Saturday, 22 March 2008

Diazepam

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?

12 comments:

Dragonfly said...

That is an interesting one. So many of the elderly I see are on a similar dose for similar reasons.
However, I have seen patients come in from nursing homes wanting to know if they have to have their "sleeper" at 7pm, or if they even need to have it at all because they don't seem to want it. Something I saw the other week was a lady who had been on the 5mg of diaz for >20 years vigorously rejecting the idea of SSRIs for her depression, because she "don't want to be on drugs". Anxiety is so much more socially acceptable than depression, which probably plays a big part.

The MSILF said...

A lot of worse things are done in medicine to keep people happy.

Elaine said...

I think you are right to let it go. 2 mg is really placebo. She is obviously not really addicted or the dose would have risen over time. Better the cost of 2mg diazepam than the cost of other, and probably institutional, care.

mandy lifeboats appeal said...

Dear Shrink

I think turning a blind eye to anything is dodgy ground.

That is not to say that I agree with stopping the Diazepam. Far from it. What works for people should be what is given.

But a medical professional with the powers to presribe any drug should always respect the power they have, the patients they prescribe to and what they are prescribing.

As a non compliant, I have only ever found Lorazepam to have helped me. Now that is no minor benzo to be messing about with...and don't I know it? Er yes I do! No one knows the powers of these drugs like the people who take them. Well, the ones that care enough to read the side effects and are concerned about what tablets do to them.

My view, based on my experience, is that we do not live in an ideal world where one tablet fits all illnesses. In an ideal wolrd I wouldn't need to take tablets.

And if I could find another tablet that has all the positive effects of lorazepam without the addictive nature, I would be taking that instead. But I haven't found it...because it doesn't exist for me.

So....in the absence of the perfect solution, I and, I assume, those women who prefer to tick along with their diazepam do the next best thing for us.

I have never gone above 2 a day (except when I had to be bought down off a high in acute care)...and my normal dose is .5mg per day, although recently (due to severe stresses on all fronts) am fluctuating between .5 and 1 mg. I know that equating that to Diazepam means I would be taking something like 5-10 mg per day but I can live with that.

The other option is a predimonantly hysterical woman who wants to kill herself. Of the 2 options, I think I have taken the better one...but i do understand medics concerns over benzos and I am glad that they prefer not to prescribe them if they don't need to and when they do prescribe them they monitor that.

I wouldn't want my GP giving me the equivalent of a blank cheque to take as many as. I need some boundaries...but also to be allowed to exist with some calm in my life.

Paul said...

Status quo sounds fine - everyone's a winner. And if they've been on these meds for years then the personal identity problem with taking psychoactive medication is either irrelevant or even reversed. That is, the effects of the meds may have become embedded within their identity - to stop taking them would, for them, mean becoming different people.

I suppose the drug company benefits as well from the status quo, although benzo's must be cheap as chips these days.

Paul said...
This comment has been removed by the author.
Calavera said...

Stupid question coming up - so brace yourself:

Is it not possible to give a placebo for a little while, to see if the drug is actually having an effect or not?

How about if you told one of them that you wanted to prescribe a different brand of Diazepam for a certain period of time - one which has better bioavailability or something - and then let one of the women take it and see what the result is?

...I told you it was a stupid question.

The Shrink said...

Paul, it's cheap stuff, yes!

Cal, not a stupid question. I've never given a placebo and sold it as something else and wouldn't do that. With new patients either I'll bit the bullet and say medication's not indicated, or I'll prescribe appropriately. It's with old patients I inherit, like these, where I come undone since I effectively compromise and collude with almost placebo drug regimens or I cause discord largely just to satisfy my own desire for how prescribing should be.

stillcrazy said...

It seems to me you did the right thing and it would be an abuse of power really to prevent these women gettting medication that they believe helps them. Most of us get/do all sorts of nonsense that we think improves our lives and others might think does the reverse (eat fattening foods, drink alcohol watch TV programmes that give us an incorrect impression of the world, use toxic fly spray). The only difference here is that the Govt has given one class of person (doctors) the right/duty of being gatekeepers to certain substances. I would say that since your predecessor didn't monitor the use of these drugs, to stop them now would be compounding rather than negating their bad practise, as who knows what unhappiness could result.
Contrariwise I suffer from extreme depression where sleep is very unlikely and anti depressants ineffective. Having finally been persuaded by my desperate partner to get sleeping pills I (which I am fortunate work for me and I don't get addicted to) I found a GP substitute would only give me 3 days supply at a time. This was inappropriate and humiliating.

The Shrink said...

Stillcrazy, thanks for popping by and commenting.

Yes, I've sort of reconciled myself to the same conclusion.

Despite feelings of personal disquiet, for these folk, in their situation, with their experiences, the status quo seems to be the right thing.

Dr Andrew Brown said...

And it was good practice for the GPs to seek a respected colleague's opinion on a contentious issue, and for the respected colleague to tell them that they were Doing OK.

A few of my patients get supplies of hypnotics from me which they use occasionally in a sensible fashion, and never abuse. I am happy with this. Occasionally I give a short supply of hypnotic to a patient to cover an acute problem with a kind but firm warning that they can't have any more. They then return to see my partner who proceeds to give them more. This drives me nuts!

Ramesh said...

Whether coming home from a hard days work or worrying about the next job, Valium 10mg has been a wonder drug for me. It calms me down and allows me to think straight.


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