Hong Kong Journal of Psychiatry (1997)  7 (1),29-35

SPECIAL TOPIC: Benzodiazepines - Uses & Abuses

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INTRODUCTION

Benzodiazepines have been very effective treatment agents for anxiety and insomnia since the 1960 (Wing, 1996). They replace the previous dependence prone minor tranquillisers like barbiturates and meprobamate. However, since the 1970 more and more cases of benzodiazepine dependence have been reported. In 1980, increasingly more and more reviews are made on high dose dependence on benzodiazepines and later dependence on therapeutic dose of benzodiazepines. Abuse has also been reported world-wide, including Hong Kong (Leung, 1996).

In Hong Kong a review on the issue of benzodiazepine dependence was first published in the local journal in 1989 (Lai, 1989). Subsequently more and more cases of abuse and dependence on benzodiazepines were reported to the Central Registry of Drug Addiction, especially among the young persons (ACAN, 1996). There had also been increase in media coverage of such cases. The Government began to tighten the prescription of benzodiazepines since 1991 by re-classifying three benzodiazepines under the category of Dangerous Drugs. By 1993, all benzodiazepines were grouped under Dangerous Drugs. Since then, their supply, storage and prescription are governed by the Dangerous Drug Ordinance. Much more paper work is thus demanded of medical practitioners and related health care professionals.

Towards the end of 1995, the Hong Kong Medical Council and Hong Kong Medical Association were both looking into the issue of setting up guidelines on the use of dangerous drugs, benzodiazepines included. This paper attempts to record and discuss the controversies arisen among the medical professionals.

USE OR MISUSE OF BENZODIAZEPINES

Use or misuse of benzodiazepines by the medical professional can be considered from the perspective of whether the use is appropriate to the particular situation in a patient at a certain time. When the use is appropriate, it is proper use. If the use is inappropriate, it is misuse.

In general there may be three major reasons for a medical practitioner to have used benzodiazepines inappropriately ---- inappropriate knowledge, by mistake and knowingly.

If one accepts the discussion of appropriateness as above, one need to answer what the normal sources of facts and data are on the use of benzodiazepines that may be taken as appropriate knowledge. One may regard medical textbooks, pharmacology textbooks, medical journals, and pharmaceutical information from different drug companies as the normal sources of knowledge. But then to what degree and extent is a medical practitioner expected to keep himself updated with all these various sources of information is yet another question to be answered.

Furthermore when one has been kept himself updated of the facts and data, who then is to decide on the interpretation of the data as they are applied to the use on individual patients? Different medical professionals can come up with different views even with the same facts and data, not to mention the possible differences in the clinical assessment and judgment of the condition of the individual patient.

PERSPECTIVES OF AUTHORITIES

As far as the medical administrators are concerned, they are presented with the information of the increasing trend of abuse of psychoactive substances (ACAN, 1996). Among the substances reported benzodiazepines are a major group. As shown in Table 1, there are three benzodiazepines reported. They are brotizolam, flunitrazepam and triazolam. All showed increase in number of reported persons abusing the medicine. The abuse date on brotizolam peaks in 1990, while both flunitrazepam and triazolam still progress to a high number by 1994 and 1995. Drop is seen with flunitrazepam. When one assumes that there is no overlap in the reported persons in the abuse of the three different types of benzodiazepines, one can add up the number of persons abusing these drugs in each year. These show total numbers of benzodiazepine abusers of progressive increase up to a maximum of 843 in 1994 and down to 695 in 1995.

There have been allegation that medical practitioners are a major source of supply of benzodiazepines to the abusers. Yet assuming a medical practitioner can see 40 such abusers a day and the practitioner does supply the benzodiazepines to them, only about twenty medical practitioners are more than enough to cover all these abusers. This is a very small proportion of the five to six thousand medical practitioners in Hong Kong.

There is also the possibility that the figures provided by the Central Registry of Drug Addicts are under reporting of the real situation. There may be much more benzodiazepine abusers not reported. According to the reports by PS 33, the counseling centre for psychoactive substance abusers, medical practitioners form less than ten percents of the source of benzodiazepines for the abusers (HKCS, 1993). Medical retail and black market are the major sources of benzodiazepine supply.

