When I completed my residency training in 2017 I never imagined so much of my clinical efforts would be directed towards educating patients about controlled substances. As I stepped into clinical practice and took over patients who had long-term relationships with providers that had retired or moved to other positions I began to notice a preponderance of patients, some elderly, taking benzodiazepines daily, frequently at high doses. Often conditions other than anxiety were being palliated with benzodiazepines to numb symptoms. Gradually escalating doses throughout years of daily use were evident as I examined their charts. All of this is in spite of clear direction that these medications are only for use in “severe, disabling anxiety or insomnia.”
As I spoke to these patients, took new histories and provided full informed consent on the risks, benefits, alternatives to their current medications another worrisome trend became evident. My patients had the perception that they had not received informed consent around their medications.
Informed consent in medicine is the process by which a patient is apprised of the risks, benefits, and alternatives to a procedure, treatment or medication they are considering. While it may be the case that in limited instances a previous provider practiced paternalistic medicine and abdicated this responsibility it is more likely that informed consent was provided to patients previously. However, their perception that they are not receiving this information is especially worrisome when considering addictive medications that require careful management, such as benzodiazepines.
It is no secret that there is a critical shortage of psychiatrists in the United States and that this shortfall in practitioners is likely to worsen in the coming years. Predictions suggest that by 2024 we may have a deficit of more than 31,000 psychiatrists. The downstream effect of this need for more providers is that those of us currently in the workforce have large patient panels and an ever-growing need to see more patients. It can often feel like patient education, and difficult conversations are not allowed for in one’s daily clinic schedule. Time pressures can lead to avoidance of transitioning patients to safer alternatives to manage anxiety, setting firm limits around addictive medications, connecting them with therapists and groups (where available) and addressing the core issue the benzodiazepine is palliating. Just authorizing the refill of the ever-escalating dose of benzodiazepine can often seem to be the path of least resistance. In a climate where reducing burnout is a ubiquitous topic of conversation it can surely seem this time investment is overly burdensome.
I suggest revisiting patient education often and keeping tight controls on benzodiazepine use to unburden our system overall. Our goal should be to carry educated panels of patients who are well managed, not dependent on inappropriate controlled substances and subject to the risk for falls, overdose, dementia and cognitive slowing posed by benzodiazepines. This will facilitate the next generation of psychiatrists stepping up to continue care and prevent needless iatrogenic harm that increases care burdens and cost to psychiatry and across specialties.
All of this is not to say that benzodiazepines should be avoided altogether. To be sure, they are effective medications but almost universally the temporary or episodic basis on which they should be used is ignored. Safe prescribing practices, investing in the patient so they are an educated participant in their own care, treatment agreements explicitly reviewed with patients and documented, and encouraging adjunctive treatment (therapy, groups, exercise, diet) can only benefit patients and is in line with treatment recommendations. Considering the risks of these medications and that up to 20 percent of nationwide benzodiazepine consumption is “misuse” we are faced with a critical issue to take head-on as a profession if we are to claim we are doing our fiduciary duty to our patients and supporting each other as providers.
Samuel Ridout is a psychiatrist.
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