Talk:Benzodiazepine/Archive 4

NICE guideline citation

The sentence "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy, but benzodiazepine use has been found to interfere with therapeutic gains from these therapies." is sourced to NICE CG022. This is a 165 page book. Please split the citations and given page number(s). Is the comment about concomitant benzo use based on solid evidence, or just a remark? For example, do the guidelines discourage it? I have been unable to find the sourced text due to the page number issue. Colin°^Talk 09:20, 21 June 2009 (UTC)

BNF

The BNF citations have page numbers. These don't help if you read the online edition, and will rapidly become out-of-date when a new edition is produced (it is a periodic publication). I know formulating terse chapter headings isn't straightforward, but how about something like this:

• Chapter: 4.1.1 Hypnotics: Benzodiazepines
• Chapter: 4.1.2 Anxiolytics: Benzodiazepines
• Chapter: 4.8.1 Control of epilepsy: Benzodiazepines
• Chapter: 4.8.2 Antiepileptic drugs: Drugs used in status epilepticus
• Chapter: 15.1.4.1 Anxiolytics and neuroleptics (Anaesthesia): Benzodiazepines

Include the page number(s) too (I don't know them so didn't include them above). Colin°^Talk 10:10, 21 June 2009 (UTC)

Sounds good to me Colin.--Literaturegeek | T@1k? 14:22, 21 June 2009 (UTC)

Anxiety, panic and agitation

There is some confusion in this paragraph as to which disorder a particular recommendation (for or against) is being made. Disorders mentioned include:

• severe anxiety
• anxiety disorders
• panic attacks
• acute panic caused by hallucinogen intoxication
• panic disorder
• panic disorder with or without agoraphobia
• acute psychosis
• acutely agitation

Some sentences are clear, others are not. For example,

• "There are no controlled clinical trials to demonstrate whether efficacy is maintained and not lost due to tolerance." efficacy for which disorder?
• "Psychological therapies such as cognitive behavioural therapy are recommended as a first line therapy; benzodiazepine use has been found to interfere with therapeutic gains from these therapies." I'm guessing we are still talking about panic disorder.
• "Lorazepam is most commonly used but clonazepam is sometimes prescribed" I'm guessing this refers to acute psychosis.
• "Long-term use is not recommended due to risks of dependence." Again, assume this is acute psychosis but why would you treat an "acute" illness long term? Is it prophylaxis against further acute psychosis?
• The intra-muscular comment probably fits better with the administration route comment at the start of the paragraph.

I suggest, that short term severe anxiety and long term panic disorder are covered within their own two paragraphs. Currently, panic disorder is first mentioned as the second-half of a sentence on the (presumably uncommon) treatment of acute panic caused by hallucinogen intoxication. Then have a paragraph on the various other nervous conditions, trying to keep them distinct (perhaps by having only one sentence per indication).

• Both panic attack and acute agitation are mentioned secondary to their route of administration of the drug. This is back-to-front in a section on indications. By all means mention these administration routes, but make that the secondary aspect of the discussion.
• The section has improved a bit wrt first-second line indications, and clinical guideline indications. But it gets one aspect wrong. It says

"benzodiazepines continue to be prescribed for the long-term treatment of anxiety disorders, although specific antidepressants and the anticonvulsant drug pregabalin are recommended as the first line treatment options."

The source (PMID 19122540) says

"Clinicians should, however, bear in mind the frequent physiological dependence associated with [benzodiazepines], and suggest both pharmacological and psychological treatment alternatives before opting for a long-term benzodiazepine treatment". Note the "psychological treatment" is absent from our text.

