SafeScript podcast 3: Benzodiazepines: Keep calm and prescribe responsibly

Hello I'm Lynn Weekes and today we'll be talking about how to manage anxiety and insomnia and ensure patient safety especially in patients with chronic pain. I have with me today Natalie Corrigan, GP Nick Carr, Jane Andersonwurf from Reconnexion and Shalini Arunogiri, a psychiatrist with experience in addiction medicine.

Benzodiazepines and Z drugs are not recommended as first-line therapy for insomnia, panic disorders or anxiety and yet about 7 million prescriptions for benzos alone are dispensed every year in Australia. High rates of ongoing benzodiazepine prescription indicate overuse for long- term problems. The combination of benzodiazepines, Z drugs or quetiapine and opioids is of particular concern with data showing these high risk combinations are responsible for 30 per cent of prescription medicine-related deaths in Victoria between 2009 and 2015.

Natalie, I'd like to start with you because you know something about the potential problems that can arise with prescription medicines. Would you tell us your story?

Natalie Corrigan (Nat C): Yeah absolutely, so when I was in my early 20s, I would say I was about 23, I remember very vividly having a panic attack at the train station. I was getting ready to go to work, it was like any other day and I went to put my ticket through the scanner that you do and for some reason I just froze and I knew I couldn't move. And that would be the first of what was going to be many panic attacks and eventually I got a referral from my GP to a psychiatrist. The psychiatrist was fantastic, she was very attentive, she listened and she had this really good bedside manner so I put a lot of trust in her. But the panic attacks were consistent and they were ongoing so she prescribed me benzodiazepines. The first thing she prescribed me was valium and when I was given the prescription, there was kind of a nonchalant attitude of: take this and we'll see how it goes. And when I first took them, it was just, I took it as prescribed it, it was one or two per day and it was like: ah I have no problems now. It went on like that and then it was like you know, I should really keep them in my purse with me just in case, the just-in-case kicked in and that would be part of my daily routine. So I would go to work, I'm ready to go, got my purse, got my ID, got my car keys, got my valium. Yes and it was very much a feeling of: geez, I cannot forget to have these with me. I didn't feel like an addict, I was very much functioning, I was working, studying, going to school, hanging out with friends, all of that. Then I think about a year into it, I started to really have the anxiety again and I started to develop little phobias and things like that, like ridiculous phobias like crossing the street, I would freeze up and I was just like, why? It started to intrude on my day-to-day life and I thought, I'll go back to the doctor because I'm actually getting concerned about this. She was on annual leave, she'd gone and taken a vacation and I was desperate to see someone. So I saw the doctor that was working on her behalf and I said: look these panic attacks, it’s sort of coming back and I've been on this medication and it's not really you know, I'm just really really high-strung and anxious all the time. He was like: very well, what I can give you is clonazepam it's going to help, it's the second drug, you can take it as needed. I remember that there was that moment where I just sort of looked at him and I'm like: is that all there is? [He] was really like: I don't know what else you want me to do for you. And in that moment there's a real feeling of desperation and trust and faith in the doctors, so I took the second prescription and I continued to do that for about three or four years on top of the valium and when my doctor returned from annual leave, she continued to fill that second prescription.

Lynn Weekes (LW): So then you were taking valium and clonazepam as well?

