Doing medicolegal assessments gives you a snapshot of the prescribing practices of GPs. Over the last year or two I have been astonished by the number of people being treated for anxiety by their GP with atypical antipsychotic medication, mainly quetiapine (Seroquel) and to a lesser extent olanzapine (Zyprexa).
I am an unashamed advocate of the use of benzodiazepines in anxiety. I have followed the professional literature for years and in the midst of the raging against their use there are a number of papers that continue to advocate for them on the basis of their safety and lack of serious side-effects.
Treatment recommendations for anxiety disparage benzodiazepine use.
For example :
The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines, despite a dearth of clinical research that shows this particular class of drugs is any more effective than others. Diazepam (Valium) and lorazepam (Ativan) are the two most prescribed benzodiazepines. Lorazepam will produce a more lengthy sedating effect than diazepam, although it will take longer to appear. Individuals on these medications should always be advised about the medications’ side effects, especially their sedative properties and impairment on performance.
Tricyclic antidepressants often are an effective treatment alternative to benzodiazepines and may be a better choice over a longer treatment period. (on PsychCentral.com 15 December 2014, quoting a 2004 paper)
The most recent edition of Therapeutic Guidelines 2013 states:
Anxiety and associated disorders
Psychological interventions should be used first-line for most anxiety disorders. However, sometimes adjunctive pharmacotherapy may be needed, usually with antidepressants rather than benzodiazepines. If short-term prescribing of benzodiazepines is necessary, consider the precautions given.
The BeyondBlue website states:
Benzodiazepines (sometimes called sedatives) are a class of drug commonly prescribed in the short term to help people cope with anxiety and panic attacks. Benzodiazepines reduce tension without making people drowsy but they are not recommended for long-term use as they can be addictive.
It appears to be a given that benzodiazepines are “bad”. Many papers attest to this and there are many papers about strategies that have been used to reduce the prescribing of benzodiazepines.
Benzodiazepine use by elderly patients is associated with adverse outcomes including increased risk of falls and fractures, motor vehicle accidents and cognitive impairment (CMAJ. Apr 1, 2003; 168(7): 835–839).
According to a paper in BMC Health Services Research 2010;10:321. doi:10.1186/1472-6963-10-321.
“Guidelines, campaigns and prescribing restrictions have been used to raise awareness of potentially inappropriate use, however long term use of benzodiazepine and related compounds is currently increasing in Australia and worldwide”
Benzodiazepines are used to treat various psychological disorders including sleep disorders, some neurological disorders and aspects of addiction and anxiety . Utilization patterns show variation in the use of benzodiazepines over the last 2 decades. During the 1990’s there was much publicity around the harmful effects of long-term use of benzodiazepines in Australia, including new guidelines and efforts to increase community awareness. This resulted in a decrease in prescribing of benzodiazepines, however since the end of these campaigns, use has been continually rising, with a 21% increase in utilisation by concession beneficiaries in Australia (elderly, over 65 years of age, and those with a low income or receiving benefits) from 2000 to 2006.
There has been recent publicity about a number of deaths associated with combined use of opiates and benzodiazepines, there is no doubt that benzodiazepines can effect respiratory centres and may potentiate the respiratory depressant effects of opiates. In particular there is concern about recreational use of alprazolam. All that is understandable but most people with anxiety do not fit into this category.
In my clinical practice I have found benzodiazepines, used appropriately, sometimes long term, have proven to be far more useful in treatment of anxiety with far fewer side effects than antidepressants that often cause obesity and sexual dysfunction.
Here are two anecdotes about my involvement with benzodiazepines.
Some years ago I was involved with a GP training program in which I was a tutor doing telephone tutoring to a group of GPs interested in obtaining a diploma of mental health. The tutorials is proceeded well until we came to the topic of anxiety. I made some comments about use of benzodiazepines. I could not believe the hostile response. It was like I was prescribing poison. Their view was that all benzodiazepines are bad, if used they should never be used for more than a few weeks and that anything was preferable to their use. They confused dependence with addiction and did not acknowledge the relatively minimal side-effects of benzodiazepines compared with antidepressant medication. Within a short time I was asked to cease my involvement in that training program, possibly because of this unpleasant tutorial.
About 10 years ago a friend of mine developed breast cancer, I had never treated her. She had been using clonazepam for 20 years for treatment of panic disorder. Her panic disorder had been crippling to the extent that she had been housebound for three or four years. After using clonazepam her panic disorder became well controlled and she was able to go back to work as a teacher and became involved in a long-term relationship. She was using anywhere between 0.25 mg-2 mg of clonazepam a day.
