Note: This article came out in the Psychiatric Times today as an edited version. I am posting the unedited version here to provide more details. I have not seen the printed version yet. I will add a link later to download a PDF version.
Those decisions are more complex and demanding in the setting of a substance use disorder and a patient who may be seeing the physician to get a prescription to use primarily to get intoxicated, to treat the effects of a primary addiction, or to potentiate the effects of another addictive drug. They are complicated when the original prescription was made by a different physician and the patient is asking for a refill. I have included a list of practical tips on both the interpersonal dimension and details about what can be useful in optimizing the safe prescription of benzodiazepines (Table 3) in that population.
Table 1. Selected benzodiazepine and benzodiazepine-like compounds (allosteric modulators of GABAA receptor)
Table 2. The Use of Benzodiazepines In Patients With Substance Use Disorders
1. Detoxification: Benzodiazepines remain the drugs of choice for alcohol and sedative hypnotic detoxification. Many treatment facilities have withdrawal protocols that use anticonvulsants or phenobarbital, but benzodiazepines have the widest safety margin and may address some symptoms of the withdrawal syndrome like anxiety better than non-benzodiazepine options. Benzodiazepines with long half-lives are generally preferable to other agents, but familiarity with options for patients with severe liver disease is also necessary.
2. Short term bridging to a more effective long term plan for treating anxiety or anxiety and depression: Withdrawal syndromes in patients with a chronic and complicated history of use can be more difficult to treat than textbook scenarios based on the pharmacological properties of the medications being used. In many situations, it is difficult to know if the withdrawal syndrome has been adequately treated, whether the underlying anxiety or sleep disorder is surfacing, whether there is a new substance induced disorder, or some combination of these processes.
3. Short term bridging in the case of a polypharmacy situation where alternative medications are less safe: Many of the non-benzodiazepine medications that are used to treat depression, sleep, and anxiety disorders have risk in a polypharmacy environment. A common flag is problems with cardiac conduction. In many of these situations it is best to avoid any medications that target the patient’s anxiety or insomnia but potentially complicate other problems and use benzodiazepines temporarily.
4. Acute catatonia, agitation, akathisia, transient anxiety due to brief severe stressors. In residential treatment centers that agitation is more likely associated with complex withdrawal states that include severe anxiety states. Benzodiazepines are useful medications to alleviate akathisia that can be the result of treatment with SSRIs or antipsychotic medications.
1. Severe treatment refractory insomnia.
2. Severe treatment refractory anxiety disorders including mixed anxiety and bipolar states and mixed anxiety and depressed states.
3. 1 and 2 only in situations where the abuse potential (dose escalation, multiple prescribers, additional illegal intoxicants) can be contained.
Table 3. Tips for Benzodiazepine Prescribing
1. Avoid emotional prescribing based on the stress of the situation or patient characteristics.
2. Have a well thought out general approach to prescribing and do not deviate from that plan.
3. Be aware of how prescribing a controlled substance can affect your decision making and the relationship with the patient.
4. Maintain a conservative prescribing bias in general and especially in the case of a suspected substance use disorder based on the risks and scenarios presented here.
5. Maintain a teaching role with the patient that includes a detailed risk benefit discussion and the rational for prescribing or not prescribing the benzodiazepine. That includes an informed consent discussion of the addiction risk and how to prevent it.
6. Consult with colleagues in difficult situations and avoid professional isolation. Solicit feedback on how colleagues would make similar decisions. In group practices controlled substance prescribing can be the basis of a quality improvement initiative and process.
1. Carefully assess patients requesting treatment with benzodiazepines especially if they are new to your practice. The diagnosis being treated and the rationale needs to be clear. Reevaluating the diagnosis and response to therapy over time is equally important.
2. Consider urine toxicology in search of other drugs especially compounds that are often used with benzodiazepines (methadone, opioids, alcohol, stimulants). If a benzodiazepine is prescribed urine toxicology also confirms adherence rather than diversion.
3. Consult a prescription drug monitoring program (PDMP). Rules vary by state and some states require checking the PDMP before the prescription of any controlled substance.
4. Consult with collateral contacts who know the patient well. If the patient is in a structured environment – know the procedures for monitoring and dispensing the medication.
5. Have a clear plan and indication for the benzodiazepine including a plan for discontinuing it and discuss it with the patient at the time of the initial prescribing decision.
6. A written document on the expectations of the patient may be a good idea as an anchor point in treatment. Although treatment contracts do not necessary improve outcomes, the expectations in terms of a single prescriber, precautions, expected outcomes and what must be avoided is generally better than a rushed conversation about the same topics. That document can be a reference point for the future decisions.
7. Close monitoring is generally necessary with collateral contacts to assure that the patient is doing well and not experiencing complications from the benzodiazepine. An important consideration in the collateral information is the patient’s functional capacity on the medication.
8. Dose escalation can be an early sign of a problem, prescriptions be counted pill counts at each visit to determine the rate at which the patient is taking the medication.
9. Develop referral patterns for non-pharmacological approaches to problems that are commonly addressed by benzodiazepines like insomnia (referral to CBT for sleep) and chronic pain (pain specialist or physical therapy referrals).