Benzos from a Psych Perspective

[ghost dog]

Hello,

I was wondering if you folks from Psych could give me a little perspective in regards to what you think of the rationale for chronic benzo usage.

I'm a doc in Canada with a family medicine and chronic pain practice. My patient / referral population is typically one that is taking benzos and opioids ( i.e. previously prescribed ). These folks have usually been on benzos for a number of years for initial insomnia, yet STILL continue to complain of poor quality sleep.

I myself don't understand the use of benzos in this situation, particularly in the above situation (i.e. failure of efficacy, and potential co-morbid respiratory depression due to synergistic effect from opioids / benzos, fall risk , etc.).

Comments?

Treatment suggestions?

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[whopper]

rationale for chronic benzo usage.

I don't have any. All the data I've seen suggests to me that it should be used temporarily at best. I've seen several problems with chronic usage.

But that said, I know plenty of doctors that give it out like candy, never tell patients of the risks of chronic usage, and then pass the buck on to the next doctor if severe problems arise out of it.

And out of the patients that had even severe iatrogenic problems as a result of it, they usually don't want to take action against the doctor that caused the problem when they finally understand that these meds can cause long-term problems but were never warned.

I almost never start benzodiazepine treatment, and when I do, I usually stop it within 2 months. About 90% of my patients that were started on it by someone else, I eventually stop it by slowly tapering it down and trying to treat the underlying problem that may have led to it, such as an anxiety disorder by giving an SSRI or other medication.

The only patients I've continued on benzos were ones where they were of such an extreme age and/or fragile health that a taper down could cause some risky problems, people that had another doctor that continued it, even against my recommendation, or someone on a low dosage where we've tried other things to get their other problem under control and more than one attempt led to no benefit.

 

[ghost dog]

I don't have any. All the data I've seen suggests to me that it should be used temporarily at best. I've seen several problems with chronic usage.

But that said, I know plenty of doctors that give it out like candy, never tell patients of the risks of chronic usage, and then pass the buck on to the next doctor if severe problems arise out of it.

And out of the patients that had even severe iatrogenic problems as a result of it, they usually don't want to take action against the doctor that caused the problem when they finally understand that these meds can cause long-term problems but were never warned.

I almost never start benzodiazepine treatment, and when I do, I usually stop it within 2 months. About 90% of my patients that were started on it by someone else, I eventually stop it by slowly tapering it down and trying to treat the underlying problem that may have led to it, such as an anxiety disorder by giving an SSRI or other medication.

The only patients I've continued on benzos were ones where they were of such an extreme age and/or fragile health that a taper down could cause some risky problems, people that had another doctor that continued it, even against my recommendation, or someone on a low dosage where we've tried other things to get their other problem under control and more than one attempt led to no benefit.

Chronic benzo use is a pet peeve of mine: I think I have 1 or 2 elderly patients in my practice on them (inherited from previous MDs, of course).

Any suggestions on sleep agents for initial insomnia (not Imovane) ?

I have a patient recently who experienced intolerable nightmares with Trazadone , and other side effects with Elavil (I can't remember exact side effect profile she complained about).

This pt has a past hx of crack and alcohol abuse, so I ain't going down the benzo pathway. Unknown to me, she was seeing a psych who was scripting her benzos episodically; for some reason, she told me that
"a friend" gave them to her when I did a UDS (and she came up positive). Hx of Fibromyalgia, for which she's on Cymbalta. Minimal response with this.

I recommended non-med management (i.e. mindful meditation,gentle aerobic exercise , etc.), but not terribly interested in this sort of modality (quel surprise)

Sedating anti-psychotics?

Lobotomy?

 

[zenman]

I'm with Whopper. I've inherited a few who have been on benzos for 20 yrs. I bring up the subject of tapering off but most won't hear of losing their crutch.

But, around here you can get Xanax for $2 a pill so if anyone wants them they'll get them.

 

[strangeglove]

How about Vistaril (hydroxizine pamoate)? It's an antihistamine with relatively low anticholinergic effects and some decent anti-anxiety effects. I use it a lot in the detox setting.

 

[whopper]

Only rarely have I seen people prefer Vistaril to benzos, and in those cases the person had some type of inflammatory issue such as chronic pain.

In the PP setting, whenever I tell patients of the problems with benzos, the overwhelming majority do not want to be on them, or if already on them, they are happy to be weaned off so long as their anxiety is taken care off by other means such as an SSRI. Edit: in other scenarios, unfortunately, the trend has been for several patients to try to get as many benzos as they can with no concern of the long-term consequences.

I forgot to mention that I do allow benzos indefinitely if the person has panic disorder to treat anticipatory anxiety. In that phenomenon, the fear of the next panic attack increases the odds it'll happen. I allow the patient to carry a supply of benzos on them as a type of lifesaver so to speak. In the patients where I allow this, they usually have their panic attacks down to a handful of times a month or even less. I've had patients who haven't had any attacks for several months but just knowing they have some benzo on standby is comforting to them.

