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Joachim Stanley considers the guidelines surrounding the prescription of Benzodiazepines, and circumstances which may give rise to a medical negligence claim.
Benzodiazepines are a form of anxiolytic medication – that is, they relieve anxiety. During the 1970s, these drugs were prescribed fairly widely in response to stress, anxiety and depression, both by GPs in primary care and in specialist psychiatric care. Over time, concern grew and following several large studies, it became apparent that they were not as innocuous as had been thought (although in the interests of strict historical accuracy, it should be pointed out that the Rolling Stones first drew attention to the perils of benzodiazepines as long ago as 1966 on “Mother’s Little Helper” – the little yellow pill referred to in the song is almost certainly Valium). It was recognised that they can be highly addictive and that withdrawal is unpleasant and potentially protracted, with symptoms sometimes persisting even after complete drug cessation.
As a clinical negligence lawyer, I have been involved in several cases in which this family of medications has featured.
Benzodiazepines are still prescribed by GPs and psychiatrists, mainly for the short term (i.e., for less than 3 – 4 weeks) relief of anxiety and stress. NICE (The National Institute for Health and Care Excellence) has published guidelines which stipulate that benzodiazepines in the treatment of anxiety should not normally be used beyond two to four weeks. The same guidelines also stipulate that anti-depressants should be the only pharmacotherapy used for the longer-term management of anxiety. If a clinician was to use a very potent benzodiazepine (e.g. lorazepam) in such a situation, the onus would be on him/her to justify its usage. If they have been used regularly over a period of weeks, it might be appropriate for the treating clinician to titrate the dose downwards gradually to achieve cessation, in consultation with the patient. If anything more than short-term usage is contemplated, then it would be reasonable for the treating clinician to warn the patient of the risks associated with this family of drugs, so that s/he can make an informed decision as to this treatment.
More rarely, it may be appropriate to prescribe these medications in the longer term. If (for example) a psychiatrist needed to treat a psychotic patient with extreme behavioural problems which were not otherwise amenable to treatment, it might be appropriate to consider long term use of a strong benzodiazepine. Effectively, if this course of action is being considered, then the condition would usually be so debilitating that it is reasonable to accept the side effects of the drug (addiction) as a sensible “trade-off” in managing the symptoms.
As with most addictive substances, the longer a patient stays on benzodiazepines, the more likely it is that habituation will develop. It is understood that the patient may be at particular risk if there was a history of previous substance abuse.
Benzodiazepine withdrawal is reported to be exceedingly unpleasant and protracted. Symptoms may be physiological (e.g., pains, tinnitus, altered sensation and balance) or psychological (e.g., severe depression, anxiety, depersonalisation), or both. Once a dependency is established, these symptoms may persist for months or years. Sometimes it can be difficult to be sure whether the symptoms are caused by the benzodiazepines themselves, or a “flare up” of the condition for which they were originally prescribed. If the patient is having problems, then admission to hospital for treatment might be appropriate.
In my experience, most medical negligence cases involving benzodiazepines centre around long-term use and addiction consequent upon that. A review of the reported cases suggests that in many cases, benzodiazepines are prescribed following a crisis in a patient who has, until this point in his or her life, been a high achiever. In almost all of these cases, benzodiazepines were not withdrawn sufficiently rapidly, and an addiction developed in consequence.
In other cases, benzodiazepines were prescribed to patients with a previous history of substance abuse (this is generally not a good idea, as such patients may be at increased risk of developing habituation).
Sadly, suicide is a surprisingly common feature of these cases, a fact which reflects the unpleasantness of benzodiazepine withdrawal, and negligence cases are then brought by family members of the deceased patient for the loss of their loved one.