New UK Benzo Guidelines Perpetuate Stigma and Enable Prescribed Harm

By Carrie Clark

The UK’s Medicines and Healthcare Products Regulatory Agency (MHRA) has announced updated warnings for “addiction, dependency, withdrawal, and tolerance” caused by benzodiazepines, gabapentinoids, and z-drugs.

Broadly speaking, any sign that medical authorities are seeking to better inform the public about the risks of psychiatric drugs is welcome, though it’s worth noting that this update has been a long time coming. The dependence risks of benzodiazepines have been known for decades. Regrettably, however, as author of The Maudsley Deprescribing Guidelines Mark Horowitz puts it, the MHRA update remains “conceptually confused and clinically inadequate.”

Conceptually Confused

That conceptual confusion starts with the crucial differences between addiction and dependence. These are distinct experiences that are only sometimes interrelated, and distinguishing between them matters very much for how patients are received by their doctors when reporting prescribed psychiatric drug harm.

Rightly or wrongly, the term “addiction” has moral overtones. We associate addiction with pleasure seeking, and addicts are generally perceived as making a conscious choice to do something that is bad for them. We may sympathize with their suffering, but ultimately the addicted individual is held responsible for their own circumstances. People harmed by prescribed psychiatric drugs, including benzodiazepines, gabapentinoids, and z-drugs, have generally made no such conscious choice.

On the contrary, this MHRA update is necessary precisely because patients have typically been deprived of that choice. Most psychiatric drugs can cause dependence, tolerance, and withdrawal, but patients are rarely warned about this at the point of prescription. Having trusted medical professionals to provide properly informed consent, patients are typically shocked when they experience severe withdrawal and learn that they have become physically dependent on a psychiatric drug. But being dependent on a substance does not mean that you are addicted to it.

Addiction vs. Dependence

Dependence is when the body adapts to the presence of a drug, causing withdrawal symptoms when it isn’t taken. Tolerance occurs via the same mechanism: the body’s adaptations to the drug can reduce its effectiveness over time, meaning that higher and higher doses are required to achieve the original effect. These are objective physiological effects.

While it may sometimes involve all three, addiction is more than just the combined effects of dependence, tolerance, and withdrawal. It’s characterized by a state of psychological fixation that drives someone to seek out a substance or activity regardless of the consequences, often causing them to act in ways that are out of character. We recognize that people can become addicted to things that are not physically dependence forming at all. Gambling doesn’t cause physical adaptations, tolerance, or physiological withdrawal symptoms. Even so, someone who stops working, showering, or socializing with friends and family in order to play online blackjack is exhibiting addictive behavior.

Only 2% of benzodiazepine users develop addiction. Nonetheless, despite briefly noting that addiction and dependence are different things, it is the perceived risk of addiction that is overwhelmingly emphasized in the MHRA update. The new patient information leaflets produced for the update are dominated by a section titled “How do I know if I’m becoming addicted?” Unhelpfully, common symptoms of dependence and tolerance are listed as potential signs of addiction, even though they may exist entirely independent of any form of psychological dependence.

These include “experiencing withdrawal side effects when you stop taking the medicine suddenly” and “feeling that you need to take more medicine than prescribed.” But when someone has become physically dependent on a drug, they need not be addicted to it in order to experience withdrawal effects when they stop taking it. Equally, people who develop tolerance may rationally feel that they need to take “more medicine than prescribed” in order to regain the drug’s original effects or to prevent inter-dose withdrawal symptoms. This is particularly so for people who take benzodiazepines, which are well known to cause distressing withdrawal symptoms between doses once a person develops tolerance to the drug.

As Horowitz states, “The inclusion of a dedicated section on recognising addiction and misuse, rather than recognising dependence and withdrawal risk, risks misdirecting clinical attention away from the most common mechanism of harm, that can affect a majority of users.” Not only that, it also risks further alienating patients already suffering the ill effects of inadequate medical advice. Being treated as an addict by a medical professional, having done nothing more than take a drug as prescribed, adds insult to injury. Harmed patients should not be made to feel morally culpable for experiencing withdrawal effects when they were not given the opportunity to make an informed choice about taking a dependency forming substance in the first place.

Clinically Inadequate

It’s notable that since the publication of The Maudsley Deprescribing Guidelines, UK health authorities have begun to emphasize the need for “slow” tapering in order to minimize withdrawal symptoms. The MHRA update follows the general trend in defining “slow” as meaning “weeks or months.” But this fails to capture the reality. In truth, safely discontinuing psychiatric drugs can take years, causing long-term disruption to the lives of patients.

As Horowitz points out, the conceptual failures of the MHRA update are thereby compounded by a lack of practical clinical guidance to enable safe deprescribing. The update provides no tapering schedules and makes no mention of the need to use liquid formulations in order to achieve small, hyperbolic dose reductions. No advice is provided on helping patients to recognize and manage withdrawal symptoms or on weighing the potential risks and benefits of reinstatement. The most severe withdrawal symptoms, including akathisia, withdrawal-induced suicidality, and protracted withdrawal injuries, are not even mentioned as things that clinicians should look out for.

In the absence of standardized practical guidance, the MHRA update perpetuates the present inadequate situation in which the quality of care received by people in withdrawal is determined largely by the individual beliefs held by their clinician. An open-minded and sympathetic doctor may be willing to support a hyperbolic taper, though the individual patient remains burdened by the need to explain and evidence their need for what should be the recognized standard of safe care. On the other hand, clinicians primed by the MHRA update to regard patients in withdrawal as “addicts,” simply seeking their next fix, are given tacit permission to reject a hyperbolic taper as unnecessary.

Conclusion

Having given clinicians the misleading impression that people experiencing withdrawal from benzodiazepines, gabapentinoids, and z-drugs can safely be dismissed as “addicts,” the MHRA update makes a lame attempt to counter the stigma it has itself created by warning doctors to use “non-judgmental language” when talking to patients harmed by psychiatric drugs. 

While it is obviously true that clinicians should be nonjudgmental, many people who have been made involuntarily dependent on these drugs will feel that the medical profession owes them a little more than the right to be free of linguistic judgment. When someone realizes that they have suffered an iatrogenic injury, a harm caused exclusively by following medical advice, they are likely to want both an explanation and an apology from the profession that has caused that harm.

This need not be about aggressively apportioning blame or condemning all medical professionals. It can take time for the long-term harms of a medical intervention to become known and understood and for health authorities to course correct with better processes for informed consent or more limited prescribing. Nonetheless, once the medical profession has recognized that it has made a mistake, as it has in the improper prescribing of many psychiatric drugs, acknowledging the harms caused by that mistake and supporting access to evidence-based relief must become an accepted part of practice. Unfortunately, as Horowitz summarizes:

Without a clear operational distinction between addiction and dependence, and without practical, evidence-informed guidance on safe dose reduction, this MHRA document risks perpetuating the very harms it seeks to address.

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