Pain, 41 (1990) 3-4 Elsevier PAIN 01590
Benzodiazepines and chronic pain Steven A. King a and James J. Strain b uPain
Management Service, Departments of Anesthesiology and Psychiatry, Mount Sinai School of Medicine,New York, NY (U.S.A.), and b Division of Beh~ivra~ medicine and Consultation Psyc~iat~, Mount Sinai School of Medicine, New York, NY (U.S.A.)
(Received 15 December 1989, accepted 21 December 1989)
Drug misuse and abuse are issues of vital importance for those who treat patients with pain. Practitioners in this field face the problem of preventing under medication secondary to myths about the abuse potential of drugs while, at the same time, needing to recognize the very real difficulties experienced by patients because of over-prescription. While there has been much debate about the appropriate use of narcotics for chronic pain patients, another commonly used class of medications, sedative/ hypnotics especially the benzodiazepines, has received little attention. The few studies that have focused on their use have found that chronic pain patients in the United States are 3-4 times as likely to be using be~odi~epines as the general population [5,7,9,11,12]. Furthermore, once treatment is initiated, it is continued for longer periods than among non-pain patients [6,7]. Because chronic pain patients often report difficulty sleeping, it is not surprising that these medications are commonly prescribed to alleviate this problem [2,10]. They are also often employed as muscle relaxants f6], However, their frequent prescription is disturbing for several reasons. The benzodiazepines are not innocuous drugs. They are addicting and their sudden discontinuation can result in serious withdrawal reactions [3]. They can produce a variety of side effects, most notably
Correspondence to: Steven A. Kin& M.D., Pain Management Service, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1192, New York, NY 10029, U.S.A.
0304-3959/90/$03.50
sedation, imp~rments in cognition, and depression, all of which interfere with the common goal of chronic pain management programs to increase the activity of the patient. Perhaps the issue of greatest concern is that not only do these medications offer minimal benefits, if any, to chronic pain patients, but in some patients they may even exacerbate pain [4,8]. Furthermore, those patients who are abusing other medications are most likely to be at risk for abusing and becoming dependent upon benzodiazepines [l]. Specifically, chronic pain patients prescribed benzodiazepines and who are also using narcotics concurrently may be at an increased risk of developing a substance dependency. As with narcotics, it is essential that the appropriate use of the benzodiazepines for the treatment of chronic pain be determined. Many questions remain: (I) Are there patients who do benefit from their use? (2) Which of the benzodiazepines are most efficacious for these patients? (3) At what point does use become abuse? (4) To what extent do these medications contribute to the depression experienced by many chronic pain patients and the pain itself? (5) When, if ever, is long-term treatment indicated? Since other non-pain groups are attempting to formulate policy for the use of benzodiazepines, it would seem important for those most closely working with chronic pain to also influence the decision making process. For example, the American Psychiatric Association’s Task Force on Benzodiazepine Dependency is in the process of submitting its final report [l]. An increasing num-
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
4
ber of governmental agencies in the United States are also turning their attention to benzodiazepine use; in New York State a law requiring that prescriptions for benzodiazepines be written on the same triplicate forms as narcotics recently went into effect. It is vital that clinicians with training and experience with chronic pain patients have input as to how benzodiazepines can and will be best employed. Additional studies need to be undertaken before policy formulated from rigorous research findings can be promulgated.
References Adams, J.E., News from the council on research: task force on benzodiazepine dependency, Psychiat. Res. Rep., 4 (1989) 3. Atkinson, J.H., Ancoli-Israel, S., Slater, M.A., Garfin, S.R. and Gilhn, J.C., Subjective sleep disturbance in chronic back pain, Clin. J. Pain, 4 (1988) 225-232. Greenblatt, D.J., Shader, R.I. and Abemethy, D.R., Current status of benzodiazepines, New Engl. J. Med., 309 (1983) 410-416.
4 Haefely, W.. The biological basis of benzodiazepine actions. In: D.E. Smith and D.R. Wesson (Eds.), The Benzodiazepines: Current Standards for Medical Practice. MTP Press, Lancaster, 1985, pp. 7741. 5 Hendler. N.. Cimini, C., Ma. T. and Long, D.. A comparison of cognitive impairment due to benzodiazepines and 10 narcotics, Am. J. Psychiat.. 137 (1980) 828-830. 6 Hollister, L.E., Conley, F.K.. Britt, R.H. and Shuer, L.. Long-term use of diazepam, JAMA. 246 (1981) 1568-1570. 7 King, S.A. and Strain. J.J., Benzodiazepine use by chronic pain patients, in prep. 8 Mantegazza, D., Tammiso, R., Vincentini, L., Zambotti, F. and Zonta. N., The effects of GABAergic agents on opiate analgesia. Pharmacol. Res. Commun., 12 (1980) 239-247. Mellinger, G.D.. Balter, M.B. and Uhlenhuth. E.H.. Prevalence and correlates of long-term regular use of anxiolytics, JAMA. 251 (1984) 3755379. Piiowsky, I., Crettenden. I. and Townley, M., Sleep disturbance in pain clinic patients, Pain, 23 (1985) 27-33. Turner, J.A., Calsyn. D.A., Fordyce. W.E. and Ready, L.B.. Drug utilization patterns in chronic pain patients, Pain, 12 (1982) 3577363. Ziesat. H.A.. Angle, H.V.. Gentry, W.D. and Ellinwood, E.H., Drug use and misuse in operant pain patients. Addict. Behav.. 4 (1979) 263-266.