Whilst in hospital after breast cancer surgery she developed an acute severe panic attack. She had mentioned that she had been using clonazepam but was not allowed to bring that to the hospital. After she was discharged I suggested that she be reviewed by a psychiatrist experienced in treating women with breast cancer. She saw the psychiatrist who was horrified that she had been using clonazepam and told her to stop using it and prescribed Aropax instead. She began using Aropax but developed weight gain, insomnia, sexual dysfunction and her panic attacks did not improve. She mentioned this to the psychiatrist who increased the dose of Aropax with a significant increase in side-effects but no improvement in her panic disorder.
She came to me in some distress “what can I do? I like my psychiatrist and it has been useful to talk about my cancer but my panic attacks are making it impossible for me to work and putting a lot of strain on my relationship.”
I suggested an option. She had two prescriptions for clonazepam at home and I suggested that she stop using the Aropax slowly and immediately start using clonazepam but not tell her psychiatrist what she was doing. She did so and her panic attacks settled. Her psychiatrist, rather smugly, said “I told you so, all you needed to do was to increase the dose!” Was I unethical? Possibly but any concern about that was outweighed by the improvement in my friend’s health.
So where are we with regard to anxiety disorder and medication. There have been many public health efforts and a great deal of money expended in trying to reduce benzodiazepine use. In Australia quetiapine is listed for treatment of Generalised Anxiety Disorder and most therapeutic guidelines recommend use of antidepressant medication as first-line treatment for anxiety.
There appear to be few people who have any neutral view about benzodiazepines. The accepted wisdom is that the BDZs are bad and that anybody who prescribes them is either incompetent or wicked and, their use must be reduced. It is noteworthy that education programs to reduce prescribing benzodiazepines by GPs have been totally ineffective. Nobody seems to have questioned whether or not the alternatives may be worse.
There is major concern about use of benzodiazepines long term but there appears to be little commensurate concern about long-term use of atypical antipsychotic drugs despite the strong possibility of long-term adverse side-effects. There appears to be little concern about giving antidepressant medication long-term for treatment of anxiety although we are all familiar with all the side-effects of that group of medications, including withdrawal symptoms.
At times I have wondered if the pharmaceutical companies have conspired to demonise benzodiazepines as they are no longer in patent and this allows them to profit greatly from use of newer antidepressant medications and atypical antipsychotics in treatment of anxiety.
The 2011 statistics from the Pharmaceutical Benefits Scheme give the following information.
Total cost of quetiapine $130 million, total number of prescriptions 820,620.
25 mg tablets (the usual dose used to treat anxiety by GPs) 294,062 prescriptions at a cost of $16,819,606. Each prescription cost $57.
Total number of prescriptions for diazepam; 2,258,000 237 prescriptions at a cost of $17,769,988. Prescriptions for 5 mg tablets totalled 1,977,635 at a cost of $15,533,180 giving a cost per prescription of $7.85.
Amitriptyline, total number of prescriptions 1,627,201 at a cost of $14,251,045. There were 555,169 scripts written for 10 mg tablets at a cost of $4,692,995 at a cost of $8.45 per prescription.
Paroxetine, commonly used for treatment of anxiety, total number of prescriptions 969,084 at a cost of $30,553,212 at a cost of $31.52 per prescription.
Sertraline, also used for treatment of anxiety in addition to treatment of depression, total number of prescriptions 2,774,837 at a cost of $74,698,325, cost per prescription $26.
My sanity was briefly restored when I read the following article. It was like hearing the first sounds of rain on a tin roof after a long drought.
The reappraisal of benzodiazepines in the treatment of anxiety and related disorders Expert Rev. Neurother. Early online, 1–12 (2014).
I urge you to read it. I will leave you with its introduction:
Recent studies have demonstrated that long-term use of BDZs for these conditions can be effective and safe and that BDZs can be combined with psychological therapy and antidepressants to produce optimal outcomes. Such findings, along with a failure to convincingly demonstrate the overall superiority of alternative pharmacotherapy for anxiety and related disorders, have given an impetus to a reconsideration of the role of BDZs. This article reviews BDZs and other pharmacotherapy options for anxiety and related disorders and suggests that treatment guidelines should acknowledge that BDZs can be used as first-line, long-term pharmacological treatment for panic disorder, generalized anxiety disorder and social anxiety disorder.