Mags GarganIt has been suggested that anti-anxiety medications are being too widely prescribed and too often used in Ireland, writes Mags Gargan
More than 12 people a week die from drug related causes or overdoses in Ireland according to the Health Research Board (HRB), and alcohol and benzodiazepines are involved in a third of all overdose deaths.
We are all familiar with Ireland’s relationship with alcohol, but what are benzodiazepines (benzos)? Some of the best known trade names for benzodiazepines are Valium, Zanex and Rohypnol. They are a form of sedative or tranquiliser prescribed to reduce anxiety or stress, encourage sleep or to relax muscles. They are also used recreationally to ease the comedown from other drugs and a black market has developed for them in Ireland.
So are benzodiazepines helpful or dangerous?
“Benzodiazepines are useful medications in certain circumstances but, as with all medications, their benefits must be balanced against the risks associated with their use for every individual patient,” said Dolores Keating, honorary senior clinical lecturer at the RCSI School of Pharmacy and head of pharmacy services at Saint John of God Hospital.
Ms Keating took part in the ‘MiniMed’ lecture last week on the rational use of benzodiazepines at the RCSI (Royal College of Surgeons in Ireland) in Dublin.
The title of her lecture came from the Rolling Stones song Mother’s Little Helper, which was released in 1965 and describes a housewife’s despair over the tedium of her life which could only be relieved by taking Valium. This was at a time when using medications for everyday anxiety became part of everyday life.
The first benzodiazepine appeared on the market in the US in1960 under the brand name Librium and it was followed in 1963 by Valium, which went on to be become one of the best-selling medications in the western world. At the time they seemed to be the ‘pill for every ill’ and were embraced by Hollywood.
“People needed relief from genuine suffering and it was also an age of consumerism. People welcomed tranquilisers in the same way as washing machines and fridges. It was also a Golden Age of advertising. Anti-anxiety medication were the ideal consumer products,” Ms Keating said.
Marketed
They were particularly marketed at the ‘bored housewife’ or ‘neurotic woman’ who suffered with her nerves, but anxiety disorders are very real conditions.
“Benzodiazepines are used for people for whom anxiety really makes it very difficult for them to negotiate life. Every day they are faced with a series of obstacles and they can’t see past them. They are mountains to climb. This person never feels safe. They yearn for sleep because it is only when they sleep that they don’t feel anxious, but that sleep never comes,” Ms Keating said.
“Benzodiazepines make people feel calm and more relaxed. They work very quickly to relive stress. Some people feel very sedated when they take them, they can feel impair concentration and reaction times, and they can feel a little unsteady and some people have memory problems.
“But despite the list of side effects benzodiazepines seem to be very well tolerated by people and very few people stop them because of side effects. They’re relatively safe medications for short term use.”
Benzodiazepines reached a peak in the 1970s but then the tide changed in the 1980s. Addiction is a serious consequence of benzodiazepine use and withdrawl is very difficult if abruptly stopped. “They began to be viewed as dangerous medications, recklessly prescribed and carelessly taken without regard for the consequences,” Ms Keating said. This led to tighter restrictions in their prescription, but also as a consequence of this, an illegal trade in benzodiazepines flourished.
Ireland came late to benzodiazepines, perhaps because alcohol has traditionally been our tranquilliser of choice. However, in 2002 a benzodiazepine committee suggested one in 10 medical cards holders was taking them. A national household survey in 2011 found that 14% of Irish people had used a benzodiazepine in their lifetime and 7% had used one in the last year. The people most likely to use them are the elderly, state dependent or professionals in higher managerial roles, and more women than men.
There is also a growing illict trade of the drugs in Ireland and drug treatment services are seeing an increase in the number of people presenting with problem benzodiazepine use.
Treatment
In 2011 benzodiazepines were involved in 173 deaths and HRB data shows that treatment figures for benzodiazepines, as a person’s main drug of addiction, jumped seven fold since 2005, from 75 cases in 2005 to 547 in 2012.
Last year former drugs minister Róisín Shortall accused the Government of not having “the political will” to implement plans she signed off on in September 2012 to crack down on the booming street trade in prescription medication, saying they are second only to alcohol “in terms of damage to society”.
Despite only being legally available on a doctor’s prescription, some people get around this by ordering benzodiazepines through the internet and others forge prescriptions or go ‘doctor shopping’, that is, getting prescriptions from many different doctors.
Dr Ida Delargy, Director of Substance Misuse Programme of Irish College of General Practioners said despite suggestions of over prescribing, doctors follow strict guidelines for prescribing benzodiazepines.
“There are clear indications for using benzodiazepines like severe anxiety, insomnia or sometimes as an anticonvulsant. GPs are now prescribing to recommended guidelines and we know a lot more about them now than when they initially came out.
“Therefore, our guidelines state we don’t prescribe them unless there are clear indicators and the condition is at the severe end of the spectrum. We prescribe at the smallest dose and for the shortest period of time. If those guidelines are adhered to they are very effective medications and very necessary medications at times.”
She said GPs have special consideration around the elderly. “Benzodiazepines can cause confusion, particularly among the elderly, and lead to poorer judgment, much higher rate of falls and fractures in the elderly and problems with driving and increasingly there is evidence of problems with cognition or brain function, and links with dementia. So we need to be extremely cautious in prescribing them for the elderly,” Dr Delary said.
There are other ways to deal with anxiety disorders and Dr Keith Gaynor, senior clinical psychologist at St John of God outpatient department, would like to see Cognitive Behavioural Therapy (CBT) at the frontline of services for treating anxiety disorders and depression.
“CBT looks at trying to move towards the thing that makes them anxious. Feel the fear and do it anyway. Move towards the anxiety and as they do it, build them up in self-confidence and show them that they are able to do it,” he said.
While CBT is one of the most effective ways of dealing with mild to moderate anxiety, it is only available on a limited scale in Ireland.
“This is something that we as a community need to say is not an additional or extra treatment but needs to be part of the front line. It is cost effective. If you pay the money into it, it pays it back in terms of people staying in work and college and being able to cope in terms of absenteeism,” Dr Gaynor said.
“What we are doing is not magical – it is not extraordinary. You shouldn’t have to go to a dentist to learn how to learn how to brush your teeth. It is really ordinary, straightforward stuff that you need at the front of the system,” he said.