Good afternoon and welcome to another presentation in the clinical update series of the annual meeting. My name is Dr. Ron Winchell. I will be your moderator today and my co-moderator is Dr. Kathy Crone. In a few moments, we will introduce our speakers on the panel. Last year, we arranged for a debate on the use of benzodiazepines with the same panelists. The reason for that was that there is great ferment in our community about the use of benzodiazepines. The problems with benzodiazepines are well known. Cognitive problems, dependency problems, vulnerability of the elderly, vulnerability of those with substance abuse problems, and other associated problems. The benefits are also well known. However, we've seen a great deal of conflict in our community about the utilization of these medications. There are those who believe that in our appropriate efforts to deprescribe when appropriate, which is frequent, to spare the elderly the risks of the side effects, to not accidentally or unintentionally give these medications to people who have risk for substance abuse. There are those who believe that we have been unfortunately throwing the baby out with the bathwater and are losing the opportunity in many ways to use these medications where their potentially unique capacities would serve us and our patients well. Serve our patients well and therefore us well. We have heard that there are environments around the country where some doctors are forbidden, not by statute, but by the organizations within which they work to prescribe any benzodiazepines. If I may say, I just heard a story today about a major medical center where the use of a benzodiazepine to treat catatonia is not endorsed, which is a principal treatment for catatonia. Also, we can't ignore the past history in this country of physicians being overly scrutinized at times. Also, the anxieties we have in talking with patients about these medications, because talking with them about stopping these medications is a very fraught conversation. Last year, we conducted a poll of the audience and asked the question, how many of you are even reluctant to bring up deprescribing with your patients? We didn't keep the data, but do any of you remember it was well over 50% just wouldn't even bring it up, even when they felt it was the appropriate thing to do? It occurs to me that one of the biggest problems with benzodiazepines, ironically, is our anxiety about their use. When can we prescribe them? When should we prescribe them? Who's looking over my shoulder? Who's going to criticize me? Am I subjecting this patient to unnecessary risk? Or if by withholding it, am I subjecting them to the risk of insufficient treatment for a condition for which there may not be an alternative acceptable treatment? Now, just to throw another wrinkle into it, our recent near escape from my practice perdition with the change in interstate regulations in prescribing controlled substances, we now have a two, two and a half year reprieve from the federal warden, leads to other complications, such as medical organizations that have a national presence. What do they do when the rules shift from state to state? So in order to help us all think about this, we decided to reassemble the same panel this year, but instead of in a debate format, we are going to have an open discussion of the panel. Right now, the way we're planning this, for about 40, 45 minutes, the panel will have opening statements, each of them, and speak between themselves for about 45 minutes or so, and then we will open it up to questions from the audience. So let's introduce our panelists. So I'm going to read the bios as we have them. Dr. Ilse Wieckers is a geriatric psychiatrist with additional expertise in health policy and health services research. She works in the Office of Mental Health and Suicide Prevention in VA Central Office, leading several national mental health programs that focus on evidence-based psychopharmacology, quality improvement, and geriatric mental health. Dr. Wieckers specializes in providing clinical care for veterans with late life mood anxiety and trauma-related disorders. I should say this does not begin to do justice to her accomplishments, which are a lesion. At the end of the table is Dr. Ed Silberman, an attending psychiatrist and professor at Tufts University School of Medicine. He focuses on psychotherapy, psychopharmacology, anxiety disorders, dissociative disorders, forensic psychiatry, and executive consultation. Kathy, would you introduce our other two panelists? By the way, there is a question for the people who are listening in via live streaming. And there are no slides on this because this is a panel discussion. So Dr. Joseph Bienvenu is an assistant professor of psychiatry and behavioral sciences and co-director of the Anxiety Disorders Clinic at Johns Hopkins Hospital. Joe, how come you're only an assistant professor? You must have a lot of accomplishments. That must be some old website. I was going to say, I was going to go to that. Sorry about that. Dr. Donovan Most is a geriatric psychiatrist and health services researcher. He has two primary areas of research interest. First, he's interested in understanding both the drivers and consequences of potentially inappropriate psychotropic use among older adults, focusing on benzodiazepines and antipsychotics. In addition, his research explores the factors that potentially drive the inappropriate, potentially inappropriate, sorry, healthcare utilization of patients with dementia. And let me add one piece. Also, podcaster extraordinaire. What is the name of your podcast? Minding Memory. What's that? It's called Minding Memory. It's about dementia. Okay. So, well, why don't we start our statements in the order of Dr. Wickers. Okay. So I'll just say a couple brief remarks to kick us off and then hand it over. I think Donovan and I have three key points that we want to make. Number one is that we believe the field of psychiatry needs to lead the dialogue around safe and judicious use of benzodiazepines for the rest of medicine. Most benzodiazepine prescribing is actually not being done by our field. It's being done by others. And the way that we speak about it and carry ourselves in the world of benzoprescribing, I think, helps inform the rest of medicine. Number two is that safe tapering is possible. Full stop. We'll talk more about that. And number three, and not as scary as you may think it is. I'll put it that way. And number three is that I think our approach to benzodiazepine prescribing is informed greatly by the concept of harm reduction. So we know in our population in particular, both of us spend most of our time treating older adults. There's oftentimes more risk of harm than benefit. And we are really aiming towards reducing the amount of harm. So the least dose necessary to ensure symptom control and good function for that patient. And oftentimes we believe, and in our practice, we have seen people on much higher doses than what that least necessary dose may be. So the idea of harm reduction is you reduce the dose. The lowest dose possible is going to reduce the harm and potential bad outcomes. So those are our three key points. Donovan, other things you'd like to add? So Ilse and I are both geriatric psychiatrists, but I think it's important to think about the harms for the most part really apply to folks of all ages. Even if we could snap our fingers and stop all benzo prescribing to older adults tomorrow, there's still a whole host of people who are aging into older adulthood, many of whom have become long-term benzo users, not because that was really the intent at the beginning of when that prescription was initiated. So I think being really critical and thinking about sort of unintended consequences when you start that benzo prescription is important. And maybe there are many other things I could say, but for now I'll just say we are not saying that no one should be on benzos. And so the idea of policy, either federal, state, health system policy, to basically ban benzo prescribing is crazy. And so just, again, bottom line, we're not saying no benzos, but we are saying there's probably more than is appropriate. Just in case you guys don't know, this is the con side. Yeah, but the problem is the reason this is not a debate is we utterly failed to disagree with one another last year. So this is now a panel discussion. Yeah, so I said last year we were in New Orleans, I said, you know, I could have picked either side. It's just which side needs someone? And I certainly have inherited patients who, as these guys were discussing, got older. They started on Alprazolam at a time and never really tolerated even newer antidepressants for panic disorder and then got old and their brains became vulnerable. And certainly I've had to taper people, and I've had to admit patients to the hospital to taper them sometimes safely, not just because of fear of seizures but also because of the emotional effects that can be quite substantial tapering off benzodiazepines. And they can be kind of delayed. You know, it doesn't make sense just in terms of the pure pharmacology. But, yes, I certainly endorse the use of lorazepam for catatonia. So do we, for the record. And these guys last year, I think Ed was making a point about, well, you know, antidepressants also have problems in patients. And these guys said, oh, yeah, we don't think that people should be on high doses of those drugs