Simply cutting off the supply of benzodiazepines to people who’ve been prescribed them for years is far from appropriate, says Bill Nelles.
Winter is almost over, but here in Qualicum, British Columbia (BC), we tend to be like the animals around us. We hibernate from November until mid-March, when we hear the roar of the tree frogs calling out for mates in our local pond.
We have a saying here, ‘Don‘t poke the bear’ – aside from its obvious meaning as a wilderness warning it also means avoiding a discussion of something that is controversial and likely to end in arguments. I heard this expression for the first time last year on a Zoom call with the BC Provincial Opioid Task Force. Benzodiazepine (BZ) policy for people on opioid agonist treatment (OAT) was on the agenda but time was running short. As we moved to the last item one of my colleagues drily observed, ‘I’m not poking the bear when there’s only 20 minutes left’.
The bear here is, of course, prescribing benzodiazepines to people who are on opiate agonists for their opioid use. So I’ll start with three clear statements: benzodiazepine use increases drug-related poisonings and mortality when taken in quantity with alcohol or opioids; these risks start to increase as you get older, so avoid excessive use; and, it is reasonable for doctors to decrease your dose.
And sincere congrats if you have done the stopping or helped someone else to do this.
But things can go too far. Four years ago we adopted a strict no benzo policy – actually prohibition – for people on OAT in this province. Doctors face serious misconduct proceedings for stable dose prescribing except in end-of-life care, and prescriptions are reviewed through a real-time network called Pharmanet so concurrent prescribing is flagged. Only tapering is permitted, as long as it is reasonably fast. This policy came in rather suddenly, and some doctors have tried hard to contain the deep distress that this caused to many patients.
But the key word here is excessive. For more than 50 years, BZ drugs have been a much safer alternative to barbiturates and other stronger sedatives. Taken on their own, they are remarkably safe. And they were often thrown at users – and I do mean scripts thrown across the doctor’s desk – as ‘shut-up’ pills by doctors who wouldn’t provide OAT.
It’s also been forgotten that BZ drugs are specific anti-anxiety and hypnotic medicines. They are not anti-depression drugs like SSRIs, although these have now become the ‘go to’ drugs for anxiety, which is not quite the same as depression. More problematic is the use of atypical anti-psychotics such as quetiapine ‘off-label’ as hypnotics, despite the manufacturers’ warning that they should not be used as sleeping medications.
Some of you will already have read about a programme in Scotland to provide access to genuine benzodiazepines as ‘safe supply’, led by no less a figure than Professor Roy Robertson – widely known as the Scottish doctor who, in a seminal study in the Lancet in 1985, alerted the UK to the high levels of HIV among injecting drug users in his Edinburgh practice. I think this is a reasonable response to current circumstances, but we can’t do it here – yet.
I can live with a policy of reducing their use in general, but people prescribed these drugs for years who cannot live without a small amount should not be cut off. By all means don’t start people on them, but have a care for those who cannot stop them and who are now purchasing toxic fakes instead. Absolute bans are rarely appropriate, tempting though they may be. Leave some wiggle-room for those who are suffering and avoid our approach.