Benzodiazepines are used to treat insomnia, anxiety and chronic back pain due to their sedative and muscle relaxing effects. They’ve got a sting in the tail though and can cause memory disruption, loss of coordination and dependence if used long term. It’s therefore recommended that other treatments, such as psychological interventions, are tried first and that the drugs are prescribed for short term use only.
However, research has shown that clinicians are over prescribing benzodiazepines and giving it to patients for long periods. The aim of this study was to review qualitative studies of clinicians’ decisions to prescribe or withdraw benzodiazepines and blend those studies into an explanatory model, to inform the development of interventions that could encourage clinicians to follow the prescribing guidelines.
The authors searched multiple databases for papers. Papers were included if they were qualitative, in a primary care setting and published between 1990-2011.
Two pairs of researchers independently extracted data from the included papers. The authors include a PRISMA diagram of the process which shows clearly the stages of the search and the review.
The authors state they used thematic analysis to synthesise the results. Thematic analysis is a stalwart of qualitative research and has been recommended for synthesising qualitative reviews (see the paper by Thomas & Harden, 2008). However, it is arguably not as rigorous as meta-ethnographic approaches which call on reviewers to specify how they integrated the multiple data sources, for example by using a ‘line of argument’ approach which aims to discover a ‘whole’ among multiple ‘parts’.
Eight papers were included in the review from seven countries, and the authors report seven analytic themes. They encompassed the changing context of prescribing (for example, changing guidance and also societal attitudes), GPs perceptions of themselves and of the patients and a perceived lack of alternative treatments. Overall, the authors report that GPs are ambivalent about prescribing and experienced conflicting pressures.
The authors present an explanatory model that aims to synthesise the multiple themes. I can firmly tell you that it has arrows and boxes in it.
The authors’ state:
Making decisions on whether or not to prescribe was often uncomfortable, demanding and complex within the time and pressure constraints of daily practice.
The GPs often made their decisions on a case-by-case basis rather than having consistent practices. For example, one theme was of ‘the deserving patient’ and GPs decided whether the patient could ‘legitimately’ use benzodiazepines. The authors suggest that these decisions might be understood as examples of cognitive heuristics, and I’d certainly be interested to see a study of heuristic decision making in this context (any health psychologists at the back?).
- Databases were searched in October 2011. It’s unusual that the review hasn’t been updated, particularly as the authors note the importance of changing contexts in primary care.
- Personally I found the ‘explanatory model’ quite confusing – quite how the themes interrelate and compare wasn’t very clear. Possibly adopting a more specific analytical process, such as line-of-argument, might have been helpful to translate the multiple themes into a more streamlined model. As it is, the authors present a good summary of the themes from the multiple papers, but there is perhaps a missed opportunity here to rigorously employ synthesis techniques and clearly bring together those themes into an overarching model. Of course, the proof of the pudding is in the eating – the test will be whether the model is useful for informing future work.
- Again perhaps because they employed a broader thematic approach rather than meta-ethnographic approach, the authors didn’t separate the data into ‘first order’ and ‘second order’ constructs. First order refers to quotations lifted from the paper, second order to comments or observations by the original study authors. It can be helpful to distinguish these to get a sense of how much of the original data (participant quotations) are being synthesised and for example to explore whether different studies put forward consistent or different interpretations.
- The authors conducted a quality analysis using the CASP qualitative research appraisal checklist (PDF) but it was notable that all the studies scored very highly and none were considered for exclusion. It’s possible that researchers publishing in this field are just all really good at qualitative research, but it might also indicate the authors were quite generous in their assessments or that the CASP checklist isn’t very helpful for making these kind of decisions – there is a debate on whether it’s even appropriate to assess quality in this way or whether it’s an inaccurate attempt to replicate the methods used in quantitative reviews.
- The authors suggest that training is needed to address GPs ‘knowledge deficits’ and educate and raise awareness and particularly target high over prescribers. However they themselves note that GPs had mixed feelings about engaging in further training and considering that those who flaunt the guidelines most are perhaps least likely to access such training, it’s not clear how helpful this would be. Would interventions aimed at decision-making be more helpful or employing external motivators such as QOF checks?
- None of the studies included nurse prescribers. Further work may be needed to explore other clinicians’ views, and also the views of patients themselves.
Sirdifield C, Anthierens S, Creupelandt H, Chipchase SY, Christiaens T, Siriwardena AN. General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis. BMC Fam Pract. 2013 Dec 13;14:191. doi: 10.1186/1471-2296-14-191.
Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008 Jul 10;8(1):45.