In the above cases, I either give a 30 pill supply that literally lasts the person the entire year if not more, or I just give out a handful (e.g. 4 pills) a month.

I also don't mind giving out a benzo if patient is having something that is on the order of a one-time event. E.g. someone about to go into an MRI machine who is scared, is going to take a plane flight and has a fear of flying etc.

But the above aren't chronic usages.

Another med I had success with is Gabapentin. I've had a few patients that were treatment resistant to SSRIs and SNRIs. Gabapentin does have empirical data showing it helps with anxiety, and it's 2nd generation cousin Lyrica is approved in the EU for anxiety disorders (though I refrain from giving out Lyrica because that has some abuse potential). I wouldn't recommend Gabapentin as a first line for anxiety, but it does work while it's in the system vs. SSRIs that can take several weeks to take effect.

 

[Bartelby]

Any suggestions on sleep agents for initial insomnia (not Imovane) ?

If they haven't tried it yet, maybe melatonin?

 

[billypilgrim37]

Low-dose remeron (7.5mg). That's my favorite sleep prn after trazodone. At that dose, it hardly scratches any receptors other than histamine.

 

[whopper]

Unless the sleep problem was severe, the initial recommendation is to try sleep hygiene first.

http://www.sleepfoundation.org/article/ask-the-expert/sleep-hygiene

A problem with medicating a sleep problem, aside from side effects, is that it could prevent the person from developing their own routines on sleeping on their own. Further, long term studies have showed that while sleep medications are effective short-term, in the long run, sleep hygiene and other non-medication approaches such as CBT have better long-term results.

Medications could also not be appropriate. E.g. in the case of obstructive sleep apnea, there isn't much data (at least that I'm aware of) where sleep meds should be given. A CPAP machine is the treatment here, along with weight loss. Some sleep meds could actually hurt the person's efforts to lose weight. Unfortunately, some doctors just give out a sleep med at the first sign of poor sleep without figuring out the cause or the recommended first step-sleep hygiene.

I usually overried the initial recommendation for sleep hygiene if the problem is severe. E.g. someone whose 3 year-old child was raped and they haven't slept in several days, or someone in a manic episode.

I have a patient recently who experienced intolerable nightmares with Trazadone , and other side effects with Elavil (I can't remember exact side effect profile she complained about).

This pt has a past hx of crack and alcohol abuse, so I ain't going down the benzo pathway.

There is data showing that those with alcohol dependence and insomnia, Gabapentin helps both. It lengthens sobriety and helps sleep.

http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2008.00706.x/full

http://www.ncbi.nlm.nih.gov/pubmed/10618048

Oh, and by the way, if anyone should be aware of the problems with long-term benzos, it should be psychiatrists. That said, I see plenty of psychiatrists give it out like candy on Halloween. I'll stop myself now before I go into a rant.

 

[ghost dog]

Unless the sleep problem was severe, the initial recommendation is to try sleep hygiene first.

http://www.sleepfoundation.org/article/ask-the-expert/sleep-hygiene

A problem with medicating a sleep problem, aside from side effects, is that it could prevent the person from developing their own routines on sleeping on their own. Further, long term studies have showed that while sleep medications are effective short-term, in the long run, sleep hygiene and other non-medication approaches such as CBT have better long-term results.

Medications could also not be appropriate. E.g. in the case of obstructive sleep apnea, there isn't much data (at least that I'm aware of) where sleep meds should be given. A CPAP machine is the treatment here, along with weight loss. Some sleep meds could actually hurt the person's efforts to lose weight. Unfortunately, some doctors just give out a sleep med at the first sign of poor sleep without figuring out the cause or the recommended first step-sleep hygiene.

I usually overried the initial recommendation for sleep hygiene if the problem is severe. E.g. someone whose 3 year-old child was raped and they haven't slept in several days, or someone in a manic episode.



There is data showing that those with alcohol dependence and insomnia, Gabapentin helps both. It lengthens sobriety and helps sleep.

http://onlinelibrary.wiley.com/doi/10.1111/j.1530-0277.2008.00706.x/full

http://www.ncbi.nlm.nih.gov/pubmed/10618048

Oh, and by the way, if anyone should be aware of the problems with long-term benzos, it should be psychiatrists. That said, I see plenty of psychiatrists give it out like candy on Halloween. I'll stop myself now before I go into a rant.

All great recommendations; I believe I've tried her on Gabapentin in the past, as she has a hx of FM. I may reattempt this med though.

I think I may give Remeron a shot, and will certainly give her a handout on sleep hygiene.

She actually took a referral for mindful meditation / tai chi this week. Whether she attends, and gives it a proper trial, is another matter all together.

