Jobbing Doctor takes a dispassionate look at how a much maligned group of drugs can be put to use in general practice.
A question for you.
What do Kenneth Williams (oooh, matron!), saxophonist Ronnie Scott, model Margaux Hemingway, the Singing Nun, Jimi Hendrix and Marilyn Monroe have in common?
It is a medical reason.
They all died directly or indirectly as a result of barbiturate overdose.
I was at medical school when we were taught all about barbiturates. Phenobarbitone, quinalbarbitone, amylbarbitone. Then they were still used. They had some value, but the risks were great, especially in overdosage, as this list showed. We were taught about the dangers, but I remember barbiturates being used on the wards – especially Tuinal – known as the ‘Yellow Submarine’.
Then, as if by magic, a new group of drugs became available. They had similar effects to the barbiturates, without the desperate risks of overdosage. It was quite exciting to be around at the time of the development of a newer, better and safer drug: the first two that became available were diazepam and chlordiazepoxide.
I remember, ah yes, I remember.
The benzodiazepines were rapidly taken up by all the interested groups – psychiatrists, general physicians, general practitioners. This was because they were so much better than the alternatives. They are a really valuable and important group of drugs.
Around 20 years ago, however, there became increasing evidence of problems with the benzodiazepines – highlighted by Barbara Gordon’s book ‘I’m dancing as fast as I can’ which chronicled the problems of addiction and withdrawal with these drugs. Over the last 10 years we have had an increasingly regulatory noise developing around the use of benzos (as they are termed on the street).
The authorities are now putting the squeeze on benzodiazepine prescribing. They are concerned about the usage in the addict population, and the fact that they have a street value. I can understand that, but that does mean that we are being closely monitored on our benzodiazepine use as doctors (prescribing, not personal use!)
A recent visit by a contract monitoring team identified benzodiazepine use as one of the measures that they were using. Needless to say that such a tool, in the hands of the ignorant, is likely to do more harm than good.
I have prescribed benzodiazepines for 35 years now. Some have come and largely gone (nobrium and alprazolam to name but two). Others we use rarely, and with much reluctance (lorazepam, for example). But the two early ones are still very valuable to use.
Here I need to be honest. I have a cadre of around 10 patients who I am attempting to stabilise and manage within the community. They are all youngish men (from 24-50), and were all regular IV drug users – on heroin. They are on a maintenance dose of diazepam (varying from 30mg to 120mg daily) and there is now some constancy in their lives. They are all off heroin (although one occasionally smokes it recreationally).
I have debated the matter with the local drugs rehabilitation centre, and there is – lets be honest – a difference of opinion about the whys and wherefores of benzodiazepine prescribing. Around half of the patients I am managing are just on benzodiazepines (possibly with hypnotics) and the other half use it as an adjunct to the daily use of methadone.
We need to remember that benzodiazepines are effective and safe. The major anxiety I have with them is about their addictive potential, and that is why I constantly review my use of them.
However, I do tend to relate the theory to the practice, and I have many cases that I can remember: one man I have managed, with controlled prescribing, to keep out of prison for ten years now.
That has to be good.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.
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