either, especially when they're elderly and have side effects. So, yeah, we're all on the same team, but we're just going to argue different sides. So where I'd like to start is by saying that there really are three distinct groups of people who take benzodiazepines who appear in the literature. One group is a group of people who have had well-diagnosed anxiety disorders and are prescribed these medications usually by psychiatrists. And that's one group. The second group, and we know a lot about that. There's a very big literature. It's not mostly new literature, but it's a very big literature on safety, efficacy, and tolerability in that group. The second group are people who are polysubstance abusers. And those people very commonly also use benzodiazepines as adjunctive drugs of abuse, either to enhance the high of their primary drug, like an opioid, or to mitigate unwanted effects of their drug of abuse. And we know a lot about those people. The third group are people who, to the extent that they appear at all, appear in the literature on withdrawal trials. But they are not the systematic part of that literature. They are the population of people in the trials about whom, if you actually read those studies, remarkably little is known. They are often people who have been treated not by psychiatrists but by primary care physicians. Very little is known about why they were treated, what the indications were. Nothing has been published. There are no systematic studies in the literature of this. Nothing has been published about what kind of treatment they had and how did it go and what was the course of treatment and how did they come to want to taper off benzodiazepines. It's a black hole. And I think that a huge part of the problem that Ron outlines at the beginning of this debate about benzodiazepines is that, at least in American and European psychiatry, we don't talk about those three groups. We talk about them as if they are one group or a group where people move fluidly from one segment to another. And there is absolutely no evidence that this is true. And instead of saying, what's the reality about benzodiazepines, I think we really need to start talking about what's the reality for one group versus the other versus the other. And maybe we can do a little bit of that today. So I'll maybe respond a little bit to Dr. Silverman's point about the three groups. So I definitely agree about the first group. That's really a minority of benzo users who have sort of well-diagnosed and documented anxiety disorders and are treated by psychiatrists. On the substance abuser's front, so at Michigan, I work with a lot of substance abuse health services researchers. And so when I talk to them about benzos, they think about misuse and abuse and addiction. I think about like a 70-year-old who got started on a little bit of C-R-A-X, Oxazepam, for sleep when they were like 60. And they're still on that benzo. So I didn't think about benzos as an issue of misuse or abuse. And so we published a paper a couple years ago using nationally representative survey data. And I will happily say that I was right among people who are 65 and over. Benzo use that's reported, that's misuse, is very, very small. It's like less than 1% of older adults reported benzo misuse. And misuse was defined either you aren't prescribed to benzo and you take it anyways or you're prescribed it and you take it other than how it's prescribed. However, were I a psychiatrist working with younger adults, if you look at overall benzo use, half of benzo use among 18 to 25-year-olds is misuse. So the prescribed past year use is around 5%. It's an equivalent amount that is misuse. And so for older adults, I don't really think a lot about polysubstance use, abuse, misuse. For younger adults, I definitely do think that that's something that you should think about. And then the final group, which is by far the biggest group, are these people who get sort of prescribed a benzo for totally murky and unclear reasons. Ilse and I have both done work looking at this where you look at the diagnoses that people have recorded. A lot of people it's for sleep. A lot of people it's like a short-term period of distress. And again, when the prescription gets started, sort of like I think it's Stephen Covey, you begin with the end in mind. So if you start that prescription without the end in mind, some of those people go on to become long-term users when that was never the intent at the beginning of their prescription. And that, I think, gets back to Ilse's point about like we as psychiatrists need to sort of think about the message that we're representing because by far the third group is the biggest group. Those people are not being prescribed to by psychiatrists. They're being prescribed to by our primary care colleagues. And so we, I think, need to be mindful about how we think about and talk about what's the appropriate way to prescribe these medications. One example, I heard a colleague in the hallway at the VA talking about this. Older patients she inherited, he'd been on Xanax, I don't know, for like 20 years or something. It was started when his dog died and he was upset. And now decades later in his 70s when he shouldn't be on this med anymore, he's super attached to it and he should have never been put on it in the first place. And so we don't want to be contributing to that. One thing I do want to say, I think we need to be careful about terminology and the word misuse in particular because it has a pejorative connotation. But the definition of it is use other than just as a prescription, as a prescriber has dictated. And in a very lovely paper that Dr. Maus and others published that showed in the population he was dealing with, about 17% of benzodiazepine use in that group was misuse. But the misuse was not abuse. The proportion of people who were taking it to get high was about 1% in that study. And that's typical. That's also typical of estimates of people who genuinely abuse benzodiazepines alone and nothing else. It's 1 or 2% as far as we can tell. But these were people who were taking it not as prescribed in order to feel better, in order to control their symptoms. And that's a very different group of people. And there are many different reasons why people will do that, some of which have to do with the people themselves as individuals, some of which have to do with the nature of anxiety disorders because people with anxiety disorders are anxious and they are very preoccupied with control. And so they do these things. And it also has to do with, unfortunately, prescribers who really don't understand very well the things that Ilse and Donovan were talking about. And they don't prescribe them properly in many different ways. And so people in their anxiety take things into their own hands and take the medication not exactly as prescribed. But these are not substance abusers. And so it's very easy, if you don't think about these things, to read the literature and say, oh, my goodness, there's such a high rate of substance abuse from taking benzodiazepines. But not in that direction. Taking benzodiazepines is not a cause of substance abuse. Substance abuse is a cause of taking benzodiazepines. And it's a very important distinction to make. Thank you. I was guessing if you looked at other things that those 18- to 25-year-olds take, it's probably pretty varied. I really like the idea of starting with the aim and the end in mind with benzodiazepines. One indication that I use benzodiazepines for is, say, a patient has panic disorder and it started relatively recently and their lives are falling off the rails. That is, they're having trouble getting to work. It's really affecting their job functioning as well as their relationships and I know that anything else I do is going to take too long for this person is going to have all these secondary effects of the panic disorder that are going to influence their lives for quite a while. But I'll talk to those patients about, I'm going to give you a temporary medication and at the same time we're going to start this other medication that will only cause side effects at first, unfortunately, but eventually will help you and is not addictive like sertraline. One thing, can I ask how often does it work that you're actually able to then stop the benzo for that person? I have great success rate one out of 100 patients is able to. No, I'm just kidding. It is certainly true that those patients who don't come off completely, don't misuse the medication and they will use it quite sparingly. It's remarkable to me also how frightened many patients with anxiety disorders are about benzodiazepines. They're really frightened of addiction. I'm thinking probably especially patients with generalized anxiety disorder. I mean, we worry about everything, those of us with GAD, and oh my God, I'm going to be addicted. I don't want to take that. Give me something that has horrible side effects instead. One thing about the benzodiazepines that is really hard, making Donovan's point a very good one, is they are so effective at taking away, especially the physical symptoms of anxiety, that they are incredibly negatively reinforcing. And so people will have this bottle, they may not have had a pill in 10 years, but it's like a rabbit's foot, that they feel like they have to have it with them at all times. Because they remember, or specifically, like their primitive lizard brain remembers how effective this