Benzos

[HikingEDRN, BSN, RN]

Hi everyone. As I've posted previously, I am an ACNP student currently rotating through the ICU. I was just wondering what others' (both RNs and NPs) experiences have been regarding benzos. It seems as though providers on rounds are not willing to schedule or even have prn benzos available for people who take them regularly. I've never seen it, but I thought benzo withdrawal was pretty nasty. I had a patient today who takes lorazepam three times a day every day. She received a prn dose overnight and scheduling it was discussed briefly but not done and I was surprised. It has happened a couple of different times on rounds with different patients.

I'm well aware of the delirium guidelines and how benzos should be avoided. I just feel that if the patient is on a home medication and takes it scheduled, it might do more harm than good to withhold it. Even a lower dose would help, I think.

What do you guys think?

[elkpark]

BZD withdrawal is "nasty" -- it can be life-threatening.

In the large academic medical center in which I work, when people come in having been on scheduled benzos at home, the medical teams typically order those medications as prns (at the same dosage and frequency that they've been taking at home, but prn instead of scheduled) or, if it's felt that the person is really taking more than they are comfortable ordering, they reduce the dosage, but not enough that the person would go into withdrawal.

I'm on the psych consultation & liaison service and, when we are consulted on someone who has been taking significant quantities of benzos on a regular basis and the primary team hasn't ordered anything, we encourage the primary team to order enough to keep the person from going into withdrawal. We often recommend a different, shorter-acting BZD if the person has been taking a BZD that we don't feel is indicated -- but something to ensure the person won't abruptly go into withdrawal.

We do occasionally see what you describe (not the medical center primary teams, typically, but in some of our affiliated community hospitals ), people who have been taking significant amounts of a BZD for a long time come into the hospital for some reason, the admitting physician thinks (correctly! :)) that it's a bad idea for the individual to be on a benzo regularly, and so just doesn't order the BZD, putting the person in danger of acute withdrawal. (Sometimes the reason we are consulted is because this has already happened and the person has gone into withdrawal, and that's what they want us to fix ...)

[VivaLasViejas, ASN, RN]

Well, that explains that. I've taken Klonopin nightly for years, but when I was in the hospital recently I had to ask for it every night, as it was listed as a PRN. I asked my attending doctor to change it to scheduled, but he just advised me to request it at bedtime as he didn't order it routinely for anyone.

That's fine if you're AA & O, but what about the little old ladies (and gents) who need those drugs and can't advocate for themselves? They're the ones I feel sorry for when doctors are so conservative about prescribing benzos. I understand their reluctance, but when someone's body has become so accustomed to having these drugs that they've become physically dependent on them, being in the hospital is NOT the time to yank it out from under them. JMHO.

[elkpark]

Well, that explains that. I've taken Klonopin nightly for years, but when I was in the hospital recently I had to ask for it every night, as it was listed as a PRN. I asked my attending doctor to change it to scheduled, but he just advised me to request it at bedtime as he didn't order it routinely for anyone.

That's fine if you're AA & O, but what about the little old ladies (and gents) who need those drugs and can't advocate for themselves? They're the ones I feel sorry for when doctors are so conservative about prescribing benzos. I understand their reluctance, but when someone's body has become so accustomed to having these drugs that they've become physically dependent on them, being in the hospital is NOT the time to yank it out from under them. JMHO.

I feel sorry for them for having PCPs who enabled them to become dependent on BZDs in the first place ... I'm amazed there are (still) docs who are willing to rx them for anyone on a long-term basis.

[HikingEDRN, BSN, RN]

Thanks for your responses everyone. I completely agree that long term benzos are very over-prescribed. Sometimes I am appalled in the ED as a staff nurse how often I see it on the home med list as a long term medication especially in people in their 20s and 30s. I don't know if that stems from not having as many anti-anxiety alternatives even a few decades ago (some older patients don't even remember when they started taking them). Having said that, I do believe they have their place for the long-term in limited situations. And regardless of how we feel about it, these people wind up in our care inpatient and it has to be dealt with. I am currently in a surgical ICU for clinical and a big concern seems to be that the dose would have to be IV versus PO. I'm not a pharmacist but I would think the dose could be adjusted for that. And like I said earlier, even a little something is better than nothing, just to prevent withdrawal.