems to be Trazodone or Quetiapine. Z drugs are quite commonly prescribed still, but usually the 3.75mg Zopiclone is the first line treatment for sleep disturbance.
Unfortunately, we have a lot of patients who we've inherited old prescriptions from. We've some who take regular Lorazepam, Temezepam and Diazepam in large doses. At their age, withdrawal would be very difficult and so we tend to continue those prescriptions unless side effects are clearly manifested. We're all acutely aware of the dangers of long term or high dose benzodiazepines in the elderly. There needs to be a whole system approach to this.
I'd definitely support the concept of all Benzodiazepines being MDA Scheduled. The excessive paperwork, prescribing, storage and administration requirements would surely make people think twice about them.

burpee

The phobic approach to benzo prescribing without alternatives annoys me as a young man. I have anxiety and sleep problems despite being very high functioning and doctors (GPs and Psychs) both do not take me seriously and say "oh you're a young guy, you should be sleeping well. Get plenty of exercise, cut down on activity in the evening and follow sleep hygiene advice." While well intention ed and useful for a first time insomniac who thinks they have the worst case ever, it is of no use to a 28 yo who literally cannot fall asleep for days despite being tired, following sleep hygiene rules (including keeping the bed for rest and sex only!) and not doing anything obviously causing a problem like caffeine. I even sleep walk. I don't do drugs, have no history of addiction or anything. I see my GP about every 6 weeks and beg him for sleep and I always run out of the quetiapine and diazepam scripts between visits because I need to use more than on the label. I am not drug seeking but a young man means 2 things: abuse of drugs and not using drugs cos his age which is unfair on me. I'm sure there are others out there. I've tried anti depressants and they did nothing and now after all these complaints I'm booked into a sleep clinic. Benzos and z drugs are now monitored as doctors prescription rate data via pharmacies. This is going to mean that young patient like me (I'm not addicted by the way, I don't get them enough to be) ar going to given the nice sleep hygiene leaflet rather than something truly useful.

burpee

And second place to acting like God goes to pharmacists. I've come across some who think I am a junkie and refuse me the script. The act as an obstruction. They are instructed to prepare a medicine and give it out, not whether they like the look of a patient. I avoid certain pharmacists for this reason now. They are judgmental and disrepectful for no reason when presented with a benzo script and a young guy.

Nonoperational

Putting a young person on regular benzos is generally a bad idea. Pharmacists are not instructed to prepare a medicine and give it out regardless. You're wrong there.

locum-motion

burpee wrote: »

...and I always run out of the quetiapine and diazepam scripts between visits because I need to use more than on the label...

And that, right there, is why your doctor doesn't want to prescribe sleeping tablets for you.

burpee

burpee wrote: »

And second place to acting like God goes to pharmacists. I've come across some who think I am a junkie and refuse me the script. The act as an obstruction. They are instructed to prepare a medicine and give it out, not whether they like the look of a patient. I avoid certain pharmacists for this reason now. They are judgmental and disrepectful for no reason when presented with a benzo script and a young guy.

Benzodiazepines are only for 2 - 4 weeks use. I would have issue with a patient been on them long term. CBT is far better than benzodiazepines in the long term. The pharmacist isn't judging you on your looks. They are worried about why anybody would be on a benzodiazepine long term. This is an issue in the UK with GP's readily prescribing benzodiazepines and patients becoming addicted. Also, you are on Quetiapine for insomnia, there is no evidence for this.

I can't emphasise enough how a medication like diazepam is a short term medication.