was at taking away the anxiety. And so I think that that can make it hard for that 70-year-old to give up that prescription. Though I would argue, in that case, we've got harm reduction is in play, right? Because they're carrying around their rabbit's foot, they're not using it often, they're using it sparingly and infrequently, but they have a couple pills in a bottle that they hold in case a panic attack comes back, right? But it's not high-level dosing, it's not daily dosing, right? So those are, I have patients that I prescribe benzos in that way for, right? And they have a handful, or people who have a very specific phobia, like fear of flying. They cannot get on a plane without a dose of benzodiazepine, and they have to go get to grandma's funeral, and it's on the other side of the country, and they can't drive. So how are we gonna get them there? With some alprazolam. That's how we're gonna get them there, right? And so they get four doses, one for each up and down that they have to do to get across the country and back, and everything goes well, right? But it's starting with the ends in mind, right? So it's a small number, it's being carefully considered, and it's not being used all the time. One of the things that I tell people, and I do not infrequently start people on a benzodiazepine for well-diagnosed anxiety disorder, with the idea that they may be on it long-term, simply because not only does it work very quickly, but the side effect profile is way better than that of antidepressants, and certain antidepressants are extremely hard to get off of, harder than benzodiazepines. But I say, look, you have to be aware at the beginning that if you turn out to be on this medication for a long time, as people get older, the potential liabilities get higher. And I talk about cognitive impairment, and I talk about coordination problems, and I say, you have to know that, and you have to know that if you start to show any signs of this, then we have to at least reduce the dose and maybe stop it. And that understanding on the part of people makes a huge difference in how easy it is to taper off. If people are on board with the reasons why they have to taper off, not, oh, you've been on this a long time, you're dependent, and nobody should be on it this long, then you have to get off. That's a whole different set than here's the reason we have to get off. And I've never had any trouble tapering anybody off. I use flexible tapers. There's no hurry. Don't go down to the next level until you're comfortable where you are. And I've not had a single patient who couldn't do that without any great trouble. But you do have to warn people and you have to educate people about the whole thing at the beginning, including what the limitations of medication are, that medication isn't gonna do it all for many people. I won't, maybe later, I'll talk about generalized anxiety disorder because that's the one condition I generally don't prescribe benzodiazepines for. It's a much harder group to treat for all kinds of reasons, but people with panic attacks, boy, you can turn their life around, just as Joe has said. So maybe two topics I'll pick up on. So the first is, Joe brought up the example of, say somebody with, I think it was panic disorder, starting them on both a benzo and an antidepressant at the same time. So another place where sort of it used to be lower, and I think it used to be in the practice guidelines and isn't anymore, please correct me if I'm wrong on that, is starting an SSRI in somebody with depression. There's this idea that if you also started them on a benzo at the same time, you could sort of help get them through that initial uncomfortable period on the antidepressant, sort of while the antidepressant was really kicking in. So a woman named Greta Bushnell did a paper that was published in JAMA Psychiatry, where they actually used data, claims data, to look at people who had a new diagnosis of depression, were started on a new antidepressant, and they compared people who were just started on an SSRI to people who were started on an SSRI and a benzo at the same time. Again, with the idea being, so the outcome in this real-world data, so they didn't have like PHQ-9 scores, what they had was, let's look and see, among people who got started on an antidepressant, how many are still on the antidepressant six months later? Because that's the whole idea of starting the benzo at the same time, is you make the antidepressant treatment more tolerable. Basically, there was no difference in who was still on an antidepressant six months later, if they, whether or not they were started with a benzo or not. Where there was a difference is, among the people who got started on a new benzo, a number of them became long-term benzo users, and the likelihood of becoming a long-term benzo user was related to the size of that initial benzo prescription. So again, the idea of, I don't think when that benzo was started, those clinicians probably weren't doing it with the intent of having some of their patients become long-term benzo users, and yet that is what happened to some of the people who were started on their benzo. So, just again, to be mindful of that strategy if you're doing a sort of dual-agent start for folks. Shifting gears to the idea, this enormous amount of anxiety people have around coming off of benzos. So there's actually a number of data out there to suggest, number of studies out there, that people can actually do this, and the wheels don't fall off. So there's a geriatrician in Canada, in Cara Tannenbaum, who published this thing called the Empower Intervention, where they used pharmacy data to identify adults 65 and over who were on long-term benzo therapy, sedative hypnotics. All the intervention was, was they sent them an eight-page booklet that had some true-false questions about this medication that you're on, there's some risks associated with it, those risks grow as you age, you should maybe think about talking to your doctor or your pharmacist. That was all the intervention was, and I think it was 25% of people who received that brochure had stopped their benzo by six months later. Incredibly light-touch intervention of people just being informed about some of the harms. And so in the VA, under some of ILSA's leadership, they, as a system in the country, benzo use is lower in the VA than anywhere else. It's come down even more to the point where I'd say, they probably shouldn't try to reduce it anymore because I think it's gonna start causing harms at this point, but benzo use went down. We looked specifically in older veterans, most of whom had Medicare Part D, so they could all go out in the community and get a community clinician to prescribe them a benzo. And when you looked at what happened to benzo prescribing overall, it still went down. So basically people who were getting their benzo through the VA and had their benzo discontinued, they didn't just go out to the community to get a benzo. So I think if tapering was such a horrific event, it would have been a flat line once you actually looked at benzos, once you added in benzos obtained through Medicare. Benzo use really did decline, people didn't go out into the community. Benzo discontinuation studies, first author is Vicens, V-I-C-E-N-S, did a discontinuation study in the United Kingdom. They randomized people to a couple different conditions, looked at usual care versus discontinuers. They looked at anxiety, they looked at depression, they looked at insomnia, they looked at alcohol use. None of those things were worse in the group that discontinued their benzo. And then in some work that we've done where we've actually done interviews with veterans who stopped their benzo during this program that ILSA was leading, we did phone calls, semi-structured interviews with, it was 21 veterans. Out of that 21, we spoke to them several years after their benzo had been stopped. A total of one of them went back on their benzo that he got through a community prescriber. Out of the 21, only two of them mentioned having any problem with withdrawal symptoms. And basically, they were all doing fine. So there is plenty of data out there to help alleviate your concerns and your patients' concerns that like, their lives will fall apart if they stop their benzos because the data just doesn't suggest that that's true. In terms of tapering, so we've talked about, certainly there are cases of patients where you would like to taper because of worsening cognitive functioning, worsening motor impairment, et cetera, often with aging or gross brain disease. Do most of the rest of you find that you have to go slower near the end, that is, at lower doses? Yes, the last 25% is the hardest. And some folks, you can't get from that last 25% all the way to zero. And I tell people when we start the discussion around tapering, that that's okay. I say, we're not going to zero, we're going to the lowest dose that's comfortable for you. That's the language for tapering. And I also say, you know, if we're meeting today in the clinic, I say, okay, it's May, let's see where we are at the winter holidays. We'll try to be halfway or to the other side of halfway in six months. And they're like, oh, six months? And I'm like, yeah, we're taking our time. We're not going fast. We're gonna make a dose adjustment every month. Maybe every two, depending on if there's a step that gets hard, we'll just hang there for a little bit. There's