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PROBLEMS AND ? SOLUTIONS
Professor C Heather Ashton, DM, FRCP
All-Party Action Group
on Tranquilliser Addiction,
House of Commons, London
November 7, 2006
School of Neurosciences
Division of Psychiatry
The Royal Victoria Infirmary
Queen Victoria Road
Newcastle upon Tyne NE1 4LP
[SLIDE 1] TITLE SLIDE
PROBLEMS AND ? SOLUTIONS
Everyone here is probably familiar with the term benzodiazepines-tranquillisers and sleeping pills like Valium, Ativan and temazepam, and the more recent but similar Z-drugs like zopiclone and zolpidem. These drugs can be fine for short-term use in acute conditions, but if taken regularly for more than about 4 weeks can cause many problems. It is these problems and what to do about them that we are here to discuss.
[SLIDE 2] LONG-TERM PRESCRIPTIONS
2004-5: >20 million prescriptions for benzodiazepines
and Z-drugs in England (PPA figures)
Over 180 long-term (>6 months) prescribed
users in every UK general practice.
1 million long-term prescribed users in UK
Uncounted number of previous long-term
users with persisting symptoms
One problem is the continuing prevalence of long-term prescriptions, despite repeated warnings from the Department of Health that use should be short-term – only 2-4 weeks. In the year 2004-5 there were over 20 million prescriptions for benzodiazepines and Z drugs in England. The figures for 2005-6 are similar though they seem to be calculated differently. Surveys of general practices show that on average there are over 180 long-term (6 months or more) prescribed benzodiazepine users in every general practice, and it is estimated that there are around 1 million long-term prescribed users in the U.K. These million people are at high risk of adverse effects caused by the drugs. Added to them are a large but uncounted population of previous long-term users who have managed to stop the drugs but are left with persistent symptoms.
[SLIDE 3] DEPENDENCE AND WITHDRAWAL
Some acute withdrawal symptoms
Panic attacks, agoraphobia Insomnia, nightmares Tremor, muscle spasms, stiffness, pain Hallucinations Depression, psychosis Fits
So what are the adverse effects of benzodiazepines and Z-drugs? The best known, perhaps, is that these drugs are addictive. When taken regularly for weeks or months, they lose their therapeutic effects. Dependence develops and there is great difficulty in stopping the drugs because of withdrawal reactions. Benzodiazepine withdrawal symptoms can be severe, worse than the illness for which they were originally prescribed, and often protracted for many months or more. Acute symptoms include panic attacks, agoraphobia, insomnia, nightmares, tremor, muscle spasms, hallucinations, depression, psychosis, fits and many more. To minimise symptoms, the drugs have to be withdrawn gradually, often over months. The management of withdrawal requires skill, patience, psychological support, frequent contact and time from the doctor – assets and expertise which most doctors do not have.
[SLIDE 4] PROTRACTED SYMPTOMS
Some protracted symptoms which may not fully reverse
- Post-traumatic stress disorder (PTSD)
- Neurological - tinnitus, neuropathy
- Motor - muscle spasms, stiffness, pain
- Cognitive impairment
Even after a successful withdrawal, some patients suffer prolonged, even permanent, symptoms including post-traumatic stress disorder, neurological and gastrointestinal problems, cognitive impairment and others. These patients are disabled, through no fault of their own, but do not always qualify for disability living allowances.
[SLIDE 5] ADVERSE EFFECTS OF LONG-TERM USE
ADVERSE EFFECTS OF
- Oversedation, memory and cognitive impairment
traffic accidents, falls and fractures, mental
confusion/dementia in the elderly
- Additive effects with alcohol/drugs
- Aggressiveness, violence
baby battering, wife beating
- Risks in pregnancy
- Illicit abuse
If withdrawal is difficult, what of patients who stay on their benzodiazepines? Unfortunately, they have problems too. Chronic use carries risks including oversedation and cognitive impairment, most marked in the elderly (yet about 40% of people in retirement homes are prescribed them and these are prone to falls and fractures and mistaken diagnosis of dementia), depression, additive effects with alcohol and other drugs, aggressiveness (including wife beating and baby battering), adverse effects in pregnancy, dependence and abuse.
[SLIDE 6] BENZODIAZEPINE-RELATED DEATHS
- 1810 UK deaths attributed to benzodiazepines 1990-96
(Home Office Statistics)
- Still 300 deaths/year in UK
accidents, overdose, suicides, drug interactions
- Road traffic accidents
1600 RTAs/year and 110 driving-related fatalities.
Another problem is that benzodiazepines actually cause deaths. They are involved in 40% of fatal self-poisoning incidents and account for around 300 deaths each year in England from accidents, overdoses, suicides, drug interactions (Home Office figures) and traffic accidents. A recent survey showed that benzodiazepines are a cause of 1600 road traffic accidents and 110 driving deaths per year in the U.K.
[SLIDE 7] ILLICIT BENZODIAZEPINE ABUSE
ILLICIT BENZODIAZEPINE ABUSE
- Over 200,000 illicit benzodiazepine users in UK
- numbers still rising
- 90% of polydrug users also take benzos
- 50% of alcoholics in detox units also take benzos
- Some use benzos alone (oral, IV, snuff)
A further problem, which has resulted from widespread overprescription, is the abuse of illicitly obtained benzodiazepines. There are probably over 200,000 illegal benzodiazepine users in the U.K. They are taken by 90% of polydrug abusers (opiates, cocaine, amphetamines, etc.) because they increase the "high" and alleviate withdrawal effects from hard drugs. 50% of alcoholics in detoxication units take benzodiazepines because they alleviate alcohol-induced anxiety and also because and alcohol/benzodiazepine mixture gives a "buzz". Some use benzodiazepines alone in high doses to obtain a "kick". The drugs were largely obtained from theft of prescriptions but now they can readily be obtained from drug dealers on the street or ordered on the internet. These illegal abusers also become addicted.
