GPs warned to steer clear of the tranquilliser trap Doctors are being told to curb the prescription of sleeping pills and tranquillisers to millions of people after admitting that they can be highly addictive and have devastating consequences.
Benzodiazepines revisited--will we ever learn? Malcolm Lader
Addiction Research Centre, Institute of Psychiatry, King's College London,
London, UK. malcolm.lader@kcl.ac.uk
Abstract
AIMS:
To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed
for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review
based on the Okey Lecture delivered at the Institute of Psychiatry, King's
College London, in November 2010.
METHODS:
A search of the literature was carried out in the Medline, Embase and Cochrane
Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in
conjunction with various terms such as 'dependence', 'abuse', etc. Further
hand-searches were made based on the reference lists of key papers. As 60,000
references were found, this review is not exhaustive. It concentrates on the
adverse effects, dependence and abuse.
RESULTS:
Almost from their introduction the BZDs have been controversial, with polarized
opinions, advocates pointing out their efficacy, tolerability and patient
acceptability, opponents deprecating their adverse effects, dependence and abuse
liability. More recently, the advent of alternative and usually safer
medications has opened up the debate. The review noted a series of adverse
effects that continued to cause concern, such as cognitive and psychomotor
impairment. In addition, dependence and abuse remain as serious problems.
Despite warnings and guidelines, usage of these drugs remains at a high level.
The limitations in their use both as choice of therapy and with respect to
conservative dosage and duration of use are highlighted. The distinction between
low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.
CONCLUSIONS:
The practical problems with the benzodiazepines have persisted for 50 years, but
have been ignored by many practitioners and almost all official bodies. The
risk-benefit ratio of the benzodiazepines remains positive in most patients in
the short term (2-4 weeks) but is unestablished beyond that time, due mainly to
the difficulty in preventing short-term use from extending indefinitely with the
risk of dependence. Other research issues include the possibility of long-term
brain changes and evaluating the role of the benzodiazepine antagonist,
flumazenil, in aiding withdrawal.
Withdrawing benzodiazepines in primary care. Malcolm Lader
Lader M, Tylee A, Donoghue J.
Source
Institute of Psychiatry, King's College London, London, England. m.lader@iop.kcl.ac.uk
Abstract
The use of benzodiazepine anxiolytics and hypnotics continues to excite
controversy. Views differ from expert to expert and from country to country as
to the extent of the problem, or even whether long-term benzodiazepine use
actually constitutes a problem. The adverse effects of these drugs have been
extensively documented and their effectiveness is being increasingly questioned.
Discontinuation is usually beneficial as it is followed by improved psychomotor
and cognitive functioning, particularly in the elderly. The potential for
dependence and addiction have also become more apparent. The licensing of SSRIs
for anxiety disorders has widened the prescribers' therapeutic choices (although
this group of medications also have their own adverse effects). Melatonin
agonists show promise in some forms of insomnia. Accordingly, it is now even
more imperative that long-term benzodiazepine users be reviewed with respect to
possible discontinuation. Strategies for discontinuation start with primary-care
practitioners, who are still the main prescribers.This review sets out the
stratagems that have been evaluated, concentrating on those of a pharmacological
nature. Simple interventions include basic monitoring of repeat prescriptions
and assessment by the doctor. Even a letter from the primary-care practitioner
pointing out the continuing usage of benzodiazepines and questioning their need
can result in reduction or cessation of use. Pharmacists also have a role to
play in monitoring the use of benzodiazepines, although mobilizing their
assistance is not yet routine. Such stratagems can avoid the use of specialist
back-up services such as psychiatrists, home care, and addiction and alcohol
misuse treatment facilities.Pharmacological interventions for benzodiazepine
dependence have been reviewed in detail in a recent Cochrane review, but only
eight studies proved adequate for analysis. Carbamazepine was the only drug that
appeared to have any useful adjunctive properties for assisting in the
discontinuation of benzodiazepines but the available data are insufficient for
recommendations to be made regarding its use. Antidepressants can help if the
patient is depressed before withdrawal or develops a depressive syndrome during
withdrawal. The clearest strategy was to taper the medication; abrupt cessation
can only be justified if a very serious adverse effect supervenes during
treatment. No clear evidence suggests the optimum rate of tapering, and
schedules vary from 4 weeks to several years. Our recommendation is to aim for
withdrawal in <6 months, otherwise the withdrawal process can become the morbid
focus of the patient's existence. Substitution of diazepam for another
benzodiazepine can be helpful, at least logistically, as diazepam is available
in a liquid formulation.Psychological interventions range from simple support
through counselling to expert cognitive-behavioural therapy (CBT). Group therapy
may be helpful as it at least provides support from other patients. The value of
counselling is not established and it can be quite time consuming. CBT needs to
be administered by fully trained and experienced personnel but seems effective,
particularly in obviating relapse.The outcome of successful withdrawal is
gratifying, both in terms of improved functioning and abstinence from the
benzodiazepine usage. Economic benefits also ensue.Some of the principles of
withdrawing benzodiazepines are listed. Antidepressants may be helpful, as may
some symptomatic remedies. Care must be taken not to substitute one drug
dependence problem for the original one.
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By MyHealthNewsDaily staff
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