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In this next Quick Take, we’re going to look at 2 aspects of the practical management of benzodiazepines that affect us every day in clinical practice. The first is based on an article by Drs. Brett and Murnion on managing benzodiazepine dependence, and then we’ll look at the work of an addiction medicine specialist from Stanford University who has an important perspective on addictive medications, including benzodiazepines.
So, first, from Drs. Brett and Murnion’s review, can benzodiazepines be used safely at all? Should we just stop prescribing them? I know some of my colleagues have actually declared that they don’t prescribe them at all. I found that rather shocking, and I’ll show you why here, now. Chronic use is one thing, and it leads to some really tricky territory, but I’d like to look at a different use, namely short term. If you could control your prescriptions very tightly—and I recognize that’s a challenge onto itself—you can avoid the issue of dependence and withdrawal entirely, at least in theory, as follows.
So, how long can a patient take a benzodiazepine every day and not face withdrawal when they stop? If withdrawal is the big risk of benzodiazepines that they’ll face eventually at some point when someone wouldn’t prescribe them anymore, can we avoid that entirely? And according to the article that I had just reviewed for Quick Takes by Fluyau and colleagues on the challenges of managing benzodiazepine withdrawal, they say the answer to that question, “How long can you go before tolerance develops and dependence and the risk of withdrawal?”, they say 1 to 6 months. And I just found that inadequate, shall we say. It’s too broad a range to be useful.
So, in this 2015 review from Brett and Murnion, which was cited by Fluyau and colleagues, I found a more detailed assertion that it’s “longer than 3 or 4 weeks.” They don’t give a reference, but, unfortunately, as far as I can tell in scouring the literature on this—admittedly I may have missed something—but it looks like this is the best we can do: Longer than 3 or 4 weeks. Meaning that if one is to use these medications for less than 3 weeks, tolerance and dependence should not be an issue. And that means that you could prescribe as long as your patient is willing to recognize these limitations and adhere to them. You could prescribe something like lorazepam for sleep in a patient with bipolar disorder, quantity 14, no refill, and not face this issue of developing a new problem for the patient with dependence. So, I think people have swung the pendulum too far in just not prescribing them, and they’re losing a useful tool.
And then secondly, while we’re dealing with the frustration of managing these medications, here’s a useful perspective from Dr. Anna Lembke at Stanford. She’s the medical director of Addiction Medicine there. She’s authored a book on the paradoxes of managing controlled substances as a physician, and she presented some material from her book in a TED Talk that I’ve linked here at Psychopharmacology Institute. What really resonated with my experience in her talk is what she calls “the medicalization of poverty.” This isn’t happening just in the United States, but I’ll use us as an example. Our social safety net has so deteriorated in the last couple of decades, and interestingly there’s been a parallel increase in the risk of opiate and benzodiazepine dependence and death. And she suggests that these are connected. One way they’re connected, at least in the US, is that being physically disabled and declared so medically can provide a monthly income. So, there’s an incentive to become disabled.
But Dr. Lembke also describes a broader connection that when people are miserable, when they’re suffering—including having anxiety over things like keeping food on the family table with no money to do so and an inability to work, whether that’s real or perceived—in that circumstance, medications like benzodiazepines and opiates are almost tailor made to alleviate their suffering. So, when we’re being asked to prescribe them, in effect we’re being asked to address the poverty that leads the patient to us. And when you see a steady stream of such patients, you can begin to see the force in the background that’s pushing them to you. So, it becomes all the more frustrating to be able to respond because often we have such limited resources for addressing that background poverty. And then on top of that, you have to say, “No, you can’t have the thing that would address your suffering right now.” I thought her description of this as the bigger picture was very useful in explaining to me some of my experience of that frustration and I hope perhaps for you as well.
In summary, then, based on the only data that I can find on this issue, in theory, one can prescribe benzodiazepines for up to 2 weeks regular use with very low risk of tolerance, dependence, and withdrawal. And secondly, the medicalization of poverty may be one of the reasons why managing benzodiazepines is so challenging and frustrating.
Abstract
Management of Benzodiazepine Misuse and Dependence
Jonathan Brett, Bridin Murnion
There are well-recognised harms from long-term use of benzodiazepines. These include dependency, cognitive decline and falls.
It is important to prevent and recognise benzodiazepine dependence. A thorough risk assessment guides optimal management and the necessity for referral.
The management of dependence involves either gradual benzodiazepine withdrawal or maintenance treatment. Prescribing interventions, substitution, psychotherapies and pharmacotherapies can all contribute.
Unless the patient is elderly, it is helpful to switch to a long-acting benzodiazepine in both withdrawal and maintenance therapy. The dose should be gradually reduced over weeks to lower the risk of seizures.
Harms from drugs such as zopiclone and zolpidem are less well characterised. Dependence is managed in the same manner as benzodiazepine dependence.
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Reference
Brett, J., & Murnion, B. (2015). Management of benzodiazepine misuse and dependence. Australian Prescriber, 38(5), 152-155