[SLIDE 8] A BENZODIAZEPINE ADDICT
Click for larger image
A complication of temazepam injection. A man aged 40 who misused drugs and had had a leg amputated after ischaemic damage from intra-arterial injections presented with blindness of recent onset. He was blind in both eyes. The left eye was ophthalmoplegic, with corneal clouding and no pupillary reflexes. This was the result of his injecting gel temazepam into the inner canthus. This substance is known to cause vascular occlusion (with permission from Thompson et al. 1993).
If anyone doubts the power of benzodiazepine addiction, this 40 year old man is an illustration. He had a leg amputated as a result of damage from intravenous self-injection and his arm veins were damaged for the same reason (some have had both legs amputated). In hospital this man injected temazepam into his eye and became blind in both eyes as a result.
According to the recent report on the government's classification of recreational drugs, benzodiazepines are rated 7th most dangerous out of 20, in terms of harm to the individual and to society – higher than amphetamines and tobacco.
[SLIDE 9] SOCIOECONOMIC COSTS OF BENZODIAZEPINES
SOCIOECONOMIC COSTS OF
- Mortality from overdose, suicide/accidents
- Aggression, violence, antisocial behaviour
- Risks to foetus, infants, children, domestic disharmony
- Job loss, unemployment through illness
- Disability, litigation
- Medical consultations, hospital admissions
- Recreational abuse - AIDS, hepatitis, unwanted pregnancy
- Costs of NHS prescriptions, DHSS disability, litigation
It is clear that inappropriate benzodiazepine prescribing and illicit use carry considerable socioeconomic costs, some of which are listed here. They include increased mortality, violence and antisocial behaviour, risks to infants, children and domestic harmony, job loss and unemployment through illness, costs of medical and hospital work, abuse (with risks of AIDS, hepatitis and unwanted pregnancy), costs of prescriptions, disability allowances and litigation.
[SLIDE 10] LACK OF TREATMENT AND PREVENTION
- Lack of available treatment
- Lack of preventive measures
All these problems are compounded by lack of available treatments for those already dependent, and lack of preventive measures.
With regard to treatment, claims from the Health Ministers Rosie Winterton in 2004, and from Patricia Hewitt in September this year are simply not true. I quote from Patricia Hewitt's letter to Margaret Beckett (dated September 20, 2006): "Individuals with dependence on benzodiazepines are able to access a range of services. In primary health care, counselling advice and psychological therapy is available". But, as I mentioned, GPs are unable to handle withdrawal; there are no dedicated NHS withdrawal clinics or counselling services. Waiting lists for psychological therapy in the NHS are as long as several months or years. For example, in Gateshead Primary Health Trust, the waiting list for a clinical psychologist at present is two years. Furthermore, psychologists (if you manage to reach one) are not trained in or familiar with benzodiazepine withdrawal.
As for secondary health care, Patricia Hewitt wrote: "Secondary care services include mental health and drug services". Yet in practice prescribed benzodiazepine patients seeking withdrawal are regularly turned away from drug dependency units (which are in appropriate for them anyway) on the grounds that these only deal with opiate and other hard drug misusers.
Maybe the ministers' claims are true on papers that sit on their desks, but they are certainly not true in practice. I and benzodiazepine help groups on the cutting edge hear every day from benzodiazepine-dependent patients unable to get help from primary or secondary health care services.
With regard to prevention, it is generally agreed that benzodiazepines are not appropriate as first line treatments for anxiety, insomnia or depression except occasionally acutely but only for a maximum of 2-4 weeks. But GPs and psychiatrists claim that they are obliged to prescribe long-term because of lack of access to alternative treatments. So the problem of benzodiazepine dependence is perpetuated by the lack of available alternative treatments in primary or secondary health care.
[SLIDE 11] WHAT WE NEED NOW
WHAT WE NEED NOW
- Dedicated NHS benzodiazepine withdrawal clinics.
- Involvement of health care workers in GP surgeries
- Provision of more psychological therapists to which
patients have prompt access
- Financial support for self-help groups/charities
- A Select Committee to investigate
I list here just a few essential requirements.
- Dedicated NHS benzodiazepine withdrawal clinics. Staffed by trained doctors and health care workers.
Involvement of health care workers in GP surgeries. These could include community nurses and pharmacists, counsellors and psychological therapists to work with GPs, suggesting and supervising withdrawal schedules and providing frequent and long-term support for patients.
Provision of many more psychological therapists to whom patients have prompt access. A recent paper from the London School of Economics (the Depression Report) calls for the training of 10,000 new therapists in the next seven years. They emphasise cognitive behavioural therapy (CBT) but less formal therapies are more applicable to benzodiazepine patients and fully-trained psychologists are rarely necessary, though specific training in benzodiazepine problems is important.
Financial support for self-help groups. These groups can be extremely helpful and are sometimes run by ex-benzodiazepine users who understand the problems. Examples of such voluntary groups are Barry Haslam's group in Oldham, CITA (Council for Involuntary Tranquilliser Addiction) run by Pam Armstrong in Liverpool, the Bristol Tranquilliser Project, and (NECA) the North East Council on Addictions in Newcastle. This charity used to have a dedicated tranquilliser support group but it lapsed through lack of funds.
Appointment of a Health Select Committee Inquiry. To investigate these and other benzodiazepine problems, including disability allowance, development of agreed nationwide guidelines for benzodiazepine prescribing and research on long-term benzodiazepine effects.
It is heartening to see so much interest shown here today, and we hope it will lead to a robust tackling of benzodiazepine problems that have for too long been neglected.
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