Benzodiazepines are invaluable therapeutic agents which in varying degrees may produce physiological dependence; moreover, their use may complicate or be complicated by the abuse of other substances.
Benzodiazepines are invaluable therapeutic agents which in varying degrees may produce physiological dependence; moreover, their use may complicate or be complicated by the abuse of other substances. In prescribing these controlled substances, more than with other medications, physicians may be perceived to be acting as International legal and ethical of the state as well as of the patient, with the potential for ethical conflict that this dual role entails.
In some circumstances it may be unethical to prescribe benzodiazepines; in other circumstances it may be unethical to withhold them, even if prescribing involves risks for the clinician.
Benzodiazepines suffer from guilt by association, in that the clinician who treats street-drug users will often see benzodiazepines used to self-medicate the consequences of that abuse. On the other hand, the clinician who treats a more heterogeneous population may see Valium diazepam misuse, but will not see true addiction, insofar as there is no dose escalation or compulsive use in spite of adverse consequences.
As with insulin and digitalis, drugs needed for long-term therapeutic use may International legal and ethical dependence, but that is not the same as addiction. The closest that benzodiazepine abuse comes to addiction is as part of a pattern of poly-drug abuse, sometimes with the rationalization that other chemical addictions require, in compensation, increasing dosages of benzodiazepines.
Long-term therapeutic use of benzodiazepines occurs primarily in three groups of patients. The largest group is those with chronic, serious medical illnesses e. It would be cruel to deny to these patients, often well advanced in age, the degree of relief offered by benzodiazepines.
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The second group is those with panic disorder. Whether benzodiazepines are more appropriate for such individuals than SSRIs or other antidepressants must be decided by weighing therapeutic versus side effects on a case-by-case basis.
However, there is no evidence of benzodiazepine abuse in this population, and chronic use tends to result in gradual dose reduction over time. The third group consists of individuals with chronic psychiatric disorders or repeated instances of acute stress.
Here, too, except for those with personality disorders, much chronic benzodiazepine use and pharmacological dependence occur in the context of legitimate treatment. Typical Dilemmas Disagreements between clinicians concerned mainly with overuse of benzodiazepines and those who focus on underuse are based in part on different perspectives, patient populations, and values.
Unfortunately, the salient dimensions of what should be a clinical controversy have all too often been obscured by the misuse of the term "addiction," which has created a false analogy between benzodiazepine dependence and addiction to substances of abuse.
This analogy, in turn, has brought with it irrelevant associations with antisocial behavior. These controversies have generated sufficient concern that the American Psychiatric Association issued a task force report on the subject. While such guidelines are useful as checklists for administrative purposes or as reminders for chart review, they are no substitute for the careful review and analysis of risks and benefits on a case-by-case basis which is the hallmark of psychopharmacological decision making.
Special care needs to be taken, therefore, when evaluating and treating a variety of vulnerable populations, including the pregnant patient, [ 14 ] institutionalized populations, such as geriatric residents of nursing homes [ 15 ] and inmates in correctional settings, people who live alone or who have a history of abuse or a disordered family situation, patients being treated with methadone, [ 16 ] and patients who are facing stresses such as examinations or testifying in court.
All of the above is easier said than done, given the increasing time pressures and devaluation of time spent with patients on the part of many managed-care reimbursement schemes.
Careful consideration is likewise needed when performing forensic psychiatric evaluations, such as employment evaluations, including applications of the Americans with Disabilities Act ADA[ 18 ] and mental-state evaluations in criminal cases, where the question of diminished capacity resulting from benzodiazepine use or dependency may arise in the determination of competency to stand trial, in the determination of criminal responsibility at trial, or as a mitigating factor in sentencing.
By getting to know the patient over a period of time, the physician can prescribe with a deeper understanding and greater confidence that the patient will work out any resulting problems within rather than outside the alliance.
Managed health care, by putting a premium on short hospital stays, short-term therapies, and the fifteen-minute psychopharmacological or internist patient visit, often precludes long-term alliance building. Physicians feel compelled not only to prescribe benzodiazepines without adequate knowledge of the patient, but even to use these drugs as substitutes for listening to and talking with patients.
On the other hand, this strategy may risk increasing dependency on a therapist who begins to be seen as an omnipotent advocate. In such cases physicians may do better to work with patients so that they can advocate for themselves.
At the same time, in their zeal to avoid feeling scapegoated, physicians should not fall into the trap of scapegoating third parties.
Instead, they should work with insurers and managed-care organizations MCOs to create cost-effective treatments that meet the applicable standards of care. Such litigation may result from the failure to take proper care when monitoring patients with known histories of substance abuse or from the failure to hospitalize such patients when appropriate as a precaution against withdrawal symptoms.
Grounds on which clinicians have been sued for malpractice involving benzodiazepine use include improper diagnosis, prescription drug interactions, cross-dependence with alcohol, failure to take appropriate measures to avoid increased drug or alcohol dependence, failure to obtain informed consent to the development of dependency on benzodiazepines, and failure to recognize benzodiazepine withdrawal.
A quick search reveals numerous instances of such civil actions in recent years.
Given the risk of accidental death from overdose, sometimes in combination with other drugs,16 or suicide in the treatment of substance-abusing or substance-dependent patients, monitoring for suicidal ideation in the context of a carefully considered and formulated treatment plan is crucial for avoiding both tragic outcomes and malpractice litigation.
Duty to third parties. A common conundrum for physicians prescribing benzodiazepines is the concern that either their proper use or misuse will lead to harm to third parties.International Child Foundation is a highly recommended, licensed Arizona adoption agency, with social workers in Phoenix and Tucson.
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