Benzos

[thinkertdm]

I've inherited an 84 yo male who has words like "frail" in his problem list who has been on alprazolam 0.5 mg po bid for the past twelve years.  The listed indication is "sleep" and "tremors".  I've never seen this guy but his refill time has come around.

Kidney function is good.  No history of falls-yet.  He's also anticoagulated with a doac.

My inclination is that this is not a safe drug, due to the risk of cognitive impairment, falls, maybe death.  I know there is probably more details, but the last thing I want is for him to have to pee and trip.  Hip or head, hasta la vista.  Someone much smarter than I told me a leading cause of disability and death in elderly are falls.

Am I barking up the wrong tree?  The np obviously thought nothing of it when they clicked refill.

I did have the nurse call, and he was agreeable to seeing mental health, which he later refused.  So I asked pharmacy for a taper schedule.

Is this wrong?  How about if he promises not to fall?

[Guest UVAPAC]

I think typically long term Benzodiazepine use is contraindicated... 

Obviously this patient has been on them for 12 years without issue.  You could consider documenting: we did discuss potential side effects of benzodiazepines including drowsiness, cognitive impairment, falls, medication interactions, and potentially even death.  Discussed that he should not be combining with other controlled substances or alcohol.  The patient reports he has been on these medications for 12 years and denies any CNS impairment, dizziness/lightheadedness, drowsiness, ETOH abuse.  Therefore I feel it is reasonable to continue this low dose of alprazolam.  (Unless you are completely opposed to it, I would send him to a psychiatrist to see if they felt long term benzodiazepine use was warranted.

[UGoLong]

If it was me, see the guy before deciding anything. We typically don’t renew anything without that. You never know; people don’t always fit into boxes. Meet him and then make your decision.


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[thinkertdm]

Good points.  I'm not sure one can make a completely informed decision when you have a chemical dependency.  Also, I'm seeing so many people on benzos without a review of why they need them.  I'm of the mind that changing ones body chemistry leads to a bill that eventually must be paid.

Last, just because he hasn't fallen doesn't mean a fall isn't coming.  The only thing that has changed over the past twelve years is him.  Enzyme levels are reduced, things metabolize slower, and what was once an innocuous dose is now a dizzy falling down dose.

 

[UGoLong]

Good points.  I'm not sure one can make a completely informed decision when you have a chemical dependency.  Also, I'm seeing so many people on benzos without a review of why they need them.  I'm of the mind that changing ones body chemistry leads to a bill that eventually must be paid.

Last, just because he hasn't fallen doesn't mean a fall isn't coming.  The only thing that has changed over the past twelve years is him.  Enzyme levels are reduced, things metabolize slower, and what was once an innocuous dose is now a dizzy falling down dose.

 

 

You sound like you have some innate beliefs about benzos that you might want to explore, such as using the word “dependency,” which I’m guessing you wouldn’t use about, say, metformin.

 

Take the time to get to know this man. Some elderly have incredible anxiety that interferes with their quality of life in major ways. See if there is a way to address both your and the patient’s concerns. Help him lead the best life he can.

 

Good luck.

 

 

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[Guest UVAPAC]

27 minutes ago, UGoLong said:

 

You sound like you have some innate beliefs about benzos that you might want to explore, such as using the word “dependency,” which I’m guessing you wouldn’t use about, say, metformin.

 

Take the time to get to know this man. Some elderly have incredible anxiety that interferes with their quality of life in major ways. See if there is a way to address both your and the patient’s concerns. Help him lead the best life he can.

 

Good luck.

 

 

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Certainly I have seen people withdrawing from Benzos, never before Metformin.  

[UGoLong]

Certainly I have seen people withdrawing from Benzos, never before Metformin.  

My point exactly; a patient could be “dependent” on both to control some pathology, but we can be quick to call one a “dependency” and the other is just a life-preserving medication that the patient needs.

All I’m asking is to take the time to know the patient before changing any of his meds.


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[HMtoPA]

BZDs are on the list of BEERS criteria (i.e., American Geriatric Society of drugs to avoid in the elderly), precisely because they increase fall risk and all the associated morbidity and mortality of that. Generally I think that BZDs are terrible for long-term, scheduled use. I occasionally use them for short-term anxiolysis in severe cases, or for long-term use as a PRN med in small quantities which do not allow daily use.

My opinion is that no one's anxiety ever got better by being on a benzo every day. The typical pattern is one of decreasing efficacy, increasing dependency, and dose escalation with no measurable improvement in Sx over time. It's like opioids for chronic non-cancer pain; it's clearly inappropriate, but widespread and commonplace.