Benzodiazepines and chronic pain Steven A. King a and James J. Strain b uPain
Management Service, Departments of Anesthesiology and Psychiatry, Mount Sinai School of Medicine,New York, NY (U.S.A.), and b Division of Beh~ivra~ medicine and Consultation Psyc~iat~, Mount Sinai School of Medicine, New York, NY (U.S.A.)
(Received 15 December 1989, accepted 21 December 1989)
Drug misuse and abuse are issues of vital importance for those who treat patients with pain. Practitioners in this field face the problem of preventing under medication secondary to myths about the abuse potential of drugs while, at the same time, needing to recognize the very real difficulties experienced by patients because of over-prescription. While there has been much debate about the appropriate use of narcotics for chronic pain patients, another commonly used class of medications, sedative/ hypnotics especially the benzodiazepines, has received little attention. The few studies that have focused on their use have found that chronic pain patients in the United States are 3-4 times as likely to be using be~odi~epines as the general population [5,7,9,11,12]. Furthermore, once treatment is initiated, it is continued for longer periods than among non-pain patients [6,7]. Because chronic pain patients often report difficulty sleeping, it is not surprising that these medications are commonly prescribed to alleviate this problem [2,10]. They are also often employed as muscle relaxants f6], However, their frequent prescription is disturbing for several reasons. The benzodiazepines are not innocuous drugs. They are addicting and their sudden discontinuation can result in serious withdrawal reactions [3]. They can produce a variety of side effects, most notably
Correspondence to: Steven A. Kin& M.D., Pain Management Service, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1192, New York, NY 10029, U.S.A.
0304-3959/90/$03.50
sedation, imp~rments in cognition, and depression, all of which interfere with the common goal of chronic pain management programs to increase the activity of the patient. Perhaps the issue of greatest concern is that not only do these medications offer minimal benefits, if any, to chronic pain patients, but in some patients they may even exacerbate pain [4,8]. Furthermore, those patients who are abusing other medications are most likely to be at risk for abusing and becoming dependent upon benzodiazepines [l]. Specifically, chronic pain patients prescribed benzodiazepines and who are also using narcotics concurrently may be at an increased risk of developing a substance dependency. As with narcotics, it is essential that the appropriate use of the benzodiazepines for the treatment of chronic pain be determined. Many questions remain: (I) Are there patients who do benefit from their use? (2) Which of the benzodiazepines are most efficacious for these patients? (3) At what point does use become abuse? (4) To what extent do these medications contribute to the depression experienced by many chronic pain patients and the pain itself? (5) When, if ever, is long-term treatment indicated? Since other non-pain groups are attempting to formulate policy for the use of benzodiazepines, it would seem important for those most closely working with chronic pain to also influence the decision making process. For example, the American Psychiatric Association’s Task Force on Benzodiazepine Dependency is in the process of submitting its final report [l]. An increasing num-
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
4
ber of governmental agencies in the United States are also turning their attention to benzodiazepine use; in New York State a law requiring that prescriptions for benzodiazepines be written on the same triplicate forms as narcotics recently went into effect. It is vital that clinicians with training and experience with chronic pain patients have input as to how benzodiazepines can and will be best employed. Additional studies need to be undertaken before policy formulated from rigorous research findings can be promulgated.
References Adams, J.E., News from the council on research: task force on benzodiazepine dependency, Psychiat. Res. Rep., 4 (1989) 3. Atkinson, J.H., Ancoli-Israel, S., Slater, M.A., Garfin, S.R. and Gilhn, J.C., Subjective sleep disturbance in chronic back pain, Clin. J. Pain, 4 (1988) 225-232. Greenblatt, D.J., Shader, R.I. and Abemethy, D.R., Current status of benzodiazepines, New Engl. J. Med., 309 (1983) 410-416.
4 Haefely, W.. The biological basis of benzodiazepine actions. In: D.E. Smith and D.R. Wesson (Eds.), The Benzodiazepines: Current Standards for Medical Practice. MTP Press, Lancaster, 1985, pp. 7741. 5 Hendler. N.. Cimini, C., Ma. T. and Long, D.. A comparison of cognitive impairment due to benzodiazepines and 10 narcotics, Am. J. Psychiat.. 137 (1980) 828-830. 6 Hollister, L.E., Conley, F.K.. Britt, R.H. and Shuer, L.. Long-term use of diazepam, JAMA. 246 (1981) 1568-1570. 7 King, S.A. and Strain. J.J., Benzodiazepine use by chronic pain patients, in prep. 8 Mantegazza, D., Tammiso, R., Vincentini, L., Zambotti, F. and Zonta. N., The effects of GABAergic agents on opiate analgesia. Pharmacol. Res. Commun., 12 (1980) 239-247. Mellinger, G.D.. Balter, M.B. and Uhlenhuth. E.H.. Prevalence and correlates of long-term regular use of anxiolytics, JAMA. 251 (1984) 3755379. Piiowsky, I., Crettenden. I. and Townley, M., Sleep disturbance in pain clinic patients, Pain, 23 (1985) 27-33. Turner, J.A., Calsyn. D.A., Fordyce. W.E. and Ready, L.B.. Drug utilization patterns in chronic pain patients, Pain, 12 (1982) 3577363. Ziesat. H.A.. Angle, H.V.. Gentry, W.D. and Ellinwood, E.H., Drug use and misuse in operant pain patients. Addict. Behav.. 4 (1979) 263-266.