no race on this. It's a slow, slow taper. If you've been on it for years, the taper's gonna take a year, is sort of my rule of thumb. Others? I was just gonna take a pin out of another grenade and lob it out here. Do benzodiazepines cause dementia? No. No. Agreed. They absolutely cause short-term cognitive impairment from placebo-controlled studies. There were some papers, it'd be like 10 years ago, that suggested that yes, there was an association between long-term use and dementia, but I'd say more, I'd say the burden, the totality of evidence at this point suggests no. Benzos don't cause, contribute to risk of neurodegenerative dementia. Yes, because you stop, or taper and stop the benzodiazepine and dementia goes away, so it's like a B12 deficiency or something. A couple of things. One, part of the distortion in the dialogue nationally about this, there was a paper that if anything was stronger than the evidence that benzos cause dementia about how antidepressants cause dementia. There was a built-in control because one type did, supposedly one type didn't, got no publicity whatsoever. Nobody got worried about it, nobody got concerned. It just, it sank without a ripple. Do I believe that we shouldn't prescribe antidepressants because they cause dementia? Absolutely not, I don't believe that, but it just shows. But getting back to what Donovan said about withdrawal, I think one of the things that we haven't appreciated adequately as a field is the importance of context, the importance of the meaning of the withdrawal to people. And there are a couple of kinds of literature that are very important there, all from the psychology literature. Psychiatrists, unfortunately, don't think deeply about these things, at least not very often. One is, what does it take to form a concept about what's going on with yourself emotionally? There was this famous old Schachter and Singer study of comparing people who had been given something which was autonomically arousing. And half the group knew what they were getting and what it would do, the other half didn't know what they were getting, didn't know they were getting anything, completely out of the range of ethics of what would be allowed today. But it was interesting, and of course the people who didn't know had a completely different emotional response to it. The other literature, which is a very current literature, is the response expectancy literature. The name associated with that is Kirsch, Irving Kirsch. And he writes mostly about the placebo effect and how malleable people's responses are. And there are studies of antidepressants that show how people do on a medicine was much more related to what they thought they were getting than what they were actually getting. If you look carefully at the benzo withdrawal literature, you see the same thing. There's a subgroup of people who were reported who thought they had been tapered off their benzos. They actually were continuing to get their maintenance dose of benzos. And they reported subjective withdrawal effects based on what they were expecting. So that the psychology of this is enormously powerful. And whether people understand why they need to withdraw or they don't, whether they have a collaborative relationship or an adversarial relationship with the clinician, whether they feel stigmatized or they don't, I mean, what Ilse said is just wonderful. I mean, it's okay, we'll check again around the holidays. Think what that message is. It's not just, okay, we'll check again in three months. It's okay, you're okay, there's no emergency, it's cool, we'll deal with it. And those people get off. And so we have not paid enough attention to that. And certainly not in the literature. If you read the withdrawal literature, there are little things like this, like these minimal interventions, which are effective, but there's very little thoughtfulness about what's going on and why. So I'm gonna pick up on the psychology thread for a second here and actually, and reflect on the fact that many of the older benzochronic users that Donovan and I have seen in our practice over the years, many of them have never been offered a trial of cognitive behavioral therapy for their anxiety or their depression. So many of them have never been offered CBT-I for insomnia, right? In part, I think, because of the misbelief that older adults can't benefit from psychotherapy. Not true. And also because at the time they were started, as you discussed many moons ago, maybe we weren't providing that therapy in as abundance as we can today. So oftentimes, I have found great success in tapering chronic users from their benzodiazepine that they've been using for years for sleep by sending them to our cognitive behavioral therapy for insomnia course that VA has stood up and implemented. We send them to learn this skillset. We empower them to take control of their sleep or likewise, take control of their own anxiety with the skills that they learn through CBT. And then we slowly start tapering the benzo. And by the time the benzo gets to zero, they're doing fine because now they've got skills that they can use themselves to help control the symptoms that they've been controlling with this pill for decades sometimes. Absolutely. Yeah, no, I mean, CBT can be incredibly useful when tapering and getting people through psychologically and getting them prepared psychologically. Great stuff that you brought up. Completely forgot what I was gonna say. Sorry. I will, there's one response. So to Joe's comment about whether benzos cause dementia. Since I am talking to a room full of psychiatrists, I will say, no, I don't think benzos cause dementia. However, there really is pretty good and consistent evidence that anticholinergic medications do. And so your chronic long-term exposure to your benztropine, to your diphenhydramine, to your hydroxazine, for folks like in midlife who you're just refilling it and they're using it pretty religiously, that is something to think about and be careful about. I wanna get back to the issue of sleep a little bit because certainly one of the things that absolutely happens is that people get prescribed benzos for sleep and then just stay on them, often by primary care docs. Benzos are not very good sleep medicines. I'm not sure I've ever prescribed a benzodiazepine for sleep and they don't last very long. And some of them don't make you very sleepy. I mean, lorazepam, it's slowed across the brain barrier. It's not very lipophilic. And that's one of the major dimensions associated with how sleepy this stuff makes you. It's just not even a good sleeper acutely. But even the ones that are, they fade over time. There is tolerance to the sedating effects, although not to the anti-anxiety effects. That's another distinction that gets lost. However, benzodiazepines are a great sleeping medication if the reason you're not sleeping is that you have an anxiety disorder. Then they work, but they work because they're treating the anxiety, not because they're making you sleepy. But for people who present with insomnia, really the first thing anybody needs to do is to try to understand what's interfering with somebody's sleep and to rule out all secondary causes. And for the people that seem to just have this sort of essential insomnia, the CBTI, mostly what it's doing is getting people not to panic about their insomnia. People develop insomnia phobia, and that's what the CBTI addresses, and that's the biggest problem. So you really want to try to deal with whatever is keeping the person up at night. And if there's nothing identifiable, you want to try to help the person cope with this in the best way possible, including normalizing it when it's really their norm. But prescribing a benzo, it's just asking for trouble, especially when people don't understand. They think they have a disease called insomnia, and they need this medicine in order to keep the monster under control. Thank you. We're just throwing out random topics. I hope that's okay, Ron. Oh, absolutely, of course. One thing, a point that I remember that I made last year, and I always make this point with our residents, Zoe Lucher's in the audience. She'll probably tell me that I didn't make it with her group, but the benzodiazepines are not very good anti-worry drugs. Compared to the so-called antidepressants like SSRIs, benzodiazepines don't take away sort of apprehension, worry, concern about future things to nearly the extent that the antidepressants do. So you probably, let's see if any of you guys agree with this. My patients, if they're on a benzodiazepine, are very unlikely to forget it when they go on vacation. However, SSRIs are not this way. I see a lot of people nodding their heads. Because they're very good. They make you feel better in the short run. Well, that's true, but they stop worrying about their treatment. I think we're gonna now open up in a few moments. We're gonna open up in a few moments to question and answers because that's gonna generate a lot more discussion. We will be taking questions from the live stream audience as well. So we will alternate between questions from you here in the auditorium and people who are listening remotely. Please come to the microphone. And while there is an inevitable inclination to want to ask about a particularly problematic patient, I would ask you to try to generalize your questions, even if they are based on a particular scenario. And I want to raise, before we do, one