 

[whopper]

Despite my occasional mentions of Gabapentin, I've noticed a highly variable response with some patients. Some, it doesn't do much of anything. Others, it zonks them out even on low dosages and to the point where even if it's taken at night, they won't be able to wake up until the late morning next day. In others, it works like a charm for anxiety.

Before I start Gabapentin, I warn the patient that there's no FDA approval, but there is empirical data backing it up, and that they could possibly be zonked out on it. For that reason, try it out on a day where if they are zonked, they will suffer less consequences, (e.g. a Friday or Saturday night). I never try it as a first-line medication for anxiety. I only start using it if the patient is showing treatment resistance to more than 2 SSRIs, and an SNRI have been attempted, with buspirone augmentation.

I do recall seeing another double-blinded-placebo controlled study regarding Gabapentin with a much larger pool of subjects (I believe over 100) where it also benefited sober patients with alcohol dependence, providing a longer duration of sobriety and improved sleep that was published in the American Journal of Psychiatry about 3-4 years ago, but after a google and pubmed search I didn't find it.

 

[Danae00]

How often would someone need to take benzos to be considered a chronic user? Is this an every day type of thing? Or would 3-5 times a month be enough if this is over a long period of time (months or years).

I have had patients who take benzos for sleeping problems, but they said they take it rarely and only as needed. I was just curious if this was a recommended approach and what the long term consequences might be.

 

[whopper]

There is no exact declared cut-off, though though more often, more likely for the dangers of dependence and addiction.

If the person has at least some significant amount of time (again, hard to exactly declare an exact time, I'd say a few days) where they are benzo free, I'd say they will likely not develop dependence if they use benzos every so often, but again, be mindful of other possible problems. E.g. the person might not be developing their own cognitive methods of sleeping or dealing with anxiety.

If a person needs a PRN med to sleep, I'd recommend a non-benzo first. In fact, I don't think I'd even give benzos at all. The only time I ever gave a chronic benzo to help a guy sleep was a guy where I tried him on all the conventional stuff, even antipsychotics, but none of them worked except Thorazine (and it only worked for a few weeks, then he developed tolerance to it, even at high dosages), or a few others but those others caused pretty bad side effects. The guy just couldn't sleep after he went through rounds of chemotherapy for cancer, and the effect seemed permanent.

I ended up putting him on a benzo for 2 weeks, then flipped it back to Thorazine 3 weeks on the hope it would prevent dependence, and then back again because it took about 3 week for him to redevelop a Thorazine tolerance.

 

[ghost dog]

Very useful info;cheers.

 

[TexasPhysician]

The only patients I've continued on benzos were ones where they were of such an extreme age and/or fragile health that a taper down could cause some risky problems, people that had another doctor that continued it, even against my recommendation, or someone on a low dosage where we've tried other things to get their other problem under control and more than one attempt led to no benefit.

I think there are a select few patients that need chronic benzos. Some severely ill patients need them to stay calm and peaceful in public. Without them, they live in inpatient units. The state hospital tries everything as well and discharges on benzos because nothing else can keep a select group of patients calm enough to function in society. You could always "snow" these patients, but they won't voluntarily continue these meds at discharge.

 

[billypilgrim37]

I think there are a select few patients that need chronic benzos. Some severely ill patients need them to stay calm and peaceful in public. Without them, they live in inpatient units. The state hospital tries everything as well and discharges on benzos because nothing else can keep a select group of patients calm enough to function in society. You could always "snow" these patients, but they won't voluntarily continue these meds at discharge.

Agreed, the SMI population is one of the few times where adjunctive chronic benzo use can be very appropriate. In the general adult mood disorder population, practically never.

 

[whopper]

Agree with the above. So long as you have enough patients, you will have patients that defy the norm. Someone once mentioned Iron Chef on the forum. Sometimes you get patients like that, where you really are facing something not in the textbooks, or so outside the norm that the treatment has to be something also out of the ordinary. It's rare, and when these things happen, I document why I did what I did, and I only continue it if it works and better alternatives were tried and failed.

I mentioned this before but I had a guy several months ago with fetal alcohol syndrome, and the guy screamed all the time, did not sleep, was extremely irritable, and pretty much met the criteria of bipolar disorder. Several of the conventional bipolar disorder treatments did not work on him, in fact he told me they made him feel even more "hyper."

After thinking about it and after about 3 weeks of no success in his treatment, I thought to myself this could be ADHD on the worst extreme I ever saw. Despite that he met a criteria of bipolar disorder, his thought process was linear and he told me he felt "hyper" all the time. His father told me the guy was cursing excessively even at 3 years old. I gave him Clonidine and he got incredibly better. To this day I'm still weirded out by it. Clonidine isn't even a good treatment for ADHD.