Nat C: Yes, so they put they put a band-aid on top of the band-aid and it just became part of my normal life and I never really exceeded the usage. So I've struggled with depression as well and in 2017, I had a really bad bout of it and I said her: you know I think I'd like to do inpatient treatment just to nip this in the bud. She said: okay let's do that. So we go in and we do the intake assessment and she's going through all the questions: do you do this, do you take this, do you take that, how much of this are you taking, how much how often do you take the clonazepam? They had never really asked me that question. She had filled my scripts regularly for the past four or five years but she hadn't connected the dots that the script refills were like clockwork with me, because I took it as needed so I was taking it every day as like as it says on the box. I said: well you know I take one-to-two pills a day as prescribed. She said: oh no, we need to get you off that right away. I said: okay. Once again, trust in the doctor, I said: yep that's what we'll do, that's fine. So I was probably taking two milligrams of clonazepam a day which sounds like nothing, it sounded like nothing to me, a small number. So I thought: okay I'll probably feel a bit “skin crawly” for a couple of weeks you know, we'll get through this. And within the first week she'd reduced me by, she'd reduced, I think I stayed there three weeks and by the time I finished my visit to the hospital, she'd reduced it by 75%, which is what we now call rapid tapering. It's not supposed to happen this quickly and I didn't know that so within a week or two of that hospital visit, I was holding onto walls to balance myself, I was extremely high-strung, I was extremely touchy and irritable. Sounds became too loud and unbearable, I would walk around the hospital with headphones and listening to music just to sort of blur out sounds which in retrospect was my brain sort of developing a coping mechanism. There were just all these things that didn't add up. I said to her: you know I'm really really having trouble walking and I'm really dreading stepping outside the hospital to go on a walk to the park, things like that. She says: oh you know this will pass in a few weeks. And when I left the hospital, when I finished my three-week stay, I went home and I left that hospital in worse shape than I came in and I went home to my parents’ place and I lay on my bed and I wept and I wept and I wept and I wept and wailed and sobbed and I was having suicidal thoughts and I couldn't figure out what was wrong with me. I remember thinking: it's only two milligrams, why am I not coping? What I didn't realise is the equivalency of what I was taking was like 15 milligrams of valium and that's one of the things that didn't get explained to me. So as the months went on, my walking got worse, my motor functioning got worse, emotionally I wasn't coping, psychologically I wasn't coping. It's very upsetting for family to have to see this and eventually I had to start using a cane, by I would say, at least August of 2017 so we’re talking about three months now. And I have a vivid memory of walking into my doctor's office with the cane and she said: what's up with the cane? And I said: you tell me. So she said: oh no you have to see a neurologist. I walked out there terrified, I thought I had a brain tumour or something. So I went on the waiting list until November and I saw a neurologist and he was the first one who was really candid with me. He said: look, I'm happy to do the MRI scan. And by the way, [for] people who go through benzo withdrawal, MRIs are basically like a rite of passage for us, we all get told we have to have an MRI scan and nothing shows up. We’re convinced that we have MS or brain tumours or God knows what. He says: I'm happy to do it, just to err on the side of caution, but I see a lot of patients like you and I don't think it's going to show up and I think it is related to the medication. And nothing shows up, I mean, by the time I went to that appointment, my sister had to physically escort me in and out of the building. So when I finally got that answer, I was like: okay. You know, I knew from my gut instinct, I knew it was the medication. And I went on to a support group on Facebook, I sort of put my story up, I said: look this is what's been happening the past couple of months. And someone knew who Reconnexion was, an organisation that worked with people to help them come off benzodiazepines but slowly and it was their entire specialty. And I called them up and I explained, I gave them like a four-month bio of what I had gone through and they said: yeah it sounds like benzo withdrawal. We had our first appointment and we did assessments and we sat down and we made a tapering plan and it was the first time I felt acknowledged and like an actual participant in my recovery and saying: yes, this is actually what I've been going through. But that started in January of 2018 and it's been really long and really slow. I reduced from 50 milligrams of valium down to eight, as of two weeks ago. Every time you make a reduction, it's like going through a fresh course of withdrawal so you don't know what it's going to be and you're just trying to function as much as you can.

LW: Congratulations, that’s a big journey.

Nat C: Thank you

LW: Jane, at Reconnexion you see people who have long-term problems with benzos and Z drugs all the time, can you tell us a bit about Reconnexions and what you do that helps?

Jane Andersonwurf (JA): Well first of all Reconnexion is a statewide service we're funded by DHHS so we've actually been around for about 30 years and helping people in several different ways. People can just phone us directly and we have a telephone support line which is manned by volunteers 9:00 to 5:00 Monday to Friday and they are competency trained. It takes them three-to-four months of training before they can get to come on the support line and they're there to provide information for people, perhaps help when people are going through withdrawal, when people ring in and they're actually having some acute symptoms and giving them some strategies to get through. If people decide that they want to come in and actually see a counsellor, we're based in Melbourne, so if people want to come in and see face-to-face counsellors we have six psychologists who are specially trained in benzodiazepine support and people do the intake tour, the Victorian intake tour and they come into the program. Alternatively, people can also have Skype consults or telephone consultations because one of the side effects sometimes in withdrawal is agraphobia and people find it very difficult to leave home. So we do try to encourage people to come in if they can for the first one or two visits and then counsellors are quite comfortable doing telephone counselling. The other thing that we offer is for prescribers and is if people want a secondary consultation. So a GP or a nurse practitioner or any allied health professional who wants to get some more information about how to do a taper can call the line and make a booking with one of the counsellors and then tell them they'll work with them. We don't prescribe so what we do need is very much good relationships between counsellors and the prescribers and so that's really important. So if somebody rings in and they don't have a prescriber, one of the jobs of the volunteers is to encourage them to find a GP who is happy to prescribe and who's happy to work with our counsellors. So that's essentially the three things we do.