question that may be of pragmatic significance. We are talking about this as one giant group of medications. There are approximately 25 benzos, about which at least 15 are available in this country. Different half-lives, several of them just renally excreted rather than hepatically metabolized. Should we be making some functional distinction between them when we choose them? Anyone want to go into that? In the elderly population, no. They're all the same. Bad. Okay. Got it. Now, I remember not being elderly. That's what I thought about when I was younger. But I think you raise a good point, which is that you've got your short half-life, long half-life, quick onset, slower onset. And clinically, that will change what we use and what may be our recommendations for which one to use, I think, probably for all of us. But in terms of the risk of harm, and in particular in vulnerable populations like the elderly, they are ubiquitously as a class. And as a pharmacologist, let me point out a compounding problem. As a person gets older, even if healthy, their hepatic metabolism across the board tends to slow down. If they've been on a stable dose of a medication that's dependent on hepatic metabolism for years, their serum level is going to start to go up. But you don't know when, because you really can't tell when each person's liver is going to start slowing down. It's a little bit different for the three that are renally excreted without being dependent on oxazepam, lorazepam, and temazepam. Outside the liver, O-T-L. Right. L-O-T. I was just going to say, it's interesting that, so Ed was talking about a sort of tolerance to the hypnotic effects of benzodiazepines, whereas people usually don't get tolerant to the anti-anxiety effect of the benzodiazepine. But you also see the half-life of an effect can be much shorter than the half-life of the drug. Like with diazepam, you have an anti-anxiety effect which goes away after a couple of hours sometimes, whereas the drug is in their body for about 30 years. Well, yeah, for some reason, everybody talks about pharmacokinetics, nobody talks about pharmacodynamics. And what Joe is talking about is pharmacodynamics, because diazepam is so lipophilic, it also doesn't hang around on the receptor for a long time, and it gets redistributed in the body within a few hours. And so patients report this, and of course, can you imagine all the docs know that the half-life is 48 hours, the patient says, gee, I don't, you know, I'm losing the effect after a few hours, the doc says, damn it, I know I shouldn't have prescribed this stuff, they're getting hooked already, and, you know, they're drug-seeking, and they're getting addicted to this stuff already. So you have to know, you can prescribe almost any of these 15 benzos, but you have to know what you're prescribing and what the characteristics are, because otherwise, confusion will reign with mischievous outcomes. And doesn't it seem that with Xanax, immediate release in particular, there is a rapid rebound effect of anxiety that seems to belie its pharmacokinetics? That's been my impression. For which one? Xanax, Alprazolam in particular, immediate release. Absolutely. So let's start to take questions. Sir? Well, thank you for putting this panel together. I'm Shubh Barman, I'm an addiction psychiatrist from Wisconsin. Just a brief comment about when you're talking about pejorative terms, I may add substance abuse is a pejorative term too. We prefer use of substance use disorders because it can have implications. I think the reason why we're having this panel, my impression is that I'm very glad you had the subtypes, because it's very important to have the subtypes of patients what you're talking about. I think the vast majority of people that we struggle with are the people with physiological benzodiazepine dependence, who do not have substance use disorders. It's almost like a similar trajectory to what happened with physiological opioid dependence, which is a distinct phenomenon from opioid use disorder. So I think we have to be very, very mindful of those factors. As far as my question is, specifically related to what is the evidence base about use of long-term benzodiazepines in treatment of psychiatric disorders? I don't think there's a lot. We're pretty much left on our own to figure out, treat your own patient, risk-benefit all the time. So I was just curious about that. And briefly may add CBT-I, excellent tool, but it's not available as easily as a prescription. There's barely any CBT-I trained clinicians out there. There used to be a CBT-I app, I know the VA has one, but there used to be another prescription app which I did prescribe, but that company become bankrupt. So sorry for the number of different things, but I'm curious about the long-term evidence base of use of benzodiazepines in the psychiatric problem. There's not as much as we would like, but there is actually a fair evidence base. There's maybe 15 studies or so of people who are followed for up to about three years on long-term benzodiazepines. There's only one double-blind controlled study, it was done by Antonio Nardi and his group in Brazil. And they were looking at, I think it was clonazepam versus maybe paroxetine over three years. But the point about that literature, the rest are naturalistic long-term follow-up studies. Carl Rickles and his group at Penn have done quite a lot of it. But the point about it is, there's no signal of a problem in any of those studies. They all find the same thing. Anybody who's looked has found the same thing. People do not tend to escalate their doses over time. The doses remain steady, they do not lose therapeutic effect, they do not get horrendous side effects. In a youngish, a non-geriatric population, you can demonstrate cognitive impairments like psychomotor slowing and processing speed. You can demonstrate coordination problems. In non-geriatric group, it's all laboratory level. The patients themselves are unaware of it, they don't feel impaired by it, they don't even notice it. None of these studies has found any problem. Unless you have substance use disorders, it's a whole different story. Yes and no. Your long-term paper of benzodiazepines do not work for patients with substance use disorders. We're going to go on to our next question, because we have many that we would like to bring to the table. So, Kathy, from the remote audience. Oh, you passed the microphone. So questions to the panel. So what does the panel suggest for those long-term users of benzodiazepines, especially Alprazolam? Sometimes they come to a new prescriber and they're already on Alprazolam 2 mg three times a day for years. And they expect us to continue prescribing the medication at such a high dosage. »» Yeah, that's rough. It's actually beyond the dose that I would use for an anxiety disorder. I think of roughly, and I know all people are different and we all have different physiology, different genetic factors that influence our metabolism of medications, et cetera, but I think of four milligrams total a day as kind of as high as I would go. So I'd be nervous if a person came in on two, three times a day. But one thing that comes up very often in regular practice is that some psychiatrists will just say, no, I don't prescribe benzodiazepines, you'll have to go elsewhere. And I think that's a problem. »» I agree. And I think the point I'll make to add on to this is, yeah, that would make me nervous. We see patients like this not infrequently that come to us as new patients in VA that have been started either in DOD or elsewhere on high dose benzos and come to us and they're looking to continue it. And our providers and myself personally would feel very nervous with that dose. But I would argue against the approach of, sorry, we can't give you any. Because that's not the right way to help create a relationship with this patient that is safe and beneficial around how to safely taper benzos. So I think it would, you know, trying to stop that dose on that day that you first meet them is probably not going to happen. But if you can start the education and the conversation and the dialogue with them about why I'm really nervous about this and why this makes me uncomfortable. And here are the things I want to have you go do. Here are the resources. I'm going to give you the CBTI coach, where did my previous questioner go? Thank you for the shout out to NCPTS, National Center for PTSD's app called CBTI Coach. Everyone go download it from the app store. It's free because the government made it for you. So anyone can use that. And it's helpful. I'd give them that. I'd give them access to, I'd give them a referral to a CBT therapist and clinic. I would start talking to them about what are your past med trials? Can we try an antidepressant? Have you ever had an antidepressant? Have you tolerated one? Let's talk about that. And here's my game plan for the next six months of how we're going to get you from six milligrams of alprazolam to maybe four over the next six months. And so we're not talking about stopping. It's about engaging in a conversation and trying to create that initial alliance with that patient around trying to reduce the harm. I think there's a lot of consternation out there about this, which I discovered when I testified against a very restrictive bill in Massachusetts about benzodiazepines. And there was a group of people there who were all benzodiazepine survivors. And they were