I am a physician Board Certified in Family Practice and Addiction Medicine, currently working 3 days a week in Addiction Medicine in a primary care setting. My interest in benzodiazepines dates to 2002 when I joined the newly formed Maine Benzodiazepine Study Group, which I worked closely with until it disbanded in 2014. The group’s goals were to gather data on benzodiazepine prescribing and use, and to educate prescribers and patients about the proper use of this class of drugs. I oversaw writing and vetting a prescribing protocol for benzodiazepines, widely distributed in Maine. I presented the work of this group at the Scientific Assembly of the American Society of Addiction Medicine on two occasions. I have treated many patients with benzodiazepine dependence, some suffering from protracted withdrawal after having stopped benzodiazepines months or even years earlier.
I know that you have a serious issue with overprescribing of benzodiazepines in Massachusetts, as we do in Maine. During the week I began writing this in June 2017, I saw 3 patients who had recently relocated to Maine from Massachusetts who had serious problems with long-term prescription benzo use and physical dependence. One of them had outright addiction to a prescribed benzodiazepine and had recently been hospitalized for an overdose of this medication.
Benzodiazepines are often prescribed casually without discussion or concern for he many problems they can cause. An initial prescription is often provided without discussing the risks of developing dependence, and without a follow-up plan for dealing definitively with the problem, leading to refills resulting in dependence and other side effects.
Research shows that benzodiazepines work well in treating anxiety in the short term but benefits fade after 6 weeks or so, and there are no randomized controlled studies showing sustained benefit in anxiety states when they are used chronically on a daily basis, as they so often are. Indeed, several anxiety-related conditions are known to be made worse or more difficult to treat when benzodiazepines are on board, for example, post traumatic stress disorder and chronic musculoskeletal pain. The only accepted indications for long-term use are a few rare neurologic conditions, including as a second line drug for certain seizure disorders. They are valuable in treating alcohol withdrawal but use in chronic alcoholism is risky and has not been shown to be beneficial. That said, I understand they are often used in chronic mental illness as a last resort when standard remedies are exhausted and this use should remain available if it is undertaken cautiously.
Besides acute side effects, Problems with benzos are well known and include addiction, severe physical dependence and prolonged withdrawal even in the absence of other signs of addiction, depression, social withdrawal, and aggravation of problems of the elderly including dementia, falls, insomnia, polypharmacy and drug interactions. They also contribute to motor vehicle accidents and risk of injury, and to drug and alcohol overdose. Studies using data from the NHS in Britain show that long-term benzo use shortens life expectancy, even when the drug was stopped years before death. Those of us working with the frail elderly can understand why: benzos work by dampening nerve signal transmission all over the brain and when you are old and frail you need all your remaining neurons in good working order to avoid succumbing to the hazards of being old and frail.
Patients who are given an initial prescription for benzos need to understand that if taken for longer than 1-2 weeks they can be difficult to discontinue. A study of benzos started after age 50, the age group with the highest benzo usage, showed that 1/3 became dependent, staying on them or getting off only with a struggle. Many papers have been published applying tapering regimens to a group of benzo dependent patients. In these studies, many patients completed the taper successfully, but 30 to 70%, depending on the study, found the taper difficult or were unable to complete it. As you will hear in testimony, a few of these tapering patients will go on to experience protracted withdrawal, with a combination of physical symptom and mental dysfunction for which we have little to offer in the way of specific treatment. Opioids have an even higher incidence of protracted withdrawal when stopped after patients become dependent, but at least for opioids there is the option of opioid replacement therapy; there is no suboxone r methadone available to treat benzodiazepine dependence or difficult withdrawal.
The problem of benzo overprescribing and high availability on the street is especially acute considering their role in the current epidemic of opioid overdose deaths we are facing. In Maine, benzos are involved in 25 to 30% of drug overdose deaths, usually in combination with opioids—they add to the respiratory depressant effect of opioids which contributes to their lethality. Most people who die from overdoses of prescription drugs had a recent prescription for the drugs involved, so these deaths are potentially preventable.
In Maine, we are having considerable success in reducing benzo prescribing through legislative action. You may be familiar with Maine’s opioid prescribing law passed by the state legislature in 2016, taking full effect this year. It limits opioid prescribing via a variety of restrictions and mandatory safety measures required for prescribing opioids. Benzos were almost by accident tagged on to this law, and though all the opioid restrictions don’t apply to benzo prescribing, enough concern and fear has been raised among prescribers to drastically curtail prescription of long-term benzodiazepine in our state. In my outpatient practice with the Mercy Hospital System in Portland, Maine, we are now treating long-term benzos with the same cautions as we do opioids, and we are just as zealous in tapering patients off benzos as we are off long-term opioids. (often the same patients are on both classes of medication, an especially concerning situation.) It is too early to quantify this observed reduction in benzo prescribing, but we should have data from our PMP program by the end of the year
While the proposed Massachusetts law may not go so far as Maine’s, I am confident that any rules that result in prescribers, dispensers, and patients becoming more aware of the risks of benzodiazepines, especially when taken more than a few weeks, will result in safer patterns of use and a reduction in dangerous overuse. It will represent a huge first step in addressing a serious overprescribing problem.
James Berry
