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.

12-hour nursing shifts can be deadly


I’ve been following a LinkedIn ANA thread about 12-hour shifts and it’s received a great many comments. Without counting, I’d say most responders to the thread are opposed to 12-hour shifts, or at least recognize the associated health problems. These shifts are typically done 3-4 times per week, consecutively. And therein lies the rub.

Here’s my story about working 12-hour shifts and how it became deadly. (more…)

Too Many Nurses in the Kitchen: CNA, LPN, RN, APRN, PHD, DNP

Back in 1990 when I was fresh out of my initial nurse training program, for a LPN, the word in the hospital corridors was that LPN jobs would soon be obsolete. Go back to school and “get your RN” was the buzz. Since rising through the nurse ranks I’ve paid attention to the demise of the LPN and it’s not just alive and well, it’s thriving, in 2014.

I’ve got some analogies: movie ratings — G, PG, R, and X. And places to receive healthcare. (more…)

Psychiatry’s Stigma In The Medical Profession

The stigma of becoming a psychiatrist.


Today’s GML (Great Medical Link) has my brain wheels turning, so here’s my first 2014 post:

While working one of those long 12-hour shifts I used to pull while on staff at a university teaching hospital in SC as a registered nurse back in 2001, I found myself once again sitting with my patient/client/charge (nomenclature dilemma is fodder for a future post) just… talking. Excessive talking with patients isn’t smiled upon by the bean counters.

“You know?” my RN colleague said to me then. “Have you ever thought about becoming a psychiatric nurse? I think you’d be really good at it.” Hmm. No, not really. (more…)

World Health Organization 66th WHA Closes Today: Universal Health Coverage And Mental Health Key Topics



The 66th World Health Assembly (WHA) closed today in Geneva, Switzerland. The WHA is the decision-making body of the World Health Organization and meets annually in Geneva. After seven days of intense discussions, they concluded with agreement on a range of new public health measures and recommendations aimed at “securing greater health benefits for all people, everywhere”.

At the closing ceremony yesterday, the President of the 66th World Health Assembly, Dr Shigeru Omi, stated: “Together we achieved a lot,” said Dr Omi. “One of the key outcomes of this Assembly is the universal health coverage that is now recognized as the key concept to underpin the work of global health in many years to come.”

The fact that universal health coverage (UHC) for every nation is a top priority for WHO/WHA shows the gravity of this problem and its seriousness. The US ought to be leading by example for the world instead of being another ball-and-chain country.

Mental health was again a key topic.

As healthcare professionals it’s easy to become narrow-sighted and to only be concerned about what’s at stake in the US. But it’s important to see health as a global issue. All nations influence the health of each other.

See below for the resolution summaries of UHC and mental health, plus a link to the conference site.


Mental Health Action Plan: 2013-2020

A resolution on WHO’s comprehensive mental health action plan 2013-2020 sets four major objectives: strengthen effective leadership and governance for mental health; provide comprehensive, integrated and responsive mental health and social care services in community-based settings; implement strategies for promotion and prevention in mental health, and strengthen information systems, evidence and research for mental health. The plan sets important new directions for mental health including a central role for provision of community-based care and a greater emphasis on human rights. It also emphasizes the empowerment of people with mental disabilities and the need to develop strong civil society and health promotion and prevention activities. The document proposes indicators and targets such as a 20% increase in service coverage for severe mental disorders and a 10% reduction of the suicide rate in countries by 2020 that can be used to evaluate levels of implementation, progress and impact.

Universal health coverage

The WHA adopted a resolution on the importance of educating health workers as part of universal health coverage. Member States expressed their ongoing commitment to ensuring that all people obtain the health services they need without the risk of financial ruin. They emphasized that universal health coverage is not just about health financing but requires strong health systems to provide a range of quality, affordable services at all levels of care.

Member States expressed strong support for WHO’s action plan and reiterated their call for a monitoring framework to help them to track progress towards universal health coverage. Many delegates expressed support that universal health coverage should feature in the post-2015 development agenda.

Obama Signs Executive Order for VA Mental Health Services


U.S. Military - Dog Tags ... U.S. Military Sui...

U.S. Military – Dog Tags … U.S. Military Suicides in 2012: 155 Days, 154 Dead (June 8, 2012) … (Photo credit: marsmet511)




Today President Obama signed an executive order to drastically and quickly ramp up mental health services for our veterans and their families. High suicide rates, compounded by substance abuse, PTSD and TBI are all driving forces behind this action. I greatly commend our president for taking a stand on this most important health care crisis.