Monday, August 20, 2012

Series: “Mental Health Revisited” by Reporter Mitsunobu Sato

Anxiety and Sleeping Pill Dependency (8)
To Commemorate Publicizing the Manual in Japanese, We Asked Prof. Ashton

The Ashton Manual in Japanese, together with updated supplement, authored by Heather Ashton, Emeritus Professor of Clinical Psycho-pharmacology at the Institute of Neuroscience, University of Newcastle upon Tyne, England, was publically released on August 19, 2012.

The release was made later than first planned, but this was due to the deliberate exhaustive measures taken to ensure the translation reads smoothly and additional annotations were made to accommodate Japanese needs.

The people in charge of producing the Japanese version of the manual, whilst maintaining contact with Prof. Ashton, were Mr. Ryo Tanaka, who we introduced previously, and Translator cum English Teacher Mr. Wayne Douglas from New Zealand. Both are victims who were given benzodiazepines long term resulting in suffering from prescription drug dependency. I would like to pay my respects to them both for translating the manual as volunteers. The medical editing was overseen by Neurologist, Dr. Hirokuni Beppu, Chief Editor of “The Informed Prescriber”, and Prof. Reisaku Tanaka, Neurophysiologist from Tohoku Bunka Gakuen University.

Included at the end of the translation is a message that Mr. Tanaka would like mental health workers to pay particular attention to. “This manual was not only translated for patients, who are at a loss due to insufficient information regarding benzodiazepine dependency and withdrawal, but it also serves as an important message / information for doctors, pharmacists, drug companies and the Ministry of Health.”

(Prof. Ashton Interview)

In the United Nations International Narcotics Control Board’s 2010 annual report, the predominant usage amounts of benzodiazepine type sleeping pills in Japan was seen as a problem and inappropriate prescribing and abuse were also pointed out. What do you think about the situation in Japan?

As I understand, Japan has more benzodiazepine prescriptions per head than any other country. However, the situation has not changed much over the last 20 years in Europe or the US, and benzodiazepines continue to be overprescribed worldwide. In some countries benzodiazepines can be bought without prescription. Furthermore, benzodiazepines can now be bought over the internet and so I doubt if the statistics are accurate in terms of the actual number of users.

There appears to be many reasons why Japanese doctors give out benzodiazepine prescriptions so easily, but the amount of doctors who prescribe with the belief that there are very few side-effects stands out in particular. Please provide a word to these uninformed physicians.

Benzodiazepines are relatively safe drugs if used alone and short-term (2-4 weeks only). Even then, they can cause falls and fractures in the elderly, traffic accidents, additive effects with other depressant drugs, and cognitive impairment-poor memory etc. Used long term, they can cause a large number of adverse effects which are described in the manual. These include oversedation, drug interactions, memory impairment, depression, emotional blunting, tolerance, dependence (addiction) and others.

They are usually prescribed for anxiety or insomnia but in long-term regular use, they lose their initial effects and anxiety can become worse than it was before, and people can develop panic attacks, agoraphobia and physical symptoms such as palpitations, and neurological symptoms. Once a person has become dependent, which can occur in a few weeks or months, it can be very difficult to withdraw from the drug.

There are cases in Japan where doctors intentionally prescribe benzodiazepines long term and produce patients who become dependent on therapeutic amounts making them repeat clients of the hospital in order to help provide more stable business for the running of their hospitals or clinics. What are your thoughts on these methods of use?

That would be medical negligence or malpractice.

There are many doctors in Japan who simply shrug things off saying “Even if you become dependent on therapeutic doses, if you keep taking them, no withdrawals will occur, and so there’s no problem”. Please let us know if there are any apparent or serious side-effects that occur when usage spans from several years to 10 or more years.

There are problems if people take them long term. However, once they become tolerant they can get withdrawal symptoms while still taking the drug. As explained in the manual, these symptoms can be serious with repercussions on, not only the person taking the benzodiazepines, but also children and the whole family, loss of job, hospital admissions for investigation of cardiological, neurological, gastrointestinal and psychiatric symptoms, and many other socio-economic costs enumerated in the manual.

