Benzo prescriptions have increased substantially — it's a major public health problem

Benzo prescriptions have increased substantially — it's a major public health problem
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A new study indicates a steep climb in benzodiazepine prescriptions in the U.S. Between 2003 and 2015, primary care physicians’ prescribing of benzodiazepines doubled. As a psychologist, who was funded a decade ago by the National Institute of Mental Health to study benzodiazepine prescriptions, I don’t find these new statistics surprising. Our health care system has some serious cracks, but solutions exist.

Benzodiazepines (sometimes called “benzos”) work to calm or sedate a person. Common benzodiazepines include Valium, Xanax and Klonopin, among others. Without a doubt, these medications are effective. They work, which is partly why physicians keep prescribing them and patients keep taking them. But, the potential negative side effects and toxicity of benzodiazepines are well-established.

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There’s no denying that long-term benzodiazepine use is associated with significant problems, such as sleep disturbance, cognitive difficulty, impairment in activities of daily living, motor vehicle crashes, accidental falls and fall-related fractures. In addition, benzos can have negative interactions with other medicines, such as over the counter sleep aids. This can increase the risk of adverse outcomes with sometimes perilous results. Indeed, more than 30 percent of overdoses concerning opioids also involve benzodiazepines.

Make no mistake about it; the high prevalence of benzodiazepine prescribing by primary care physicians is a public health problem. This is a pattern that persists despite clear evidence that these medications may pose significant health risks and despite the availability of medications and psychotherapies that offer safer alternatives for the problems for which benzodiazepines are typically prescribed.

Almost a decade ago, my colleagues and I undertook a mixed-methods study to understand long-term benzodiazepine prescribing by primary care docs and the continued uptake of these medications by older adults. We approached this investigation by hearing from all sides – physicians, patients and hospital administrators. Here’s what we found.

Physicians were well aware of practice guidelines defining appropriate and inappropriate benzodiazepine use. They knew that use is justified if it is intermittent, brief and for purposes of symptom relief. However, no physician believed benzodiazepine use was a serious problem in their clinical practice.

Primary care physicians largely minimized or ignored the potential for adverse health effects and prescribing guidelines were criticized as out of touch with real-world problems. Physicians also spoke about competing medical management issues that were of higher priority during relatively brief medical appointments. To quote one physician, “The sad fact is primary care doctors make choices... there’s almost sort of a running tally going on in your head when you’re talking to a patient. Do I want to open this can of worms right now or do I want to deal with these four other things that are going to result in a heart attack if I don’t deal with them?”

Physicians also anticipated patient dissatisfaction with not being able to quickly solve their problems as well as resistance to any such efforts to stop benzodiazepines once these medications are started. Doctors also explained that they didn’t want to withhold a medication that provided relief to their patient. They did not view their patients as drug-seeking or escalating in dose, actions that might tip them off to a possible addiction.

Similarly, the patients we interviewed explained that they wanted a quick fix and were very satisfied with the effectiveness of their benzodiazepine. Patients described coming to rely or psychologically depend on their benzodiazepines to help them control daily stress and bring tranquility. Some patients saw benzodiazepines not as a life-enhancing luxury, but as necessary to maintain a normal life. Most of the patients denied or minimized their experience of side effects and expressed resistance to taper or discontinuation of these medications.

While this may seem like an intractable problem, we recommended a two-track public health strategy to address the issue. In principle, primary care physicians agreed that short-term treatment with benzodiazepines was the best practice. Thus, there needs to be education and training programs that teach physicians how to present this model to patients and implement it effectively. As one of the physicians in our study explained, “When you put somebody on an antibiotic for bronchitis, you don’t give it to them with the expectation that there’s no end. You give them the end expectation at the same time that you start it. If you want to use benzodiazepines, that’s how you have to use them. You have to use the benzodiazepines with an end in sight.”

A second strategy needs to be aimed at training physicians in the skills of benzodiazepine taper and discontinuation. Once a person is taking a benzo for a period of time, it’s somewhat hard to get off of it. And, many older long-term benzodiazepine users and their physicians perceive tapering of use as an arduous, low priority, time-intensive task. To be effective, we need a large-scale, multi-pronged effort, to convince physicians of the threats of long-term benzodiazepine use and provide them with specific counseling skills. In fact, medication taper coupled with psychotherapy represents the best strategy.

Inappropriate use of benzodiazepines by outpatients is a public health problem. And, provision of these prescriptions by primary care physicians is a quality of care issue. We can do something about it. We must.

Joan Cook is a psychologist and associate professor at Yale University who researches traumatic stress and clinically treats combat veterans, interpersonal violence survivors and people who escaped the former World Trade Center towers on 9/11.