At a minimum, I personally would need to see the patient before I refilled, and unless there were some very compelling reason to continue at current dosing, I would probably be initiating a taper, albeit a gradual one in light of the duration of use. Good luck.

[Lexapro]

I'd most likely taper. And shame on that NP for keeping him on it. But I used to do geropsych and saw multiple people fall and break hips, give themselves a bleed, etc., on benzos so I am pretty adamant about getting older folks off of daily benzos. Benzos are fine until they're not, as far as I'm concerned. It is unlikely that the Xanax is doing anything for his anxiety as he is now tolerant of the medication and any anxiety he feels when he misses a dose is due to withdrawal. I'd have him come in and evaluate the whole clinical picture (what anxiety disorder is he suffering from specifically? Benzos do not have a long term indication for sleep. Why can't he sleep? Why is he tremulous?) before refilling. Perhaps he has a long history of failing every other anxiolytic medication/therapy and requires the Xanax (doubtful but possible). It is pretty telling that he refused his mental health referral.

I had pretty good success slowly switching people over to an equivalent dose of a longer acting benzo (clonazepam, sometimes diazepam though diazepam accumulates and can be riskier for falls) and then slowly taper over the course of a few months. Gabapentin can help.

Here is a great resource: https://benzo.org.uk/manual/bzcha02.htm

[UGoLong]

The OP posted that he/she hadn’t met the patient yet. I’d be upset if someone who never met me sent me to a psych referral too.

If all we so is follow protocols instead of tailoring our treatments to individual patients, then we’re in the wrong profession.


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[thinkertdm]

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[UGoLong]

I wouldn’t refill it without seeing him. Or fill it for two weeks until they can work him into my schedule.


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[HMtoPA]

6 hours ago, UGoLong said:

The OP posted that he/she hadn’t met the patient yet. I’d be upset if someone who never met me sent me to a psych referral too.

If all we so is follow protocols instead of tailoring our treatments to individual patients, then we’re in the wrong profession.


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There is literally nothing that meeting the patient would do that would make me think a 12-year Hx of daily BZD use was okay, nor convince me that it was a tenable indefinite solution. Sorry. Never mind the fact that he's a frail 84 years old.

No amount of tremor, insomnia, or anxiety is going to kill the patient. A fall in an 84-year-old frail individual is deadly serious, however. Not to mention, I personally would be very reluctant to have my name on the Xanax bottle in his medicine cabinet if/when he takes a spill, should his surviving family members decide to sue.

[UGoLong]

Then go ahead and practice medicine remotely by preconcieved notions. I’m done here.


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[HMtoPA]

Believe it or not, there are a few absolutes in life, and in medicine, too. If you really think that chronic BZD use is no different than daily metformin, that tells me how much you know. Frankly, I think you sound dangerous.

[UGoLong]

Believe it or not, there are a few absolutes in life, and in medicine, too. If you really think that chronic BZD use is no different than daily metformin, that tells me how much you know. Frankly, I think you sound dangerous.

 

I don’t. I think it’s dangerous to make decisions about any patient you’ve never seen. And that, sir, is the only point I have been trying to make.

 

Some of the other posters have made suggestions about what could be excellent alternatives (longer-acting meds, etc).

 

It all starts with treating your patient as a human being and arranging to meet him or her face-to-face, especially when you have doubts about their treatment to date. And, if you have to, bridging their existing meds briefly until you can get them in.

 

 

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[HMtoPA]

Lol, I thought you were "done here?" Or is that only if you get the last word?

Of course I would meet the patient face-to-face, and of course I would bridge their existing meds until then, and of course I would initiate a (very gradual, in this case) taper by converting to longer-acting meds (I said as much in a previous post).

But what I wouldn't do, under any circumstance, is entertain the idea of continuing an indefinite Rx for BZDs. In any patient, but least of all one who is a major fall risk. There is simply no good indication for it, and no amount of "meeting with the patient" will change that.

Just like I know I will never stab any of my patients in the eye with an 18G needle - it's bad for them. Why would a face-to-face meeting change that?

[LT_Oneal_PAC]

I agree that really no geriatric (no one really) needs a daily benzo. I hate benzos altogether and wrote for maybe 60 total pills in 3 years for all my patients combined, but we are treating this man like a seeker. He didn’t do this to himself. Someone did it to him. He trusted that last provider who got him dependent, thinking they were doing what was best for him. Now you step in and without talking to him, from my understanding, decide this is going to stop. You’re doing something, giving him a referral, but to him this just feels like you saying no and then punting to someone else his problem. A significant part of our job is establishing rapport. So while benzos are bad, I wouldn’t hesitate to bring this guy in, call him personally to explain why you want to see him and it’s because you care about him, small refill to make it to next appointment. Explain why this may have been okay in the past, as you don’t want to be seen as adversarial with th last provider he already trusts, why it’s not okay for him any more, and how you’re going to get him through it. Having done this before, it can be painful for all involved, but they are much more likely to work with me and make that psych appointment I get them.

