WhatIamdoing insisted that I accept abuse from LG as given and get on with the program. So, what is wrong with this paragraph? LG reverted it three times, after each sentence as I was writing it. (Note for LG: Mind WP:TLDR and AGF. I will stop reading your argument beyond ten sentences and at the first word of abuse. Note for Eubulides and everyone: "Please ignore for a second style problems with the last view and some other grammar and style problems and concentrate on the content.")
SUGGESTED: "The data on the The effects of long-term use is contradictory. One interpretation of this data, exemplified by Ashton maintain that benzodiazepines have all the characteristic of drugs of dependence and result "in the insidious development of increasing psychological and physical symptoms." On the prolonged exposure they may worsen anxiety and cause depression, and deficits of learning, memory and attention. [1] Another view counters that "despite considerable scientific evidence that the risk of drug abuse with benzodiazepines is low, there is tremendous prejudice against their use in many individuals, in certain treatment settings, and even countries (e.g., United Kingdom)." This view argues that the short-term treatment for generalized anxiety disorder and panic disorder makes no sense as these disorders continue long-term. Its proponents assert that the current practice is to "continue treatment for 6 to 18 months before tapering and attempting discontinuation." [2] An intermediate, empirical, position advocates careful and limited use of benzodiazepines. In this view, if the prolonged treatment is necessary, the patient reports sustained benefits from a benzodiazepine and no signs of misuse are visible, there is no harm from this practice. [3]"
CURRENT:"The long-term adverse effects of benzodiazepines include a general deterioration in physical and mental health and tend to increase with time. Not everyone however, experiences problems with long-term use. The adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs. [4] [5] Additionally an altered perception of self, environment and relationships may occur. [6]
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Discussion
I've fixed the refs. Please place any comments below. WhatamIdoing ( talk) 18:15, 25 June 2009 (UTC)
Ref is not discussing long-term effects so ref is being misused to say things that aren't in citation. The statement "data is conflicting" is opinion by Sceptical Chymist and is therefore original research. I cannot agree with this original research and misuse of refs. They are only discussing long-term use. It is fine to discuss the fact other doctors believe in long-term use. This is represented in the article already and I don't oppose this. As far as the UK being "extreme" I think that it is only fair to then state how some countries eg hong kong have benzos listed as dangerous drugs and countries like Holland and several other european countries have stronger stances against benzos and then cite how America's health body publishes research connecting benzos to cancer and there is a team of doctors in America who campaign against benzos whereas this is not the case in the UK, gotta keep things in perspective. To be honest though, I think pitting America against the UK is going to lead issues unless we put it in balance by listing other countries which have stronger stances than the UK. I also think that it would worsen the article.-- Literaturegeek | T@1k? 19:41, 25 June 2009 (UTC)
You are welcome to provide citations saying that the long term effects are exagerated. I intentionally added the statement that "not everyone is effected by adverse long-term effects" one because it puts it into context, does not exagerate it and 2 because it is true. One tip as well, all of the studies into benzos which follow people up for 6 - 12 months show improvements in some measure, physical, mental health. The drug companies and regulatory bodies don't challenge this data, they just ignor it so I think it is unlikely that you will find a source that challenges it but if you find one I am not opposed to you using it. just opposed to using irrelevant refs to do a synthesis and original research is all. There are lots of good psychiatry and addiction books which discuss these long-term effects. I can provide more citations if you like.-- Literaturegeek | T@1k? 19:47, 25 June 2009 (UTC)
The problem as I see it is that Sceptical feels that NPOV policy means that refs can be misused and original research is allowed in these cases to achieve neutrality. I cannot agree to this editing practice.-- Literaturegeek | T@1k? 19:50, 25 June 2009 (UTC)
The "intermediate" position is original research and implies that clinical guidelines and systematic reviews are "extremist" thus I feel it is not me who is breaking NPOV but you. We must stick to refs and no original research. Hope this helps clarify my position.-- Literaturegeek | T@1k? 19:53, 25 June 2009 (UTC)
P.S. thanks to those who are trying to resolve this. I believe it is impossible to resolve this without outside eyes so your help is much appreciated.-- Literaturegeek | T@1k? 19:55, 25 June 2009 (UTC)
The evidence based truth is the abuse potential of benzos is "moderate" or intermediate. The abuse potential is not high and it is not low. I dunno where authors got the low stat from, never seen a review of animal and human studies which came to that conclusion. They are still commonly abused by drug misusers.-- Literaturegeek | T@1k? 21:01, 25 June 2009 (UTC)
Oh you mean conflicting with cognition, the review author in ref 6 concluded that impaired cognition did occur, so you are using primary sources within a review to come up with your own conclusions,,, but,,, this is already discussed in the cognitive section Benzodiazepine#Cognitive_effects, which I still don't fully agree with. What I am looking for is a long term follow-up study say 6 - 12 months post withdrawal which finds no improvements in physical or mental health. Do you have any refs which says data is conflicting in this regard? Reference two does not say that the data is conflicting and does not discuss long-term effects so thus I feel is original research and a misuse of a ref. I find your approach to discussing references remains combative.-- Literaturegeek | T@1k? 22:08, 25 June 2009 (UTC)
