Benzodiazepine withdrawal among chronic daytime users in general practice

Withdrawal of chronic day-time users from benzodiazepines is rarely attempted in general practice because patients are considered more dependent on their medication than analogous night-time users. forms of brief inter by to reduce intake of benzodiazepines in chronic day-time users. A the development of a


Patients
The study was carried out in an inner city teaching practice in south London with a practice list of 13,000 patients. Patients were selected according to the following criteria: daytime benzodiazepine usage with or without night time use, use every day for at least one year and aged over 18 years. Those under the care of a psychiatrist or with a history of psy chosis or dependence on alcohol or other substances were excluded. Thirty-one daytime users were ident ified who fulfilled the selection criteria of whom ten agreed to participate in the trial.

Procedure
The ten patients who agreed to participate were given: (a) an initial consultation in which the study was explained and a gradual programme of withdrawal of benzodiazepines over 12 weeks was planned (b) a self-help booklet. This was written for the study and covered general information on tranquillisers, withdrawal symptoms, ways of stopping, cognitive behavioural strategies, benefits of stopping and suggestions for further reading (c) a questionnaire on attitudes to benzo diazepines (d) the General Health Questionnaire (12 questions).
In addition, half of the patients were randomly selected to receive four counselling sessions with their own GP lasting ten minutes and offering support and practical advice.
All patients were followed up with repeat assess ments at 12 weeks and 12 months. During this period, the total benzodiazepine dose (daytime plus night time) was recorded.

Findings
Five of the ten patients in the trial stopped their use of benzodiazepines altogether over the 12 week period. Two more reduced their use by over half but the remaining three were unable to achieve reduction over 12 weeks.

One year follow-up
None of the patients who withdrew or reduced their dosage at 12 weeks relapsed after one year.
Of the five who failed to stop during the 12 week programme, three had halved their dosage and one had stopped at review one year later.
Only one of the original ten patients had not benefited after one year in terms of reduced dosage.

The views of patients
Just two of the patients reported that their doctor had previously suggested reducing their medication. In spite of this, seven of the ten had themselves attempted reduction and all but one felt that they ought to reduce their dosage.

Comparison between Minimal Intervention Group and General Practitioner Counselling Group
The results of the two approaches for intervention are summarised in Table 1

Comments
This study demonstrates that high withdrawal rates can be achieved among the among the sub group of chronic benzodiazepine users who take day-time medication.
Although chosen for study on the assumption that chronic daytime users of benzodiazepines would be particularly resistant to attempts at withdrawal, nine out often patients could reduce or withdraw success fully. This equals the proportion of chronic night-time users who may be successful at withdrawal (Giblin et al, 1983).
Our results suggest that minimal intervention (one consultation plus a booklet) can be effective although numbers were too small to determine which of the two forms as more effective.

Do we misunderstand our patients?
In the light of these results it is surprising that with drawal is not a more common practice. This study highlights possible misunderstandings within the doctor-patient relationship that may act to perpetu ate long-term prescribing. Many doctors regard long-term benzodiazepine users as unable or unwill ing to stop taking the drug, and liable to relapse even if they attempt to do so. This study challenges these assumptions. A total of 75 years of benzodiazepine use was successfully ended when 50% of the patients stopped after a relatively simple non-coercive inter vention. Nearly all (9 out of 10) reported that they wanted to cut down or stop their tablets, although the views of those who refused to participate in the trial (14 out of 31) may well have been different. Finally, not one of those successful in stopping returned to benzodiazepines during the year of study.

Do our patients misunderstand us?
The belief that doctors encourage use of benzodiaze pines is probably widespread. Only two out of ten patients in this study reported that their general prac titioner had ever previously suggested reduction of their dosage. In a survey of long-term users in another inner city practice (King et al, 1990)24 out of 64 (37%) patients actually believed that their doctor encouraged their use of benzodiazepines and the majority (52%) had no idea how the doctor regarded their use. It seems that the message that doctors dis courage long-term use is not successfully transmitted to patients.

The booklet
This study has served to pilot out own booklet, written from the viewpoints of both the psychiatrist (Dr Seltzer and M.K.) and general practitioner (M.A.). All those in the study reported that they had read it and found it useful. The booklet has been a collaborative effort and we hope to test the modified version in a much larger study in order to promote the case for wider availability of such literature to general practitioners through, for example, the Health Education Authority.
In conclusion, our results demonstrate that a selected minority of chronic day-time users of benzodiazepines can successfully reduce or stop their medication with brief intervention by general practitioners. Current, long-term prescribing of benzodiazepines may be in part maintained by misunderstandings in the doctor-patient relation ship. The level of benzodiazepine prescribing in general practice could fall significantly if booklets on withdrawal were widely available for patients to read.