A study recently published in JAMA found that as our profession has been working tirelessly to curtail prescriptions for opioids—attempting to bring an end to a drug overdose epidemic that now claims more lives (70,237 deaths in 2017) than automobile accidents—we are prescribing more and more benzodiazepines. Increasingly, the study found, many of these prescriptions for benzodiazepines are coming from primary care providers.
I have helped contribute to this problem. Benzodiazepines are useful drugs and I have often prescribed them to my own patients. Most patients use them appropriately and find benefit from them, especially when used in the short term for a temporary problem or while waiting for another medication, such as an SSRI, to work. I’ve also had patients angrily storm out of my office when I refused to prescribe a benzodiazepine. I have colleagues who rarely prescribe benzodiazepines and have had patients fire them because of their unwillingness to prescribe these medications.
I am not here today to point fingers and blame. I am not a benzodiazepine zealot. I want to ask us to sit down and have a conversation about our role and responsibility in the alleviation of suffering.
Anxiety, when proportionate and appropriate, serves to warn of us potential danger. However, anxiety, especially when severe and misdirected, is miserable and disabling. While it is also part of the human condition, I'm not a Pollyanna about anxiety. While we may all need a little bit of anxiety to be motivated to get out of bed each morning and tend to our days, the tsunami of anxiety that leads our patients to request a benzodiazepine is inundating and paralyzing.
The JAMA study found that the number of primary care visits that ended in a benzodiazepine prescription increased from 3.8% in 2003 to 7.4% in 2015. Oftentimes, these drugs are being co-prescribed with other sedating medications that can contribute to a risk of death by overdose. A 2018 study found that when opiates are combined with benzodiazepines, the risk of overdose quintuples in the first 90 days of co-prescribing. We are a conscientious profession, so what is driving us to participate in this risky pattern?
Unsurprisingly, the answers are complex. On the supply side: The drugs work quickly. Other anxiolytic medication classes usually work less immediately and are less robust in their effect. Nonmedication alternatives exist, but it is difficult to teach mindfulness in a 7-minute visit. Sometimes health insurance limitations or a shortage of available therapists make it difficult to refer a patient with anxiety to CBT or other nonmedication treatments. When all you have is a hammer, everything looks like a nail.
Providers are called to relieve suffering. Many of us entered this profession because it is satisfying to see a patient improve as a result of our efforts. One of the interesting findings from the study was that benzodiazepines are being prescribed by primary care providers for conditions like back pain (which does not require a stretch of the imagination, as diazepam has long been prescribed for muscle tension), because the screws have been tightened on traditional analgesics like opiates.
On the demand side: Patients have been promised robust, rapid treatments for their ailments by the medical-industrial complex of the pharmaceutical industry and well-intended healthcare providers. Patients pay a lot of money for health insurance, and want something that works and don't have patience for things that don't work quickly. As Psych Congress 2018 keynote speaker and Drug Dealer, MD author Anna Lembke, MD, pointed out, the supply and demand forces merge uncomfortably in a consumer-driven healthcare market, where providers live in fear of bad reviews from patients. Many large health care systems randomly collect patient satisfaction data from patients. Patients who are upset that you didn't prescribe the drug they wanted don't leave good reviews, and this can impact compensation, promotions, and the ability to attract new patients.
Supply and demand aside, one must ask, why is our society so anxious that we are increasingly petitioning our medical providers for relief?
Anxiety, it seems, is the mental illness that is most aligned with the zeitgeist of the 21st century, a time in which connectivity has created an expectation of productivity and pressed the capacity of our attention to its limit. A lack of economic security, especially for a generation just entering adulthood saddled with student loan debt, stagnant wages, and economic uncertainty is an obvious nidus of unease. A warming atmosphere has now changed weather patterns in a way where climate change is no longer hypothetical and raises the very real fear that our planet as we know it will not be the same in our lifetimes or our children’s lifetimes. Add to this the voyeuristic ability to compare oneself to our peers via social media, where curated versions of ourselves hide the gnawing fears that we are not living our lives to their full potential (there is even a neologism for this phenomenon: FOMO, or “fear of missing out”). In short, with all of this weighing on us, how could we NOT be anxious?
Undergirding this response to anxiety is a complex relationship with suffering, largely driven by aversion and the expectation that somehow the experience of suffering has become optional. So if our profession is to move beyond the simplistic notion that all emotional pain can be eliminated with the swipe of our pens on our prescription pads, how then do we help our patients change their relationship with the experience of suffering? I invite you to add your thoughts to the conversation below.
Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, California, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of the Psychiatry & Behavioral Health Learning Network or other Network authors. Blog entries are not medical advice.