These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
A far cry from the facetious stigma as ‘mother’s little helper’ in the 1960s; problematic use of benzodiazepines is now largely an “indiscriminate” problem occurring across most sociodemographics, says Dr Adam Straub, addiction medicine physician and general physician.
While prescriptions have fallen over the last decade, thanks in part to real-time prescription monitoring services and recognition of risk, about three per cent of the population continue to use benzos long term.
Many patients have been on these ‘short-term’ drugs for decades or years, so spotting the signs of problematic use can be a challenge. Subsequently weaning and modifying them is an even more thoughtful process, but is well worth the effort, says Dr Straub.
One in three patients prescribed benzodiazepines use them after three months, and 15% use them for more than 12 months.
While dependence is a major concern, long-term use can be problematic even if the person isn’t dependent.
“It can also lead to cognitive impairment that, depending on how long, can be more or less recoverable. There is an increased risk of overdose. Often as a single agent, it’s not fatal, but if it’s used in combination with other drugs, the additive effects with other depressants significantly increases the risk of death,” explains Dr Straub.
“Benzodiazepines are always affecting your judgment and your reaction speed, and do
increase the frequency of traffic accidents. They are sedative drugs, so you can run the risk of oversedation, especially if the person that you’re treating has other CNS-depressing agents on board.”
Benzodiazepine use in older people presents unique issues.
The depressant agents affect the CNS, leading to increased falls and fractures.
For those with usage spanning several years, it can be challenging to know the root of any cognitive decline.
“It becomes, ‘Is the cognitive impairment we are seeing related to a proper dementia development or is it related to the brain being knocked off from benzos?’,” explains Dr Straub.
For some patients who’ve tried the alternatives and/or require anticonvulsant, long-term benzos may still be their best option.
Dr Straub stresses dependence occurs across all sociodemographic groups.
The longer someone is on the drug, and the higher the dose and potency, the greater the likelihood of dependence.
He has noticed some trends with particular drugs in his clinical practice.
For example, it’s not uncommon for people over 60 to take temazepam as an intended short-term solution for sleep – but continue it long term.
“It’s ending up as a regular medication and then gets left because it’s too hard because if you miss a dose or two, you feel terrible, so the GPs just leave it. Then you end up with, ‘this isn’t strong enough anymore, so I take two tablets’, and there’s an escalation of doses,” says Dr Straub.
“Diazepam gets thrown in as a catch-all, and unfortunately gets used more as a first line treatment, rather than third or fourth line, which it really should be. That one you often see in more of your younger group initially, but then you also see it in your 40s, 60s, 80s, who have been on it for 20 or 30 years.”
He also points to a trend of nitrazepam dependence in lower socioeconomic groups and people with co-occurring mental health conditions.
Not all long-term use is dependent.
If signs are vague, pay attention to the rate of dispensing and any emotional responses to conversation around reduction.
“Is somebody getting their medications a little bit early? Have I seen a bit of dose escalation over the last six or 12 months? Every time we have a conversation about reducing it, somebody gets anxious about reducing it, and so we don’t. Never finding the right time to have the conversation about reducing because the patient becomes difficult,” says Dr Straub.
If dependence is suspected, set aside time for a medication review, framing the conversation around overall patient safety and long-term wellbeing.
Dr Straub recommends using the ICD-10 criteria for substance use disorder.
Dependence requires three or more of the following criteria in the last 12 months:
The DSM-5 provides additional criteria and classifies dependence into mild, being 2 to 3 symptoms, moderate, as 4 to 5, or severe, 6 or more of the 11 categories.
Slowly, in a word.
Do not rapidly taper or cease benzos because sudden withdrawal can have fatal consequences.
The risk of withdrawal increases with the chronicity of use and the dosage, especially with short-acting agents. Non-dependent use may also result in withdrawal.
“People jump the gun and reduce too much too fast. They say, ‘You’ve been on this for a long time, we’ve got to get you off it’ and reduce 15% or 25% in the first step, and wonder why the patient decompensates,” says Dr Straub.
“Don’t wean them while they’re in crisis or if something in the biopsychosocial situation is unstable. Just pause the reductions, try not to go back up, but just stabilise.”
For patients on multiple benzodiazepines, general guidance is to convert to a single agent before considering weaning.
“A gentle weaning regimen is recommended, either using the existing medications or, preferably, converting to diazepam and weaning by small increments as tolerated,” Dr Straub says.
Aim for 10% reduction every two weeks if possible, but some patients may need to lengthen this period significantly.
Plan for the symptoms of withdrawal and prescribe things to deal with those symptoms. Consider using a longer-acting benzodiazepine to reduce the effects of withdrawal.
Staged supply of medications should be implemented where possible, and inpatient withdrawal may be appropriate.
“Put in as much support around the patient during that weaning period, friends, family, counsellors, etc. Who else can we gather? Use everybody you’ve got. Consider your local alcohol and other drug services for those patients that you’d identify with dependence,” says Dr Straub.
Trialling alternatives to benzodiazepines is also crucial during the weaning process.
For example, antidepressants or antihistamines can be effective for insomnia, as well as implementing sleep hygiene and/or relaxation techniques. For anxiety, medications such as SSRI, NASSA or SNRI — or antipsychotics — and/or psychological therapies such as CBT, can be effective.
Dr Straub recommends speaking gently about usage or weaning.
Timing is key, as people will often be quite concerned about the implications of stopping the drug.
“Don’t do it when they’re destabilized. Don’t do it when there’s a lot of stress going on in their life. Plan it appropriately,” Dr Straub says.
“Signpost it for a future review, saying, ‘next time you come in we’ll just go through your medications as a regular review, make sure that we’re doing all the right things, see if there’s any issues’.”
He recommends:
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