Identification Of Problems Among Longterm Benzodiazepine Users

Physicians frequently encounter patients, or family members of patients, who are concerned about the possible adverse effects of long-term use of a benzo-diazepine in the treatment of anxiety or insomnia. In helping to structure the decision making for such a patient, we use the Benzodiazepine Checklist (DuPont, 1986; see Table 10.2). There are four questions to be answered:

1. Diagnosis. Is there a current diagnosis that warrants the prolonged use of a prescription medicine? The benzodiazepines are serious medicines that should only be used for serious illnesses.

2. Medical and nonmedical substance use. Is the benzodiazepine dose the patient is taking reasonable? Is the clinical response to the benzodiazepine favorable? Is there any use of nonmedical drugs, such as cocaine or marijuana? Is there any excessive use of alcohol (e.g., a total of more than four drinks a week, or more than two drinks a day)? Are other medicines being used that can depress CNS functioning?

3. Toxic behavior. Is the patient free of evidence of slurred speech, staggering, accidents, memory loss, or other mental deficits or evidence of sedation?

4. Family monitor. Does the family confirm that there is a good clinical response and no adverse reactions to the patient's use of a benzodiazepine? Because people who abuse drugs deny drug-caused problems and often lie to

TABLE 10.2 Benzodiazepine Checklist for Long-Term Use

1. Diagnosis. Is there a current diagnosis that warrants the prolonged use of a prescription medicine?

2. Medical and nonmedical substance use. Is the dose of the benzodiazepine the patient is taking reasonable? Is the clinical response to the benzodiazepine favorable? Is there any use of nonmedical drugs, such as cocaine or marijuana? Is there any excessive use of alcohol (e.g., a total of more than four drinks a week, or more than two drinks a day)? Are there other medicines being used that can depress the functioning of the CNS?

3. Toxic behavior. Is the patient free of evidence of slurred speech, staggering, accidents, memory loss, or other mental deficits or evidence of sedation?

4. Family monitor. Does the family confirm that there is a good clinical response and no adverse reactions to the patient's use of a benzodiazepine?

Standard for continued benzodiazepine use: a "yes" to all four questions.

their doctors, and because many family members are concerned about long-term benzodiazepine use, we generally ask that a family member come to the office at least once with the patient who is taking a benzodiazepine for a prolonged period. This gives us an opportunity to confirm with the family member, while the patient is present, that benzodiazepine use produces a therapeutic benefit without problems. If there is a problem of toxic behavior or abuse of other drugs, we are more likely to identify it when we speak with the patient's family members; if not, we have an opportunity to educate and reassure both the patient and family members when they are seen together.

Most patients without a history of addiction produce four "yes" answers to these four questions. Even a single "no" answer deserves careful review and may signal the desirability of discontinuation of the benzodiazepine. After completion of the Benzodiazepine Checklist, if there is clear evidence that long-term benzodiazepine use is producing significant benefits and no problems, and if the patient wants to continue using the benzodiazepine (which is, in our experience, a common set of circumstances for chronically anxious patients), then we have no hesitancy in continuing to prescribe a benzodiazepine, even for the patient's lifetime.

On the other hand, many anxious patients, even when they have good responses without problems, want to stop using benzodiazepines. Other patients do not want to stop using a benzodiazepine, but they do show signs of poor clinical response or trouble with the use of a benzodiazepine. In either case, discontinuation is in order, and it is an achievable goal.

Some critics of benzodiazepines, including Stefan Borg and Curtis Carlson of St. Goran's Hospital in Stockholm, Sweden (Allgulander, Borg, & Vikander, 1984), have expressed concerns about the possibility that benzodiazepine use may lead to alcohol problems in patients without a prior history of alcohol abuse, especially in women. The simple advice to a long-term medical user of a benzodiazepine is not to use alcohol, or to use alcohol only occasionally and never more than one or two drinks in 24 hours. Most anxious patients who do not have a prior history of addiction either do not use alcohol at all or use it only in small amounts. The Benzodiazepine Checklist helps the physician, the patient, and the patient's family identify any problems (including alcohol abuse) at early stages, thus facilitating constructive interventions.

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