Monday, 14 September 2009

Benzodiazepines

I've differing views on the use of lorazepam and other benzodiazepines (here and here).

The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.

Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.

The outcomes were rather heartening.

Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.

One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.

Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.

Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.

I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.

But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?

Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.

On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.

A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.

Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.

10 comments:

Mandy said...

Having the title 'Ms Lorazepam 2008 and 2009', think it only fit I come and share my five pennath here.

I know there are those that balk at my comments about benzos but it should be a case of experience over theology and what actually does work.

I can't recount the many medications I have been on, mostly over the last 20 years. All I can say is the ones that worked, without too severe side effects, only worked for a short while and most of them didn't make me feel better but much worse.

For anyone who has found a medication that works for them...I say 'good on ya' and wish it was the case that more meds worked for more people who needed them. That would be the ideal, certainly in a medication driven psychiatric service. However, it is patchy and anyone who says otherwise has not been trialled on different drugs over a period of time.

The ideal for me would be lorazepam without the addictive qualities. I can't understand why big pharmas haven't been busting at the seams to make them.

It isn't just me either. My Dad, bless his tortured heart, has been given loads more than I have. None of which have improved anything. He is now half way through a course of 12 ECT treatments (which, as yet, have made no difference to his mental state).

Having suddenly withdrawn my father off benzos..I think he had gone a couple of weeks without, the doctor has now made a U turn and re-prescribed them as PRN.

If the tablet does the job, then why not give it.

Considering some of the states I have been in and seen my father in, having taken psychiatric medication. I think it is cruel to keep prescribing them.

I know there is so little else but in the absence of, I really think it is time pharma companies along with the psychiatric world looked at developing drugs on and from benzos which have the qualititive' effects. Really with the amount of really bad medications that are being produced that could be achieved.

It must be about the money...it really must because it certainly doesn't seem to be about making people feel better.

Such is my view.

Chris said...

Hey Doc,

I have a certain curiosity that I would like for you to quench. As you are probably aware, the shortage of psychiatrists in the U.S. is increasingly looking abysmal. Nurse prescribers/extenders are becoming common-place here in the practice of mental health. In fact, mental health is one of the faster growing areas of advanced practice nursing in the United States. I am aware that the NHS does utilize nurse practitioners/extenders, but I am curious as to how common-place they are, and if the numbers are as common in psychiatry as in primary care. Please enlighten me.

Tiger said...

Ahh, yes. I'm a huge fan of clonazapam. Mostly because it works--nothing else has ever calmed me down as effectively. My psychiatrist? Not so much a fan. Granted, she specializes in addictions, and we all know that benzos are addictive. I'm wondering what she's going to suggest when I tell her that the buspirone she has me on is making me way too dizzy, (especially as I take it 3x a day) and I want off?

moviedoc said...

See my post on benzo's at:

http://behavenetopinion.blogspot.com/

Alice Thomas said...
This comment has been removed by the author.
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