Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Making Alliances With Patients Dependent on Benzodiazepines: A Provider's Experience

Alan Amberg, MSN, APRN, PMHNP-BC

Abstract

Tens of millions of benzodiazepine (BZD) prescriptions are written annually for the outpatient management of anxiety disorders and insomnia. Many prescribers do not follow published treatment guidelines for these disorders. Psychiatric–mental health nurse practitioners (PMHNPs) regularly meet patients who have been treated with BZDs for years. The dangers posed by outpatient BZD use are recognized, especially among older adults, and their use should be minimized or eliminated. There are multiple manualized approaches to outpatient down-titration of BZDs, but little evidence about which methods really work. To effect change, it is essential that PMHNPs establish a sound therapeutic alliance with these patients, especially by using their skills in therapeutic communication. One major conflict that may occur early in the relationship is the patient's expectation that the BZD medication regimen will continue indefinitely and their unwillingness to risk discontinuing the drug. This conflict commonly raises nonadherence to a down-titration plan or patient termination of the relationship. It is essential that PMHNPs take the time and patience to build strong therapeutic alliances with patients to design and implement a successful BZD discontinuation regimen. [Journal of Psychosocial Nursing and Mental Health Services, 58(1), 29–32.]

Abstract

Tens of millions of benzodiazepine (BZD) prescriptions are written annually for the outpatient management of anxiety disorders and insomnia. Many prescribers do not follow published treatment guidelines for these disorders. Psychiatric–mental health nurse practitioners (PMHNPs) regularly meet patients who have been treated with BZDs for years. The dangers posed by outpatient BZD use are recognized, especially among older adults, and their use should be minimized or eliminated. There are multiple manualized approaches to outpatient down-titration of BZDs, but little evidence about which methods really work. To effect change, it is essential that PMHNPs establish a sound therapeutic alliance with these patients, especially by using their skills in therapeutic communication. One major conflict that may occur early in the relationship is the patient's expectation that the BZD medication regimen will continue indefinitely and their unwillingness to risk discontinuing the drug. This conflict commonly raises nonadherence to a down-titration plan or patient termination of the relationship. It is essential that PMHNPs take the time and patience to build strong therapeutic alliances with patients to design and implement a successful BZD discontinuation regimen. [Journal of Psychosocial Nursing and Mental Health Services, 58(1), 29–32.]

Psychiatric–mental health nurse practitioners (PMHNPs) often inherit patients who were started on benzodiazepine (BZD) medications and then poorly monitored, without a discontinuation plan. Long after treatment with the drug has failed, patients may continue to believe that the medication helps, despite evidence to the contrary. The very action of opening a bottle and taking a pill has a placebo effect. Patients may believe that no other change on their part is required and they never need to feel anxious, as long as they have BZDs. The problem is that BZDs never address the root problem.

Patients criticize PMHNPs for reversing the work of other prescribers, questioning why they should trust our solutions. Often, patients cannot discontinue BZD use without strong withdrawal symptoms. They may also endure replacement antidepressant agents prescribed may take weeks to work, if at all. Thus, it is hard to convince patients to discontinue their use.

Despite manualized approaches and suggested regimens for BZD deprescribing (Ashton, 2002; National Institute for Health and Care Excellence [NICE], 2015; Pottie et al., 2018; World Health Organization, 2009), a 2018 Cochrane review of pharmacotherapy for outpatient BZD tapering showed no definitive method (Baandrup et al., 2018). The conclusion of the review, which included 35 studies and 18 different replacement agents, was that most of the studies were of low quality (Baandrup et al., 2018). In the 2015 Cochrane companion review on psychosocial interventions, there was low-quality evidence for combined cognitive-behavioral therapy (CBT) and gradual dose reduction (Darker, Sweeney, Barry, Farrell, & Donnelly-Swift, 2015). Currently, there appears to be no clear method to assist patients in forgoing BZDs in favor of safer treatments for their anxiety.

The Therapeutic Relationship

Without realizing it, patients ask PMHNPs to medicate anxiety and the environment. PMHNPs work to make patients feel safe when they expose their fears. PMHNPs also bolster their strengths and help them envision a life with anxiety that is normal, tolerable, and useful.

Psychiatric–mental health advanced practice nursing is well-equipped with a triple foundation in nursing, psychotherapy, and pharmacotherapy to provide key elements to treat BZD dependency: a therapeutic nurse–patient relationship, which is essential to patients' understanding of information and engaging in treatment.

Who Can They Trust?

Anxiety terrifies patients dependent on BZDs. They view it as intolerable and do everything to avoid it. For years, these patients have believed that BZDs were their most reliable “friends.” Before patients can be engaged in a reasoned conversation about safer treatment, they must understand their unreasonable behavior. Because to patients, what they are doing is reasonable.