I can't access that page of the book on google books but no I am not saying that. I am saying that it means the use of the drugs is controversial because of their adverse effect profile with differing opinions on the risk-benefit ratio but equally I found a page where the author clarified his views on the controversy where he said those advocating long term use for anxiety are a minority view in the literature (he cited some authors promoting the view so he was referring to literature). Also the quote is not directly relevant to dispute long-term adverse effects of benzodiazepines on physical and mental health and whether improvements occur after withdrawal from long term use. If you disagree, I am open to how it could be used in the benzo article. I am not opposed to compromising. Let me know your thoughts. Perhaps we could add a sentence before the long-term effects saying "their is major controversy surrounding the risk benefit ratio and the incidence of long-term adverse effects of benzodiazepines." Whilst it is not discussing the long-term effects on physical mental health and whether people improve after withdrawal,,, I think it might be a borderline case of using common sense and bending the rules a little but if that is what is needed, I happy to come up with a compromise.-- Literaturegeek | T@1k? 01:54, 26 June 2009 (UTC)
It does not back up the view the "data is contradictory" but does back up the viewpoint that there is controversy over opinions of the risk benefit ratio.-- Literaturegeek | T@1k? 02:01, 26 June 2009 (UTC)
I think a compromise can be reached, see above. All I want is the sources to be accurate represented, undue weight is not used etc.-- Literaturegeek | T@1k? 02:04, 26 June 2009 (UTC)
[Edit conflict with Meodipt] I know people who use benzos and are not suffering mental or physical adverse effects from it so I admit and know for a fact that people do exist who do not suffer adverse effects due to long-term use. They may be "functionally" dependent on the drug but it does them no psychological or physical harm. The main thing though is to focus on reliable sources. I am not opposed to older sources if newer sources don't exist but not a fan of debunking new research with old research. Thanks for your views Meodipt. I do appolgise for losing my cool.-- Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)
Good idea on long-term use, how about this citation. Quote, "Long term prescription is occasionally required for certain patients."-- Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)
I think that we go by what the best quality sources say. A non-systematic review of a few uncontrolled clinical trials would not be superior to a systematic review of the literature. I don't see a big conflict between NICE and the APA when the author says this. "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532-- Literaturegeek | T@1k? 02:31, 26 June 2009 (UTC)
How representative of the consensus view of the professionals is this sample of the long-term side effects from the current version of the article?
The [long-term] adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs.
Below I will try to present a random sampling of psychiatric textbooks from my shelf, warts and all. The Sceptical Chymist ( talk) 02:39, 26 June 2009 (UTC)
I have a few questions about this U Sheffield paper, which is used several times in the article: <ref name=cgftmamoa2004>{{cite web|author=McIntosh A, Cohen A, Turnbull N ''et al.''|title=Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder|url=http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf|publisher=National Collaborating Centre for Primary Care|format=PDF|year=2004|accessdate=2009-06-16}}</ref>.
1. The paper proclaims itself to be a "guideline"; however, it contains the following caveat on p 2: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." I wonder if using a real NICE guideline would be better.
2. This paper is 165 pages long. I believe that for each citation a page number should be provided. At the very least, a shorter range of pages could be given, if all citations are from the same part or chapter. For example, it would be nice to have numbers/range for the pages that confirm the bold parts in this sentence: "Their use beyond two to four weeks is not recommended in clinical guidelines, as tolerance and a physical dependence develops rapidly, with withdrawal symptoms including rebound anxiety occurring after six weeks or more of use.<ref name=cgftmamoa2004>" (bold mine, TSC).
3. This paper is used to support the following statement: "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy; benzodiazepine use has been found to interfere with therapeutic gains from these therapies."(emphasis mine, TSC). LG reverted my failed verification tag with the following edit summary: "Page six Sceptical. I don't fake refs." [3]. I look at page 6 and still cannot find support for the bold part of this statement. The Sceptical Chymist ( talk) 00:46, 27 June 2009 (UTC)
I thought you were talking about the cited sentence before that which is on page 6. [4] See page 76 for this statement.-- Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)
Try page 81 as well.-- Literaturegeek | T@1k? 13:34, 28 June 2009 (UTC)
See
How NICE clinical guidelines are developed (e.g. page 8). Technically, what has been linked to is the "Full guideline", which contains all the background evidence for the guideline, as well as the recommendations. The "NICE guideline" contains only the recommendations from the full guideline, without the information on methods and evidence. If you read the process you see the "full guideline" is fully reviewed to the point of issuing the guideline, and the "NICE guideline" is effectively a mechanically edited version of that. Note, that NICE have amended the "NICE guideline" for Anxiety
[6] but not the "Full guideline"
[7]. But that appears to be a minor change regarding "prescribing advice for venlafaxine".