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies: Benzodiazepines are used to treat… http://t.co/0tEDiQLpk0
@Mental_Elf cos some GPs still think they r a treatment for alcoholism n have never heard of cross-addiction
‘Why do GPs overprescribe benzodiazepines? Synthesis of qualitative studies’ Interesting @Mental_Elf post by @dr_know http://t.co/FxUc8KQZvC
@GeorgiaBelam @Mental_Elf @dr_know in my practice we tried to be benzo free. got more abuse from patients over this than anything
@GeorgiaBelam @Mental_Elf @dr_know Then We took over the list of a very popular single handed GP and found many on benzos. Hard to wean off
@DoctorAngry @GeorgiaBelam @Mental_Elf @dr_know Can’t just withdraw the drug w/o offering something else for non-drug Rx of anxiety
@DoctorAngry @GeorgiaBelam @Mental_Elf @dr_know ” pill factory” GP’s r v popular but not acting in best interests of pt
@GeorgiaBelam @Mental_Elf @dr_know Also when doing MHA Assessments was struck by frequency with which Psychs told pa.t to get benzo from GP
@DoctorAngry @GeorgiaBelam @Mental_Elf @dr_know Definitely. Most aggressive pts were benzo addicts, n other GPs will undermine cos easier
@buletproofcardi @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know Just Benzo addicts? Not poly substance misuse? Most of my LT B users LT anx
@buletproofcardi @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know Benzo (and now pregabalin) use high in p/subs misuse so harder to treat!
@buletproofcardi @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know Chronic anx v disabling & difficult 2 treat -ltd access to psych tpy!>>
@tadhg50 @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know Benzo withdrawal horrible n need lotsa support but NA free n available 24/7
@tadhg50 @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know ppl need to understand that the drugs r producing the anx not treating it 1/2
@tadhg50 @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know 2/2 addicts gen no idea wot the drugs actually do so important 2 explain
@buletproofcardi @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know >>Most Dr’s I know just want to help alleviate sx . Not easy rltshp!
@tadhg50 @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know short-term gain = long-term pain. Px is helping the dr not the pt
@buletproofcardi @Mental_Elf @DoctorAngry @GeorgiaBelam @dr_know Agree! Different Pat gps require diff approaches too! Ltd resources/access!
@GeorgiaBelam @nursingbard @Mental_Elf @dr_know ITU now trying to go benzo free too, patient memories during sedation sound horrific
@GeorgiaBelam @nursingbard @Mental_Elf @dr_know also trying to ventilate somone with tolerance due to long term benzo use is a nightmare
@MsNaughtyCheese @Mental_Elf @GeorgiaBelam @nursingbard @dr_know Need to get addiction services out of psychiatry n make multidisciplinary
@MsNaughtyCheese @Mental_Elf @GeorgiaBelam @nursingbard @dr_know medical FX of chem dependency r wide-ranging n ignored
… with also an interesting consideration of individual decision making when prescribing, & the heuristics we use http://t.co/FxUc8KQZvC
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies http://t.co/DhklivyV7i via @sharethis
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies – The Mental Elf http://t.co/2h3L9fxz89
Today @dr_know summarises a systematic review of GPs’ experiences & perceptions of benzodiazepine prescribing http://t.co/pQ3dj2ozax
They overprescribe because they do not understand the cognitive effects long-term
Why do GPs over prescribe? http://t.co/HW7aZIGvSm
Mental Elf: Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies http://t.co/IWvcKfpDrt
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies – See more at: http://t.co/uektD7OGfG
The ‘deserving patient’ gets them. And possibly sells them on. Interesting paper on why GPs over-prescribe #benzos: http://t.co/SZjNJJMV3Y
@Sectioned_ We have a spectacular GP #headclutcher in our blog today http://t.co/pQ3dj2ozax Does that count?
@Mental_Elf @Sectioned_ That’s a beauty!
#Headclutcher of the week goes to @Mental_Elf http://t.co/6gz3SkjJ9F My GP looked just like this when she prescribed diazepine on Monday!
@Sectioned_ @Mental_Elf that’s a very fine #headclutcher!
@Sectioned_ @Mental_Elf Hahaha! Professional #Headclutcher ahoy!
@Sectioned_ @Mental_Elf there’s nothing to touch the efficacy of benzo’s if you’re all alone in the world, frightened and old = life-saver
New @Mental_Elf blog on benzo over prescribing http://t.co/ge9koja3Sy v important issue & gd points made but bit of missed opportunity imo
Review finds that GPs have mixed feelings & experience conflicting pressures towards prescribing benzodiazepines http://t.co/pQ3dj2ozax
@Mental_Elf So they should!
@Mental_Elf Friend has been px 84 diazepam by GP, she is in SS’s, mmm shall we try thinking how MHP’s could help trying to alleviate anx
On methodological note,I think this is good eg of how a more rigorous analysis could have been delivered more insight http://t.co/a4TngXJpPe
(As opposed to being ‘for the sake of it’ or just nitpicking which I think sometimes people suspect it is) http://t.co/a4TngXJpPe
Why do GP’s over-prescribe benzodiazepines? http://t.co/jkIvvMy2tI
Review: GPs make benzodiazepine prescribing decisions on a case-by-case basis rather than having consistent practices http://t.co/pQ3dj2ozax
@Mental_Elf I can tell that I have been left on them for over a decade. only reason I’m coming off them is I demanded too.
Don’t miss: Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies http://t.co/pQ3dj2ozax
@Mental_Elf Mine doesn’t Two weeks worth they gave me and no more.. Is this the exception rather than the rule then?
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies https://t.co/XQFNfE0WO8
Why do GPs over prescribe benzodiazepines? Synthesis of qualitative studies http://t.co/wQDYYZ2qK5 via @sharethis @dr_know
Why do GPs over prescribe #benzodiazepines? Synthesis of qualitative studies http://t.co/r3DXpSqpbJ via @sharethis