talking about how benzodiazepines had ruined their lives. And here I was testifying in favor of them. I really thought I was going to get death threats, et cetera. What actually happened? I get referrals from that. And I think I get referrals because I said what Ilse just said. It's crazy to take people off cold turkey, to take people off arbitrarily. You have to work with this. That's the only thing I can imagine that I said that connected me with these people. And I've gotten people calling me from all over the United States saying I need help tapering off benzodiazepines. Isn't it also reasonable if you find yourself after that kind of initial interaction with a patient in that situation to create some space of time and say, look, these are all the reasons why. We don't have to start this today. We need a relationship. But this is our goal. But isn't it reasonable to say if, however, we have not really begun moving towards that goal in six months, it will be reasonable. I'm not sure that I can treat you because I can't give you a treatment that I don't think is the right treatment. You can't go and ask a surgeon for an appendectomy if you need a tonsillectomy. But if you say no right away, you drive them underground. Or into withdrawal. And from that dose, they'll be on the neurology service there. Okay. Please. Thank you so much for this wonderful panel. I am a private practitioner in suburban Philadelphia. And I see a significant number of people who have primary anxiety disorders, sometimes comorbid with mood disorders. And I'm talking about all age groups. The younger as well as people who are closer to geriatrics. I see a significant percentage of people who are with anxiety disorder using medical marijuana and even alcohol. They are not primary substance abusers I'm talking about. I'm talking about people who have legitimate anxiety disorders and generally cooperative. In that scenario, I have sometimes used benzodiazepines with the comparative analysis of using long-term medical marijuana versus using PRN benzodiazepines. Many of the patients have successfully been able to taper off the marijuana and also even taper off the alcohol. So this is a complex question, but I wanted some of the thoughts of our leaders here. Thank you for bringing that up. So you know, medical marijuana, it's kind of an oxymoron in that marijuana has not really been studied for much of anything. We had an expert from our substance use disorder group come give us a talk about marijuana because medical marijuana was coming to Maryland and now we're getting just legalized marijuana. But you know, the companies that sell it, you know, they're not FDA regulated or anything. And I bet you all of us in this room have seen at least one patient who's developed a panic disorder as a result of the first use of marijuana, period. And marijuana can have all kinds of horrible side effects. And alcohol is a very effective anxiolytic, short-term anxiolytic, and long-term it's quite anxiogenic. But yeah, I mean, we see many patients, and I think the longitudinal research and the longitudinal family research really shows that one route to alcoholism is having an anxiety disorder that's not otherwise treated, even including social anxiety disorder, you know. Alcohol definitely reduces social anxiety quite substantially. So I think, you know, if you're following a patient who has been drinking too much, who's been smoking too much marijuana, and you're able to get them a benzodiazepine, especially that they could take as they really need it, and use other treatments, psychotherapy, antidepressants, et cetera, I think that that's a win. Apropos of that point about panic attacks and marijuana, John Klein used to say that the second most potent elicitor of panic attack after carbon dioxide and inhalation is marijuana. And when you hear people say, I got paranoid of marijuana, my strong suspicion is you're seeing a simultaneous acute episode of panic attack and social anxiety disorder. And when you have social anxiety disorder fueled by the magnitude of panic attack, it feels nearly delusional. That's my clinical impression. So question from the remote audience. Any update on the association of benzodiazepine exposure pre-surgery and the risk of delirium? Delirium. Oh, yeah. I mean, I think one thing that happens post-op is that if you don't know what the medications and other substances that somebody was imbibing before they have an operation, you can run into all kinds of trouble. I mean, certainly DTs is a risk, but you can also have a quite uncomfortable, even if the person's not seizing, and prolonged, miserable time coming off of benzodiazepine if you don't know that the patient was on it prior to surgery. And Kathy could probably answer that question, too, as a CL psychiatrist of many years. You think that was okay, what I said? I think that's fine. I think that's very true. Sir? So if I'm not supposed to give benzos to substance abusers, and you consider marijuana users substance abusers, I'm not supposed to give it to people who risk becoming old, well, there's nobody left. Yay, we win. Just kidding. If I fight against chronic benzos, well, then when you say that the studies, the long-term studies of people who take chronic benzos, they don't seem that bad. So I don't know, why are we so intent on not giving them? I'm sorry, I didn't hear every word you said. The studies for long-term use of benzos don't show anything particularly horrible. I think he's basically saying, what's all the fuss? What's all the fuss? That's it. I think all of us have a patient who's getting older and is still on the same dose they were on when they were 30, and develop problems. But yeah, I wouldn't assume. Also, back to that question about long-term studies, we really don't have great long-term studies of any of our patients, if you're talking about decades. You also said something about substance abuse. Of course, I wouldn't prescribe any of these things to, I wouldn't prescribe psychotropics to an active substance abuser most of the time, but everybody assumes that people with a history, a past history of substance abuse are at high risk for getting into trouble on benzodiazepines. The literature base does not indicate that. I would call your attention to a, I think, 2001 review in the American Journal on Addictions by Posternack and Mueller, and they reviewed such evidence as there is, and it was another one of those things of no signal. There was no indication either that people with a past history of substance abuse tended more to abuse or misuse the benzos, nor that the use of benzos stirred up addictive behaviors. My favorite story about that is a patient of mine who was an ex-heroin abuser, and I could never get her to take as much benzodiazepine as I was prescribing. She'd take the half a milligram of lorazepam and cut it up into four pieces, and take one of the four pieces. I'd say, you know, I don't think this is doing you any good. Why don't you take more? I don't want to get hooked. So one other thing that we have not brought up yet, and I think ... There's an AV person sitting at a desk right outside that door. Would someone grab them? God is punishing us for saying that. Oh, my goodness. Oh, we got them. On a Sunday. Okay. On a Sunday. Okay. I wanted to ... One thing that has not been mentioned yet, a population that we have not talked about risk of harm for. This is a population that we have not talked about risk of harm for. a use of benzos with is our patients with post-traumatic stress disorder. There's convincing evidence that use of benzos as a treatment for PTSD causes more harms than benefits. And so I wanted to make sure that that got put out into the room and that we all sat with that for a second since we were thinking about the folks that we probably wanna avoid using benzodiazepines as a population. I would just add, I don't know if this is what you were talking about, Ilse, but if you're trying to prevent PTSD in people who've just been traumatized, giving a therapeutic dose of a benzodiazepine will make it much more likely that the person will have long-term PTSD. That's been shown with very small studies, but they were consistent and the effects were so large that they were able to stop. They stopped doing other studies on it. That said, all treatment should be individualized. I have a patient who was a cop who was at ground zero at the Boston Marathon bombing and got PTSD. And I tried to prescribe everything in the world except the benzodiazepine. I tried antidepressants. I tried prososin. He either wasn't helped or couldn't tolerate anything. And the only thing that's really helped him is some diazepam. So I was a very reluctant prescriber of it, but there are such people. So everybody, to some degree, may be his own case. So the only thing that I will add to that is sometimes I think clinicians can sort of take that as a license to provide treatment that is contrary to what well-conducted studies tell us. There are the, in fact, harms of treatments that we're using. So just a note of caution around the like, N of one of my patient in front of me, I can do this thing, even though there are lots of studies out there that actually say in the big picture way, this is a harmful treatment for that person. So just a note of caution. Can the quote, rabbit's foot, pill in the pocket that you all referred to earlier, interfere with CBT? Yes. That's a very short answer to that question. But