Professor Ashton has fully endorsed my assessment which is as follows:
1. The reports recommend an 8-10 week withdrawal schedule. This completely disregards the current BNF guidelines stating that withdrawal may take up to a year. It also disregards the work of Professor Ashton. GABA receptors require a period of time in order to regain their affinity for GABA and abrupt withdrawals do not allow this process to take place and lead to acute and protracted withdrawal symptoms. This practice is also not consistent with the NHS Clinical Knowledge Summaries provided for doctors’ guidance and based on Professor Ashton’s work.
The reports also state that ‘there is ‘no optimum rate for tapering or duration’. How can they therefore recommend 8-10 week withdrawal schedules if they are also saying they do not know what an optimum rate or duration is?
2. The reports further recommend a cut-off point of a maximum of 6 months for benzo withdrawal. This is not consistent with the recommended rate of withdrawal in the NHS CKS which is 10% of the total dose every two weeks or so and has to be flexible and under the patient’s control. For instance, many patients are on between 10 to 30 mgs of diazepam per day (or the equivalent in other benzos) and 6 months would only allow a tapering of 5mg. To suggest a ceiling of 6 months, and therefore a much quicker rate of withdrawal, would inevitably lead to many people being damaged by acute and protracted withdrawals.
Why do they think these are appropriate recommendations?
3. The reports state that they are unable to assess the scale of the problem even though this was one of the review’s prime objectives.
4. The reports state that long term use is appropriate for recurrent anxiety. This is again contradictory to the BNF guidelines advising that use should be restricted to 2 to 4 weeks, and to evidence that not only are benzos not effective as anxiolytics after a few months but that they also cause the very symptoms they are prescribed to treat, including anxiety and other withdrawal symptoms, as tolerance occurs.
5. The reports state that withdrawal symptoms do not occur for 2-3 days in short acting benzos, when in reality they can occur after only a few hours e.g. lorazepam has a half life of 8-20 hours. Therefore people on short acting benzodiazepines need regular doses thrice daily I order to avoid inter-dose withdrawal symptoms. This is a very basic error and further demonstrates a complete lack of knowledge of the subject.
6. The reports assert that there is no evidence of anatomical or functional damage after long term use. The reason for this is that the little research that has been carried out has either been ignored or not followed up; even the MHRA concede that more research is required. The reports have failed to fulfil the promise to address Professor Malcolm Lader’s 1980 studies showing that 7 out of 14 patients on Benzos had brain damage.
7. The reports state that there are no problems associated with withdrawal from zolpidem or zalepon. In fact, z drugs work on benzodiazepine receptor sites and have the same inherent withdrawal reactions, as reported by the few charities offering withdrawal support.
What scientific evidence do they have to support this statement?
8. The report does not include Clonazepam (589,200 prescriptions 2009/10 Hansard [31600]. The reason they give is that it is indicated for epilepsy and is assumed not to be prescribed for anxiety or insomnia and therefore would distort the figures. This is despite the fact that it is known to have been widely mis-prescribed for other indications including insomnia and muscle spasms and is twenty times stronger than diazepam and has caused addiction and long term damage.
As their assumption is wrong, Clonazapem should be included in their statistics.
9. The report is full of misleading statistics; for example it asserts ‘32,510 people in drug treatment who reported problems with prescription or over-the-counter medicines only 3,735 were not also using illegal drugs’. This implies that the scale of the problem, which they say elsewhere in the report that they cannot quantify, is only a few thousand people who are not also on opiates. The 1.5 million prescribed benzodiazepine addicts estimated by Professor Ashton in 2001 would not be in ‘drug treatment’ but remain hidden and under ‘treatment’ by their GPs.
10. The reports state that patients have no difficulty finding local help. In reality there is little help available and the few charity help-lines remain inundated. GPs have nowhere to obtain expert help for their patients. The report repeatedly refers to drug treatment centres but does not specify which centres they are referring to making their inclusion meaningless.
Also, an objective of the report was to conduct an audit of specialist help. Some of these have still not been contacted e.g. The Bristol and District Tranquiliser Project.
11. The reports have mixed up opiates, benzodiazepines and codeine products in the same statistics and presentations. This has resulted in pages of charts confusing iatragenic and illicit drug problems and disguising the failure to quantify the number of patients addicted to prescribed benzodiazepines or to provide an appropriate action plan.
In conclusion the recommendations about the rate and duration of tapering are not based on current guidelines. Serious harm, long term damage, great suffering and suicides are reported by tranquilliser support charities. Many more of these will be inevitable if these recommendations are followed.
John Perrott