It is often the case that artists are in the vanguard of exposing societal problems. In 1966, the Rolling Stones issued the first clarion call about casual use of Valium® (diazepam) in “Mother's Little Helper.” Decades later, rappers, such as Eminem, Lil' Xan, Kendrick Lamar, and Drake, have continued to warn us about the dangers of benzodiazepines (BZDs).
The current BZD crisis is coming fast on the heels of the opioid crisis, with which we have struggled for years. The general public and health care community are now beginning to realize this problem. However, providers continue to prescribe these potentially dangerous drugs liberally and improperly, despite practice guidelines that discourage this practice (Olfson, King, & Schoenbaum, 2015).
Drug fatality rates rise when BZDs are used to enhance the euphoric effects of opioids (Jones & McAninch, 2015). There is synergism between these two respiratory depressants (National Institute on Drug Abuse, 2018), which has been implicated in the drug-related mortality increase seen by emergency departments in the United States (Gomes, Mamdani, Dhalla, Paterson, & Juurlink, 2011). As with opioids, BZDs are addictive (Lader & Kyriacou, 2016). Withdrawal symptoms can occur following abrupt cessation of the drug after only 3 to 4 weeks of regular use (Brett & Murnion, 2015). The American Psychiatric Association (2009) cautions that “significant numbers [of individuals] (ranging from 33% to 100%) are unable to complete a taper of the medication after 6 weeks to 22 months of treatment” (pp. 58–59).
Many patients, often older women, have been prescribed BZDs for the treatment of anxiety, insomnia, or both (Kalapatapu & Sullivan, 2010). Often, there is no single provider overseeing the care of these patients, and old prescriptions get renewed long after the original need has been forgotten. Feeding this dysfunctional pattern is the provider's idea that older adults are too old to learn nonpharmacological techniques to manage anxiety. This provider attitude is disrespectful and just plain wrong. Older adult patients can be taught the dangers of chronic BZD use as well as evidence-based anxiety and insomnia management techniques (Klainin-Yobas, Oo, Suzanne Pey, Yew, & Lau, 2015). Older adults who use BZDs have the most to lose in terms of poly-pharmaceutical drug interactions; predisposition to falls, confusion, dizziness, and memory loss; and susceptibility to dementia (Maust, Kales, Wiechers, Blow, & Olfson, 2016).
What You Will Learn in this Issue
In this special issue of the Journal of Psychosocial Nursing and Mental Health Services, nurses and other professionals have written about judicious use and deprescribing of BZDs to outpatients and inpatients.
Pharmacist Travis Suss and medical anthropologist Michael Oldani (2019) describe a multi-disciplinary home-based program that gently nudges older adults toward tapering BZD medications. A team of professionals assumes intersecting roles in helping a vulnerable population manage grief, anxiety, and insomnia without BZDs.
Psychiatric nurse practitioner Alan Amberg (2019) offers a view of anxiety as something unavoidable, and even necessary in human life. He helps his patients accept and cope with anxiety, rather than trying to obliterate it with BZDs.
The article by nursing professor Kathleen Delaney (2019) is a call to action to inpatient psychiatric staff nurses in decreasing pro re nata (PRN) administration of BZDs for anxiety and behavior management. Nurses are in control of PRN medications and are advised to use them cautiously. Delaney comments on how this drug problem is being addressed by nurses in other countries.
My own article, with coauthors Teresa Savage and Nimmi Rajagopal (2019), describes a successful intervention with providers in a community clinic to encourage deprescribing of BZDs for outpatient anxiety and insomnia. A follow-up commentary by marketing professor Angela Lee (2019) opines about why these providers changed their prescribing behavior.
Nurses Lead the Way
The nursing profession is the most trusted in the United States (Brenan, 2018). We must honor this trust by being truthful and helpful to our patients. Inpatient and outpatient staff nurses as well as advanced practice RNs must take the lead in educating patients and colleagues about the extraordinary risks posed by BZDs. We must remember the ethical principle of nonmaleficence (do no harm) as we prescribe and administer treatments for anxiety. Our patients depend on us to do the right thing, even if they sometimes object to our decisions. We must continue to be the profession that can always be trusted.