no, I mean, I think it has to be addressed. The cognition, which is not probably held so much by the cerebrum as it is held by the deep brain, the limbic system. So it has to be sort of, unlearned is not the right word, but new learning has to occur that overwhelms that belief. Because I just think people are sort of stuck there. They're chained to that rabbit's foot. Can you clarify what you think that, what the mechanism of that is, in the sense of why, if they are engaging in CBT, why would it not work if they have the rabbit's foot? Oh, well, if they believe that the rabbit's foot is the thing that is helping them, as opposed to the CBT, if they don't buy into the CBT model and how it's gonna work, et cetera, but they say, well, this is only working because I have this external, quite expired pill bottle. Not to quibble with that, but I do have a fire extinguisher in the kitchen. I also do not engage in practices that would promote a fire. Are they really mutually exclusive? Do you have? No, I think we're talking about the patient's belief here. If they believe that the rabbit's foot is what's keeping them from being, as opposed to thinking as a panic button. The classic rabbit's foot is non-pharmacologic. It's the presence of a trusted person. Say for people with panic attacks, I can't go to the store without my husband, and it's very much the same mechanism. Yeah, it's so funny how often people with agoraphobia, they'll be comfortable even if their two-year-old is with them. It's completely illogical, but it's not the cerebrum we're talking about. It's the limbic system. Very patient person in the pink shirt. Thank you, and thank you for such an interesting, thought-provoking panel. I'm a general psychiatrist from New Zealand. I entirely endorse the statement around psychiatrists taking the lead in this field. This is more of a comment than a question, but I really just wanted to come out in support of our colleagues in primary practice, who do write the majority of prescriptions for the third group of patients that you were talking about. But I think as psychiatrists, it's beholden on us to provide our primary practice colleagues with the support that they need. They're isolated, and they're often very scared to prescribe benzos. If at all, in my country, they'll do them in very, very small doses, preferentially out of fear, I suspect. They'll write homeopathic prescriptions for more often than not, SSRI medications. Go away, take that one for the rest of your life. You'll be fine, at least you won't become benzo addicted. But to my mind, more worryingly, will be the prescriptions for the atypical antipsychotics, specifically quetiapine, which is now the most commonly prescribed medication in New Zealand, usually for its purported anxiolytic sedative quality. And I think now we're looking at just an enormous wave of potential problems that come in small apart from excessive daytime sedation. But more specifically, the huge wave of the atrogenic metabolic disaster that's coming from quetiapine over prescription coming from fear of benzodiazepine prescription. So I just wanna really put a plug out to support our colleagues in primary practice. Access to psychotherapy, at least in New Zealand, is negligible, it's inaccessible, it's unaffordable. They have minuscule time in a 15 minute, seven minute, three minute consultation to do any skill provision themselves. If they're gonna do something, it's gonna be written on a bit of paper and handed over. I think it's something of a tragedy that the majority of that is something with far more adverse health implication than a benzodiazepine prescription if it's prudently prescribed. I agree 100%. I think, I worry about the use of the atypical antipsychotics for insomnia. And for a while there, our residents at Hopkins used to hand out the atypical antipsychotics like candy. Like, oh, these can't harm you, but we're not gonna give you that Ativan stuff because that will kill you. Um. Kathy? Can you speak about the use of benzodiazepines in bipolar disorder? That's an important question. And that is a place where I do think about the atypical antipsychotics. Because patients, particularly with bipolar, one disorder, I don't know about you guys, but I'm nervous about giving them an antidepressant dose of an antidepressant. Even if they're on Depakote, which could have some anxiolytic effect in the right patient. Like, with a mixed state with a lot of anxiety. So, but yeah, I do think of drugs like quetiapine as well for patients like that. Because I'm not, I don't want to give them sertraline and have them cycle and, you know, maybe commit suicide. And I think it makes a big difference whether you're talking about acutely or for maintenance. Acutely, if you have an acute, psychotic, agitated person with mania, triple therapy. A mood stabilizer, a neuroleptic, and a benzodiazepine. Long term, boy do I try hard to keep it to a mood stabilizer. And nothing else if I possibly can. So, this actually gets me to a fourth group of people prescribed benzos who are people with other non-anxiety psychiatric conditions who get prescribed a benzo as an adjunctive add-on treatment to whatever the other primary pharmacotherapy is. And that is done by us, by psychiatrists. And so, we're really limited because the evidence here, none of these are really from high quality controlled studies, so it's all observational studies. But pretty much when you look across the board whether it's a benzo add-on in somebody with schizophrenia, in bipolar disorder, in depression, in dementia, the outcome of the group that has the benzo add-on is never better. And even by chance, occasionally, you would think the benzo group would do better. They never do better. And you could say, well, it's because those are sicker patients, the patients who are getting benzos who are sicker. So, there's the paper specifically with schizophrenia that I think is well done. And Mark Olfson was the first author, I think Olfson was the first author, where they basically looked at patients with schizophrenia who were on an antipsychotic, and then they looked at different add-on medications. So, if it was another antipsychotic, it was a mood stabilizer, it was an antidepressant, or it was a benzo, and they looked at time to hospitalization, psychiatric hospitalization, or emergency department visit, and the people who were on an antipsychotic plus a benzo were the worst. They were the first people to get hospitalized again, the first people to end up in the ED. And you can't say that a person on an antipsychotic plus a benzo is, they're probably not that much clinically sicker than the person who's on two antipsychotics, but the benzo add-on group in all of these observational studies always does worse. But just a moment, a bit of skepticism, that schizophrenia, is there parallel data that controls the presence of anxiety in mood disorders? Roger McIntyre was speaking about treatment resistance depression this morning and made the point, the presence of anxiety is an indicator of lower probability of response to an SSRI altogether. Yeah, it's true. And I would, do we know if we have that data outside of schizophrenia? I would have to look it up. I think, you know, just agitated depression, we all see this, you know, somebody who's never been anxious in their lives, in their 40s, they suddenly look like they have horrible GAD, and then you ask them about their self-attitude and it's in the tank, and you realize, yeah, this person is in their first major depressive episode, they will get better, usually, with an antidepressant, but they can have horrible anxiety, and should we be using benzodiazepines? Often, they don't want to, so. But I would consider at least a low dose to try to take the edge off, just because you see that their suffering is so acute. Dr. McIntyre also made the point this morning with our mood disorder patients, who do not fully respond to treatment, one should at least think of addressing symptoms specifically where we can, anxiety being a particularly prominent one, so that might be an area, and of course, there is pretty good data supporting the efficacy of benzos in treating anxious depression subset. It may be a unique group, one of the groups where we need to be a little bit more open, even though we need all the same caveats in place about protecting the patient. By the way, Donovan, this might be a good point to mention, the website, that we haven't posted the link yet, but with your permission, we'll post the link to the session about benzotapergitis. Yeah, so just as part of a project, we developed a website meant to be sort of clinician-facing, really more primary care clinician-facing, as kind of a one-stop shop for resources that are out there, publicly available resources, around education for benzos, alternatives for insomnia, for anxiety, but the thing I think is the coolest is we have a taper calculator, so the website is, it's www.benzobasics.com, and with the taper calculator, you can select the dose, the benzo a person is on, the dose that they're on, and then there's not really any good sort of trial data around what a benzotaper should look like, with the Ashton Manual and this Empower Intervention, using it on that, we essentially have a, it will calculate a taper schedule for you with the steps, you know, by such a percent, each step of the taper, the smallest step of the taper is limited to half of a pill, of whatever