Colin°^Talk 10:06, 21 June 2009 (UTC)

I think that I have resolved these issues Colin, thanks for pointing them out.--Literaturegeek | T@1k? 05:11, 24 June 2009 (UTC)

Side effects

The third paragraph needs a copyedit, preferably by someone with access to the sources. The second sentence "With long-term ... occurs." is just broken. It also states these "occur", as in, always. Is that really true? The third sentence needs to make clear which "impairments are not serious" (I'm guessing the residual impairments, not the impairments during therapy, which have already been described as "moderate to large".) There's a fair bit of repetition resulting in wordiness. The paragraph says there are a "range of cognitive areas" affected but only mentioned "visuospatial memory". If visuospatial memory is the only significant cognitive area affected, the whole paragraph should make that clear from the outset. Otherwise, perhaps we need to indicate which cognitive areas we are talking about (or say that all or many areas are affected, if that is the case).

The sentence "Additionally an altered perception of self, environment and relationships[62] and adverse effects on physical and mental health may occur." is unsatisfactory. The use of "additionally" sort of makes these an afterthought. And the two clauses:

• altered perception of self, environment and relationships
• adverse effects on physical and mental health

are separate issues that should not be strung together. The second clause seems to include the whole of ill health in all forms; what is it saying that hasn't been said already. Colin°^Talk 10:35, 21 June 2009 (UTC)

Thanks Colin. I believe that I have resolved these issues.--Literaturegeek | T@1k? 11:12, 23 June 2009 (UTC)

Requested page protection

I can no longer edit this article under these intolerable conditions. I have requested page protection for edit warring by Sceptical. I find his attitude and editing alongside him very antagonistic and it is only going to provoke me to personal attacks. There is zero chance of the article passing FA if it is going to be constantly edit warred so may as well forget it.--Literaturegeek | T@1k? 14:31, 21 June 2009 (UTC)

I do not understand what is going on. Would you agree if I reverted the article to the last version by Colin? I feel too many unilateral, undiscussed changes are being made to the article too fast. —Mattisse (Talk) 15:01, 21 June 2009 (UTC)

I would not be opposed Mattisse. I want dispute resolution but feel someone who does not understand the medical literature has formed an opinion using original research and are fighting systemic reviews with weak reviews and taking refs out of context. Thank you for your input.--Literaturegeek | T@1k? 15:06, 21 June 2009 (UTC)

The link to FDA APPROVED LABELING FOR XANAX XR" (pdf) is broken and I get a "page not found" error. Also, is it a good idea to mention that an author is employed by drug companies, as many of them may be? —Mattisse (Talk) 16:28, 21 June 2009 (UTC)

I deleted that one, thanks. I dunno I have mixed thoughts, I am happy to just leave the COI issues out of the article. My main problem is the falsifying of refs and original research and deleting anything that doesn't agree with original research or weak uncontrolled studies.--Literaturegeek | T@1k? 18:04, 21 June 2009 (UTC)

What are "naturalistic studies"? Is that like a case history, or something else? —Mattisse (Talk) 18:20, 21 June 2009 (UTC)

I googled it and it says this,[1]. I am not sure they are naturalistic studies, because the long term studies that I am aware of were basically patients being asked "Do you think the medication is still effective?" or similar, so it wasn't an observation in a natural environment so I think that description is inaccurate but would need to see full text. It was where patients were brought in for interview at follow-up points and asked their dosage and if they felt medication was effective. It was a questionaire, an extension of a short term study.--Literaturegeek | T@1k? 18:38, 21 June 2009 (UTC)

Uncontrolled questionaire studies by Pfizer and Roch pharm would be a good discription.--Literaturegeek | T@1k? 18:39, 21 June 2009 (UTC) Although I would need to see full text to be sure. :)--Literaturegeek | T@1k? 18:54, 21 June 2009 (UTC)

Dispute resolution

Issues to resolve with Sceptical. Ignoring me and continuing edit warring on article when I am appealing for discussion, eg Talk:Benzodiazepine#Withdrawal_section and never respondingg to my points. This type of thing or when we engage in discussion you ignor my points, don't address them and then just keep firing accusations at me I find very combative as it makes me feel under attack and also that I am talking to a brick wall. I request this stops to resolve dispute. Faking refs, making them say the opposite of what they say or distorting them and original research must also stop.--Literaturegeek | T@1k? 18:34, 21 June 2009 (UTC)

