Dr. Bob's Psychopharmacology Tips

Appropriateness of long-term treatment with benzodiazepines

From: Jaime Smith <evb@yknet.yk.ca>
Date: Fri, 22 Dec 95 07:53:39 -0800
Subject: Long-term treatment with benzodiazepines

I would think that in the absence of abuse or dependency long term administration of benzos would be appropriate if the quality of life is significantly enhanced. I have come across a few patients in that situation in 20 years and recall a letter to the NEJM some years ago from a patient who did well on 15 mg of diazepam for years, then ran into an internist who insisted he d/c it, which he did, and he felt quite miserable for months, until he found someone to represcribe it. In most cases I would try to d/c the drug but when QOL is involved we should ask ourselves who do we serve anyway, patients or textbooks?

Date: Fri, 22 Dec 1995 10:46:08 -0500
Subject: Long-term treatment with benzodiazepines
From: "Kenneth R. Cohen M.D." <krcmd@computer.net>

It seems to me that if a patient is on a chronic, stable dose of BZ, with apparent benefit, and without indications of other substance dependency or adverse reactions, continuation treatment is probably reasonable. Whether it is optimal would depend upon individual values and risk-benefit analysis.

Date: Fri, 22 Dec 1995 09:34:27 -0800 (PST)
From: "H. Westley Clark" <carter@itsa.ucsf.EDU>
Subject: Long-term treatment with benzodiazepines

Long term benzodiazepine treatment may be indicated in select patients. You, of course, must have a strict treatment plan--ideally, written and signed by the patient.

The patient must be apprised of the dependency syndrome associated with even low dose chronic benzodiazepines. The patient should be made aware of tolerance and withdrawal syndromes. Even if the stress is time limited, e.g., a new job, the issues of physiological dependence must be carefully explained.

If you choose to proceed, prescriptions should be regulated carefully. Refills should not be automatically granted. The prescription should be re-evaluated every 30 days. You should agree on an initial fixed time period for the prescription. You should agree on a maximum time period for the prescription.

You should have a toxicology screen for illicit substances performed before initiating the prescription. You should verify through the interview and contact with other physicians whether there is a history of alcohol or drug abuse.

You should require the patient to use one and only one pharmacy. Every 6 months, you should contact the pharmacist and review the prescribing history and detail the prescribing plan.

If you prescribe for more than a year, you should recommend that a case conference occur, with all involved practitioners (or their representatives) attending.

The reluctance of physicians to prescribe for long periods of time is not surprising, given that the Medical Board, the DEA, and the patient may seek recourse for inappropriate prescribing.

The medical rationale for the use of chronic benzos should be carefully established and documented. The fact of medical benefit from the benzos should be carefully established and documented. By involving all parties, even the patient's signficant other (if there is one), the physician can establish a medical purpose for the prescribing.

Periodic physical examinations by the prescribing physician or at least by the treatment team is also critical.

This sounds like a lot. It is. However, if the flak comes, it is best to be covered.

Date: Fri, 22 Dec 1995 19:44:32 -0500 (EST)
From: Donald Franklin Klein <dfk2@columbia.edu>
Subject: Long-term treatment with benzodiazepines

I have no problem with long term monitored bzd prescription. The McNair trial used chlordiazepoxide (Librium) 80 mg/d.

From: "Alsgaard, Hartley" <HartleyA@hsc-dhs.state.sd.us>
Subject: Long-term treatment with benzodiazepines
Date: Fri, 22 Dec 95 18:35:00 PST

It seems there are people that function with benzodiazepines on board and do not function without them. Yet, repeatedly they get taken off their medication by well intentioned practitioners.

I recall one such fellow whose business disintrigrated and marriage became strained each time there was a new doc at the MHC that took him off his BZD. Some would not restart his lorazepam 2 mg TID even when he fell apart, so he would seek help elswhere. He could at least get a family practitioner to provide it. (Sometimes less may be more).

When I set up my private practice he was just being weaned off the BZD by the new doc at the MHC, so he came to me. He said he preferred to be in the hands of a psychiatrist, if possible. He told me his story and asked me only to keep him on lorazepam while I got his records and considered the case. I did. He'd been tried on everything in the mainstream armamentarium for anxiety and nothing else had worked. I contacted all the local and nearby pharmacies (small town) and there was nothing amiss in his prescription filling activities. I (of course) tried to taper him down and it didn't work, so I just kept him on it and documented everything I had done.