the smallest pill available for a given benzo is, and then you can change the dates and the length of the taper, and you can copy, paste it into your chart, into your note, so anyways, www.benzobasics.com, I would be delighted if anyone would use it, meant to be useful. We'll post a link eventually in the app associated with this session. Next question, please. Hello, thank you again, my name is Chandan, I'm a Consultation Liaison Psychiatrist in Dallas, Texas, and I just wanted to ask about a topic that hasn't been discussed yet, which is just disparities in benzo prescriptions, so just numerous studies show that white people are prescribed benzos at far higher rates than black and brown people, and women more than men, and I was wondering if you had any insights into why? I definitely see this in Baltimore, that is, with probably not just benzodiazepines, but also opiates, that black people, for whatever reason, are assumed to be at high risk of addiction. Yeah, we have a horrible addiction problem in Baltimore, but it affects all of us. And that's, it's absolutely true, and it's one of those cases where it's almost certain that racism is at play there. And potentially the outcome of the racism is some people are potentially being exposed to less of a bad thing, so it's hard to tease apart what's going on there, but then there's also a problem of, again, the subset of the population who really do need this medication, and they're not getting it because of racism. So it's very much there, it's definitely not been looked at as much in benzos as it has been in opioids, but it's absolutely true that minoritized populations are less likely to get these medications. And it goes a step back from that, too, to diagnosis. We know that in this country, African Americans are more likely to get misdiagnosed as having a primary psychotic disorder, and this impacts our diagnosis of anxiety disorders because a lot of people with social anxiety disorder are misdiagnosed as being paranoid because the nuances of the thinking are not explored. And I can remember treating such a guy who was African American who had been treated as having schizophrenia for years, and he didn't have schizophrenia at all. He had an anxiety disorder, and it was not easy to convince even him at that point that this was the case. This is another example of the huge impact that cultural context has on how we use many medications, I think, and we're not going to start on Adderall, and although we're not reviewing it today, last year when we had the debate, we started with a slideshow on the history of anxiety and the social context and implications for treatment in this country going back over 100 years. Oh, question from the remote audience, please. Can the panel summarize what we know about absolute harms associated with long-term benzodiazepine use and address all-cause mortality, falls risk, cognitive impairments, possible exacerbation of depression, and additive respiratory depression? Do we have clear relative risk numbers at the population level? Well, standing on one foot, please. I don't. Do you want to talk about the benzo overdose? Off the top of my head, no, I cannot answer all those things. I think in general, I think it's unlikely that there's much of a contribution to, say, all-cause mortality. There is absolutely increased risk of overdose when people are co-prescribed opioids. I don't remember the relative magnitude of that. For fall-related injury, the odds ratio with exposure to a benzo compared to not is about 1.6, so about 50% higher odds of fall-related injury in older adults. Similar risk, actually, for motor vehicle accidents. That's something people don't really think about. It's actually also around 60% increased. It's actually that effect is attenuated in older adults. That's a risk that's higher in the population under 65. They've done, like, simulator studies, and it seems like people don't maintain their lane position when they're exposed to a benzo, and that's about the extent of numbers off the top of my head. And from a slide deck that I just pulled up on my phone, about one-half of the deaths involving opioid analgesics, in about one-half of the deaths involving opioid analgesics, more than one type of drug was specified as contributing to the death. Benzos, as a class, are most commonly involved, 30%. Okay, and then in VA data, and this is a study that was published in 2015 by PARC, 50% of opioid overdose deaths are on concurrent benzos. Among opioid users, the risk of death goes up as the benzo dose goes up. So there's a dose response to the overdose death risk when you're co-prescribing benzos and opioids, hence the harm reduction. All the harms. Yeah. All the harms. Yeah. It's a dose response, so hence the harm reduction. That could be a good APA topic in itself, concomitant use of opioids and benzos. And keep in mind that sometimes the opioid prescriber is separate from the benzos. Correct. Oh, there's statistics about that. Something like, I don't know, 20% or maybe more have gotten two drugs from different prescribers. Yep. We have time yet for a couple more questions. Before we do, I want to emphasize one major take-home point from the panel today. It's our fear of talking with patients about deprescribing that inhibits deprescribing and also inhibits prescribing because we don't want to get there. So a lot of, I think, what we have to do in addressing our patients' anxiety is first address our anxiety. And the best way to do that is to educate yourselves and ourselves with this information. And we know that one of the ways in which people learn medical information most frequently is from our colleagues. Not always the best idea, but please take this message home to your colleagues as well. Yes. So I work at a teaching hospital in New York City. And one of the things I've observed among the residents and younger psychiatrists is they really try their very best to avoid benzodiazepines altogether now that there's this pervasive negative tide of sentiment toward the class of drugs. And so what they do instead, you know, many anxious patients can't tolerate antidepressants. They find them overly stimulating or activating is they've switched to gabapentin and hydroxazine, drugs which are arguably less efficacious, inferior. And so I asked the panel, is that a good thing, that now we're, rather than using benzodiazepines, we've switched to hydroxazine and gabapentin? Staying away from the Seroquel, but now getting people the gabapentin toxicity. I mean, you know, gabapentin can be wonderful medication for the right person at the right dose, but it can also have quite substantial toxicity. And don't forget the anticholinergic stuff. I mean, it's probably worse with diphenhydramine than it is with hydroxazine, but. There's a literature on what happened in New York State when they put in this thing about triplicate prescriptions for benzodiazepines, and it's exactly what you described. Benzodiazepine prescription went way down and prescription of other things like neuroleptics, barbiturates even, all kinds of things that you wouldn't like went way up. So, you know, be careful what you wish for. I would suggest also, teaching residents in New York City, I would also suggest to not skip potential trials of gabapentin. The probability of efficacy is probably not high, but for a number of patients, boy, it hits the mark very well, and for many people who have other substance craving, or for some people who have other substance craving, it will help diminish that substance craving. So it's, and they work fairly quickly when they do, so it is, it's worth a trial if you think appropriate as an alternative. And it can help with neuropathic pain, too. And can help with neuropathic pain, and pregabalin should not be forgotten in this regard. But also, I'm a little, I use a lot of quetiapine as well, but a bit leery about the negative effects of all the weight gain, which turn back on our brains as well, ultimately. Remote question, please. Given the issue of time, I'm gonna ask, what's the best written resource on benzodiazepine prescribing, and especially deprescribing, for the general psychiatrist? Benzobasics.com. Boom, boom, you beat me to it. Check it out, it's great. Yeah, but also, if folks don't know, there's this thing called the Ashton Manual. It's kind of, maybe a little bit old school, the headshot, she's no longer with us, the headshot on her website is amazing. If you just Google the Ashton Manual, it's really, she basically ran a benzo detox clinic in the United Kingdom. It's very accessibly written about the mechanism of action of benzos, goes through a whole bunch of different taper scenarios and examples, so I think that's a great place. And also, the VA has a fantastic academic detailing services as taxpayers. All of those resources are available for free. Some of those are on benzobasics.com, but you can also just Google VA academic detailing and find their information there. The half-life of this panel discussion can go on forever, but we are going to have to use a benzo antagonist in order to say, call it an end. I want to thank our wonderful panel who've graced us with their presence again this year. Thank you for an excellent presentation.

benzodiazepines

clinical practice

Dr. Ron Winchell

Dr. Kathy Crone

cognitive impairment

dependency

panic disorder

catatonia

withdrawal

tapering

anxiety disorders

polysubstance use

prescribing practices