LW: Thank you, Nick can I come to you. Natalie’s story was very much working with her psychiatrists and that will be one scenario. Another is that people really are being seen by their GPs most the time and I think we could say, GPs prescribe most of the benzos of those 7 million benzos that are prescribed. What's happening there?

Nick Carr (Nick C): So Natalie’s story was so profound and thank you so much because there was a wealth of stuff in there. One of the things you said was that first valium tablet you took, you think: wow I have no problems now. And this is one of the dangers, it's such an effective quick fix for problems. So one of the things that happens I think in primary care is there's pressure on [them] to do something. There might be a huge wait for psychological treatment, someone wants something done now. I can get someone some psychological help and maybe fix their problem in three or four months’ time, or I could give them a benzo and they will feel better, like Natalie did, now. And there's a bit of a perception I think in primary care that these drugs are actually relatively safe. So this is where a story like Natalie's is so important, GPs need to understand the dangers of these drugs. We’re talking a lot about prescription medication overdose, the fact that we kill more people with our prescription medications, benzos and opiates, than die in the road toll. But death is just one measure, there's that huge problem with addiction. Natalie doesn't appear in any statistic because she's still alive and yet look at the harm that befell her from becoming addicted to these drugs. One person using benzos talked about how it stole her soul for 30 years so that itself is a very real harm. There are other harms. People forget that these drugs can have quite long “half-lives” so there can be effects on driving, operating machinery. For older people, falls. These are not safe drugs and this is a message which has to get out to doctors.

LW: Yes, I think that we all agree on this, that these are medicines we don't want to use often, but would you ever initiate somebody on a benzodiazepine or Z drug?

Nick C: So initiation of benzos is something I do very rarely. About the only times I can think when I would consider initiating something is if there's a really short-term issue, so someone has some short-term stress related to an exam or job interview or something like that or a relationship breakdown. Sometimes you'd think about benzo when starting someone on a complex psych drug like an SSRI and you might need to cover short-term side effects. But interestingly when I talk to people about the potential harms of benzos, a lot of people I talk to choose not to take them. One of the things I say when people are really pressing me, they say: but I want one now. I say: I can fix your problem today and risk making you a drug addict for life, is that really what you want?

LW: And how do you follow them up, how do you monitor them if you do start someone [on these drugs]?

Nick C: So if I do have to give someone benzos short-term, it's going to be small quantities. I don't need to give people 50 valium, you can write a script for five or for 10. I'm going to give them this really severe warning about the risks and dangers. I often talk about: this is emergency use only, this is not regularly used. And then I'm going to see them again soon and if there's a real concern that this is starting to slip into regular use, jump on it early.

LW: Ok that's great, actually Shalini, what about you because you're seeing lots of patients I guess in your practice, what strategies do you use to limit the duration of treatment or the dose of benzos that have been being used?

