An approach to maintenance An approach to maintenance Benzodiazepine prescribing Benzodiazepine prescribing

Dr Malcolm BruceDr Malcolm Bruce

Consultant Psychiatrist in Addiction Consultant Psychiatrist in Addiction NHS Lothian NHS Lothian

malcolm.bruce@lpct.scot.nhs.ukmalcolm.bruce@lpct.scot.nhs.uk

I started with this….I started with this….Heroin addictionHeroin addiction– MM doesn’t workMM doesn’t work– I/V abuse TemgesicI/V abuse Temgesic– HepC plus epidemicHepC plus epidemic– Shortage of needlesShortage of needles– Police witnessesPolice witnesses

– Ah! Thank God for Ah! Thank God for benzodiazepinesbenzodiazepines

– Px 100mg DZ, Px 100mg DZ, 60mg TZ60mg TZ

Evolutionary response

Current BDZ Guidelines:Current BDZ Guidelines: Assessment

BDZ treatable clinical problem Addiction

Not Tx resistant Tx resistant

(Tx > 4 wks)

Brief Definite

Situational Identifiable

Stress Endpoint Currently Currently

(Tx < 1 wk) (Tx < 4 wks) excluded from excluded from

treatment treatment

guidelines guidelines

Why exclusion unacceptable..Why exclusion unacceptable..Blanket exclusion incompatible with Harm Blanket exclusion incompatible with Harm Reduction philosophyReduction philosophyRepeated exposure to illicit market and all Repeated exposure to illicit market and all that bringsthat brings– Other illicit drugsOther illicit drugs– Variable quality and contentVariable quality and content– Variable supply with consequent mood Variable supply with consequent mood

changeschangesNo engagement in motivational process to No engagement in motivational process to change behaviour, encourages deceptionchange behaviour, encourages deceptionLost opportunity in contingent Lost opportunity in contingent managementmanagement

BDZ Guidelines:BDZ Guidelines: Addiction AddictionBDZ Addicts should be treated by BDZ like BDZ Addicts should be treated by BDZ like anyone else, i.e as clinically indicated (Applies anyone else, i.e as clinically indicated (Applies primarily to Tx for disorders other than BDZ primarily to Tx for disorders other than BDZ abuse or dependence):abuse or dependence):– Following a careful assessment of risks & benefitsFollowing a careful assessment of risks & benefits

– If sufficient or clear evidence of treatment resistance If sufficient or clear evidence of treatment resistance to other non-BDZ treatmentsto other non-BDZ treatments

Precautions: Monitor them carefully and review Precautions: Monitor them carefully and review them regularly to ensure the treatment is still them regularly to ensure the treatment is still clinically indicated (cf. analogy with pain Tx)clinically indicated (cf. analogy with pain Tx)

ImplicationsImplicationsPatients Patients should not be excludedshould not be excluded from treatment from treatment simply simply becausebecause::– They have an Addiction and / or are BZ usersThey have an Addiction and / or are BZ users– They are none BZ treatment resistantThey are none BZ treatment resistant– They may develop and / or legalize a dependencyThey may develop and / or legalize a dependency

(although these factors must be taken into account in the (although these factors must be taken into account in the assessment and clinically appropriate treatment given)assessment and clinically appropriate treatment given)

Not recommending an “opening of the floodgates”, but Not recommending an “opening of the floodgates”, but more sophisticated assessments of the risks and benefits of more sophisticated assessments of the risks and benefits of benzodiazepine treatmentbenzodiazepine treatment in individual patients, with no in individual patients, with no automatic exclusionsautomatic exclusions

Summary of Next BDZ Guidelines?Summary of Next BDZ Guidelines?Use lowest dose for briefest timeUse lowest dose for briefest time

Use for > 4 weeks should be reserved for cases who are Use for > 4 weeks should be reserved for cases who are resistant to non-BDZ treatmentsresistant to non-BDZ treatments

Use only one BDZ (give more at night if need hypnotic + Use only one BDZ (give more at night if need hypnotic + anxiolytic). Use the minimum number of BDZ if more anxiolytic). Use the minimum number of BDZ if more than one is needed to fulfil a variety of rolesthan one is needed to fulfil a variety of roles

Dose used should be in therapeutic range (i.e. BNF Dose used should be in therapeutic range (i.e. BNF limits)limits)

Reduce gradually after long term use. There is only a Reduce gradually after long term use. There is only a need to reduce gradually after short term use (>2/52) if need to reduce gradually after short term use (>2/52) if it has been shown that withdrawal will be problematic it has been shown that withdrawal will be problematic

Only use for severe symptoms, or where the patients Only use for severe symptoms, or where the patients total distress from comorbid conditions warrants use for total distress from comorbid conditions warrants use for mild or moderate symptomsmild or moderate symptoms

Indefinite BDZ treatment is occasionally justifiedIndefinite BDZ treatment is occasionally justified

Addicts should be treated as clinically indicatedAddicts should be treated as clinically indicated