So which should we cite? Well, NICE tell us in their FAQ:
Colin° Talk 12:11, 29 June 2009 (UTC)
I have questions about this sentence: "Drawbacks of benzodiazepines including worsening of sleep quality such as increased light sleep, decreased deep sleep as well as tolerance, dependence and rebound effects[38][39]"
1. The abstract of reference [38] PMID 18824834 only states: "The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives.". Perhaps, there is something in the full text that supports the worsening of sleep quality. Would it be possible to quote it?
2. Reference [39] PMID 7525193 (Ashton, 1994) has three problems.
a) It does not support the purported "worsening of sleep quality". To the contrary, it states "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep."
b) It is 15 years old, and was written before the introduction of many non-benzodiazepines. It states, for example, that "Benzodiazepines and related drugs are probably the best (as well as the most widely used) hypnotics at present available."
c) Ashton does not, generally, represent the mainstream medical views. In various publications, she advocated the views that BDz have "all the characteristics of drugs of dependence", result "in the insidious development of increasing psychological and physical symptoms" and cause "neurological damage" when taken long-term in therapeutic doses.
If possible, we should find a better reference. The Sceptical Chymist ( talk) 01:45, 27 June 2009 (UTC)
C. Ashton does not say they cause neurological damage, she says it is possible and one of your psychiatric text books quoted a review saying pretty much the same that data is conflicting on whether benzos cause brain damage so her views are in keeping with the evidence base. The world health organisation. Again one of your psychiatric text books which you want to quote, I looked it up and it reviewed the evidence that benzos cause increasing psychological and physical symptoms and concluded that they did and recommended that most long-term users of benzos be withdrawn from long-term use. Benzos would have to have the characteristics of drugs of dependence otherwise the world health organisation would not have listed them as Schedule IV controlled drugs.
I extensively re-wrote the Benzodiazepine#Anxiety, panic and agitation chapter. This re-write (below) separates anxiety disorders from other indications, removes multiple redundancies and acknowledges the existence of a controversy about their long-term efficacy. Is there anyone who opposes to this version? The Sceptical Chymist ( talk) 03:09, 27 June 2009 (UTC)
Because of their effectiveness, tolerability and rapid onset of anxiolytic action, benzodiazepines are frequently used for the short-term treatment of anxiety.
[1] Their use beyond two to four weeks is not licensed and is not recommended in evidence based clinical guidelines, as tolerance and
physical dependence may develop rapidly.
[2]
[3] The guidelines recommend
antidepressants, the
anticonvulsant drug
pregabalin and
cognitive behavioural therapy as the
first line treatment options.
[4]
[2] In addition, benzodiazepine use has been found to interfere with therapeutic gains from psychotherapy.<ref name=cgftmamoa2004 /better reference needed> Deleted per comment
[11]. These clinical guidelines are often ignored in general practice because GAD and PD are chronic conditions, and it is "highly unlikely that less than 4 weeks treatment would be of value". In practice, if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
[5] added per comment
[12]
There has been a controversy as to whether the benzodiazepines maintain their anti-anxiety action long-term, and the issue still remains undecided. A majority of the follow-up studies do not suggest a significant loss of therapeutic effect over time. Furthermore, they do not provide evidence that the increase of dose is necessary to maintain the anxiolytic action. [1] A recent review on clonazepam notes that some longitudinal data "suggest an ability to maintain improvement without tolerance for up to three years"; however, long-term controlled studies in panic disorder are lacking. [6] Another review of longitudinal studies notes that the improvement is maintained in 30–60% of patients with panic disorder on the same or lowered dose and suggests that there is not "significant development of therapeutic tolerance" to benzodiazepines. [7]
Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. [8] They are also used to treat the acute panic caused by hallucinogen intoxication. [9] Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. [10] They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania. [11] [12]
The Sceptical Chymist ( talk) 03:09, 27 June 2009 (UTC)
Psychological symptoms of anxiety may respond better to antidepressant drugs than to benzodiazepines, but there have been few comparator-controlled studies, and most reveal no significant differences in efficacy between active compounds (Mitte et al., 2005). Benzodiazepines have only limited efficacy against depressive symptoms, and given the comorbidity of GAD with depression and potential hazards associated with prolonged use of benzodiazepines, antidepressant treatment is preferable to prescription of benzodiazepine anxiolytics in ‘cothymia’ and other mixed conditions (Ballenger et al., 2001; Baldwin et al., 2005; Mitte et al., 2005). There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988); it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable (Taylor, 1989; Romach et al., 1995), but this remains a minority view.
