Benzodiazepines Risk, Abuse, and Dependence

Dear Editor:

In response to a letter to the editor published in the November issue of Psychiatry 2009 [Preparing for a Benzodiazepine Tsunami. Psychiatry (Edgemont) 2009;6(11):12], Dr. Prabhakar warns the psychiatric professional community about the risk of a proposed change in the Medicare prescription plan through which benzodiazepines will be reinstated after several years of being excluded from coverage in their formularies. He is concerned that this will result in a “tsunami” of benzodiazepine abuse and “other side effects” associated with these medications.

We found Dr. Prabhakar’s comments troubling in several respects.

Dr. Prabhakar expresses his alarm at and disapproval of provisions in Section 175 of the Medicare Improvements for Patients and Providers Act of 2008. He would like to see benzodiazepine prescription coverage denied to those on Medicare as occurred in the Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and in effect since 2006. In support of this, he cherry picks evidence to support his position (even when it does not). He fails to cite a larger body of contrary evidence on several points and misrepresents evidence several times.

For example, he cites a 2001 article by van Haaren, Lapane, and Hughes as a source of evidence that “in many cases benzodiazepines were overprescribed.” In fact, this paper does not provide evidence that benzodiazepines were overprescribed. Van Haaren concluded that the triplicate prescription policy “did affect prescription and administration of benzodiazepines in nursing homes in states with, versus without, a triplicate prescription policy. Lack of substitution with other drugs makes it unclear whether overprescribing occurred in states without a policy, or undertreatment occurred in the state with a policy.” Such a study of nursing home residents is hardly a reliable reflection of over-prescription of benzodiazepines in the general population.

Dr. Prabhakar states that “several studies failed to demonstrate any rise in the use of other psychotropic medications after MMA was enacted.” Yet he fails to give a single citation on this point. In fact, several studies clearly provide evidence that the New York state triplicate prescription policy did result in the increased use of older, more dangerous sedative-hypnotics, such as barbiturates and meprobamate, and an increase in prescriptions for benzodiazepines in the neighboring state of New Jersey in the years following this policy.^1–3

Dr. Prabhakar mentions the increased risk of falls in elderly on benzodiazepines and cites a 2007 article by Wagner et al to report that the MMA “resulted in about 50 to 60 percent reduction in benzodiazepine use.” However, he fails to mention that the same Wagner et al study concluded that “policies that lead to substantial reduction in the use of benzodiazepines among elderly persons do not necessarily lead to decreased incidence of hip fractures. Limitations on coverage of benzodiazepines under Medicare Part D may not achieve this widely assumed clinical benefit.”

While benzodiazepine substance dependence and abuse can occur, the overwhelming weight of epidemiological evidence⁴ suggests that this is a problem only for a very small minority of patients (0.6% for abuse and 0.5% for dependence among users) and that the rates of abuse of benzodiazepines are significantly lower than the rates of abuse of food.

The US Food and Drug Administration (FDA) approves medications as safe and effective for specific indications. They do post-marketing surveillance on benzodiazepines and other psychiatric medications. If the FDA thought that benzodiazepines were not safe or effective or that the risk-to-benefit ratio was unfavorable they would intervene with appropriate warnings. Benzodiazepines do not have a black box warning, like all antidepressants, all atypical and typical neuroleptics, and anticonvulsants. They are effective where indicated. They do have a significant withdrawal syndrome that needs to be managed properly. All physicians need to taper benzodiazepines very slowly over weeks rather than over days to minimize this risk.

We do not need medical vigilantes policing physician prescribing practices with policies that are at variance with the FDA prescribing information guidelines and are based on cherry-picked data and self-righteous prejudices and threats of loss of prescribing privileges.

To deliberately and selectively deprive people over 65 of benzodiazepines, as Dr. Prabhakar advocates, could be considered age discrimination in violation of the Civil Rights Act of 1964. Medicare for those over 65 is a right rather than a privilege. To further deprive some of those under 65 on Medicare who have disabilities and impairment from conditions that would benefit from a benzodiazepine would be a violation of the American Disabilities Act. Physicians and even medical vigilantes would prefer not to be on the wrong side of such legal action.

In summary, we recommend that medical authors proposing overzealous action learn to evaluate evidence in a balanced manner, not misquote the authors they cite and not cite evidence that does not exist.

With regards, Rosario B. Hidalgo, MD
University of South Florida College of Medicine. Depression and Anxiety Disorders Research Institute

David V. Sheehan, MD, MBA
University of South Florida College of Medicine, Depression and Anxiety Disorders Research Institute