What Can Be Done About Anxiety?

Anxiety is part of human life. What would our patients' lives look like with adaptive and tolerable anxiety?

When patients look dispassionately at anxiety, it is often a revelation. They are surprised that anxiety is not an intolerable or unacceptable response to the unknown, but rather a normal one. Patients are often surprised that mild-to-moderate anxiety is an asset in many situations, such as the first day on a job or when saying “I do” (i.e., getting married).

Our ancestors simultaneously relied on anxiety to warn them about danger and also attempted to contain it. Societal anxiolytics were culture, faith, and family structures. Ancient anxiolytics included drugs such as alcohol and behaviors such as meditation. These ancient (yet still current) methods helped soothe the anxious. Societal structures taught resilience.

In our lifetime, we have experienced a cataclysmic upending of social structures (e.g., loss of extended family, no longer living in the same place for generations), which soothed anxiety by giving life security and predictability. Alongside this decline of support (i.e., predictable family roles, shared place, and shared beliefs), patients are hammered by the 24-hour news cycle that presents all that is aberrant and horrifying in the world. The news rarely covers the well and happy, and as a result, patients are pumped full of anxiety. In everyday life, it becomes hard to distinguish the imminent threat from that which is unlikely. Anxiety is one of the most common psychiatric disorders and is often comorbid with depression, posttraumatic stress disorder (PTSD) (Lamoureux-Lamarche, Vasiliadis, Préville, & Berbiche, 2016), and other psychiatric conditions, such as obsessive-compulsive disorder (OCD) and insomnia (Dell'Osso et al., 2015). Accompanying the focus of the media on disaster is the omnipresent pharmaceutical marketing message that anxiety is resolved easily by consuming a pill (Quinones, 2015).

Treatment

When Are Benzodiazepines Appropriate?

Dell'Osso et al. (2015) performed a meta-analysis comparing guidelines for BZD use from the British Association of Psychopharmacology, NICE, American Psychiatric Association (APA), and World Federation of Societies of Biological Psychiatry. Most of these bodies recommend caution and vigilance in prescribing BZDs, advocating only short-term and/or “last resort” use. However, the APA permits maintenance on alprazolam for panic disorder (Stein et al., 2010).

Patients may become angry at the suggestion that they have been incorrectly treated by their past providers. This scenario presents a teachable moment to discuss changes in international guidelines. Patients need information about the extreme caution PMHNPs are starting to use not only when prescribing opioids (Dowell, Haegerich, & Chou, 2016), but also BZDs. In Illinois, the new full practice authority law requires physician consultation for prescribing these drugs (Illinois Governmental Acts, 2019).

Treatment Contract

It is beyond the scope of this article to discuss detoxification schedules. As noted above, the literature yields limited and conflicting ideas.

One obstacle to a manualized approach is the patient needing time, handholding, and trust-building. Equally problematic is the determined provider with a set detoxification schedule in mind. The British NHS NICE Clinical Knowledge Summary (NICE, 2015) presents recommendations to keep patients engaged in treatment during deprescribing (Table 1).

National Institute for Health and Care Excellence Clinical Knowledge Summary Guidelines

Table 1:

National Institute for Health and Care Excellence Clinical Knowledge Summary Guidelines

Most important is the emphasis on building a relationship with the patient. Ashton (2002) articulates that there is no need to deprescribe BZDs with urgency; patients who feel forced will rebel. It is important to give them time to trust that their fears will be listened to and they will be treated well. Patients must be ready to handle each dose reduction and need to know that PMHNPs are their partners. Providers should gently continue the pressure to reduce the dose but be aware that there is usually no hard deadline.

Influenced by Ashton (2002), I developed these personal practice guidelines:

  • Listen carefully and do not minimize or ignore patients' fears. Let them know I am a partner who will not abandon them.
  • Choose the least harmful medications in the fewest number and lowest dose.
  • Do no harm—do not create or support addiction.
  • Do not continue dangerous BZD prescriptions written by other providers who may not know the prescribing guidelines for these medications.
  • Set the goal of freedom from BZDs, and a treatment culture that supports this goal.

Conclusion

BZDs are seductive to patients with anxiety or insomnia because they provide a fast way to avoid uncomfortable feelings. BZDs have a limited place in the treatment of anxiety, as they should only be used for immediate, strong, and short-term relief, especially while waiting for other medications and psychotherapy to take effect. International guidelines, especially those that were developed in America and Britain, show that antidepressant agents and various psychotherapies (e.g., CBT) are first-line treatments of anxiety. BZDs come much further down the list for long-term treatment of any anxiety disorder, with or without comorbidities such as insomnia, depression, PTSD, or OCD.