Shalini Arunogiri (SA): Yes, I think both Nick and Natalie have really touched on and some of the key issues with continuing prescribing and I think when you know first script is being initiated. There are those those risks and those warnings that can come along with that and I think informing the person to watch out for that, for instance, that just in case. And you know: I'm needing to take it with me on the tram on the train, just to put it in my pocket just in case, those sort of things So the person actually has that in their mind, in terms of what's going to happen, what to look out for. But I think also you know, Nick's mentioned in terms of a busy general practice, you can't necessarily be across everyone that you're managing and all of the scripts you generate and that's where some of the infrastructure and having a workflow, that really helps. I think having these timelines and SafeScript can support something like that where for instance, Natalie mentioned that you know: this is such a surprise that the doctor hadn't realised you know how many medications were equating with that date of pickup. To be able to see that immediately when you open up someone's file for instance and going: hang on a minute, this equates to you know x amount in tablets per day, the x amount of milligrams per day can be really much more powerful. [It] doesn't rely on the person and how they’re going that day in terms of how behind they're running in their clinic to be able to pick up: hang on a minute, this is an alarm sign. So I think having that really clear picture in mind and also having those dates in mind, both for the person as well, written and given to them in the start, you know: you're going come back, we’ve booked an appointment two weeks from now, four weeks from now, six weeks from now and we can actually track how that's travelling. But I think the other really key thing that everyone's talked about is this is a medication solution for a whole range of difficulties isn’t it, a whole range of life problems, a whole range of stresses. As you mentioned Nick, the wait for psychological treatment can be really difficult especially in the public sector, where there’s no out-of-pocket costs. So I think it's really about trying to understand what's the role going to be for this individual person, for medication in their lives and what are the other things that are not being addressed by initiating the script? What are the other things that we can start to put in place here? And until there's a clear plan for those other things, what's the role of medication? So I think those kind of things we start to think about in that formulation.

LW: So having a really holistic approach to this, not jumping on just the one treatment and I think your comment for psychiatrists particularly who aren't all computerised or don't necessarily use a computer in their interaction with the patients, as GPs generally do, it may not be immediately obvious how much they've prescribed of something because it's not sitting in front of them. But now with SafeScript, they will have that in front of them so it's actually quite an advantage I think. Practice policies can also help, staged supply, limited supply as you as you suggested Nick, are all opportunities for limiting the amount of medicine that's being used and also knowing how much is being used. Clinical practice is not always straightforward though and so we do still see people who are taking benzodiazepines and opiates and and most practices we'll have some patients on those combinations. So Nick, if you had a notification in SafeScript and that came up when you saw a patient, someone you'd been treating for some time and that was your first inkling that there was a problem. That perhaps you've been managing them for pain and they're also receiving some benzodiazepines from another prescriber, how would you react to that? And then what would you do?

Nick C: Yes, wonderfully topical as it happens because this did happen to me, literally, the other day. So I was with a husband and wife and the wife said: while I'm here, could I just get some more of my sleeping tablets, you know I don't use them very much? And I looked back and sure enough she hadn't had a script for 18 months [and] I thought: this is probably okay. So we had a little bit of a chat. But then I went into SafeScript and I saw, actually she'd been getting scripts every month.

LW: So you weren't expecting that obviously?

Nick C: It's a terrific way of then starting a conversation gently: you know you need to talk to me a bit about what's going on here.

LW: And Shalini, for you in your practice, if you're managing someone say for anxiety or depression and then you find they're also using opiates perhaps from another prescriber, quite reasonable that they should be seeing two different doctors for different conditions, what sort of conversation do you think you might have if you had a notification in SafeScript? And also would you talk to the other doctors about it? How would you bring them into the conversation?

SA: Yes, I think it depends on the medication combinations we’re talking here but I think certainly for psychiatry and definitely for addictions counsellor, I think we look at any concomitant benzo and opioid script as a high-risk sign. We know that the combination is really important and really risky and I think if I'd opened up a SafeScript notification that popped up I'd immediately, I'm changed tack in that conversation and our conversation’s going to focus on now, really about what's necessitating the two scripts? I think in that sort of situation it’s probably not going to be concomitant script gets rolled out, because certainly in lots of people who have complex kind of problems including chronic pain for instance and anxiety disorders, that's a really common scenario. So the the presence of both those scripts isn't necessarily an indication to stop prescribing both those things but what you have now, as Nick has articulated, is information and that's information that you would not have had before presumably. So that's a touch point to be able to discuss with a person that actually gives them an informed decision about the risks of being on both of those things. It's also an opportunity then to clarify what's the interaction between both those conditions and both of those medications. I think in these sort of situations, I would always try to communicate with the other prescriber because SafeScript alone is not going to do that communication for us. And it's trying to clarify from the other prescriber of what the plan is to with that medication, if they're you know on a tapering plan for instance? What are the actual risk-mitigating strategies that have already been put in place? For instance, staged supply and so on. So it's definitely an opportunity there to liaise with the other prescribers.