The Sceptical Chymist ( talk) 16:02, 27 June 2009 (UTC)
Look guys this arguing over what constitutes the truth is really not helpful. Both of your versions are too POV, LG's has an anti-benzo slant and SC's is correspondingly pro-benzo, neither of which is suitable for the "finished" article. Clearly there is not a consensus among experts in the field regarding a number of these issues, so both of you stop trying to prove that there is and attacking each other over minor details! I don't see why you can't just acknowledge the disputes in the sources and explain both viewpoints instead of each trying to delete the others work so it only shows the view of the experts you agree with.
For each of these issues why don't you each just write your own version one after the other, i.e.
anti Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.
pro However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating actute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
Both those statements are supported by the references you have provided, and show both sides of the argument. Now you guys do the same for all the other paragraphs under dispute... Meodipt ( talk) 22:24, 27 June 2009 (UTC)
80% of benzo users are elderly according to two sources I have seen so this would show most people who are on benzos long-term are on them before the prescribing guidelines came into effect. I would submit that those elderly people many of them were on benzos from the 1970's. I have a source but it is primary source which interviewed GPs and they said that it was usually them that suggested benzos in the first place for short-term use but for long-term use it is not the doctor's will but pressure from the patient to get repeat prescriptions. So long-term use is mostly patient driven rather than doctor driven.-- Literaturegeek | T@1k? 13:03, 28 June 2009 (UTC)
Actually I did reply to Sceptical's diff up there as I always did. He is just playing dirty trying to smear me. More combative editing. Since you agree with Meodipt regarding minority views not being given undue weight are you happy to acknowledge your own source that says long-term use being effective is a minority viewpoint?-- Literaturegeek | T@1k? 13:05, 28 June 2009 (UTC)
Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.
However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating acute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. [8] They are also used to treat the acute panic caused by hallucinogen intoxication. [13] Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. [14] They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania. [15] [16]
The Sceptical Chymist ( talk) 12:46, 28 June 2009 (UTC)
I am just a research who likes dig deeper in to issues just for the fun of it. You may find the following PMID links useful.
Knock-out drugs: their prevalence, modes of action, and means of detection.
The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data.
LC-MS-(TOF) analysis method for benzodiazepines in urine samples from alleged drug-facilitated sexual assault victims.
Prevalence of drugs used in cases of alleged sexual assault.
Pictures in clinical medicines. Recovery of cerebral blood perfusion from transient hypo-perfusion due to acute benzodiazepine poisoning coinciding with generalized convulsion as withdrawal syndrome.
Abuse of alcohol and benzodiazepine during substitution therapy in heroin addicts: A review of the literature.
Comparison of five benzodiazepine-receptor agonists on buprenorphine-induced mu-opioid receptor regulation.
Use of psychotropic substances by the elderly and driving accidents.
Illicit drugs, medications and traffic accidents
Benzodiazepine withdrawal in subjects on opiate substitution treatmen
Pattern of benzodiazepine use in psychiatric outpatients in Pakistan: a cross-sectional survey
Fatal drug poisonings in a Swedish general population
Memory function in opioid-dependent patients treated with methadone or buprenorphine along with benzodiazepine: longitudinal change in comparison to healthy individuals
dolfrog ( talk) 01:10, 1 July 2009 (UTC)
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WhatIamdoing insisted that I accept abuse from LG as given and get on with the program. So, what is wrong with this paragraph? LG reverted it three times, after each sentence as I was writing it. (Note for LG: Mind WP:TLDR and AGF. I will stop reading your argument beyond ten sentences and at the first word of abuse. Note for Eubulides and everyone: "Please ignore for a second style problems with the last view and some other grammar and style problems and concentrate on the content.")