I agree with Ashton (2002) that the key to a successful BZD taper is the combination of time to develop trust, early commitment to the treatment agreement, and time for psychoeducation. Patients need time to adjust to each dose reduction while adding psychotherapy, antidepressant agents, or other medications. A strong nurse–patient alliance can improve the chance of success in managing anxiety without using potentially harmful medication. Relationship is the key.

References

  • Ashton, C. (2002) Benzodiazepines: How they work and how to withdraw (aka The Ashton Manual). Retrieved from https://www.benzo.org.uk/manual/contents.htm
  • Baandrup, L., Ebdrup, B., Rasmussen, J., Lindschou, J., Gluud, C. & Glenthøj, B. (2018). Medications for discontinuation of long-term benzodiazepine use. Retrieved from https://www.cochrane.org/CD011481/ADDICTN_medications-discontinuation-long-term-benzodiazepine-use
  • Darker, C., Sweeney, B., Barry, J., Farrell, M. & Donnelly-Swift, E. (2015). Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database of Systematic Reviews, 5, CD009652.
  • Dell'Osso, B., Albert, U., Atti, A., Carmassi, C., Carra, G., Cosci, F. & Fiorillo, A. (2015). Bridging the gap between education and appropriate use of benzodiaz-epines in psychiatric clinical practice. Neuropsychiatric Disease and Treatment, 11, 1885–909. doi:10.2147/NDT.S83130 [CrossRef]
  • Dowell, D., Haegerich, T. M. & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Morbidity and Mortality Weekly Report, 65(1), 1–49. https://doi.org/10.15585/mmwr.rr6501e1 PMID:26987082
  • Illinois Governmental Acts, Joint Commission on Administrative Rules. (2019). Administrative Code Title 68: Professions and occupations, Chapter VII: Department of financial and professional regulation subchapter b: Professions and occupations Part 1300 Nurse Practice Act Section 1300.465 full practice authority. Retrieved from http://www.ilga.gov/commission/jcar/admincode/068/068013000D04650R.html
  • Lamoureux-Lamarche, C., Vasiliadis, H.-M., Préville, M. & Berbiche, D. (2016). Post-traumatic stress syndrome in a large sample of older adults: Determinants and quality of life. Aging & Mental Health, 20(4), 401–406. https://doi.org/10.1080/13607863.2015.1018864 PMID: doi:10.1080/13607863.2015.1018864 [CrossRef]
  • National Institute for Health and Care Excellence. (2015, April). Benzodiazepine and Z-drug withdrawal. Retrieved from https://actionpddwordpressdotorg.files.wordpress.com/2015/11/benzodiazepine-and-z-drug-withdrawal-nice-cks.pdf
  • Pottie, K., Thompson, W., Davies, S., Grenier, J., Sadowski, C. A., Welch, V. & Farrell, B. (2018). Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Canadian Family Physician, 64(5), 339–351 PMID:29760253
  • Quinones, S. (2015). Dreamland. New York, NY: Bloomsbury.
  • Stein, M., Goin, M., Pollack, M., Roy-Byrne, P., Sareen, J., Simon, N. M. & Campbell-Sills, L. (2010). Practice guideline for the treatment of patients with panic disorder. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
  • World Health Organization. (2009). Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. Section 4.4. Withdrawal management for benzodiazepine dependence. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK310652

National Institute for Health and Care Excellence Clinical Knowledge Summary Guidelines

DisorderGuideline
AnxietyTherapeutic interventions by the prescriber and psychotherapy may help. Propranolol is another option for severe anxiety.
DepressionAntidepressant agents are recommended for depression and anxiety. Antipsychotic agents are not recommended.
InsomniaLess likely to be a problem if withdrawal is slow. Take a good history of alcohol, caffeine, and other drug use. Recommend nonpharmacological options as well.
Authors

Mr. Amberg is Psychiatric Nurse Practitioner Consult Liaison, Department of Psychiatry, Northwestern Memorial Hospital, Chicago, and Psychiatric Nurse Practitioner, 7 Hills Healthcare Center, Dundee, Illinois.

The author serves on a speakers bureau for Janssen Neuroscience; however, he declares no potential conflicts of interest, financial or otherwise, for the current article.

Address correspondence to Alan Amberg, MSN, APRN, PMHNP-BC, Psychiatric Nurse Practitioner Consult Liaison, Department of Psychiatry, Northwestern Memorial Hospital, 201 E. Huron Avenue, Galter 13, Chicago, IL 60611; e-mail: alan_amberg@nm.org.

Received: June 13, 2019
Accepted: September 23, 2019

10.3928/02793695-20191218-06

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