Anyway benzodiazepines are reclassified under the Dangerous Drug since 1991 for the above mentioned three drugs and by 1993 all other benzodiazepines are included. According to the Department of Health the sales pattern of benzodiazepines to private medical practitioners in general shows a fall in the past few years as in Table 2.

As can be seen from the Table, only eight kinds of benzodiazepines are included. Other than chlordiazepoxide, others are usually used as hypnotics. The unit for each medicine means either one tablet or one capsule. As some medicine have units of more than one strength, the actual amount of individual benzodiazepine used by private medical practitioners can only be calculated with the sales of medicine of individual strengths known. Chlordiazepoxide and diazepam are sold at up to 15 million units and 24.4 million units respectively in 1991. The figures drop to 6.3 million units and 11.5 million units for chlordiazepoxide and diazepam respectively in 1995. It may be a bit worrying to note that the sale of lorazepam ranks third in sale with 7.7 million units in 1991 and down to 4.3 million units in 1995. Patients taking lorazepam are known to have particular difficulty in withdrawing from the medicine.

For the purpose of estimation of number of persons taking a unit of benzodiazepine each night everyday throughout the year, one can add up the units of all the medicines in the table and divided by 365 days. The results are shown in Table 3. The number of persons taking one unit of benzodiazepine a night throughout the year range from 134 thousand in 1991 to 67 thousand in 1995. These are only estimations as all other benzodiazepines sold to private medical practitioners and all benzodiazepines sold to hospitals and public clinics have not been included. The number of patients in the public services are of course much larger than the number of patients seen in the private sector. With these figures one would need to ask what sort of conditions these patients are suffering from such that they need to take benzodiazepine on a daily basis, and whether some may no longer need the benzodiazepine.

With the hard work of the authorities concerned, a number of medical practitioners were found and judged to be dispensing benzodiazepines inappropriately and record of the dispensing of such benzodiazepines not kept properly. The public media were much focused on the issue of 'the king and the queen of pills', who were selling large quantities of benzodiazepines daily to their patients. Unfortunately, cases judged and sentenced by the Medical Council as malpractice were successfully appealed through the court.

One of the reasons why a medical practitioner highly suspected to have dispensed a benzodiazepine improperly cannot be penalised is that it has not been possible to establish that the medical practitioner has not used the benzodiazepine in bona fide medical treatment. The Medical Council and the Hong Kong Medical Association both felt the need to do something. One might suspect that their intention was to pin down the few 'black sheep'. They came up with the decision of setting up guidelines on the use of Dangerous Drugs, benzodiazepines included. During the process of working out the guidelines there were a lot of dissenting voices. Guidelines were officially promulgated by the Hong Kong Medical Council in April 1996.

PERSPECTIVES OF PSYCHIATRISTS

The Hong Kong College of Psychiatrists had been invited to participate in the Ad Hoc Committee of the Hong Kong Medical Association on Guidelines on the Use of Dangerous Drugs. The intention to set up guidelines so as to pin down the "new black sheep' differed from the intention of the College to help in setting up the guidelines to promote good standards in clinical practice.

The Councils of the Hong Kong College of Psychiatrists endorsed a set of Guidelines on the Use of Benzodiazepines for its own members in March 1996. The College guidelines spell out the effectiveness of benzodiazepines in general when they are used in the proper conditions for the appropriate patients. The recommendations on the short term use of benzodiazepines in the minimum dosage in anxiety and insomnia are specified. Cautions and risks are also stated. Pharmacological properties of individual benzodiazepines need to be noted. Caution in the use of related medicine is also mentioned. Comprehensive assessment of the patient and the use of biopsychosocial approach in the management of individual patient are also emphasised.

PERSPECTIVES OF FAMILYPRACTITIONERS

The Estate Doctors Association (EDA) is an organisation embracing all general medical practitioners working in clinics in public estates. It also includes other medical practitioners, often those in family practice. Its membership is about 1500.

Feeling of members of EDA on the Guidelines was one of worry of control and restriction to clinical practice of general practitioners. EDA did a survey on its members on the issues related to the Guidelines. Some of the items were about the use of benzodiazepines. Some of the results are quoted as follows (EDA, 1996).