LW: You touched on that, the fact that someone might be tapering or there could also be a reaction from a doctor that is, you know, surprised by seeing somebody taking something, that they do stop something suddenly or do reduce something quickly, as we we heard Natalie discuss. So Jane can you just remind us about those harms that can be associated with rapid withdrawal of benzodiazepines and what you do at Reconnexion to prevent those harms?

JA: Certainly there's a risk of having some sort of an epileptic seizure at times so we really advise not to come off what we call “cold turkey”. Sometimes there is a reaction, we have people call the support line saying: I've been cut off in SafeScript. Which is not actually the case. I think what's happened is perhaps some prescribers do get a bit of a shock and or they haven't been the person prescribing and so there's a little bit of a reaction. We suggest that people reduce by 10% of the total dose every two-to-four weeks which is quite a slower reduction. I think even the RACGP guidelines, it's 15% every two weeks, it's a little bit quicker anyway. And I think that's one of the problems too, is that there are a few different sets of guidelines out there for the psychiatrist versus the GP vs different countries etc. But I guess after 30 years of doing it, of helping people, the 10% every two-to-four weeks seems to work for people. As Natalie said in her story, when you're on a higher dose, that means it's going to be a longer taper and every time there's a reduction, there's likely to be withdrawal symptoms. These will vary amongst individuals and there's also no predicting as to which symptoms a certain person will get. And then as Natalie said, as in her case, each time you do a reduction perhaps that more symptoms may appear. I think one of the things for people who come into our program really appreciate is being validated. I think too often we hear stories of [people] not being believed and being sent off for lots of tests and things like that, [thinking]: oh no it can't be the benzos, I'll just come off too quickly. So basically a slower taper, switching over to a longer-acting benzodiazepine, usually diazepam, and then doing 10% every two-to-four weeks, monitoring how that goes for the person, dealing with the withdrawal along the way and then very much having the person have control over that reduction as well. Yes so that they can monitor how they're feeling. Don't do a taper if you're just about to go into an exam or or do something stressful. So stay stable and then taper when you're able to manage it. And there's no predicting how long it will take for any one person. It's the other big question How long will this take? How long's a piece of string? We just don't know.

Nick C: Like with all the addiction problems, you've got to be prepared for relapse that so people can't necessarily taper gradually down to zero and nice, smooth stuff. So we've got to be prepared that at rough times people go back down and work with that.

LW: That’s right, I just want to change tack for a second to talk about quetiapine because it's also flagged in SafeScript. So Shalini, can you talk a bit about it and we know we see a lot of low-dose quetiapine, 25 milligrams, probably being used for insomnia, not really clear, a lot prescribed in general practice? What do you think the role of low-dose quetiapine is?

SA: Yes so the inclusion of quetiapine in this podcast, which mainly focuses on benzodiazepines is in itself a sign of, I think, what low-dose quetiapine is generally being used for. And I think from an addiction perspective, I guess we see it in very much the same space and in the sense of low-dosing quetiapine in the 25 to 50, take it as needed and concerningly take it as needed but in a very large box. The standard quantity is a large quantity is, it's in the same territory at the sort of risks and order-of-harms that we see with benzodiazepines. Often it's a quick fix for insomnia in the same way that temazepam or diazepam [is in] some cases. But I think the introduction to this repertoire of things that people can use as quick fixes it's interesting because there's increasing information out there about the risks and harms associated with benzodiazepines. Subsequent to that, there was more harm information available to prescribers on Z drugs and so there's, in relative terms, there's been less discussion about the risks of quetiapine, the information around overdose deaths for instance and the implication of quetiapine in that. But also the implication of quetiapine in the same sort of harms we've been talking about so far, [for example] the drowsiness, the fuzziness, the withdrawal, the long-term side effects. Quetiapine acts on a whole range of different receptors as well so in comparison to the benzodiazepines, we're really talking about a whole range of different neurotransmitter systems that are being affected for a long time here. So in relative terms, it's not a simpler drug to come off as well in that sense and you know the Victorian data around harms really shows how it's implicated in a whole range of different harms including accidental and unintentional overdoses but also intentional overdoses and self-harm. So it's really one of those drugs that would be in that same category.

LW: So use [quetiapine] with caution as well.

Nick C: Quetiapine is also one of these drugs which is now a drug of misuse. So GPs need to know this is a drug that is being abused, people are crushing it up, they're smoking it, they're misusing it in all sorts of ways.

