Clinical question

[finalpsychyear]

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Got a 64 year old guy who has chronic insomina and some recent memory issues and had been on diazepam 5mg for 20+ years (terrible!!) and his psychiatrist who just moved decided it was now time to taper him off a few months ago. The pcp was managing and now has cut him off completely over a month now and patient says he hasn't slept since february 10th..

Anyways, the meds that have been tried: non-benzo meds such as trazodone, doxepin, benadryl/vistaril and i believe the pcp tried seroquel, roserem with no effect.
I try and limit controlled meds but is there a consensus on what works better on patients who have been on long term benzos... I don't really use lunesta, ambien, sonata. The cognitive issues concern me in the patient and those meds can worsen them and I am hesitant to give him anything that may impair him further. It just isn't leaving many choices since many things have already been tried.

 

[splik]

seriously why did they taper this guy off who had been stable on a piddly diazepam for 20+ yrs. You don't do that if the pt doesnt want it. It's just cruel. These are the patients who you just leave indefinitely on it. Now we shouldn't do this for the most part today, but when someone has been on it for the better part of their life and their are no abuse issues, it is more trouble than not to try and taper. Instead of continuing this ridiculous carousel of different drugs put him back on his valium for goodness sake and hope it still works! the more disgraceful thing here was to take this poor pt off the valium in the first place!

the 5mg valium is not the cause of his memory issues.

and how in the hell is doxepin, benadryl or vistaril (anticholinergics) any better if you are concerned about cognitive issues, they are worse!

(apologies for all the exclamation marks but it is very frustrating we have gone from one extreme of liberal benzos to the other of seeing benzos as all bad)

 

[splik]

Also as an aside, I am not concerned about the z-drugs in pts with cognitive impairment. they are okay. They cause amnestic episodes for sure in a sizable minority of patients but there is no convincing evidence they cause or exacerbate the cognitive deficits we see in these older pts. similarly while benzos should generally be avioided in pts with OSA (though i have used short courses on occassion), z-drugs are usually okay.

also remember pts who can't sleep well also tend to have cognitive problems including executive dysfunction and impairments in attention, concentration, memory, impulse control and judgement

 

[slappy]

Also as an aside, I am not concerned about the z-drugs in pts with cognitive impairment. they are okay. They cause amnestic episodes for sure in a sizable minority of patients but there is no convincing evidence they cause or exacerbate the cognitive deficits we see in these older pts. similarly while benzos should generally be avioided in pts with OSA (though i have used short courses on occassion), z-drugs are usually okay.

also remember pts who can't sleep well also tend to have cognitive problems including executive dysfunction and impairments in attention, concentration, memory, impulse control and judgement

There is actually pretty decent evidence of poor cognitive performance while on benzodiazepines. Whether or not this translates to actual cognitive decline is a different question. There's also the increased risk of falls, even on 5 mg of Valium. That said, I probably would have started with patient education, and let the patient decide whether or not they want it to be tapered. I would've also offered a referral for CBT for chronic insomnia when/if the patient had opted to taper.

 

[splik]

poor cognitive performance on benzos is not what we're talking about and there isn't evidence that is the case in someone taking a stable tiny dose of valium for over 20 years. The evidence for benzos causing cognitive decline is mixed. Some studies have suggested possible acceleration of dementia (and possible increased amyloid deposition) others have found the opposite. A recent study found no causal association of benzos and cognitive decline.

Is there an increased risk of falls for someone on 5mg valium for much of their life? maybe, maybe not. Old people who sleep poorly or get up during the night are also at increased risk of falls. Confounding by indication is a massive problem in these observational studies. I have no doubt that starting someone on benzos acutely (even younger people I have seen this with) can increase fall risk because GABA receptors are primarily found in the cerebellum and thus incoordination is not uncommon with these drugs. But i am much more skeptical of this being the case in someone who has been on the drugs for years especially if started in when they were young (and thus are better able to habituate to the effects on coordination etc). I am not aware of any post hoc or secondary analyses of data sets that have looked at whether chronic benzodiazepine use (i.e. years and years) on people who then age is associated with increased falls risk.

 

[nitemagi]

I'd work to maximize sleep hygiene practices, clarify is it early or mid insomnia, use sleep/wake triggers appropriately. Add melatonin. Reduce barriers to sleep (anxiety, etc). Set expectations that things will improve with time.

 

[hello1234!]

If they are on it for 20 + years, it's tough to get them off. Another thing to keep in mind is the risk of falling in the elderly associated with poor sleep. Pt doesn't sleep well due to no more benzo and could fall. There is no good answer. Having said that I never prescribe Valium.

Another possibility, has the patient had a sleep study for sleep apnea?