As shown in Table 4, majority feel that benzodiazepines are not easily addictive, doctors are not directly responsible for patients' drug abuse, and drug peddling by doctors are not common nor serious. Majority feel that there shall be guidelines, but not written in the code of practice. They do not feel that the 'black sheep' will behave with the guidelines. They do feel that more control over medical dispensaries is necessary. Some 19% indicate that benzodiazepines are easily addictive and 8% feels that doctors are directly responsible for patients' addiction, while 11.5% feels that drug peddling by doctors are common and serious.

Opinions and comments collected during the survey are compiled as in Figures 1,2 & 3. With regard to the use of benzodiazepines, the conditions quoted include anxiety neurosis, stress syndrome, and psychosomatic symptoms. It can be seen that family practitioners recognize the presence of stress as a cause leading to the presentation of patients to them. It also appears that somatic symptoms regarded by family practitioners to be of psychological origin are common.

Palpitation and low back pain have been quoted as examples of such conditions. Family practitioners regard the effects of benzodiazepines to calm the suffering from stress, emotional instability and to calm fear. They regard the medicine to be very useful for psychosomatic symptoms.

Maybe it is related to the format of the survey and its limitation, no mention has been made about the significance of psychosocial interventions in the management of patients with the conditions mentioned. It is important for a condition caused by psychological factors or other stresses to be helped with psychological treatments and that stresses need to be removed or impacts reduced. Medicine, if indicated at all, plays only a facilitatory role of temporary symptomatic relief of anxiety and insomnia.

As to the comments on the misuse of benzodiazepines, it is noted that comments are made on the use of benzodiazepines in the private sector as being very common and that money is an issue in the misuse. It is also noted of the comment on "Last money in the transitory period'.

Comments on the proposed guidelines are shown in Figure 2. It may be debatable whether the Guidelines as proposed are very restrictive and disadvantageous towards correct treatment and the doctor-patient relationship. The feelings of restriction and control on treatment of patients are expressed. It is further expressed that general practitioners are stepped on by specialists. How the Guidelines on the use of certain medicines that apply to all medical practitioners is perceived as an instrument of one group of doctors fighting on another group is thought provoking and worrying. Medical practice is based on scientific evidences. As discussed above on the issue of use or misuse, there may be unsettled issues on the expected sources of updated scientific data and their interpretation. Yet the allegation that the Guidelines is a step on the general practitioners and to weaken their strength is perhaps less a reflection of differing views on the interpretations of scientific data, but more a reflection of tension and stress on the part of some general practitioners.

Comments on the use of benzodiazepines by general practitioners as in Figure 3 serve as very good points of reflection to the current clinical practice and the working relationship between the general practitioners and the psychiatrists. It is well recognised that majority of patients with minor psychiatric disorders are seen in the family practice setting by family practitioners. Psychiatrists only see a small proportion of these patients when they are referred to them by family practitioners. In Hong Kong there is no such need of the formality of referral to a psychiatrist in the private sector. Patients with different degrees of psychiatric disorder may go to see a psychiatrist directly. On the other hand, there is no definite delineation of the sorts of patients a medical practitioner may or may not see in the private sector. Thus a family practitioner or a specialist of various specialties may manage whatever patient who come to see him. Expertise may thus be built up in the management of patients with minor psychiatric disorder by family practitioners through education, training, research and development. It may be a question to answer whether a psychiatrist is in a position to comment on the appropriate management of a patient with minor psychiatric illness in the setting of family practice. It is known that conjoint efforts have been made abroad between the family practitioner and the psychiatrist in the training, research and management of patients in the setting of family practice.

That a patient may become more worried should his family practitioner initiates to refer him to a psychiatrist may happen in Hong Kong. It reflects the underlying misunderstanding about psychiatric illness and the role of a psychiatrist. It, of course, also reflects the stigma against the mentally ill and thus the worry and fear when one is suspected to have psychiatric illness and the need to see a psychiatrist. One has to hope that there is no similar misunderstanding and stigma against the mentally ill among the medical professionals. The work to reduce the stigma against the mentally ill requires the conjoint efforts of all medical professionals. The comments on the public psychiatric clinics need to be clarified. If these have been misunderstanding, it may be helpful to see how these have occurred and how the misunderstanding can be corrected. That psychiatrists prescribe long term anxiolytic drugs to their patients need to be researched into. Whether there is such a group of patients requiring long term anxiolytics and whether they still require such. It is fair to refer a patient back to his family practitioner should he be deemed as stable without further need of expert psychological treatment. In fact, if a psychiatrist acts as a consultant to a family practitioner, after seeing a patient referred from a family practitioner, he should refer the patient back to the family practitioner when the psychiatrist deems that he has finished his job.