In Japan the amount of cases where benzodiazepine type anxiolytics are being prescribed to adolescent youth and children is also on the rise. If you have any particular points of concern with regards to cases of prescribing to developing children, please let us know.

The brain continues to develop until about the age of 21. Giving benzodiazepines to children impairs this development and prevents the learning of new skills, especially skills for coping with anxiety and adversity and cognitive (intellectual) skills, so that the child may never reach his/her full intellectual or emotional potential.

The Ashton Manual in Japanese, which so many people have been waiting for with anticipation, has now been publically released. However, the reality in Japan is that, even if people want to reduce and stop the drugs using the manual as a guide, there are hardly any doctors who are able to provide any support with abstinence. Given these circumstances, how would you advise on progressing with reduction?

Perhaps it would be better to read the manual through in its entirety first. Then before beginning the reduction process, consult your doctor and inform him of your intentions.

Your doctor's agreement and co-operation is necessary since he/she will be prescribing the medication. It may be a good idea to tell him that you have read the manual already and highlight any points that you feel he should be made aware of, as many doctors are still inadequately informed and are not always aware of the risks involved.

When reducing, it is advisable to consider the following cautionary points.

1. The possible need to switch to a long acting benzodiazepine before starting the tapering process

2. The importance of equivalent doses if switching to another benzodiazepine (See table in manual)

3. Complete the withdrawal from benzodiazepines first if being co prescribed with any antidepressants to help avoid depression during withdrawal

4. The need for you to be in control and to be able to taper at your own pace

5. The need for regular monitoring by the doctor

6. The need to be able to accommodate any of the influential factors relating to individuality as this has an influence on the withdrawal experience. This may include adapting a schedule to individual needs as all eventualities cannot be covered in the schedules suggested in the manual.

Metabolic enzymes in Japanese people including the liver etc differ from that of westerners, and subsequently, some cases have been highlighted where conversion to diazepam is not recommended. How should such cases in ethnic differences be handled?

Some genetic differences occur in Asian populations. Due to this, it has been said that some individuals have found it difficult switching to diazepam as recommended. The important thing is to accommodate individual factors.

Prof. Ashton, you spent many years running a benzodiazepine withdrawal clinic, however, there is no sign of any such clinic here in Japan. When did these kinds of clinics first appear in England, and how many were there? Also, were these clinics established with government support? Are any of these withdrawal clinics remaining today?

There were only about 2 specialised clinics in the UK- Prof Lader in London ran one from about 1980; mine in Newcastle started in 1982. Both were in hospitals under the National Health Service (NHS). But both closed down in the 1990s, following our retirements, and were not replaced.

There are no official NHS services now, and support is provided only by charities- not medically staffed, though working with some general practitioners who agree to prescribe for benzodiazepine withdrawal schedules. There are such charities- Benzodiazepine Support Groups- in Liverpool, Bristol, Bradford, Oldham and Camden (part of London) but that is all, and most of the population does not have access to these centres.

The situation in the UK is woefully inadequate. The number of benzodiazepine prescriptions has actually increased.

The Ashton Manual has so far been translated into 9 different languages. What kind of feedback have you had?

Unfortunately, doctors do not read the manual and most are ignorant of withdrawal methods. But benzodiazepine users all over the world do read it, and I get inquiries every day about benzo withdrawal. Literally 100s have written to say that the manual “saved my life” – or words to that effect. I hope the situation improves in Japan.

Misdiagnosing as schizophrenia, over diagnosing of depression, extraordinary prescribing of numerous prescriptions and large doses, doctors showing anger towards patients when they try to seek a second opinion, frequent cases of sudden deaths, suicide etc. The critical public eye is becoming more and more drawn towards the numerous problems erupting out of mental health.

In this column, we endeavour to explore new pathways towards improving mental health and we delve deeper into issues that are usually too long for the usual printed newspaper.

The Series “Mental Health Revisited” is managed by Reporter Mitsunobu Sato of the Medical Information Division. Please forward any comments or information to: t-yomidr2@yomiuri.com. In some cases your e-mails may be used for our articles.

20 August 2012

Yomiuri Newspaper

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