SUGGESTED: "The data on the The effects of long-term use is contradictory. One interpretation of this data, exemplified by Ashton maintain that benzodiazepines have all the characteristic of drugs of dependence and result "in the insidious development of increasing psychological and physical symptoms." On the prolonged exposure they may worsen anxiety and cause depression, and deficits of learning, memory and attention. [1] Another view counters that "despite considerable scientific evidence that the risk of drug abuse with benzodiazepines is low, there is tremendous prejudice against their use in many individuals, in certain treatment settings, and even countries (e.g., United Kingdom)." This view argues that the short-term treatment for generalized anxiety disorder and panic disorder makes no sense as these disorders continue long-term. Its proponents assert that the current practice is to "continue treatment for 6 to 18 months before tapering and attempting discontinuation." [2] An intermediate, empirical, position advocates careful and limited use of benzodiazepines. In this view, if the prolonged treatment is necessary, the patient reports sustained benefits from a benzodiazepine and no signs of misuse are visible, there is no harm from this practice. [3]"
CURRENT:"The long-term adverse effects of benzodiazepines include a general deterioration in physical and mental health and tend to increase with time. Not everyone however, experiences problems with long-term use. The adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs. [4] [5] Additionally an altered perception of self, environment and relationships may occur. [6]
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Discussion
I've fixed the refs. Please place any comments below. WhatamIdoing ( talk) 18:15, 25 June 2009 (UTC)
Ref is not discussing long-term effects so ref is being misused to say things that aren't in citation. The statement "data is conflicting" is opinion by Sceptical Chymist and is therefore original research. I cannot agree with this original research and misuse of refs. They are only discussing long-term use. It is fine to discuss the fact other doctors believe in long-term use. This is represented in the article already and I don't oppose this. As far as the UK being "extreme" I think that it is only fair to then state how some countries eg hong kong have benzos listed as dangerous drugs and countries like Holland and several other european countries have stronger stances against benzos and then cite how America's health body publishes research connecting benzos to cancer and there is a team of doctors in America who campaign against benzos whereas this is not the case in the UK, gotta keep things in perspective. To be honest though, I think pitting America against the UK is going to lead issues unless we put it in balance by listing other countries which have stronger stances than the UK. I also think that it would worsen the article.-- Literaturegeek | T@1k? 19:41, 25 June 2009 (UTC)
You are welcome to provide citations saying that the long term effects are exagerated. I intentionally added the statement that "not everyone is effected by adverse long-term effects" one because it puts it into context, does not exagerate it and 2 because it is true. One tip as well, all of the studies into benzos which follow people up for 6 - 12 months show improvements in some measure, physical, mental health. The drug companies and regulatory bodies don't challenge this data, they just ignor it so I think it is unlikely that you will find a source that challenges it but if you find one I am not opposed to you using it. just opposed to using irrelevant refs to do a synthesis and original research is all. There are lots of good psychiatry and addiction books which discuss these long-term effects. I can provide more citations if you like.-- Literaturegeek | T@1k? 19:47, 25 June 2009 (UTC)
The problem as I see it is that Sceptical feels that NPOV policy means that refs can be misused and original research is allowed in these cases to achieve neutrality. I cannot agree to this editing practice.-- Literaturegeek | T@1k? 19:50, 25 June 2009 (UTC)
The "intermediate" position is original research and implies that clinical guidelines and systematic reviews are "extremist" thus I feel it is not me who is breaking NPOV but you. We must stick to refs and no original research. Hope this helps clarify my position.-- Literaturegeek | T@1k? 19:53, 25 June 2009 (UTC)
P.S. thanks to those who are trying to resolve this. I believe it is impossible to resolve this without outside eyes so your help is much appreciated.-- Literaturegeek | T@1k? 19:55, 25 June 2009 (UTC)
The evidence based truth is the abuse potential of benzos is "moderate" or intermediate. The abuse potential is not high and it is not low. I dunno where authors got the low stat from, never seen a review of animal and human studies which came to that conclusion. They are still commonly abused by drug misusers.-- Literaturegeek | T@1k? 21:01, 25 June 2009 (UTC)
Oh you mean conflicting with cognition, the review author in ref 6 concluded that impaired cognition did occur, so you are using primary sources within a review to come up with your own conclusions,,, but,,, this is already discussed in the cognitive section Benzodiazepine#Cognitive_effects, which I still don't fully agree with. What I am looking for is a long term follow-up study say 6 - 12 months post withdrawal which finds no improvements in physical or mental health. Do you have any refs which says data is conflicting in this regard? Reference two does not say that the data is conflicting and does not discuss long-term effects so thus I feel is original research and a misuse of a ref. I find your approach to discussing references remains combative.-- Literaturegeek | T@1k? 22:08, 25 June 2009 (UTC)
