Kids are different today, I hear ev’ry mother say

Mother needs something today to calm her down
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day

Mother’s Little Helper, The Rolling Stones

On the Reading of the Week

This Reading will be part of a two-paper, two-part series. The selection was made with the editorial board of the International Psychiatry Twitter Journal Club, allowing us to consider these papers now, and to continue the conversation on Twitter and include experts from Canada and around the world.

In this week’s Reading, we’ll look a major new JAMA Psychiatry study: “Benzodiazepine Use in the United States” by Olfson et al. (I’ve attached the paper in PDF format.)

Next week, we’ll look at a study that sought to reduce benzodiazepine use in the elderly.

And, of course, both papers will be up for discussion at the next International Psychiatry Twitter Journal Club on January 21 and 22. Interested? Follow @psychiatryJC.

On Benzodiazepines

It says much about a medication that it would be so culturally prominent as to merit an entire song by The Rolling Stones at the peak of their 1960s popularity. Yet, Valium was “Mother’s Little Helper,” whose opening verse is above. (You know a drug must be badly overused if even Mick Jagger is fretting prescribing habits of physicians.)

The Rolling Stones

Valium and several other benzodiazepines were invented by Dr. Leo Sternbach. The scientist, working for Roche, drew on his experiments with dyes. As the story goes, Dr. Sternbach used a kettle with a big wooden paddle and his first human test subject was… Dr. Sternbach.

Dr. Sternbach

If the approach was crude – especially compared to the “high-tech, high-expense” drug development of today – the result was stunning: Valium, first introduced in North America in 1962, became the most-prescribed medicine in the U.S. between 1969 and 1992. (!)

But commercial success is not necessarily good medicine.

Benzodiazepines are addictive. And a growing literature connects them to everything from cognitive issues to increased fractures. So with the passage of time (the sixties are over and the Rolling Stones’ member have entered into their geriatric years), as we understand these medications better and as guidelines encourage the use of alternatives, have Valium and its sister drugs fallen out of fashion?

On the JAMA Psychiatry Study

This week’s Reading looks at benzodiazepine use in the United States. Though the data set is American, the paper is relevant across the west – and concerning.

Yes, benzodiazepines have a role. A patient once credited me with saving his marriage because I prescribed him some Ativan making it possible for him to board a flight for his honeymoon.

But there is strong literature cautioning against its extensive use and, in particular, its long-term use.

And this paper suggests that benzodiazepines remain both extensively used and used often long term.

The JAMA Psychiatry study draws from a huge data set: the 2008 Lifelink LRX Longitudinal Prescription database, covering 60% of all U.S. retail pharmacies.

A few points on the Olfson et al. paper:

  • A quick summary of use: women and the aged. That is, women were 3 times more likely to take benzodiazepines than men; use increased with people’s age.

Percentage of Population in the United States in 2008 With Any Benzodiazepine Use by Sex and Age.

  • And use was common: “Among adults 18 to 80 years of age, 5.2% (11 491 677 of 219 799 647) of the sample filled at least 1 prescription for a benzodiazepine in 2008.”
  • And use included long-term use: “Long-term use of benzodiazepines, defined as filling at least 120 days of supply during the study year, steadily increased with age. The percentage of persons in the United States with long-term benzodiazepine use increased from 0.4% (18-35 years of age) to 2.7% (65-80 years of age)…. Among older adults who are treated with benzodiazepines, nearly one-third use benzodiazepines on a long-term basis.”
  • Prescription patterns suggest primary care clinicians were much more likely to prescribe than psychiatrists: “Most individuals with long-term benzodiazepine use received all of their benzodiazepine prescriptions from nonpsychiatrist prescribers… In all age and sex groups, fewer than 1 in 10 individuals using long-acting benzodiazepines received a prescription from a psychiatrist.”

Since insomnia increases with age and since benzodiazepines are frequently used for insomnia, the trend is understandable.

But is it appropriate?

As the study authors note: “clinical guidelines recommend that benzodiazepines and other hypnotics should only be used on a short-term basis for severe and impairing insomnia and only initiated following careful consideration of nonpharmacological options, such as sleep hygiene, stimulus control, and relaxation.”

Are these findings new or surprising?

No and no – as you know, many studies have pointed in this direction. (Indeed, the literature is so robust that you may be quietly wondering if future Readings of the Week will consider whether it’s sunny in Southern California or Maple Leafs fans have been disappointed in past hockey seasons.)

Still, the study is remarkable for its size and scope.

And in it’s clear conclusion:

Given the divergence between clinical practice and expert opinion, guidelines urging cautious prescribing to older patients appear to be independently insufficient to reduce long-term use in older people.

Where then do we go from here?

Tannenbaum et al. consider patient education as a way of reducing benzodiazepine use in the elderly. And their JAMA Internal Medicine paper is the subject of our next Reading of the Week.

JAMA Psychiatry – BDZ use in the US.PDF