92% of MEDEX
graduates in the employed in full-time practice settings, most in the private
country
are
sector, and 98% Letters, if clearly marked "For Publication," will be published as space permits and at the
discretion of the editor. They should be typewritten triple-spaced, with five or fewer refer¬ ences, should not exceed two pages in length, and will be subject to editing. Letters are not
acknowledged.
Withdrawal of
Diazepam
To the Editor.\p=m-\Severalletters within the past year have expressed concern about the overprescription of di-
azepam (229:521, 1974; 230:375, 1974). Recent clinical experience has convinced me that this concern is justified. The manufacturers' literature warns of physical addiction to diazepam or other benzodiazepines, mainly with excessive doses. However, I have seen several patients experiencing barbiturate-type withdrawal symp-
toms after four to six months of
diazepam therapy in doses as low as 15 mg/day. Symptoms such as tremors, agitation, fearfulness, stomach cramps, and sweating made patients extremely uncomfortable, but dangerous reactions, such as convulsions, did not occur. All of these patients had been admitted to a psychiatric hospital for depression. They were generally reluctant to stop using diazepam, but when the symptoms subsided after two to four weeks, they were usually happy to be free of medication. (Interestingly, these patients tolerated tricyclic anti-
depressants poorly.) The possibility of physical
addiction to nonexcessive doses of the benzodiazepines has some support from the research literature. Covi et al1 re¬ ported "a minor abstinence syndrome of the barbiturate type following the abrupt withdrawal of chlordiazepoxide administered in therapeutic doses for periods longer than 16 weeks." In a previous study at the same labora¬ tory, patients showed an increase in symptoms after 10 to 14 weeks of therapy with a fixed dose of chlordiazepoxide,2 the type of tolerance well known with addictive drugs such as the barbiturates. Metabolic and pharmacodynamic studies have dem¬ onstrated that diazepam is metabo¬ lized at a faster rate after six weeks, with larger doses being required to maintain the same blood levels be¬ yond that time.3 " This phenomenon Edited
by John D. Archer, MD, Senior Editor.
of a drug catalyzing its own destruc¬ tion after a period of time is well known with the barbiturates. How¬ ever, with the benzodiazepines there is a very wide variation of blood lev¬ els, metabolism and tissue accumula¬ tion (perhaps unlike the barbiturates) among individuals, which may influ¬ individual susceptibility to ence addiction. Though addiction to di¬ azepam may develop in only a small percentage of patients, it is so
abundantly prescribed (225:1637, 1973), that a large number of people may be affected. Also, the possibility of depression after prolonged diaze¬
pam treatment, as reported in an¬ other letter (226:1572, 1973), under¬ scores the need for further study and caution with this drug. David Haskell, MD Boston University School of Medicine Boston
L, Lipman RS, Pattison JH, et al: Length of anxiolytic sedatives and response to their sudden withdrawal. Acta Psychiatr Scand 49:51-64,1973. Covi Park 2. LC, Lipman RS, et al: Factors affectL, ing withdrawal response to certain minor tranquilizers, in Cole JO, Wittenborn JR (eds): Drug Abuse: Social and Psychopharmacological Aspects. Springfield, Ill, Charles C Thomas Publisher, 1969, pp 93-108. 3. Kanto J, Iisalo E, Lehtinen V, et al: The concentrations of diazepam and its metabolites in the plasma after an acute and chronic administration. Psychopharmacologia 36:123-131,1974. 4. Zingales IA: Diazepam metabolism during chronic medication: Unbound fraction in plasma, erythrocytes and urine. J Chromatogr 75:55-78, 1973. 1. Covi
treatment with
MEDEX\p=m-\FiveYears Later To the Editor\p=m-\Initiatedin 1969 at the University of Washington School of
Medicine, the MEDEX system of training and deploying physician extenders into areas of need has quietly surpassed all expectations. By having
practicing physicians, medical associations, and medical faculties work closely in collaboration with the programs, the concept has produced nine medical school regional training centers that are training MEDEX students for 34 states. David Lawrence (MEDEX/Northwest in Seattle) and William Wilson (MEDEX/Utah) have submitted an article for publication that describes in addition:
are
in the field of
medicine.