I can't access that page of the book on google books but no I am not saying that. I am saying that it means the use of the drugs is controversial because of their adverse effect profile with differing opinions on the risk-benefit ratio but equally I found a page where the author clarified his views on the controversy where he said those advocating long term use for anxiety are a minority view in the literature (he cited some authors promoting the view so he was referring to literature). Also the quote is not directly relevant to dispute long-term adverse effects of benzodiazepines on physical and mental health and whether improvements occur after withdrawal from long term use. If you disagree, I am open to how it could be used in the benzo article. I am not opposed to compromising. Let me know your thoughts. Perhaps we could add a sentence before the long-term effects saying "their is major controversy surrounding the risk benefit ratio and the incidence of long-term adverse effects of benzodiazepines." Whilst it is not discussing the long-term effects on physical mental health and whether people improve after withdrawal,,, I think it might be a borderline case of using common sense and bending the rules a little but if that is what is needed, I happy to come up with a compromise.-- Literaturegeek | T@1k? 01:54, 26 June 2009 (UTC)
It does not back up the view the "data is contradictory" but does back up the viewpoint that there is controversy over opinions of the risk benefit ratio.-- Literaturegeek | T@1k? 02:01, 26 June 2009 (UTC)
I think a compromise can be reached, see above. All I want is the sources to be accurate represented, undue weight is not used etc.-- Literaturegeek | T@1k? 02:04, 26 June 2009 (UTC)
[Edit conflict with Meodipt] I know people who use benzos and are not suffering mental or physical adverse effects from it so I admit and know for a fact that people do exist who do not suffer adverse effects due to long-term use. They may be "functionally" dependent on the drug but it does them no psychological or physical harm. The main thing though is to focus on reliable sources. I am not opposed to older sources if newer sources don't exist but not a fan of debunking new research with old research. Thanks for your views Meodipt. I do appolgise for losing my cool.-- Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)
Good idea on long-term use, how about this citation. Quote, "Long term prescription is occasionally required for certain patients."-- Literaturegeek | T@1k? 02:16, 26 June 2009 (UTC)
I think that we go by what the best quality sources say. A non-systematic review of a few uncontrolled clinical trials would not be superior to a systematic review of the literature. I don't see a big conflict between NICE and the APA when the author says this. "it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable, but this remains a minority view." Page 532-- Literaturegeek | T@1k? 02:31, 26 June 2009 (UTC)
How representative of the consensus view of the professionals is this sample of the long-term side effects from the current version of the article?
The [long-term] adverse effects can include cognitive impairments and affective and behavioural problems. Feelings of turmoil, difficulty in thinking constructively, loss of sex-drive, agoraphobia and social phobia, increasing anxiety and depression, loss of interest in leasure persuits and interests, an inabilty to experience or express feelings also occurs.
Below I will try to present a random sampling of psychiatric textbooks from my shelf, warts and all. The Sceptical Chymist ( talk) 02:39, 26 June 2009 (UTC)
I have a few questions about this U Sheffield paper, which is used several times in the article: <ref name=cgftmamoa2004>{{cite web|author=McIntosh A, Cohen A, Turnbull N ''et al.''|title=Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder|url=http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf|publisher=National Collaborating Centre for Primary Care|format=PDF|year=2004|accessdate=2009-06-16}}</ref>.
1. The paper proclaims itself to be a "guideline"; however, it contains the following caveat on p 2: "The views expressed in this Publication are those of the authors and not necessarily those of either the Royal College of General Practitioners or the National Institute for Clinical Excellence." I wonder if using a real NICE guideline would be better.
2. This paper is 165 pages long. I believe that for each citation a page number should be provided. At the very least, a shorter range of pages could be given, if all citations are from the same part or chapter. For example, it would be nice to have numbers/range for the pages that confirm the bold parts in this sentence: "Their use beyond two to four weeks is not recommended in clinical guidelines, as tolerance and a physical dependence develops rapidly, with withdrawal symptoms including rebound anxiety occurring after six weeks or more of use.<ref name=cgftmamoa2004>" (bold mine, TSC).
3. This paper is used to support the following statement: "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy; benzodiazepine use has been found to interfere with therapeutic gains from these therapies."(emphasis mine, TSC). LG reverted my failed verification tag with the following edit summary: "Page six Sceptical. I don't fake refs." [3]. I look at page 6 and still cannot find support for the bold part of this statement. The Sceptical Chymist ( talk) 00:46, 27 June 2009 (UTC)
I thought you were talking about the cited sentence before that which is on page 6. [4] See page 76 for this statement.-- Literaturegeek | T@1k? 14:23, 27 June 2009 (UTC)
Try page 81 as well.-- Literaturegeek | T@1k? 13:34, 28 June 2009 (UTC)
See
How NICE clinical guidelines are developed (e.g. page 8). Technically, what has been linked to is the "Full guideline", which contains all the background evidence for the guideline, as well as the recommendations. The "NICE guideline" contains only the recommendations from the full guideline, without the information on methods and evidence. If you read the process you see the "full guideline" is fully reviewed to the point of issuing the guideline, and the "NICE guideline" is effectively a mechanically edited version of that. Note, that NICE have amended the "NICE guideline" for Anxiety
[6] but not the "Full guideline"
[7]. But that appears to be a minor change regarding "prescribing advice for venlafaxine".