 

[Shikima]

His insomnia will be the same as the guy who's had a nightcap for 20+years and now cannot sleep unless he gets his nightcap. It's going to take a number of months for the brain to reorganize itself and also would benefit from CBTI.

And one has no way to ascertain if he had been abusing it or not.

Moral of the story, don't use BZD/Z-BZD for chronic insomnia. There is no evidence to support this.

 

[Unico]

Is there an indication for biofeedback in this setting?


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[Shikima]

Is there an indication for biofeedback in this setting?


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No.

 

[Jules A]

Really he hasn't slept since February 10th? I'd get specifics on the actual sleep pattern which should be helpful. I'm sure labs have been done but also consider neurocognitive disorders that might be concurrently causing memory deficits and sleep disruption.

 

[perox124]

Get sleep log

 

[st2205]

Get sleep log

 

[nexus73]

Liability wise, I would document informed consent regarding all the scary side effects of diazepam, including falls, cognitive issues, etc. You have tried several other medications and the only thing you know has worked is the diazepam. If the patient was agreeable to tapering I would go extremely slowly, like 1 mg (or even 0.5 mg) decrease per month, with no rush to completely discontinue if the patient had problems.

 

[PistolPete]

His insomnia will be the same as the guy who's had a nightcap for 20+years and now cannot sleep unless he gets his nightcap. It's going to take a number of months for the brain to reorganize itself and also would benefit from CBTI.

And one has no way to ascertain if he had been abusing it or not.

Moral of the story, don't use BZD/Z-BZD for chronic insomnia. There is no evidence to support this.

Agree with this post. This guys brain has been bathed with a benzo for 20+ years, now he's off of it, and it's gonna take several months, probably at least a year for his brain to get used to not have a benzo. I'd be empathic, but lower expectations.

 

[finalpsychyear]

seriously why did they taper this guy off who had been stable on a piddly diazepam for 20+ yrs. You don't do that if the pt doesnt want it. It's just cruel. These are the patients who you just leave indefinitely on it. Now we shouldn't do this for the most part today, but when someone has been on it for the better part of their life and their are no abuse issues, it is more trouble than not to try and taper. Instead of continuing this ridiculous carousel of different drugs put him back on his valium for goodness sake and hope it still works! the more disgraceful thing here was to take this poor pt off the valium in the first place!

the 5mg valium is not the cause of his memory issues.

and how in the hell is doxepin, benadryl or vistaril (anticholinergics) any better if you are concerned about cognitive issues, they are worse!

(apologies for all the exclamation marks but it is very frustrating we have gone from one extreme of liberal benzos to the other of seeing benzos as all bad)

Hi. I have only seen the patient 1x but the pcp was trying all sorts of meds that i listed including those anticholinergics. Appreciated your input. The guiness world record is 11 days of no sleep so i think some of this is inaccurate.

 

[Merovinge]

Hi. I have only seen the patient 1x but the pcp was trying all sorts of meds that i listed including those anticholinergics. Appreciated your input. The guiness world record is 11 days of no sleep so i think some of this is inaccurate.

Assuming they were getting sleep dosing of Doxepin (3-10mg), I have not seen much evidence for anticholinergic concerns. Current psychiatry (which means not a lot) states under 25mg not reported anticholinergic effects and if you look at the Ki binding, Doxepin being I believe the most anti-histiminergic drug available for sale in the US vs a modest at best antimuscarinic profile is not overly scary. I agree anticholinergics should be generally avoided but the devil is in the binding details.

 

[Shikima]

Hi. I have only seen the patient 1x but the pcp was trying all sorts of meds that i listed including those anticholinergics. Appreciated your input. The guiness world record is 11 days of no sleep so i think some of this is inaccurate.

Sleep-wake state distortion. They're embellishing to obtain medications.

 

[Merovinge]

Sleep-wake state distortion. They're embellishing to obtain medications.

Oh and here I thought all my patients who haven't slept "at all... in a month" were being totally on the up and up.

 

[nexus73]

Sleep-wake state distortion. They're embellishing to obtain medications.

He's probably after some quaaludes

 

[Bartelby]

I agree with splik, just keeping this guy on the small dose of Valium (with careful education about the risks) sounds very reasonable, unless you see evidence of new problems developing related to the Valium. It especially sounds better than starting an antipsychotic (Seroquel) as a replacement to me.

 

[birchswing]

is there a consensus on what works better on patients who have been on long term benzos

Surprisingly enough in the 60 plus years benzos have been around, no one got around to that. Just deriving and marketing new ones with higher and higher potency.

