Irish Medical News

The problem with addiction and benzodiazepines

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According to the Government, benzodiazepine prescribing levels in Ireland are unacceptably high. So what are politicians doing to address this and are there enough supports available for the growing number of patients with benzodiazepine dependence?


 

Benzodiazepines have proven to be a highly effective drug for many decades, so much so that they are now one of the most widely used prescription medicinal products in the world and are among the most prescribed medications in America.

Yet benzodiazepines and Z drugs are viewed by many as somewhat destructive and dangerous because of the risks associated with dependency when used long-term.

According to the Government, benzodiazepine prescribing levels in Ireland are unacceptably high and various initiatives are due to be introduced to tackle the perceived problem.

The initiatives include tackling over-prescribing by introducing new prescribing rules and, regarding the illicit trade of benzodiazepines, additional legislative controls around exports, imports and possession.

Yet these two measures alone will not go far enough critics argue, with a much more multifaceted solution urgently required to adequately respond to such a complex problem.

Indeed, many of the complexities surrounding problematic benzodiazepine usage are simply being ignored.

The actual scale of benzodiazepine dependence in Ireland is unknown, despite claims that prescribing is too high.

Ireland is not alone in this regard. In the UK it is estimated that as many as 1.5 million could be reliant, but again, there are no official figures.

In addition, there are no national guidelines in Ireland on how to address benzodiazepine dependence.

Support services are lacking for those who involuntarily become addicted to the drug, with many patients trying and failing to break their addiction, doctors claim.

Withdrawal symptoms can last six weeks or longer and ironically include many of the symptoms they were prescribed to treat including anxiety, insomnia, headache, panic attacks and palpitations.

So is the Government really serious about helping patients to relieve benzodiazepine dependence and are prescribing levels in Ireland really too high?

There are generally two cohorts of patients who use benzodiazepines, according to Dublin GP Dr Garrett McGovern, who specialises in alcohol and substance abuse.

The first are those who present with anxiety or insomnia and who are prescribed benzodiazepines to help relieve the symptoms.

More women than men are believed to be addicted to benzodiazepines but there is no information on the demographics of all patients provided benzodiazepine prescriptions in the State.

When used for over a month a patient is likely to become addicted to the drug, therefore short-term use is advised in most cases.

Benzodiazepines are used to treat insomnia and anxiety; about 10 per cent of the population is believed to be suffering from some form of anxiety in Ireland at present. It can also be used during alcohol withdrawal.

The second cohort is drug users. Benzodiazepines are commonly used by heroin and opiate users to enhance the effects of opiates and as an alternative when heroin is in short supply.

Dr McGovern advised that, in areas outside Dublin, heavy benzodiazepine use often disguises the lack of treatment of heroin users, which is a real problem.

There are also two groups of benzodiazepines – those accessed legally and illegally. Examples of benzodiazepines include diazepam, lorazepam (trade name Ativan), chlordiazepoxide, oxazepam, temazepam, nitrazepam, loprazolam, lormetazepam, clobazam and clonazepam.

Currently, anyone can easily buy products purporting to be diazepam and other types of benzodiazepines on the internet.

Greater controls on the illicit trade of benzodiazepines and other drugs are due to be introduced later this year under the Misuse of Drugs Act in a bid to counteract illegal trading.

Yet, unfortunately, this will do nothing to help those already dependent on benzodiazepines.

As alluded to above, GPs have been blamed for over-prescribing benzodiazepines yet GPs have contended that the rise in illegal benzodiazepines in Ireland is to blame.

GPs have also said that prescriptions from the general adult psychiatry services that are transcribed onto GMS prescriptions are impacting on prescription data from GPs.

There is also nothing to stop a patient going to several different GPs to get a prescription for benzodiazepines.

The lack of counselling services available to patients dependent on benzodiazepines has also served as a bone of contention among GPs, who have criticised the Government for failing to introduce solutions that are in the best interests of patients.

But according to Dr McGovern, counselling services alone will not reduce benzodiazepine use.

According to a 2011 PCRS report, which contains information on the 100 most commonly prescribed products in Ireland via the GMS scheme, diazepam is the 25th most commonly prescribed drug in the State with more than 506,000 prescriptions recorded.

Alprazolam was the 30th most commonly prescribed product, with 456,000 prescriptions recorded in 2011. Temazepam was 83rd with 180,000 prescriptions and flurazepam was 86th on the list with 177,000 prescriptions.

That means that at least 1.1 million prescriptions for benzodiazepines were made through the GMS system.

It is not known how many private prescriptions for the drug are prescribed in Ireland every year and the figures above exclude private prescriptions.

In 2010, diazepam was 23rd on the list and alprazolam was 30th. Temazepam was 74th and flurazepam was 78th. This would suggest that between 2010 and 2011 prescriptions, at least in the GMS Scheme, decreased somewhat.

A 2010/2011 survey by the National Advisory Committee on Drugs (NACD) on the use of sedatives or tranquilisers (commonly benzodiazpines) in Ireland showed that the number of people using sedatives or tranquilisers over their lifetime rose by 32 per cent when compared to figures for 2006/2007.

The numbers that had used the drugs in the last year increased by 38 per cent, the survey revealed.

More women than men were using sedatives or tranquilisers but lifetime prevalence rates in both sexes had increased since 2006/2007.

More adults aged 35-64 were using the drugs, yet lifetime usage rates for those aged 15-34 had increased. Some 95 per cent of those surveyed said they got their prescription from a doctor.

The survey also revealed that the recession was impacting drug use patterns among certain cohorts, with the unemployed and those in managerial or professional occupations now more likely than others to take sedatives or tranquilisers.

Use of benzodiazepines in Ireland and Europe is on the rise, the survey stated, adding that, “such medicines can be more easily obtained than illicit drugs and the potential for their misuse is widespread”.

South Dublin GP Dr Cathal Ó Súilliobháin believes that the Government is adopting the wrong approach in trying to control prescriptions, which he said would not deal with the problem of dependence.

There is also the argument and widely held view in the medical community that sometimes the benefits of staying on benzodiazepines for long periods far outweigh the risks.

According to Professor of General Practice at University College Cork (UCC), Colin Bradley, a number of fitness to practice hearings before the Medical Council have related to benzodiazepine prescribing, which he said had helped to raise awareness of the issue.

He added that the HSE was actively bringing doctors to the attention of the Medical Council regarding benzodiazepine complaints from the public.

GPs needed more support to assist in alleviating benzodiazepine dependence, he stated, along with increased addiction support services.

Benzodiazepines are recognised as problematic when used long-term, yet they are still not receiving the same attention as opiate addiction, he added.

Indeed, this view was echoed somewhat in an analysis of the role benzodiazepines in the development of substance misuse problems in Ballymun by the Ballymun Youth Action Project.

Published last year, it recommended investment in services to assist medical practitioners and advised that, “there is an urgent need to develop non-pharmaceutical supports for benzodiazepine detoxification and alternatives to benzodiazepine therapy”.

More information about prescribing benzodiazepines in methadone maintenance was recommended along with greater awareness and information among the community about benzodiazepines.

The report also found that a large number of patients in the area had been using benzodiazepines for several years.

That being the case, while there is recognition of a problem in Irish society, it appears that not enough is being done to tackle dependence and to help patients.

More and more people are using benzodiazepines but it is not clear if prescribing levels are in fact too high, due to a lack of data on why patients are being prescribed benzodiazepines and the growth in stress and anxiety levels among the population following the economic downturn.

 

 

 

 

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