Nearly 90% of MEDEX graduare working with primary care physicians, most of whom (76%) are family physicians. Seventy percent of MEDEX graduates are employed in towns under 20,000 in size; most gradates
uates are in towns of less than 10,000. The two MEDEX programs oriented to urban care have been equally suc¬
cessful in placing graduates into underserved urban settings. • While most graduates are male (since the programs initially empha¬ sized retraining of returning military corpsmen), there is a distinct trend to include more women, particularly from nursing, in classes now in train¬ ing (eg, nurses comprise one third of the present MEDEX/Northwest class). Patient acceptance as well as physician acceptance of MEDEX graduates has been uniformly high. • Productivity gains of 20% to 50% have been noted in MEDEX/physician practices as a result of the intro¬ duction of the MEDEX system. As a consequence of the MEDEX approach as it has been evolved by the programs, but more to the credit of the MEDEX graduates themselves, are the results of last December's Pri¬ mary Care Physician's Assistants Certifying Examination adminis¬ tered by the National Board of Medi¬ cal Examiners. The MEDEX gradu¬ ates' scores averaged higher than those of graduates of similar programs. This is in spite of the fact that the one-year MEDEX training is only one-half to one-quarter the length of other programs. The MEDEX model is set apart from other programs training new health service providers. The MEDEX model trains physicians to delegate tasks to MEDEX graduates, in addi¬ tion to providing competency-based training for the MEDEX students themselves. As important, MEDEX is unique in that its deployment mecha¬ nism has produced dramatic results in terms of placement of qualified grad¬ uates into areas of medical need. The recent review of physician-extender programs by the US Government Ac¬ counting Office (B-164031[5] "Train¬ ing, Placement and Use of Assistants to the Primary Care Physician") sub¬ stantiates this view. It appears that an even more sig¬ nificant phenomenon is occurring
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
'
graduates in the employed in full-time practice settings, most in the private
country
are
sector, and 98% Letters, if clearly marked "For Publication," will be published as space permits and at the
discretion of the editor. They should be typewritten triple-spaced, with five or fewer refer¬ ences, should not exceed two pages in length, and will be subject to editing. Letters are not
acknowledged.
Withdrawal of
Diazepam
To the Editor.\p=m-\Severalletters within the past year have expressed concern about the overprescription of di-
azepam (229:521, 1974; 230:375, 1974). Recent clinical experience has convinced me that this concern is justified. The manufacturers' literature warns of physical addiction to diazepam or other benzodiazepines, mainly with excessive doses. However, I have seen several patients experiencing barbiturate-type withdrawal symp-
toms after four to six months of
diazepam therapy in doses as low as 15 mg/day. Symptoms such as tremors, agitation, fearfulness, stomach cramps, and sweating made patients extremely uncomfortable, but dangerous reactions, such as convulsions, did not occur. All of these patients had been admitted to a psychiatric hospital for depression. They were generally reluctant to stop using diazepam, but when the symptoms subsided after two to four weeks, they were usually happy to be free of medication. (Interestingly, these patients tolerated tricyclic anti-
depressants poorly.) The possibility of physical
addiction to nonexcessive doses of the benzodiazepines has some support from the research literature. Covi et al1 re¬ ported "a minor abstinence syndrome of the barbiturate type following the abrupt withdrawal of chlordiazepoxide administered in therapeutic doses for periods longer than 16 weeks." In a previous study at the same labora¬ tory, patients showed an increase in symptoms after 10 to 14 weeks of therapy with a fixed dose of chlordiazepoxide,2 the type of tolerance well known with addictive drugs such as the barbiturates. Metabolic and pharmacodynamic studies have dem¬ onstrated that diazepam is metabo¬ lized at a faster rate after six weeks, with larger doses being required to maintain the same blood levels be¬ yond that time.3 " This phenomenon Edited
by John D. Archer, MD, Senior Editor.
