Over the last month two GPs have referred their patients to me "on diazepam" for their anxiety.
Both ladies have been on diazepam for anxiety for decades.
Both ladies had stable mental health on diazepam, with no panic attacks, no reduction of Activities of Daily Living or constricted behavioural repetoire, no altered symptoms or presentation, no distress.
Both ladies had no side effects on their diazepam.
Both ladies had the option of other ways of coping presented to them, neither sought to do so. Whatever I suggested was politely declined, they were quite happy staying on their diazepam, thank you kindly.
Both ladies were averaging diazepam 2mg twice a day. Neither was getting more, I went through their boxes of tablets at their homes, counted how many they'd got, counted when they were dispensed, knew when the repeat prescriptions were due and it all matched up. Compliance with prescribed medication was spot on.
Both ladies had a diagnosis of "anxiety" made decades ago on what, to me, seemed somewhat spurious grounds. But I accept that medical notes are just notes, so the true situation isn't always well captured. Both ladies were started on diazepam, it worked, nobody's revisited the diagnosis or treatment and they've remained on it for decades.
Both ladies believe their diazepam does them good, keeps them well, causes no problems and they're both desperately keen to continue on it. Both felt that without out it they'd "be terrible" and become very unwell very quickly. Doctors have said so, which is why they take their medication so meticulously. Both truly believe they've a need for this medication. Both firmly believe this medication is powerfully potent in maintaining their wellbeing thus without it they believe, with great certainty, that they'll be vastly worse.
Tricky one, this. If it was 5mg of diazepam four times a day I'd have issues with it, but 2mg bd is a very modest dose. Pharmacologically, it's a dose you don't get hooked on. So they're not chemically dependent on the benzodiazepine and, in fact, it could be stopped. Psychologically they're both strongly wedded to the notion that diazepam = health and no diazepam = illness. Decades of experiential learning ahs proved this to them, they've continued on diazepam and been well, so there you go, it has to work.
Neither wanted help in anxiety management (not having been anxious for decades). Neither really knew why they had to see me at all. Having discussed options we all agreed there wasn't any need for them to see me again, but I'd be happy to do so if they wanted to. They left with open appointments, so can book in to see me without a referral, and I wrote back to their GPs saying that all seemed well. Both GPs were happy with things being reviewed and the decision being to continue.
Does make me wonder, though, whether medication of dubious benefit should be continued, even if it's safe and cheap and seemingly effective, just to please the patient and make life easier for medics. Because, objectively, there's no reason for the medication to be continued and a drug free trial makes good pharmacological sense.
Of course, the two ladies would resist this vociferously, but they can't prescribe so the decision's ultimately not theirs to take.
Turning a blind eye to diazepam 2mg bd, is that acceptable or is that an anthema to Evidence Based Medicine and the thin end of the wedge of poor practice?