Thursday 5/9/16 APNA CPI preconference discussion on benzo pitfalls: notes from the lecture

Benzo discussion Dr. Limandri:

My impression: great info, so much material to cover though so she mostly skimmed the surface. Lots of the info seemed to come from her own experience. Some material came from the UK — Ashton Manual which I refer to often and it’s full of good info.

Below are my mostly unedited notes from this session along with some lyrics from a famous Rolling Stones song relevant to subject.

  1. Women use this class of med more than men. 25-50 yr age range is highest; multitasking requirements for women in that age bracket; middle aged, white, wealthier higher utilizers of benzos. The Rolling Stones wrote a famous song about women using Valium, “Mother’s Little Helper” in the 1960s — here are the lyrics:

What a drag it is getting old
“Kids are different today, ”
I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill
There’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day

“Things are different today, ”
I hear ev’ry mother say
Cooking fresh food for a husband’s just a drag
So she buys an instant cake and she burns her frozen steak
And goes running for the shelter of a mother’s little helper
And two help her on her way, get her through her busy day

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Men just aren’t the same today”
I hear ev’ry mother say
They just don’t appreciate that you get tired
They’re so hard to satisfy, You can tranquilize your mind
So go running for the shelter of a mother’s little helper
And four help you through the night, help to minimize your plight

Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old

“Life’s just much too hard today, ”
I hear ev’ry mother say
The pusuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way, through your busy dying day

Notes con’t:

2. More deaths for those who were regular daily users v the infrequent.

3. 3 weeks is the longest time they should be prescribed, per the speaker. Most long term users stay at same dosages, but they have rebound anxiety and end up raising the dose over time. When your patient c/o anxiety while on a benzo — and you choose to up the dose — you’ve done opposite of what you were supposed to do.

4. Primary care providers are the bigger offenders, that is, prescribe benzos the most, possibly because they feel pressured to solve all the problems of their patients.

5. Studies are reporting on stats by psychiatrists and not NPs. Add the NPs and the stats would be different.  For many providers it’s much quicker to write the script than it is to  do MI or other counseling in an effort to back off the dose or taper off. There are providers out there that will write for benzos with no intent to stop because it’s lucrative work, sad to say.

6. GAD has so many somatic c/o so they end up in primary care and while there they end of getting a rx for benzo.

7. Best anxiolytics are SSRIs. Take a bz to bridge until they kick in, for 2-3 weeks, and then stop without taper.

8. DSM5: MDD with anxious distress… emphasize the last part and that it’s linked to the first, as say of encouraging someone to try and SSRI.

9. Why do many people with trauma dislike taking bzd? They feel a loss of control when on them, less reactive, less fight/flight.

10. Dementia and increased falls.

11. It’s expensive to treat all the collateral damage, eg, falls, car accidents, etc.

12. 2.5 x higher rate of suicide attempts: from a big study in Taiwan she mentioned (I don’t have the reference).

13. Anterograde amnesia (use midazolam in your teaching and why it’s used in medical procedures), dissociation, cognitive impairment, paradoxical anxiety that is proven in PET scans. It makes you not care about the anxiety, not care about possible risks. hinders fight/flight — exactly what trauma survivors don’t want.

14. Cognitive impairment makes it hard to learn the skills needed to curb anxiety.


16. CBT to get people off benzos: question why you think it’s helping your anxiety.

Questions from the audience:

State hospitals and volatile patients and common use of bzd’s: increases impulsivity but they’re slower and we can catch them. Use a different gaba med that’s not the benzo receptor: lamictal and gabapentin. both slow the firing and allow staff time to think. State hospitals may want to use benzo cause it’s cheaper.

Alternative anxiolytics: Effexor — more adrenergic at higher doses. 75mg is antidepressant. Fetzima more adrenergic at lower doses so better tolerated. Buspar helpful; others: lamitical and gabapentin. alpha and betas blockers: trauma clients do better on these and feel it right away.

Schizophrenia and benzos: no indication but had been used for akathisia.