So which should we cite? Well, NICE tell us in their FAQ:
Colin° Talk 12:11, 29 June 2009 (UTC)
I have questions about this sentence: "Drawbacks of benzodiazepines including worsening of sleep quality such as increased light sleep, decreased deep sleep as well as tolerance, dependence and rebound effects[38][39]"
1. The abstract of reference [38] PMID 18824834 only states: "The longer-acting benzodiazepines are associated with next-day "hangover" effects and, as a result, have been largely replaced by agents in the nonbenzodiazepine class, which typically have shorter half-lives.". Perhaps, there is something in the full text that supports the worsening of sleep quality. Would it be possible to quote it?
2. Reference [39] PMID 7525193 (Ashton, 1994) has three problems.
a) It does not support the purported "worsening of sleep quality". To the contrary, it states "Benzodiazepines in general hasten sleep onset, decrease nocturnal awakenings, increase total sleeping time and often impart a sense of deep, refreshing sleep."
b) It is 15 years old, and was written before the introduction of many non-benzodiazepines. It states, for example, that "Benzodiazepines and related drugs are probably the best (as well as the most widely used) hypnotics at present available."
c) Ashton does not, generally, represent the mainstream medical views. In various publications, she advocated the views that BDz have "all the characteristics of drugs of dependence", result "in the insidious development of increasing psychological and physical symptoms" and cause "neurological damage" when taken long-term in therapeutic doses.
If possible, we should find a better reference. The Sceptical Chymist ( talk) 01:45, 27 June 2009 (UTC)
C. Ashton does not say they cause neurological damage, she says it is possible and one of your psychiatric text books quoted a review saying pretty much the same that data is conflicting on whether benzos cause brain damage so her views are in keeping with the evidence base. The world health organisation. Again one of your psychiatric text books which you want to quote, I looked it up and it reviewed the evidence that benzos cause increasing psychological and physical symptoms and concluded that they did and recommended that most long-term users of benzos be withdrawn from long-term use. Benzos would have to have the characteristics of drugs of dependence otherwise the world health organisation would not have listed them as Schedule IV controlled drugs.
I extensively re-wrote the Benzodiazepine#Anxiety, panic and agitation chapter. This re-write (below) separates anxiety disorders from other indications, removes multiple redundancies and acknowledges the existence of a controversy about their long-term efficacy. Is there anyone who opposes to this version? The Sceptical Chymist ( talk) 03:09, 27 June 2009 (UTC)
Because of their effectiveness, tolerability and rapid onset of anxiolytic action, benzodiazepines are frequently used for the short-term treatment of anxiety.
[1] Their use beyond two to four weeks is not licensed and is not recommended in evidence based clinical guidelines, as tolerance and
physical dependence may develop rapidly.
[2]
[3] The guidelines recommend
antidepressants, the
anticonvulsant drug
pregabalin and
cognitive behavioural therapy as the
first line treatment options.
[4]
[2] In addition, benzodiazepine use has been found to interfere with therapeutic gains from psychotherapy.<ref name=cgftmamoa2004 /better reference needed> Deleted per comment
[11]. These clinical guidelines are often ignored in general practice because GAD and PD are chronic conditions, and it is "highly unlikely that less than 4 weeks treatment would be of value". In practice, if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
[5] added per comment
[12]
There has been a controversy as to whether the benzodiazepines maintain their anti-anxiety action long-term, and the issue still remains undecided. A majority of the follow-up studies do not suggest a significant loss of therapeutic effect over time. Furthermore, they do not provide evidence that the increase of dose is necessary to maintain the anxiolytic action. [1] A recent review on clonazepam notes that some longitudinal data "suggest an ability to maintain improvement without tolerance for up to three years"; however, long-term controlled studies in panic disorder are lacking. [6] Another review of longitudinal studies notes that the improvement is maintained in 30–60% of patients with panic disorder on the same or lowered dose and suggests that there is not "significant development of therapeutic tolerance" to benzodiazepines. [7]
Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. [8] They are also used to treat the acute panic caused by hallucinogen intoxication. [9] Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. [10] They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania. [11] [12]
The Sceptical Chymist ( talk) 03:09, 27 June 2009 (UTC)
Psychological symptoms of anxiety may respond better to antidepressant drugs than to benzodiazepines, but there have been few comparator-controlled studies, and most reveal no significant differences in efficacy between active compounds (Mitte et al., 2005). Benzodiazepines have only limited efficacy against depressive symptoms, and given the comorbidity of GAD with depression and potential hazards associated with prolonged use of benzodiazepines, antidepressant treatment is preferable to prescription of benzodiazepine anxiolytics in ‘cothymia’ and other mixed conditions (Ballenger et al., 2001; Baldwin et al., 2005; Mitte et al., 2005). There has been some reaction against the general advice that benzodiazepines should only be prescribed for up to 4 weeks in regular dosage and then tapered off as this can be less efficacious than taking a placebo (Tyrer et al., 1988); it being argued that some patients who respond well to benzodiazepines have chronic disorders for whom continued treatment is desirable and justifiable (Taylor, 1989; Romach et al., 1995), but this remains a minority view.