[charlottew]

I agree there are no absolutes. I had a 102 year old (!) family member, who had been on xanax for YEARS. For the last ten years of his life I tried to suggest to him, gently, that the xanax was a fall risk, and that he should try to stop, or taper. 

Nope. No how, no way. He wouldn't give them up. I saw him on a regular basis, he never seemed overly sedated to me. Of course he was frail in his 90's (who isn't?), but the germ of the matter is that he had some significant and long-standing anxiety, he was dependent on the benzos to alleviate this, and he wasn't going to change.

In the end, he fell and broke his hip, it was terminal since no-one would take him to the OR for repair at 102. Actually it's probable his hip broke , causing the fall.

I guess what I'm saying is, I know The Guidelines say benzos are contraindicated in the elderly. Certainly when I treat older folks in the hospital, I avoid starting benzos (in the context of delirium risk). 

However, for people that have been on benzos for a very long time, it can be very difficult to stop. Anxiety and depression in the elderly is a very real thing. People self-medicate all the time for anxiety (EtOH), which has health risks too. 

I agree (as usual!) with UGoLong, try to see the entire picture of the person. Especially if they're an older person. Everyone deserves to be treated with respect - that includes making an effort to understand their individual situation. I tried to get my family member to stop taking the Xanax, but in the end I concluded it would upset him more to try to get him to taper, than was worth the theoretical benefit. 

[HMtoPA]

20 hours ago, charlottew said:

I agree there are no absolutes. I had a 102 year old (!) family member, who had been on xanax for YEARS. For the last ten years of his life I tried to suggest to him, gently, that the xanax was a fall risk, and that he should try to stop, or taper. 

Nope. No how, no way. He wouldn't give them up. I saw him on a regular basis, he never seemed overly sedated to me. Of course he was frail in his 90's (who isn't?), but the germ of the matter is that he had some significant and long-standing anxiety, he was dependent on the benzos to alleviate this, and he wasn't going to change.

In the end, he fell and broke his hip, it was terminal since no-one would take him to the OR for repair at 102. Actually it's probable his hip broke , causing the fall.

I guess what I'm saying is, I know The Guidelines say benzos are contraindicated in the elderly. Certainly when I treat older folks in the hospital, I avoid starting benzos (in the context of delirium risk). 

However, for people that have been on benzos for a very long time, it can be very difficult to stop. Anxiety and depression in the elderly is a very real thing. People self-medicate all the time for anxiety (EtOH), which has health risks too. 

I agree (as usual!) with UGoLong, try to see the entire picture of the person. Especially if they're an older person. Everyone deserves to be treated with respect - that includes making an effort to understand their individual situation. I tried to get my family member to stop taking the Xanax, but in the end I concluded it would upset him more to try to get him to taper, than was worth the theoretical benefit. 

But he was a family member, not a patient. You had no legal liability for him being on Xanax. It's a totally different when you have that kind of skin in the game.

Not to mention, there is no indication for treating anxiety long-term with Xanax. Sure, we do off-label stuff all the time, but there are better options than Xanax. I've met plenty of patients with supposedly disabling anxiety who want benzos, but won't consider SSRIs, Buspar, CBT, etc. They only want the quick fix. And I get it, it works, in the short term. But I've never seen a patient on long-term BZDs whose anxiety actually improved. It makes them not only physically dependent, but emotionally crippled. It erodes their resilience, because they absolutely never have to really deal with even a slightly uncomfortable situation.

And if someone chooses to self-medicate because they can't get the prescription they want - well, that's on them. That is the worst kind of manipulation to try and burden a provider with. There are legal and ethical consequences to our actions that we might have to deal with - chart reviews, privileging actions, lawsuits - in a bad outcome situation, it would be very easy to make an otherwise competent provider appear negligent if their prescribing practices were more lenient than the norm, or in opposition to established guidelines. I suspect no one would care how deeply you felt for the patient and their situation, but I'm not willing to risk my professional livelihood on it.

Sometime what is best for the patient is not the same as what the patient wants. I would rather potentially upset a patient than contribute to their inappropriate medication, but that doesn't mean I would do so in a combative, antagonistic way.