Weatherford Democrat

April 21, 2013

VETERANS' CORNER: Many vets with PTSD still prescribed benzodiazepines


Weatherford Democrat

— By JIM VINES

Department of Veterans Affairs doctors are continuing to prescribe tranquilizers such as Valium and Xanax to veterans diagnosed with post-traumatic stress disorder, despite VA guidelines advising against their use for the condition.

Almost a third of veterans being treated for PTSD are prescribed benzodiazepines, a class of sedatives commonly used to treat insomnia, anxiety, seizures and other conditions.

Researchers found that benzodiazepine prescriptions by VA doctors for PTSD patients declined from 37 percent to 30 percent between 1999 and 2009, but it remained at 30 percent through 2012. The VA health care system experienced a huge increase in the number of veterans being treated for PTSD, increasing three-fold in 10 years to about a half million patients in 2009.

Benzodiazepines have been around since the 1960s, when they became the sedative of choice and replaced barbiturates, which carried a high risk of overdose and abuse. Benzodiazepines has become the preferred PTSD drug treatment because of their usefulness in managing anxiety and insomnia.

The current clinical practice guidelines for managing PTSD, co-authored by the VA and Department of Defense, caution medical providers against using benzodiazepines due to lack of data and growing evidence for the potential risk of harm. Studies, however, have not shown benzodiazepines as effective treatment for what are called the core PTSD symptoms of avoidance, hyper arousal, numbing and dissociation. In fact, the drugs may impede other effective treatments for PTSD. Mounting evidence suggests that the long-term harms imposed by benzodiazepine use outweigh any short-term symptomatic benefits in patients with PTSD.

Studies that compared the use of a benzodiazepine called Alprazolam and a placebo for alleviating PTSD symptoms found the slight reduction of anxiety was offset by withdrawal symptoms after just five weeks of use. The use of benzodiazepines is especially problematic in PTSD patients who also have substance-abuse disorders or mild traumatic brain injuries. The DOD/VA guidelines especially caution their use with patients suffering from combat related PTSD because more than half of such patients abuse alcohol or drugs. Once initiated, benzodiazepines can be very difficult, if not impossible, to discontinue due to significant withdrawal symptoms compounded by the underlying PTSD symptoms. 

Most of the VA prescriptions for benzodiazepines for PTSD patients are made by mental health providers  rather than primary care physicians, who should be more aware of the VA/DOD guidelines, according to a study published March in the journal Psychiatric Services. The study analyzed VA prescription records from 2009 of 357,000 veterans with PTSD. Findings also suggest that these particular providers contribute considerably to the misalignment between guideline based care and actual practice.

This study did not determine the causes of such misalignment but offered a few possible reasons. Many mental health providers inherit patients who previously received benzodiazepines from other clinicians, creating an immediate tension as the clinician seeks to balance individual patient factors with the need to provide guideline supported care. Further studies are needed to determine whether the high prescription rates for benzodiazepine are due to ignorance.

The majority of PTSD patients in the study were Vietnam War era veterans, who perhaps began taking benzodiazepines years before guidelines were in place. Newer studies involving Iraq and Afghanistan veterans are in the works.

For all concerns, contact a VA Regional Medical Center or personal physician. Speak to you again next week.

Jim Vines is commander of AmVets Post 133.