The comment that patients cannot afford to see psychiatrists financially worth clarification. The public service is open to serve the needy and finance should not bar a patient from receiving adequate treatment. There has not been any survey on the charges of psychiatric consultation and treatments in Hong Kong in the private sector. It may be helpful if such a survey can be done to indicate what the average and reasonable consultation charges may be to dispel any misunderstanding about the affordability of seeing a psychiatrist because of finance.

The response from the President of the Hong Kong Medical Association was 'Need not fear', 'the guidelines are just reasonable clinical practice', and 'there is no mention of psychiatrists'. The issues, as you know are not yet settled. Unfortunately the Dangerous Drugs issue has become an area of concern in the current election of office bearers of the Hong Kong Medical Association.

Research has yet to be done on the prevalence of long teni: use and dependence on benzodiazepines locally. Education of the public including an official information leaflet on the appropriate uses and risks of benzodiazepines has yet to be arranged.

ISSUES REFLECTED IN THESE PROFESSIONAL CONTROVERSIES

Clinical practice changes with time and advancement of scientific knowledge. Good practice twenty years ago may not have been appropriate now. Guidelines now may have been outdated long before twenty years later.

There are overlap of clientele between practitioners of different disciplines. In the use of benzodiazepines, whether a psychiatrist is in a position to comment on the management of patient in the setting of family practice is for further consideration. There is lack of communication among medical professionals, not to mention the lack of conjoint research.

As seen from some of the comments above, general practitioners are feeling the pressure of changes in the community. There are grievances that things are not the same as before.

That a patient can seek consultation of a practitioner at his clinic and obtain his prescription in the same clinic is of much convenience to the patient. It may, however, foster a misconception on a patient that he is paying for the medicine he obtains. A patient may not learn that he need to pay for the consultation and the consultation worth money more than the medicine he has been supplied. There may be also a tendency for a medical practitioner to charge more as he prescribes more medicine. Whether the current practice of a clinic serving simultaneously as a dispensary is a healthy arrangement warrants further consideration of the medical professionals.

The benzodiazepines issue also reflects in part that private practice is no longer as rewarding as in the past. The previous relationship between the public and the private health care services has been changed. The public service used to be limited and the private sector was to cover what had not been provided. Now that the public service has been progressively expanded while the number of medical practitioners in private sector has remained high, the balance between the public and the private sector in the proportion of patients each serves has changed. More pressure is thus put on private practitioners. At the same time, the private medical service has never been organized. There is no planning of the number of private practitioners required in individual districts. There is no planning of the proportion of practitioners of various specialties in the private sector. Medical practitioners, be they from public sector or private sector, are in a way resources of a society. They need to be appropriately organized to serve the need of the society. Wastage of the manpower and time of a medical practitioner is in a way wastage of the resources of the society. With the fast growing expansion of the Hospital Authority, the likelihood of further expansion of services of the Department of Health, and the ever increasing number of medical graduates from both medical schools in Hong Kong, it is necessary that the whole health care system need to be planned and organized with proper roles accorded to each individual medical practitioner, public and private included.

Benjamin Lai, MBBS(HK), MRCPsych, DIP. PSYCHOTHERAPY(IABMCP), FHKCPsych, FHKAM(PSYCH) Psychiatrist, St. Teresa Hospital, Psychiatrist, Hong Kong Christian Service, Hon. Consultant Psychiatrist, PS 33, Consultant Psychiatrist,
Adventist Hospital, Tsuen Wan. Rm 504, Belgian Baank Building, 721 Nathan Road ,Mongkok, Hong Kong.

*This paper is presented in the scientific symposium on "Benzodiazepines Controversies: from use to abuse" organized by the Hong Kong College of Psychiatrists on 12 June 1996.