I have just chatted with Dr Andrew Rees about human needs and benzodiazepines. In both our clinical experiences benzodiazepines cause more angst and grief than opioids and alcohol misuse.
The question is often asked, why do I need to come off benzodiazepines. Well firstly they are harmful, and secondly, they impair engagement with psychosocial interventions. The harms of benzodiazepine use include respiratory depression, accidental overdose and unfortunately in extreme cases death. They increase the risk of falls and impair cognitive functioning. These effects are more pronounced as we age, so therefore the adage of "let sleeping dogs lie", and failure to wean the elderly off a "stable" dose of benzodiazepines that have been used for years is not ethically tenable.
Getting off benzodiazepines seems to be more of a challenge than getting off prescription opioids or alcohol. But why is this the case?
I think that they are universally experienced as a sticking plaster. They help with the immediate sting of psychic pain. But unfortunately, unlike other sticking plasters which can facilitate healing, the benzodiazepine sticking plaster does not stimulate healing. I liken the psychic pain and suffering that benzodiazepine treat to a persistent hangover.
The open wound remains, and when the pills wear off (and when the plaster is ripped off) the pain and suffering come back. No healing occurs and in fact all we are doing when we use benzodiazepines for more than four weeks is contributing to the development and then perpetuation of an additional mental health condition i.e., a chronic benzodiazepine dependency associated with withdrawal symptoms that can be as bad or worse than the original symptoms for which the benzodiazepine was initially prescribed, and which are relieved by ongoing use of benzodiazepines. The perpetual cycle continues.
Th appropriate management of such dependency relies on two simultaneous approaches, firstly the gradual weaning of the dose of the benzodiazepine, and secondly the appropriate adequate treatment of the underlying condition for which the benzodiazepines were initially prescribed. These two approaches really do need to occur simultaneously, because on the one hand benzodiazepines impair engagement with psychosocial therapeutic interventions, and secondly without such treatment the underlying illness will continue to cause psychic pain.
The idea of having to Come off benzodiazepines can instil horror in some people. Immediate thoughts of "How will I cope" dominate our thinking. To those who react this way I offer a message of hope. Coming off benzodiazepines is not inevitably associated with severe withdrawal symptoms, and most people can tolerate a very gradual wean off benzodiazepines. The trick is to do it slowly, especially when you get to lower doses. During this time, it is also important to engage with other therapies to deal with underlying mental health disorders.
Dr Andrew Rees suggests the use of a coaching approach, whereby rather than telling the patient why they need to come off benzodiazepines (and deflecting the almost inevitable rebuttal and assertion that they need to stay on their benzodiazepines) a doctor should ask the patient what their ideas concerns, and expectations are of their underlying disease process. What would health look for them? What would they want to do were they to be free of the shackles of their mental health disorder (and free of their benzodiazepines use)? Teaching the patient how their benzodiazepine use is impairing their dreams may be a way of unlocking both those dreams and the patient from their benzodiazepine dependency.
Our dreams are part pf our creativity, an essential human need. Tapping into this seam of common human experience may allow doctors to connect with patients with more empathy and understanding and hopefully less combatively.
As Andrew says: "If you don't have dreams, how do you know if you have achieved them?"