Anyway a few changes have been made today by myself and I have backtracked from a couple of edits to move towards dispute resolution.--Literaturegeek | T@1k? 18:34, 21 June 2009 (UTC)

Attempt at dispute resolution, I agree that use of benzos has a controversial evidence base in panic disorder and is notable enough to mention both sides of debate. It is a significant enough view point to mention. It is not a fringe viewpoint but it is not a majority opinion so should not be abused or given undue weight. My issues are faking or taking out of context or using weak references to challenge systemic reviews by expert panels and goiing on POV edit warring deletion and fake data battles on this FA candidate article.--Literaturegeek | T@1k? 18:48, 21 June 2009 (UTC) It is mentioned in the article now so hope this point is resolved.--Literaturegeek | T@1k? 18:52, 21 June 2009 (UTC)

I also tried to address the numerous {{POV}}, {{clarifyme}} and other tags Sceptical put on the article. These tags were put on an article undergoing FAC without adequate discussion or attempt to seek consensus on this talk page or the FAC page first. I also restored some material that was removed without concensus that was adequately referenced. I believe Literaturegeek | T@1k? is under a lot of pressure here and urge all changes to the article content be discussed on this talk page before major edits to the article. —Mattisse (Talk) 19:13, 21 June 2009 (UTC)

Matisse, you are wrong. I discussed the disputed issues at length with LG on this page. Please read [2], this [3], and this[4]. Only after LG refused to listen to my arguments and moderate his stance, I placed the POV tag on the chapters. The Sceptical Chymist (talk) 10:31, 22 June 2009 (UTC)

I think that it was because he got caught faking refs and doing original research so he is flagging citations as failing verification to try and make editors think I am faking references. He really is a carbon copy of Mwalla and scuro, I think you know Mwalla. well maybe not as bad as them he does do a lot of constructive edits. WP:DISRUPT is what is going on. I also suspect he is flagging section as POV as a way of saying if you don't do what I want i will screw up FA review. This needs to stop before we can engage in dispute resolution.--Literaturegeek | T@1k? 02:03, 22 June 2009 (UTC)

Thanks for acknowledging the stressfulness of the situation Mattisse. I think that this will be my last FA article LOL. :)--Literaturegeek | T@1k? 02:39, 22 June 2009 (UTC)

Mattisse is not wrong. Your links disprove your statement that I didn't respond as they show that I did respond. I responded to all of your comments that you were doing original research and that the refs were irrelevant. For example using CT scans which only detect brain structure changes eg tumors, brain damage from car crashes or significant brain tissue loss etc to disprove neuronal changes or damage. I refused to agree with inaccurate original research using irrelevant refs was all and you ignored my comments because they disproved your original research theories and misinterpretation of the medical literature.--Literaturegeek | T@1k? 20:43, 22 June 2009 (UTC)

All I ask is that we move on, put the past behind us and listen and respond to each others arguments. I do not want this to be a competition between you winning and I winning. I want this to be an effort to get the best quality and most comprehensive article possible free of factual errors.--Literaturegeek | T@1k? 20:47, 22 June 2009 (UTC)

A risk of dependence and a withdrawal syndrome when discontinued.

