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- Page navigation anchor for Sourcing the sound: avoidance of surgery for pseudo-tinnitusSourcing the sound: avoidance of surgery for pseudo-tinnitusWe faced this kind of experience in outpatient of otolaryngology. Such therapy may also be effective for patients with otolaryngology.A 34-year-old man complained the tinnitus, which had continued for more than 10 years, he had not received any treatment, including psychotropic medications, because of its unknown origin except surgery. He received the diagnosis of tinnitus caused by a stapedial reflex in a university hospital for couple years ago. He underwent left stapedius muscle removal to prevent the stapedial reflex. However, the left-sided tinnitus did not resolve after the surgery. He visited our clinic because of the continuous tinnitus in his left ear.Otolaryngeal examination performed including nasolaryngeal-fiberopotic and pharyngealscopic1 studies, showed no abnormalities of the ears, nose, and throat, although we noted clicking sounds of 1–2 Hz originating from the patient’s nasopharynx (near the left soft palate and Eustachian tube) which occurred simultaneously with left soft palate elevation. The sounds appeared to result from rhythmic myoclonic jerking of the levator veil palatine muscle or tensor veli palatini muscle.For treatment, the patient was prescribed twice-daily clonazepam 0.5 mg (morning and evening). After 14 days on this regimen, the involuntary continuous myoclonic palate elevation and tinnitus had resolved. There were simil...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Authors' response to Prof Siriwardena's letterAuthors' response to Prof Siriwardena's letterWe thank Prof Siriwardena for his comments and would like to take this opportunity to respond.Firstly, Prof Siriwardena is mistaken to state unequivocally that guidelines have failed to reduce benzodiazepine and z-drug prescribing. Since the introduction of guidelines in the early 2004,1 benzodiazepine prescribing has fallen from 3.5% of patients in 2000 to 2.5% in 2015.2 However, we do agree that too many clinicians still do not follow guidelines for complex reasons. Where our disagreement is most serious, however, is where Prof Siriwardena’s implies that we are wrong to insist on guidance adherence as the reasons for non-adherence are complex. We hold that the reasons for guidance adherence (given the human damage non-adherence causes) are far more persuasive than the reasons for non-adherence, however ‘multifaceted and complex’ the reasons for non-adherence may be.Secondly, he criticises us for advocating more research into the harms associated with long-term BZD use. While we agree that existing evidence exposes multiple serious harms, patient reports indicate that many other harms have not been captured in the existing evidence base. Furthermore, serious data gaps still remain regarding the percentage of long-term users of BZDs affected by withdrawal, and how different species of withdrawal correlate with dosage, length of use, and withdrawal method, needs to be d...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Long-term benzodiazepine and Z-drugs use in the UKLong-term benzodiazepine and Z-drugs use in the UKThe authors thank Dr. McNally for his insightful and considered comments on our work. He argues that “patients are…interested in individual risk.” This may well be the case, but it is not the question we asked, which concerned the number of people during the study period who had been taking BZDs for over a year. We asked this particular question because of the view that prioritising and/or funding treatment of BZD dependence is not possible while the size of the alleged problem remains unknown. This question has been answered accurately with the temporally-restricted data analysed for our study – that is, the percentage of BZD patients who have taken the drugs for longer than a year in the period covered by the data available represents the scale of the problem for the purposes of determining the number of people who may be in need of treatment presently. This does not constitute an example of the denominator fallacy, because we were not estimating efficiency nor risk nor probability, but simply the number of patients that may be in need of help with withdrawal. As Dr. McNally says, “Doctors…need to be aware of prevalence.” This is what was measured and what was reported.This is not the same as asking how many patients go on to become long-term users, nor the risk of any given patient doing so – answering these questions requires different methods and, crucially, different data. As Dr. McNa...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Long term benzodiazepine use a surveyLong term benzodiazepine use a survey
This turns out to be disappointing for two reasons. Firstly, the "How this fits in" box says "the authors offer recommendations on how the problems... can be best addressed." Indeed, they do - but only in the online version, which has to be looked for.Sadly, the recommendations aren't all that helpful.
They are, of course, correct to say that BZDs should only be prescribed short-term
Sadly, after that, they are all over the place, asking for more dedicated services (good luck with that...) and a national helpline/website which they assert, without references, will make a big difference.
Really, the answer is in our own hands. The information in Heather Ashton's work from 15 years ago, which is referenced, provides all the information needed. Often after just a conversation that these are dangerous drugs long term (associated with increased morbidity and mortality - although the reasons aren't clear) patients will stop of their own accord. For the others, a slow withdrawal over a period of months is usually bearable and attainable. It just takes a bit of effort. We are the ones signing the prescriptions and we can learn to say "no".
As Des Spence says in the same issue, though in a different context "address unreasonable behaviour head on". Long term prescription of BZDs is unreasonable behaviour.
Competing Interests: None declared. - Page navigation anchor for Prescribed drug dependence services for long-term benzodiazepine and Z-drug use: treating the problem while ignoring its causesPrescribed drug dependence services for long-term benzodiazepine and Z-drug use: treating the problem while ignoring its causes
Davies and colleagues highlight the issue of inappropriate long term benzodiazepine and Z-drug prescribing1 but their conclusions and recommendations are flawed.
Firstly, they suggest that prescribing should be reduced by ensuring adherence to existing guidelines for prescribing and withdrawal, or developing new guidelines where needed.
Guidelines have failed to reduce benzodiazepine and z-drug prescribing: clinicians do not adhere to recommendations to use hypnotics and anxiolytics short term and only after trying psychological therapies.2 The reasons for this are multifaceted and complex,3 with recent systematic reviews suggesting why this may be and what can be done, including strategies for services, practitioners and patients, to reduce the initiation and continuation of benzodiazepines and offer options for effective withdrawal.4,5.Secondly, they advocate more research into the harms associated with long-term BZD use, as well as the demographics and geography of long-term users. Many studies have investigated harms from long term benzodiazepine use, including risks of cognitive impairment,6 falls,6 hip fractures7 and road traffic collisions.8 The existing literature on variations in benzodiazepine prescribing due to sociodemographic, case -mix, practice and other factors9 means extrapolating from their local survey may have led to inaccu...
Competing Interests: None declared. - Page navigation anchor for Long-term benzodiazepine and Z-drugs: committing the denominator fallacy?Long-term benzodiazepine and Z-drugs: committing the denominator fallacy?
In a US population of patients co-prescribed benzodiazepines with antidepressants, only 12% went on to long term use.1 Yet in this UK study, '35% of all users of BZD are taking these drugs long term'. How can we reconcile these two findings? One possibility is that UK prescribing is more liberal than in the US. Another is that the UK study looked at BZDs (benzodiazepines and Z drugs), whereas the US study looked at benzodiazepines alone.
Another explanation is the difference between individual risk and prevalence. In a survey of 1 year's BZD prescriptions, you are likely to include those patients who started in previous years and are still receiving a BZD prescription, but omit shorter-term users from previous years. This increases your numerator (longer-term users) but omits short-term users from the denominator (all users), inflating the percentage of longer-term users. In fact, it is not clear how they calculate 'that 35% of all users of BZD are taking these drugs long term'. If for example the search strategy was 'all patients prescribed BZD in 2014 or 2015', then longer-term users who started in 2013 or earlier would be captured, but shorter-term users would not. It may therefore be valid to say that 'over the time period studied, 35% of patients prescribed a BZD are taking these drugs long term'. This does not, however, equate to the risk to an individual of their BZD use becoming long term (which Bushnell...
Show MoreCompeting Interests: None declared.