In the iatrogenic benzo community, the consensus is that nothing reliably helps but time and a very slow taper. Anecdotally various people have success with various supplements, either GABAergic or anti-glutamergic. Throwing Seroquel and Buspar and all the things people tend to throw at benzo patients never made sense to me, as it seems to lack an understanding of how benzos work, why they stop working, and what happens during withdrawal. Even some of the wackiest treatments like flumazenil after a patient has stopped have some theory behind them (their theory is that the benzodiazepine receptor sites need to be resensitized).

Sounds like he tapered too fast. Some of the Valium metabolites last so long that after a week you'd just be starting to feel the first day's cut. It depends on which of the metabolites he responds to most strongly. Valium is probably the most ideal benzo to taper from given its longer half-life metabolites and the low doses available.

5 mg really isn't that much, especially when you compare the equivalency to how much is being handed out in Xanax with patients being told it's a "cleaner" drug.

 

[Shikima]

Rationalization.

 

[finalpsychyear]

I agree with splik, just keeping this guy on the small dose of Valium (with careful education about the risks) sounds very reasonable, unless you see evidence of new problems developing related to the Valium. It especially sounds better than starting an antipsychotic (Seroquel) as a replacement to me.

I live in a state where opioid abuse is a big problem and it has trickled into less prescribing for all controlled drugs. Patients keep telling me that their doctors are too scared to keep prescribing benzo medications because of this. Is there some national crackdown on benzo prescribers? I thought as long as you are getting drug screens and the patient is testing positive for the prescribed medication and they are being counseled and advised appropriately on the side effects and addictive potential then things are ok. What am I missing so my license is safe?

 

[WisNeuro]

Is there some national crackdown on benzo prescribers?

Hopefully it's just more prescribers making good medical decisions in prescribing. The past two VAs that I've worked at are pretty much clearing it out of the formulary. I haven't seen a new xanax prescription in about 2 years.

 

[Merovinge]

I live in a state where opioid abuse is a big problem and it has trickled into less prescribing for all controlled drugs. Patients keep telling me that their doctors are too scared to keep prescribing benzo medications because of this. Is there some national crackdown on benzo prescribers? I thought as long as you are getting drug screens and the patient is testing positive for the prescribed medication and they are being counseled and advised appropriately on the side effects and addictive potential then things are ok. What am I missing so my license is safe?

I find it reprehensible to be prescribing large doses of BZDs to pts with known opioid problems. When they tell you they control their anxiety with 10 bags of heroin a day, I cannot fathom how someone justifies their oath to do no harm by filling a script bottle with 120mg of Xannies. I think like 75%+ of celebrity suicides are on this cocktail and it's not as though the common man is not dying from it either.

 

[WisNeuro]

Why not just find it reprehensible to prescribe large doses of BZDs in pretty much any patient?

 

[st2205]

Why not just find it reprehensible to prescribe large doses of BZDs in pretty much any patient?

It's implied.

I know, I know. Insert anecdote.

 

[Merovinge]

Why not just find it reprehensible to prescribe large doses of BZDs in pretty much any patient?

I personally do, but I can't exactly make a compelling argument that anyone who is giving 4mg of Xanax a day to pts is a bad provider (again, I think they are, but it's not overtly clear from the literature). When I see folks discharged from an inpt psych unit with 120mg of Xanax, 450mg of Oxycodone and their Utox was positive for heroin on admission... that's a pretty easy case to make for bad medicine.

 

[cbrons]

Also as an aside, I am not concerned about the z-drugs in pts with cognitive impairment. they are okay. They cause amnestic episodes for sure in a sizable minority of patients but there is no convincing evidence they cause or exacerbate the cognitive deficits we see in these older pts. similarly while benzos should generally be avioided in pts with OSA (though i have used short courses on occassion), z-drugs are usually okay.

also remember pts who can't sleep well also tend to have cognitive problems including executive dysfunction and impairments in attention, concentration, memory, impulse control and judgement

Can you explain the OSA no benzos but ok for z drugs thing?

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[Shikima]

Can you explain the OSA no benzos but ok for z drugs thing?

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Neither group is encouraged when addressing OSA at the same time. Belsomnra supposedly increases the AHI also.
Now here is where clinical judgement comes in - risk vs benefit and given that they are compliant with PAP therapy.

 

[SeniorWrangler]

He probably would have done better with a super slow taper over several months but now the deed is done. I haven't found anything that works great for these patients but had some success with valerian root.* If you can get them behaviorally activated during the day and clean up sleep hygiene, that helps too. His condition is more like the so-called PAWS -- postacute withdrawal syndrome that substance abusers get, probably due to long term changes in brain function.

* Eye of newt is hard to find these days so I go with the next best thing.