Lois M. Platt, DNP, APRN, LCPC
Rush University College of Nursing
- Amberg, A. (2020). Making alliances with patients dependent on benzodiazepines: A provider's experience. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 29–32. doi:10.3928/02793695-20191218-06 [CrossRef]
- American Psychiatric Association (2009). Practice guideline for the treatment of patients with panic disorder. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
- Brenan, M. (2018, December20). Nurses again outpace other professions for honesty, ethics. Retrieved from https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx
- Brett, J. & Murnion, B. (2015). Management of benzodiazepine misuse and dependence. Australian Prescriber, 38(5), 152–155. https://doi.org/10.18773/austprescr.2015.055 PMID: doi:10.18773/austprescr.2015.055 [CrossRef]26648651
- Delaney, K. R. (2020). Let's talk about benzodiazepine use: Inpatient psychiatric nurses initiating the conversation. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 33–38. doi:10.3928/02793695-20191218-07 [CrossRef]
- Gomes, T., Mamdani, M. M., Dhalla, I. A., Paterson, J. M. & Juurlink, D. N. (2011). Opioid dose and drug-related mortality in patients with nonmalignant pain. Archives of Internal Medicine, 171(7), 686–691. https://doi.org/10.1001/archinternmed.2011.117 PMID: doi:10.1001/archinternmed.2011.117 [CrossRef]21482846
- Jones, C. M. & McAninch, J. K. (2015). Emergency department visits and overdose deaths from combined use of opioids and benzodiaze-pines. American Journal of Preventive Medicine, 49(4), 493–501. https://doi.org/10.1016/j.amepre.2015.03.040 PMID: doi:10.1016/j.amepre.2015.03.040 [CrossRef]26143953
- Kalapatapu, R. K. & Sullivan, M. A. (2010). Prescription use disorders in older adults. The American Journal on Addictions, 19(6), 515–522. https://doi.org/10.1111/j.1521-0391.2010.00080.x PMID: doi:10.1111/j.1521-0391.2010.00080.x [CrossRef]20958847
- Klainin-Yobas, P., Oo, W. N., Suzanne Yew, P. Y. & Lau, Y. (2015). Effects of relaxation interventions on depression and anxiety among older adults: A systematic review. Aging & Mental Health, 19(12), 1043–1055. https://doi.org/10.1080/13607863.2014.997191 PMID: doi:10.1080/13607863.2014.997191 [CrossRef]25574576
- Lader, M. & Kyriacou, A. (2016). Withdrawing benzodiazepines in patients with anxiety disorders. Current Psychiatry Reports, 18(1), 8. https://doi.org/10.1007/s11920-015-0642-5 PMID: doi:10.1007/s11920-015-0642-5 [CrossRef]26733324
- Lee, A. Y. (2020). Psychological insights underlying decreased benzodiazepine prescribing. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 50–51. doi:10.3928/02793695-20191218-09 [CrossRef]
- Maust, D. T., Kales, H. C., Wiechers, I. R., Blow, F. C. & Olfson, M. (2016). No end in sight: Benzodiazepine use in older adults in the United States. Journal of the American Geriatrics Society, 64(12), 2546–2553. https://doi.org/10.1111/jgs.14379 PMID: doi:10.1111/jgs.14379 [CrossRef]27879984
- National Institute on Drug Abuse. (2018). Benzodiazepines and opioids: Overdose death rates. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids
- Olfson, M., King, M. & Schoenbaum, M. (2015). Benzodiazepine use in the United States. Journal of the American Medical Association Psychiatry, 72(2), 136–142. https://doi.org/10.1001/jamapsychiatry.2014.1763 PMID:25517224
- Platt, L., Savage, T. A. & Rajagopal, N. (2020). An intervention to decrease benzodiazepine prescribing by providers in an urban clinic. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 39–45. doi:10.3928/02793695-20191218-08 [CrossRef]
- The Rolling Stones. (1966). Mother's little helper. On Aftermath [album]. Hollywood, CA: RCA.
- Suss, T. & Oldani, M. (2020). Little helpers no more: A framework for collaborative deprescribing of benzodiazepines in older adults. Journal of Psychosocial Nursing and Mental Health Services, 58(1), 23–28. doi:10.3928/02793695-20191218-05 [CrossRef]