Elsevier

Social Science & Medicine

Volume 62, Issue 5, March 2006, Pages 1237-1249
Social Science & Medicine

Views of general practitioners and benzodiazepine users on benzodiazepines: A qualitative analysis

https://doi.org/10.1016/j.socscimed.2005.07.016Get rights and content

Abstract

Effectively assisting benzodiazepine users to cease use requires a greater understanding of general practitioners’ (GPs) and benzodiazepine users’ views on using and ceasing benzodiazepines. This paper reports the findings from a qualitative study that examined the views of 28 GPs and 23 benzodiazepine users (BUs) in Cairns, Australia. A semi-structured interview was conducted with all participants and the information gained was analysed using the Consensual Qualitative Research Approach, which allowed comparisons to be made between the views of the two groups of interviewees. There was commonality between GPs and BUs on reasons for commencing benzodiazepines, the role of dependence in continued use, and the importance of lifestyle change in its cessation. However, several differences emerged regarding commencement of use and processes of cessation.

In particular, users felt there was greater need for GPs to routinely advise patients about non-pharmacological management of their problems and potential adverse consequences of long-term use before commencing benzodiazepines. Cessation could be discussed with all patients who use benzodiazepines for longer than 3 months, strategies offered to assist in management of withdrawal and anxiety, and referral to other health service providers for additional support. Lifestyle change could receive greater focus at all stages of treatment.

Introduction

Benzodiazepines are very widely prescribed (Higgins, Cooper-Stanbury, & Williams, 2000), particularly for anxiety and insomnia (Lader, 1999), but also for a range of other somatic symptoms and emotional problems (King, Gabe, Williams, & Rodrigo, 1990). Prescribing benzodiazepines has been seen as sound practice when used short-term, having few side effects and high safety (Spinks, Bulbeck, Del Mar, Glaziou, & Nikles, 2000). However, benzodiazepines also have high potential for dependence (Kan, Breteler, & Zitman, 1997). The Australian National Health Survey (1995) (Australian Bureau of Statistics, 1999) found that 58% of 359,300 benzodiazepine users had used them for 6 months or more, and a study of 15 UK general practices found that 84% of 3234 patients continued use for at least 8 months (Holden, Hughes, & Tree, 1994).

Cormack and Howells (1992) contrasted prescribing practices of high and low benzodiazepine prescribers. High prescribers reported that patients expected prescriptions and had no desire to increase psychological skills. Low prescribers said there was scope for non-prescription approaches, and were doubtful about the usefulness of benzodiazepines. Providing patients with alternate treatments at initial presentation (e.g. problem solving training) results in similar improvements to benzodiazepines after 7 months (Catalan et al., 1991). However, while GPs’ reported first-line therapies for anxiety and insomnia may include relaxation therapy, counselling and stress management, many patients are unwilling to try these and are resistant to counselling referral (Linden, Baer, & Geiselmann, 1998).

Qualitative studies of BUs find that less than 50% regard their medication as helpful (King et al., 1990). Continued use is often attributed to difficulties associated with stopping (e.g. sleeplessness, persistent anxiety, fear of withdrawal symptoms; Barter & Cormack, 1996; Iliffe et al., 2004). A naturalistic study found that 59% of users felt markedly or moderately helpless to solve their benzodiazepine problem. Cessation of use is assisted by ongoing support from GPs or other health professionals and from friends or relatives (Ashton, 1994). Common strategies to cease benzodiazepines include monitoring intake, setting reduction targets, attending self-help groups, and finding out about benzodiazepine dependence (Spiegel, 1999).

This paper describes a qualitative study of GPs and benzodiazepine users to gain more detailed understanding of perceptions relating to starting, continuing and stopping benzodiazepine use. It examines the degree of similarity between these perceptions.

Section snippets

Participants

Semi-structured face-to-face interviews were conducted with GPs and users in the tropical holiday and regional centre of Cairns, Australia and surrounding rural districts. Recruitment continued until respondents reflected a range of locations, and no new information emerged. GP recruitment strategies included Divisional newsletters, flyers at workshops, and individual faxes. Users had at some time been prescribed daily benzodiazepines for 3 months or more. Users’ recruitment was through

GPs

Thirty-six GPs were approached to take part, and 28 (78%) agreed. Sending faxes to GPs was the most successful strategy with 19 respondents, representing 70% response rate. There were 20 male and 8 female GPs, of whom 22 were from group practices, 2 from solo practices and 4 from other settings. Time in general practice averaged 14 years (Range=6 months—35 years, with only one GP in practice less than 12 months). Fifteen were from the Cairns area, nine were within an hour's drive, and four 5 h

Discussion

The primary reason for benzodiazepine users presenting to GPs was difficult life events, whereas GPs identified acute/stressful situations as the primary reason for prescribing. Both GPs and users identified sleep and mental health problems as other reasons for benzodiazepine use. Prescribing the drug was also more likely to occur when patients presented in a distressed state. Alternatives such as providing counselling or referral to other services were not routinely offered to patients,

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    In our study, multiple participants reported that they would be open to deprescribing their benzodiazepine, if the idea were brought up by their prescriber. This aligns with work by Parr et al.27 who found that adults who stop benzodiazepines make that decision on the basis of a suggestion by a PCP or family member.28 However, there is a long-standing history of inadequate communication between patients and physicians about benzodiazepines.

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