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.

1,892 American Flags Memorialize Veteran Suicides on National Mall

Using Flags to Focus on Veteran Suicides –

American Flags Memorialize Veteran Suicides

It’s hard to believe that 22 veterans take their own lives every day in the US. Some people probably believe those numbers can’t possibly be accurate.

The world places such stigma on the diagnosis of mental illness that coming up with a solution is not easy. The denial is enormous. Placing close to 2,000 American flags across the National Mall makes it hard to ignore, unless one questions the accuracy of the statistic.

Do the math: 1,892/90=21.02. The flags represent veteran suicides since January 1, 2014. That would be about 22 per day.

The stigma doesn’t lie just with people suffering from depression or other conditions. It prevents medical professionals from choosing to practice psychiatry as a medical specialty because they are stigmatized by their peers for choosing to practice psychiatry.

Why are we so ashamed of revealing emotions? To the extent that we’re willing to turn our cheeks while 22 American veteran’s kill themselves everyday?

Last year Washington made a cash infusion into mental health services in hopes of shoring up the ranks of psychiatric providers. Doing so only seems to have bought a little time, enough to say, ‘OK, we’re doing something to fix the problem’. But a year later we don’t seem to have made any progress.

Nurses are a group that’s poised to fill in the gaps of providers, if the number-crunchers would get to work.  Placing a mental health RN in every primary care practice will help — I guarantee.

I follow hiring trends at the Veterans Administration Medical Center in Western North Carolina and I rarely see mental health jobs posted (the process of getting hired at the Veterans Administration is abysmally outdated and time-consuming, so much so that I’ve heard of courses being offered in How To Get A Job At The Veterans Administration).

Until we can acknowledge the enormous White Elephant in the room that is “mental illness” we aren’t going to make much progress. Next time you are out with your friends look around, see and believe, that 1 in 4 of everyone around you has at one time or another had to seek help for emotional challenges.

I applaud the veterans and their caregivers who took the time to place those 1,892 little American flags on the National Mall in Washington, DC. Progress is rarely made by being silent.






ACA Attempts Mental Health Parity But Where Are The Providers?



A good article by Ben Hartman, MD published in The Gupta Guide about lack of providers in mental health.

Telepsychiatry is discussed here in the article. It’s being used partly because of the lack of clinicians willing to specialize in psychiatry. It’s a Band-aid and ought to stay that way otherwise it will take the place of face-to-face encounters in this challenging field, and that will be a dangerous thing. We don’t want this to become “treatment as usual”.

Primary care providers are continuing to be the mainstay for providing mental health but they lack the training (not required) and the time.

I’ll go back and say again that every PCP office ought to have a mental health RN in place to assist the PCPs. When clients are identified as needing further screening, they simply go to the RN’s office for further triage.

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…)

The Suicide Detective –

The Suicide Detective –


“For reasons that have eluded people forever, many of us seem bent on our own destruction. Recently more human beings have been dying by suicide annually than by murder and warfare combined. Despite the progress made by science, medicine and mental-health care in the 20th century — the sequencing of our genome, the advent of antidepressants, the reconsidering of asylums and lobotomies — nothing has been able to drive down the suicide rate in the general population. In the United States, it has held relatively steady since 1942. Worldwide, roughly one million people kill themselves every year.”

–article author, Kim Tingley

Insomnia Linked To MI Risk In Women


In today’s ANA SmartBrief:


A large study (n=700) of men v. women (over 5 years) looking at the link between lack of sleep and heart attacks shows that — yep — women are at a higher risk for MI than men.


Nurses that work 3rd shift need to take extra precautions to safe-guard their health. Insomnia and breast cancer are increased health threats for these night-time angels.



Sleeping (Photo credit: lifebeginsat50mm)






Meditation reduces PTSD symptoms in nurses | National Nursing News

Meditation reduces PTSD symptoms in nurses | National Nursing News.

We need as much science to support PTS therapies, especially from our profession.

“Practicing a form of meditation and stretching can help relieve symptoms of post-traumatic stress disorder and normalize stress hormone levels, according to a study of nurses.

More than 7 million adults nationwide are diagnosed with PTSD in a typical year, according to background information for the study, which is scheduled for publication in The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism”.

Life Care Books in Continuing Care Settings

Life Care Books in Continuing Care Settings


elderly man reading tablet

The use of Life Care Books (LCB) in Continuing Care settings helps to preserve memories, and is especially valuable to persons with dementia, including their families and caregivers. This link is to a NIH study in 2008 conducted in Ireland on the value of creating Life Care Books (yes, they are of value). They can be a source of comfort, and help an individual to recognize that their life was indeed full and rich and had great meaning. There’s a lot of hopelessness, sadness, and grief among residents in long term care, and taking the time to create a LCB is something that can make a real difference.