of a drug catalyzing its own destruc¬ tion after a period of time is well known with the barbiturates. How¬ ever, with the benzodiazepines there is a very wide variation of blood lev¬ els, metabolism and tissue accumula¬ tion (perhaps unlike the barbiturates) among individuals, which may influ¬ individual susceptibility to ence addiction. Though addiction to di¬ azepam may develop in only a small percentage of patients, it is so
abundantly prescribed (225:1637, 1973), that a large number of people may be affected. Also, the possibility of depression after prolonged diaze¬
pam treatment, as reported in an¬ other letter (226:1572, 1973), under¬ scores the need for further study and caution with this drug. David Haskell, MD Boston University School of Medicine Boston
L, Lipman RS, Pattison JH, et al: Length of anxiolytic sedatives and response to their sudden withdrawal. Acta Psychiatr Scand 49:51-64,1973. Covi Park 2. LC, Lipman RS, et al: Factors affectL, ing withdrawal response to certain minor tranquilizers, in Cole JO, Wittenborn JR (eds): Drug Abuse: Social and Psychopharmacological Aspects. Springfield, Ill, Charles C Thomas Publisher, 1969, pp 93-108. 3. Kanto J, Iisalo E, Lehtinen V, et al: The concentrations of diazepam and its metabolites in the plasma after an acute and chronic administration. Psychopharmacologia 36:123-131,1974. 4. Zingales IA: Diazepam metabolism during chronic medication: Unbound fraction in plasma, erythrocytes and urine. J Chromatogr 75:55-78, 1973. 1. Covi
treatment with
MEDEX\p=m-\FiveYears Later To the Editor\p=m-\Initiatedin 1969 at the University of Washington School of
Medicine, the MEDEX system of training and deploying physician extenders into areas of need has quietly surpassed all expectations. By having
practicing physicians, medical associations, and medical faculties work closely in collaboration with the programs, the concept has produced nine medical school regional training centers that are training MEDEX students for 34 states. David Lawrence (MEDEX/Northwest in Seattle) and William Wilson (MEDEX/Utah) have submitted an article for publication that describes in addition:
are
in the field of
medicine.
Nearly 90% of MEDEX graduare working with primary care physicians, most of whom (76%) are family physicians. Seventy percent of MEDEX graduates are employed in towns under 20,000 in size; most gradates
uates are in towns of less than 10,000. The two MEDEX programs oriented to urban care have been equally suc¬
cessful in placing graduates into underserved urban settings. • While most graduates are male (since the programs initially empha¬ sized retraining of returning military corpsmen), there is a distinct trend to include more women, particularly from nursing, in classes now in train¬ ing (eg, nurses comprise one third of the present MEDEX/Northwest class). Patient acceptance as well as physician acceptance of MEDEX graduates has been uniformly high. • Productivity gains of 20% to 50% have been noted in MEDEX/physician practices as a result of the intro¬ duction of the MEDEX system. As a consequence of the MEDEX approach as it has been evolved by the programs, but more to the credit of the MEDEX graduates themselves, are the results of last December's Pri¬ mary Care Physician's Assistants Certifying Examination adminis¬ tered by the National Board of Medi¬ cal Examiners. The MEDEX gradu¬ ates' scores averaged higher than those of graduates of similar programs. This is in spite of the fact that the one-year MEDEX training is only one-half to one-quarter the length of other programs. The MEDEX model is set apart from other programs training new health service providers. The MEDEX model trains physicians to delegate tasks to MEDEX graduates, in addi¬ tion to providing competency-based training for the MEDEX students themselves. As important, MEDEX is unique in that its deployment mecha¬ nism has produced dramatic results in terms of placement of qualified grad¬ uates into areas of medical need. The recent review of physician-extender programs by the US Government Ac¬ counting Office (B-164031[5] "Train¬ ing, Placement and Use of Assistants to the Primary Care Physician") sub¬ stantiates this view. It appears that an even more sig¬ nificant phenomenon is occurring
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
'
