As a physician in a rural health clinic, I frequently see patients who complain of anxiety. The majority of these patients are in their 20s to 40s. Some have never been evaluated by a mental health professional, and many of these patients take benzodiazepines on a chronic basis. After current review, I wonder if we as primary care physicians are good at treating anxiety, or are we contributing to drug dependency?
Benzodiazepine dependency is a growing health concern. According to the Drug Abuse Warning Network (DAWN), visits to the emergency department involving benzodiazepines increased 141% between 2004 and 2010. Benzodiazepines were involved in 28.4% of emergency department visits involving pharmaceutical related suicide attempts during that time. The arrest reports in my local newspaper attest to the problem of the illicit sell of benzodiazepine in my area.
Most current guidelines recommend SSRIs and SNRIs as first line treatment for generalized anxiety disorder. Buspar and Lyrica have been shown to be effective adjuncts if needed. A number of randomized clinical trials support the use of benzodiazepines, but for short term use only (up to 6 weeks). Importantly, benzodiazepines are ineffective in treating depression, which often exists as a comorbid condition. Cognitive behavioral therapy is also often helpful in treating anxiety.
We all know the physical dependency that benzodiazepines cause. The abuse of this drug is also well known. Most of us are familiar with current guidelines concerning their use. Why then, is the problem of benzodiazepine abuse getting worse?
One reason is that patients are often insistent on being prescribed benzodiazepines as first-line therapy for treatment. Patients already on taking them are reluctant to try a new medication due to the strong physical dependency that benzodiazepines cause. I have had patients become angry when I tried to discuss weaning their benzodiazepines and trying other medications. Patients have also become accustomed to expect benzodiazepines. They have family members taking the medication for anxiety and expect to have it prescribed to them also.
Changing our prescribing practices to conform to current guidelines and trying to use SSRIs and SNRIs as first line medications for anxiety disorders will be challenging for many of us. The challenge will be due somewhat to prescribing habit, but mostly to patient insistence of their preferred medications. We should discuss with our patients the risk of dependency to these drugs, and that alternative therapy is available. While we are not mental health experts, we can provide self-help literature and relaxation techniques.
The effort to confirm to current guidelines will eventually pay off in fewer patients being dependent on benzodiazepines, and eventually, in less pressure from our patients for these drugs as their expectations change.
Tara Reynolds is a physician.