Tolerance can develop to their effects and there is also a risk of dependence and a withdrawal syndrome when discontinued. Please correct the sentence for style. Risk of dependence when discontinued?? Since dependence is defined through the withdrawal syndrome, and indeed the difficult withdrawal is what is bad about BDs, I suggest simply leaving withdrawal syndrome. Or you can leave only dependence. For example see, Oxford handbook of psychiatry, p 348: "BDZs (e.g. alprazolam or clonazepam) should be used with caution (due to potential for abuse/dependence/cognitive impairment) but may be effective for severe, frequent, incapacitating symptoms. Use for 1-2 weeks in combination with an antidepressant may 'cover' symptomatic relief until the antidepressant becomes effective. N.B. 'Anti-panic' effects do not show tolerance, although sedative effects do." The Sceptical Chymist (talk) 10:49, 22 June 2009 (UTC)

A physical dependence is what causes the withdrawal syndrome, so yes withdrawal is a result of dependence but we need to include both because most lay readers are not going to realise that a dependence also includes a withdrawal syndrome because of the dependence. Although perhaps we could reword it? Yes medical books may just use dependence without saying withdrawal syndrome but that is because those books are aimed at healthcare professionals who are familar with medical jargon and definitions. If you were to stop random people on the street and ask them what the medical word dependence means you would get a high number of people who would not mention withdrawal or who may not even know dependence is a form of "addiction" or being "hooked" in lay language.--Literaturegeek | T@1k? 20:39, 22 June 2009 (UTC)

Long-term use tendency to cause or worsen cognitive deficits, depression and anxiety.

The effects of long-term use or misuse include the tendency to cause or worsen cognitive deficits, depression and anxiety. It is true that misuse results in all of the above, especially because the misuse of BDs usually happens in the context of multidrug abuse. However, there is no evidence that the long-term use of therapeutic doses cause or worsen depression and anxiety. I suggest removing it. Or provide full citations below in support.The Sceptical Chymist (talk) 10:54, 22 June 2009 (UTC)

Is there any literature on titrating doses and tailoring the benzodiaepine to the individual? I think this would help to describe what is an effective dose. If there is too much drowsiness the dose would be reduced or a shorter half-life benzodiazepine used instead, or another class of drug substituted. Snowman (talk) 15:02, 22 June 2009 (UTC)

There seems to be a surprising lack of empirical data on the benzodiaepines that take into account diagnoses, duration of treatment, type of benzodiaepine, coexistence of other treatments/drugs, drug use/abuse, age, individual differences to the development of side effects/habituation/tolerance and other subject factors etc. There is almost no methodologically tight research on long-term use. There seems to be general agreement on risks of dependence, unpleasantness of withdraw etc. but there seems to be a divergence between this consensus and actual prescribing patterns. I was surprised to see the figures in this 2004 reference: 10 million prescriptions a year in England alone, 80% to the elderly. [5] I wonder if the percentages are similar for the U.S., Canada, Australia, France etc. My observations of physician prescribing practices is that they are generally willing to prescribe these drugs. So the warnings of the literature may be disregarded in practice. Also, are the 'Z-drugs' an improvement, or are their risks the same? —Mattisse (Talk) 15:19, 22 June 2009 (UTC)

Opposed Sceptical because references were talking about prescribed users and there are lots of studies which have found this but as this is FA article I can only cite secondary sources which I have done.--Literaturegeek | T@1k? 15:25, 22 June 2009 (UTC)

Without referring to any literature, but being familiar with the subject matter, I would be inclined to say what is unknown in the introduction, generally in line with what User Mattisse says above. This would replace several parts of the current introduction, and of the article. Perhaps several parts of the third and fourth paragraphs of the introduction are currently problematic in emphasis. Snowman (talk) 16:01, 22 June 2009 (UTC)

Yes guidelines are ignored up to a point. A lot of the benzo users are chronic users from the 60's, 70's and 80's which include the elderly. Doctors in general try to avoid putting people on long-term on benzos certainly as a first line therapy but a lot of patients will pressure the doctor for the pills and refuse to stop them after short term use or else if they get a patient who is not responding to other psychotropic drugs they use them.--Literaturegeek | T@1k? 20:27, 22 June 2009 (UTC)

