Benzodiazepine Prescribing In Primary Care Settings: Issue for Concern? Louis E. Baxter, Sr., M.D., FASAM Executive Medical Director Professional Assistance Program, New Jersey, Inc.
Benzodiazepine Misuse Abuse - Dependence Using for recreational purposes Continued long term use against medical advise Use of drug with other potentially psychoactive substances (alcohol) Abusive or addicted users inhale or inject BZD Long term prescription use without re-evaluation evaluation of necessity for continued use
Health Related Complications Overdose and death with other drugs (opiates) Black outs, memory loss, paranoia, violent and criminal behavior Seizures and psychosis in the dependent patients Phlebitis, abscesses, pulmonary embolism, rhabdomyolysis, and hepatitis B & C in the intravenous users
Rates of Misuse BZD are rarely used as the primary DOC; usually is abused by poly-drug abusers BZD is the most frequently abused pharmaceutical by SAMHSA study 2 nd to Opiates 35% are obtained from Emergency Rooms 26% of suicide attempts involve BZD Alprazolam is #1 followed by clonazepam, lorazepam,, and diazepam
Pitfalls for the Physicians Ethical and Legal issues must be considered d re: long term use in chronically medical ill, panic disorder, and the chronic psychiatrically ill. Vulnerable e populations: o pregnant, institutionalized, tut inmates, methadone patients, acute situational patients (exam takers or court testifiers) Duty to Third Parties prescription may lead to harm to others (MVA, illegal acts, etc) Criminal Prosecutions of Physicians for alleged improper prescribing (plea bargaining by patients) Lack of consultation psychotherapy Lack of documenting decision making process Others
General Guidelines for Prescribing Benzodiazepines Avoid prescribing to known poly-drug users including those with dependence Dose reductions should be with patient consents Patient advisement of long-term use risks Patients should use one physician for all prescriptions Regularly scheduled Treatment Reviews
General Guidelines for Prescribing Benzodiazepines Use of non-medication management for anxiety and insomnia Detoxification from BZD using long acting BZD and slowly tapering doses with counseling Management of anxiety and insomnia should rely largely on non-pharmacologic interventions BZD should be prescribed at the lowest dose to be effective and for the shortest period of time possible Residents of aged care facilities, BZD should be slowly tapered and discontinued wherever possible and used only as needed to control anxiety or agitation
Remedies to Improve Benzodiazepine Prescribing A review of interventions* i * over the past 20 years showed that: Educational Interventions (PCPs, consumers, and long term care facilities) Audit and Feedback Interventions (long term care facilities and PCP) Alert Interventions ( educational approaches to PCPs and pharmacists) Lead to a 19% reduction in BZD use sustained for a 2year period *Improving the of benzodiazepine-is is it possible? A non-systematic review of interventions tried in the last 20 years-aleshia J Smith and Susan E Tett SBIRT www.sbirt.samhsa.gov PCSS-P P www.pcssmentor.org ; www.pcssprimarycare.org/pcss/pcssmentors.php
Conclusions Abuse of Benzodiazepines is a major public health h problem -2 nd only to Opiate Abuse??? BZD are often times over prescribed and prescribed to too long Long acting BZD are being under utilized when long term BZD therapy is indicated Better screening for abuse and addiction potential need to be performed There is an underutilization of non-pharmacologic strategies t to treat t anxiety and insomnia. i BZD prescribing should be coupled with therapy and counseling in more instances than it is today PCSS-P is available to help primary care physicians with issues pertaining to drugs, alcohol, and prescription medications.