It seems we would rather let someone live a life of torment or even die (lots of mortality with anxiety, you know) than give him BZD. And we're pretty good at feeling self righteous about it, too. But then self righteousness is fruitful ground for self examination.

Date: Fri, 22 Dec 1995 22:35:29 -0500 (EST)
From: David Tobolowsky <dmtmd@dcfreenet.seflin.lib.fl.us>
Subject: Long-term treatment with benzodiazepines

As long as you get informed consent re the risk of physical and psychological dependence and see the patient routinely for supportive therapy, it would not necessarily be bad to prescribe benzodiazepines.

Date: Sat, 23 Dec 1995 01:36:33 -0500 (EST)
From: Steven King <kingpain@astro.ocis.temple.edu>
Subject: Long-term treatment with benzodiazepines

The current view regarding benzodiazepines is that they are generally contraindicated in patients with chronic pain.

From: HrgSmes@aol.com
Date: Sat, 23 Dec 1995 17:50:50 -0500
Subject: Long-term treatment with benzodiazepines

I've seen a number of folks on Ativan, Xanax, or Klonopin who seem to do quite well without raising their dose or showing any sign of tolerance and get worse when some enthusiastic practitioner (myself included) decides it's time to withdraw it and try something else. These folks usually suffer from some form of chronic anxiety.

On the other hand, I have also seen people who get cognitively impaired on Xanax and depressed on Klonopin, usually at the inception of therapy. In my limited experience, it's impossible to predict who is going to be a long time responder without problems and who will get into difficulties. Certainly circumspection should be used about prescribing long term benzos, but I think we have to take into account this group of stable long term users who function well with the drugs on board.

Date: Mon, 25 Dec 1995 15:08:05 -0500 (EST)
From: Charles S Berlin <cberlin+@pitt.edu>
Subject: Long-term treatment with benzodiazepines

I have a patient who has both Crohn's Disease and a panic disorder. These have been comorbid for more than 15 years. This patient has experienced excellent control of his panic disorder with Librium. Over the years, whenever the Librium was stopped, not only did the panic disorder flare up, but so did the Crohn's. He has never abused the Librium. The reason he became my patient is that he had previously been getting treatment at the VA, but they eventually refused to further prescribe the Librium, telling him that he was an addict because he had stayed on the med chronically (even though only taking it as prescribed). He thus came to me in relapse, I resumed the Librium, and he's done fine since then on the same dose. I've now followed him for maybe five years in this manner, and neither of us feel the need to "prove" once again that he'll do worse off this med. I'd be prepared to vigorously argue the clinical appropriateness of this to any monitoring agency that might question it.

Date: Fri, 22 Dec 1995 16:25:20 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: Long-term treatment with benzodiazepines

"Medical" use is not Sedative Abuse or Dependence if there is an approved reason and it is taken within guidelines, with no evidence of overuse.

Date: Tue, 26 Dec 1995 22:06:23 -0500 (EST)
From: David Tobolowsky <dmtmd@dcfreenet.seflin.lib.fl.us>
Subject: Long-term treatment with benzodiazepines

Substance dependence is associated with a deterioration in functioning; therapeutic use should be associated with an improvement in functioning. I try to avoid benzos in patients with histories of substance abuse or dependence. In panic patients, I prefer short-term use of clonazepam, institution of a tricyclic or SSRI, and discontinuation of the benzo once the other drug begins working, coupled with cognitive-behavioral and/or interpersonal psychotherapy. If other meds aren't tolerated or effective and therapy doesn't suffice, then long-term use is OK. My worry is, what if they develop an acute medical problem that prevents p.o. meds, since alprazolam may not be fully cross-tolerant with injectable benzos?

Date: Tue, 26 Dec 1995 05:48:21 -0500
From: gsdavids@niagara.com (George Davidson)
Subject: Long-term treatment with benzodiazepines

I know there are people out there who need long term benzos, since very respectable people tell me so. The strange thing is, I haven't met one so far. I keep antidepressing my patients with psychotherapy after the pills kick in, with such wonderful results that none of my patients feel the need for benzos any more. The exceptions are the severely personality-disordered and the few that can't tolerate any of the safe antidepressants, and the non-tolerators seem to be getting more rare as I learn useful tips for avoiding the side effects or perceived side effects.

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