I think there are many assumptions about benzodiazepines, but little hard data about long-term use. I sense there is a big difference between standards in the U.S. and the U.K. in their use. Although the standard rhetoric is available in the U.S., the fact is that they are all Schedule IV drugs, meaning that a doctor can prescribe a three month supply (say 360 1mg tablets of Xanax, p.o. qid, which is a high dose) with refills. This indicates to me that officialdom is not very worried about benzodiazepines. —Mattisse (Talk) 20:42, 22 June 2009 (UTC)

There have been efforts to put either certain benzos or all benzos into schedule III drug class in the USA/FDA and even as high as the world health org but are always opposed by the drug manufacturers quite vigorously. Infact the last panel of the ACMD which recommends drug policy here in the UK recommended all benzos be placed into schedule III but then somehow Roche Pharm managed to get their top doctor in the UK into the top position on the ACMD so the the moving of benzos into schedule III died a horrible death so to speak. I can provide refs for this if you like. I believe if benzos weren't a legally prescrible drug they would be schedule III long ago. I did a whiile back think of a "controversy section" but decided against it because then I would be invaded by sockpuppets and endless drama by drug companies so not worth the effort of reffing all this stuff and it doesn't really interest me as I want to just build a factual article on the drug rather than drug company conspiracies. The other issue which is perhaps relevant as well is overdose potential, for example opiates which cause a less severe withdrawal syndrome than sedative hypnotics were made illegal mainly because of their overdose potential but also abuse potential. Same with barbs, it was their overdose potential which knocked them up the ladder in drug classification.--Literaturegeek | T@1k? 20:59, 22 June 2009 (UTC)

I would like to see the references on this. For one, Roche is only one of many manufacturers, and almost all but the newest are sold in generic form and are very cheap. I don't know what the ACMD is, but the psychiatrists I know do not think benzodiazepines (or benzos, as you call them) are a big deal and that they are relatively safe. It is almost impossible to kill oneself with an overdose, unless combined with liberal amounts of alcohol. They are safer in this respect than antidepresants. There is zero hypo about benzodiazepines, unlike amphetamines, for example. They are not a signifigant law enforcement problem. —Mattisse (Talk) 21:29, 22 June 2009 (UTC)

Yea but Roche will defend benzos as a class because if all their rivals benzos get rescheduled or a bad name then it affects the drug class so the benzo companies will defend the drug class as well as their individual products. Here is the quote. "all the benzodiazepines should be re-scheduled under Schedule 3 of Part II of the 1985 regulations."[6] ACMD annual report 1999 They are not a significant law enforcement problem because they are schedule IV drugs so they are not a priority for focused law enforcement operations. Amphetamines and other potent CNS stimulants have the highest (even higher than opiates) drug liking, i.e. psychological dependence, but they have a low physical dependence capacity so it depends what aspect of a drug you are comparing. I disagree there is zero hype, there are concerns in the USA over the abuse of benzos, in particular alprazolam (xanax). Benzos are widely abused and infact equal or are more commonly abused than say opiates in statistics for prescription drug abuse. :)--Literaturegeek | T@1k? 22:28, 22 June 2009 (UTC)

But that is a 1998 report, and a U.K. one at that. I am beginning to think that the U.K. has reacted somewhat overly to a drug class that is relatively benign, and one that is actually effective in contrast to many psychotropic drugs. While no one knows how antidepressants actually work, and question whether they work more effectively than placebo, the effectiveness of the benzodiazepines is clear. A schedule IV drug can be prescribed freely in the U.S. It just means it must be prescribed. But so does an antidepressant. Benzodiazepines can be prescribed in batches of a three month supply at one time with liberal refills. I don't quite get your reasoning that because it must be prescribed, that prevents abuse. Opiates must be prescribed also. But they can only be a 30 day supply, and the prescription must be filled within three days. The prescription of benzodiazepines has no such limitations. Also, you appear to have one reference from a primary source, dated 1999, saying that they are a serious abuse problem. (See my complaint below.) —Mattisse (Talk) 22:57, 22 June 2009 (UTC)