The Sceptical Chymist ( talk) 16:02, 27 June 2009 (UTC)
Look guys this arguing over what constitutes the truth is really not helpful. Both of your versions are too POV, LG's has an anti-benzo slant and SC's is correspondingly pro-benzo, neither of which is suitable for the "finished" article. Clearly there is not a consensus among experts in the field regarding a number of these issues, so both of you stop trying to prove that there is and attacking each other over minor details! I don't see why you can't just acknowledge the disputes in the sources and explain both viewpoints instead of each trying to delete the others work so it only shows the view of the experts you agree with.
For each of these issues why don't you each just write your own version one after the other, i.e.
anti Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.
pro However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating actute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
Both those statements are supported by the references you have provided, and show both sides of the argument. Now you guys do the same for all the other paragraphs under dispute... Meodipt ( talk) 22:24, 27 June 2009 (UTC)
80% of benzo users are elderly according to two sources I have seen so this would show most people who are on benzos long-term are on them before the prescribing guidelines came into effect. I would submit that those elderly people many of them were on benzos from the 1970's. I have a source but it is primary source which interviewed GPs and they said that it was usually them that suggested benzos in the first place for short-term use but for long-term use it is not the doctor's will but pressure from the patient to get repeat prescriptions. So long-term use is mostly patient driven rather than doctor driven.-- Literaturegeek | T@1k? 13:03, 28 June 2009 (UTC)
Actually I did reply to Sceptical's diff up there as I always did. He is just playing dirty trying to smear me. More combative editing. Since you agree with Meodipt regarding minority views not being given undue weight are you happy to acknowledge your own source that says long-term use being effective is a minority viewpoint?-- Literaturegeek | T@1k? 13:05, 28 June 2009 (UTC)
Clinical guidelines say CBT and antidepressants should be first-line treatment for anxiety because when effective, the benefits of these treatments tend to be more sustained over time, whereas benzos often produce rebound anxiety and recurrence of symptoms following cessation of use. Where benzos are appropriate, clinical guidelines recommend only prescribing for 2-4 weeks max because of development of tolerance and declining efficacy along with risk of dependence and side effects.
However benzodiazepines tend to produce faster relief of symptoms, and so may be more appropriate in some instances, especially in treating acute anxiety conditions such as panic attacks. Also since anxiety disorders are often chronic, long-term conditions for which it is "highly unlikely that less than 4 weeks treatment would be of value" the prescribing guidelines are often ignored in practice; if the patient and the physician find the treatment useful, the benzodiazepine may get continuously or intermittently prescribed over the long-term, even when the risks of dependence are known and explained.
Benzodiazepines are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. [8] They are also used to treat the acute panic caused by hallucinogen intoxication. [13] Benzodiazepines are also used to calm the acutely agitated individual and can, if required, be given via an intramuscular injection. [14] They can sometimes be effective in the short-term treatment of psychiatric emergencies such as acute psychosis as in schizophrenia or mania, bringing about rapid tranquillization and sedation until the effects of lithium or neuroleptics (antipsychotics) take effect. Lorazepam is most commonly used but clonazepam is sometimes prescribed for acute psychosis or mania. [15] [16]
The Sceptical Chymist ( talk) 12:46, 28 June 2009 (UTC)
I am just a research who likes dig deeper in to issues just for the fun of it. You may find the following PMID links useful.
Knock-out drugs: their prevalence, modes of action, and means of detection.
The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data.
LC-MS-(TOF) analysis method for benzodiazepines in urine samples from alleged drug-facilitated sexual assault victims.
Prevalence of drugs used in cases of alleged sexual assault.
Pictures in clinical medicines. Recovery of cerebral blood perfusion from transient hypo-perfusion due to acute benzodiazepine poisoning coinciding with generalized convulsion as withdrawal syndrome.
Abuse of alcohol and benzodiazepine during substitution therapy in heroin addicts: A review of the literature.
Comparison of five benzodiazepine-receptor agonists on buprenorphine-induced mu-opioid receptor regulation.
Use of psychotropic substances by the elderly and driving accidents.
Illicit drugs, medications and traffic accidents
Benzodiazepine withdrawal in subjects on opiate substitution treatmen
Pattern of benzodiazepine use in psychiatric outpatients in Pakistan: a cross-sectional survey
Fatal drug poisonings in a Swedish general population
Memory function in opioid-dependent patients treated with methadone or buprenorphine along with benzodiazepine: longitudinal change in comparison to healthy individuals
dolfrog ( talk) 01:10, 1 July 2009 (UTC)
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