LW: So Natalie you've told us a great story and it's really good to hear that your dose tapering’s gone well. You told me a story about trying to get medicines on a weekend when you were you were really running out and going to a medical centre, just tell us quickly about that because I think SafeScript can help with that situation.

Nat C: Yes, I think SafeScript is so overdue in terms of how it's going to prevent stories like mine. One Sunday I realised I had like one tablet left and [at this point in time], my whole life now revolves around this medication. I've got to keep track of how many pills I have, I've got to then go get the script, then I have to fill the script. It's just my whole life centres around it. So I was like: oh my God, I have to get my medication and there is a real sense of dread and panic when we're in this situation. So I think I went to about two or three different clinics and I thought you know this is going to look, bad this is going to look like doctor shopping, which is an issue. So what I did to try and counteract that is I brought my Reconnexion letter that my treating therapist had provided and I finally get to see the doctor and I present the letter and explain my circumstances and he just slumps back in his chair very matter-of-factly and says: sorry sister, can't help you. That really put me in a conundrum of what do you want me to do because the thing about us going through benzodiazepine withdrawal is: we’re dependent, we don't think of ourselves as addicts. To get that addict treatment was horrible, I was furious, I was so insulted and then I couldn't get my medication. So I'm wondering how doctors are going to navigate around that?

LW: That's a really good question, in fact I think the SafeScript can help with that. So Shalini and maybe then Nick, do you want to tell us how you think SafeScript might kick in there?

SA: So that's a really difficult situation to be in, a weekend where there’s nowhere to go and your usual people are not there and I think what you articulated Natalie about the dread and the panic, I mean it really heightens the reason why you're on this medication in the first place and then, how are you trying to come off the medication? It really is brought to a point, to that situation isn't it? I think what SafeScript can do here is really promote the sense of trust between the prescriber and the person. That it takes the situation out of the person's hands where you don't need to travel with your letter and you don't have to say: no, this is legit. Because all you've got on the program on SafeScript are really the facts of when the medication was dispensed and when the prescription was initiated. So it takes all of that necessity I think out of the picture.

Nick C: Now the difference is that that doctor should be able to look on SafeScript and say: oh, actually this woman Natalie sitting in front of me is telling me the truth. Previously we had no way of knowing so I would have supported that doctor saying: I have no idea whether this woman's telling me the truth or not, [so] the safest thing is not to prescribe for her. Now there's an alternative, we can go on SafeScript and find out: actually Natalie is telling me the absolute truth and it is the right thing to give this woman a prescription.

LW: So it takes away the distrust as well which is really important. So really SafeScript is giving us that opportunity for lots of conversations and conversations supported by the facts, so we are trusting each other but at the same time we're having honest conversations about what's really happening.

While we all know that benzodiazepines are overused and that quetiapine is not recommended for insomnia, most GPs will regularly face the dilemma of a patient prescribed these medications who is using high doses or unsafe combinations. Ensuring patient safety in this situation by routinely attempting dosage reductions to safer levels, having in place a contract to ensure a single prescriber and a single pharmacist and having an all-of-practice policy will be helpful. SafeScript is an additional tool for monitoring patient safety especially in patients on long-term concomitant benzodiazepines or quetiapine with opioids.

Reconnexion is a Victorian government-funded service to assist patients and clinicians manage problematic use of benzodiazepines. They can be contacted on 1300 272 266. More information and resources to support your management of anxiety can be found in SafeScript online training modules and your local PHN SafeScript health pathways. The SafeScript GP clinical advisory service provides peer-to-peer advice to GPs managing patients with complex pain addiction or mental health needs and they can be contacted on 1800 812 804. Links to all these resources can be found at www.dhhs.vic.gov.au/safescript

Thank you to our guests Natalie Corriga, Nick Carr, Jane Andersonwurf and Shalini Arunogiri. Our next podcast will look closely at the importance of language, reducing stigma and weighing up the risks and benefits of opioid treatment for people with chronic pain. The take-home messages from today's podcast are that patients with chronic pain using benzodiazepines, Z drugs or quetiapine are at increased risk of harm; a combination of judicious prescribing; setting goals for dose reduction and regular monitoring as well as counseling can help keep patients safe while you work towards deprescribing these medicines if and when that will be possible. Thanks for listening and have a great day.

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