Medicare to Pay Doctors and Nurse Practitioners for Care Coordination

Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients –

“This is time-consuming and challenging work,” said Dr. Matthew J. Press, an assistant professor of health care policy at Weill Cornell Medical College in New York. In a recent article in The New England Journal of Medicine, he described his experience coordinating care for a 70-year-old man with bile duct cancer in the liver.

Over 80 days, Dr. Press said, 10 doctors helped care for the man, who had five procedures and 11 office visits before a surgeon removed his tumor. Dr. Press, the patient’s primary care doctor, communicated 40 times with the other clinicians and 12 times with the patient or his wife.

This is a task that nurses have been doing for many years, under titles such as “RN Patient Advocate” and “RN Care Coordinator”, and being paid well to do so in the private sector. The new law also states that primary care providers of Medicare recipients be available 24/7 365.

With the tidal wave of baby boomers looming, chronic illnesses such as depression could break the back of the Medicare system, and possibly the Affordable Care Act, if medical care for these high-dollar illnesses isn’t ramped up. It will be interesting to see how this new legislation unfolds.

Turmeric, the Golden Spice – Herbal Medicine – NCBI Bookshelf

Turmeric, the Golden Spice – Herbal Medicine – NCBI Bookshelf.

antiinflammatory spices

Asian Spices

“…antioxidant, anti-inflammatory, antimutagenic, antimicrobial, and anticancer agent…” — what more can we ask for in a supplement? Asian countries also have some of the lowest incidences of Alzheimer’s in the world, and yes, they consume a lot of curcumin.

Adding a daily supplement of turmeric to your diet can only be beneficial. It’s widely available at health food stores and not expensive.

This NIH article’s references are mostly from the past 10 years so I feel it’s worthy of bookmarking. Excellent article with a lot of valuable information.

Seth Rogen and Alzheimer’s: Mystery of the Empty Seats

In February 2014 Sen. Tom Harkin held a hearing about Alzheimer’s in America. There’s been an enormous storm of dialogue on social media that resulted from the 6 minute YouTube clip showing Seth Rogen’s testimony. But it wasn’t just his personal story about Alzheimer’s that’s caused such a ruckus. The backlash is about all the empty seats at the hearing. Here’s Seth’s testimony.

Because I was interested in seeing what happened before and after Seth’s testimony, I watched the entire 2.5 hour hearing. The best minds in science fighting Alzheimer’s were there answering questions. Congressman Dennis Moore, who recently resigned because of his own diagnosis of AD, also gave testimony. One would think that his own colleagues would be there in a show of support. But they weren’t. What a diss!

Here is a clip from an investigative story by CNN, soon after the hearing, where Seth Rogen is interviewed and they discuss the empty seats — at the end of this video please note that AD is now the 3rd leading cause of death, not the 6th:

If you’re interested in learning more and want to watch the full hearing, go to this site:

Dementia Village: No more lock-down “memory units”

My mother was placed on the antipsychotic medication Zypexa during a rough stage of her ordeal with Alzheimer’s.  Her need for this medication was never reviewed in the months and years after she started it. There is no doubt in my mind that it could have been discontinued had she been able to receive humane and dignified care.

“Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia”: this is one recommendation of Choosing Wisely. An initiative of the ABIM Foundation, Choosing Wisely is focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.

I’m not sure it’s possible for capitalist societies to put good care above profits.


India, Alcohol, Turmeric, and Alzheimer’s Disease


Alcohol use on the rise in India : The Lancet.

India has the lowest incidence of Alzheimer’s Disease (AD) in the world and it’s believed that one of the reasons might be their high consumption of turmeric.

Interestingly, India is also one of the countries with the lowest alcohol consumption rates. Alcohol is a known contributor to dementia. With alcohol use now on the rise in India, researchers should pay close attention to trends in AD prevalence in India over the next few decades.

So would it then be accurate to recommend increasing turmeric in our diets and minimizing or abstaining from alcohol use based on this information? Maybe.