Lockup Doc

As a psychiatrist who has now been practicing for over a decade, I think back to the days of residency and fellowship and realize how much my approach to prescribing benzodiazepines has changed.

One of the key faculty members in my psychiatry residency program was considered an expert in treating anxiety disorders. He was very liberal with his prescription of benzodiazepines, the anti-anxiety class of medications including diazepam (Valium), clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax) and others.

Having no other frame of reference, I naively adopted his unsparing prescription-writing habit of these not-so-benign medications. I unquestioningly steered down this path for the first couple years of my post-training practice.

Then I had the good fortune of working with a very competent group of experienced psychiatrists who were in full-time clinical practice. Regularly collaborating on cases with them helped to initiate my transformation to more conservative, and in my opinion, more appropriate,  prescribing habits.

My prescription style inevitably evolved further when I entered the foreign land of correctional health care. If one prescribes benzodiazepines liberally in a prison setting, he or she will become the unwitting victim of droves of drug-seeking inmates and the archenemy of already-skeptical security staff. Controlled substances in a correctional setting are problematic for numerous reasons that are beyond the scope of this article.

As a result of my experiences in various settings, I have developed some guidelines that I believe can be helpful in prescribing benzodiazepines. My goal is simply to provide excellent clinical care while simultaneously managing risk.

1. Develop your own practice protocol for benzodiazepines. I believe the key to providing good care and avoiding trouble revolves around the seeming paradox of being consistent with how and when you prescribe these medications yet ensuring that you individualize the care you are providing. It may be prudent to provide patients who are receiving their first benzodiazepine prescriptions from you with your own oral and/or written guidelines so that they know your “rules” up front. Then, if you suspect misuse it is much easier to take them off the medication. Decide ahead of time how you will handle “lost” prescriptions, early refill requests, or suspicions of abuse or diversion. Consider informing patients that a condition of your prescribing these medications to them is that they obtain the prescriptions only from you. Some doctors request that their patients bring their medication bottles into each appointment so that they can verify the correct remaining quantity of pills.

2. Obtain and document clear informed consent. In addition to the common side effects, be sure not to leave out the potential risk for physiological dependence, serious withdrawal, and potential impairment when driving or operating machinery. Doctors have been sued by patients who have become “addicted” to benzodiazepines.

3. Consider non-benzodiazepine alternatives. It is not typically necessary to use benzodiazepines first-line for anxiety disorders. Selective serotonin reuptake inhibitors (SSRI’s) such as escitalopram, citalopram, sertraline, paroxetine, and fluoxetine as well non-SSRI’s such as venlafaxine XR, buspirone, and others are used as first-line agents for treating various anxiety disorders (some FDA-indicated and some off-label, depending on the diagnosis). Note: Use extreme caution when prescribing antidepressants to patients with bipolar disorder.

4. Avoid very short-acting benzodiazepines. Alprazolam (Xanax) and triazolam (Halcion) have very short half-lives and consequently are more prone to causing problems with rebound anxiety, physiological dependence, and withdrawal. To read an interesting and very popular post entitled “Why Docs Don’t Like Xanax,” head over to Shrink Rap.

5. Aim for short term use. Some patients will need indefinite treatment with benzodiazepines for chronic anxiety disorders. However, when possible use non-benzodiazepine alternatives in these patients (see #3 above), and use the benzodiazepines in patients with acute transient stressors or to counteract the usually temporary insomnia or restlessness that may occur when SSRI’s are initially started. Try to limit use to a few days or a few weeks.

6. Be very cautious treating patients with suspected or documented substance abuse histories. Some will say never to prescribe benzodiazepines to this group. My personal opinion is that it is ideal to avoid prescribing to them when possible, but in reality there still may be select cases where doing so is providing the best care. I would strongly recommend using a written treatment contract with such patients. If you do prescribe to these patients (unless you are treating alcohol withdrawal), never prescribe to those actively drinking or using drugs. Consider limiting prescription quantities to one week in less trustworthy patients.

7. Try to avoid benzodiazepines in the elderly. This was a point heavily emphasized in my geriatric psychiatry fellowship. Benzodiazepines, especially in the elderly, can cause falls, sedation, and cognitive impairment. Of course, since always and never are usually the wrong answers, if you must prescribe these medications to elderly patients, do so rarely, and avoid long-acting agents such as diazepam and clonazepam. An intermediate-acting agent such as lorazepam used at extremely low doses for a brief duration is probably best.

8. Expand the field if necessary. If you feel that you are out of your comfort zone with a specific case, then consider referring the patient for a second opinion (even if you are a psychiatrist).

9. Prepare not to be liked by some patients. KevinMD.com recently featured a post by physician writer, Dr. Edwin Leap, entitled “Good Doctors Sometimes May Make Patients Unhappy.” This article nicely expands on my point that responsibly providing quality medical care occasionally requires setting limits and disappointing some patients.

What are your thoughts about prescribing benzodiazepines? Please share your comments.

*Please note that this article is intended to provide information and my personal opinions to the medical community and other interested readers. It is not intended to be used by anyone as medical advice. Do not stop or change any medication as a result of any information contained in this article. Please consult with your own physician or other health care professional if you have concerns or questions about your own medications.