Hi Mattisse, It is not just the UK which says bad things about benzos. the USA does to. The National Institutes of Health in the USA has a paper on their website which promotes the view that prescription use of benzos may be associated with an increased rate of cancer deaths.[7] The UK has nothing about cancer deaths on gov websites. Perhaps I am reading the situation wrong but feel we are making this a national issue rather than an evidence base issue of this. I would rather not go down this path, first of all it increases the chance of disputes and also I am a great admirer of the libertarian founding principles of America (see my userpage to see my libertarian political beliefs) and what it stands for individual liberty and freedom etc. I might be over-reacting but better safe than sorry. I never said that making a drug prescription only prevents abuse, but it does reduce abuse. Alcohol and nicotine can as we all know be bought in shops and as a result they are the most commonly abused drugs and cause the most addiction.--Literaturegeek | T@1k? 23:52, 22 June 2009 (UTC) --Literaturegeek | T@1k? 23:52, 22 June 2009 (UTC)

Well, I for one do not accept the propoganda from any government website. I can't tell quite what that link is.[8] The National Institutes of Health is just as reliable has the "Home Office". That is why we rely on peer-reviewed review articles and recent meta-analyses for referencing information. Please stick to this standard in using references for this article. —Mattisse (Talk) 00:22, 23 June 2009 (UTC)

I have been sticking to using secondary sources for this article, I haven't added any primary sources to the article. It is only when we went off-topic I gave some government reports for stats.--Literaturegeek | T@1k? 00:32, 23 June 2009 (UTC)

I appreciate all the good work that you have done on this article! It is just that I detect a subtle systemic bias here, not supported by evidence, against this class of drugs that, by and large, is one of the few effective drugs available for the types of problems it addresses. Just think of the drugs people used to take before benzodiazepines existed! Barbiturates, opiates, amphetamines ... —Mattisse (Talk) 01:07, 23 June 2009 (UTC)

I know, I think we both are just enthusiastic wikipedians and just want what is best for the article and wikipedia. :) I appreciate all of your good work you do to, I can see all of the barnstars you have gotten. I feel the facts that I am standing up for are accurate. It isn't even controversial in the literature that sedative hypnotics potentially cause a medically dangerous withdrawal, grand mal convulsions, at least from high doses but yet I then have to prove that sedative hypnotics cause a worse withdrawal than say opiates. Opiates I admit have a higher abuse potential/euphoria and are much higher associated with drug related crime than benzos, same with cocaine and amphetamines, that is uncontroversial and widely known. I feel I am reporting non-controversial medical facts (perhaps not common knowledge to lay people I admit) and people are assuming these facts are part of my "bias". Some aspects are controversial I admit as with any drug. If the controversy or disagreement in the literature isn't fringe then I am not opposed to it being reffed in the article. I can and have compromised with Sceptical on the anxiolytic tolerance. I agree that the older drugs are overall worse than benzos and benzos are an improvement. This is reffed in he article. I am trying to make the article as factually accurate as possible. please assume good faith with me but with that said feel free to challenge me if you feel something needs challenging, that is how we get the article improved and up to FA. :)--Literaturegeek | T@1k? 02:16, 23 June 2009 (UTC)

With that said like everyone or most people I have a bias towards what I believe the truth is but I am not a difficult editor, I am open to dialogue and compromise on disputed issues. :)--Literaturegeek | T@1k? 02:22, 23 June 2009 (UTC)

The propensity to cause addiction

This is from the lead: Long-term use is not recommended due to their propensity to cause tolerance, physical dependence, addiction and upon cessation of use, a withdrawal syndrome. Including addiction in this list is controversial is not widely accepted.

For example, Principles and practice of psychopharmacology, (Janicak, 2006, p.463-5): "In this context, the BZDs have been the subject of a debate that centers on issues related to overuse, misuse, and abuse. Indeed, many BZD-treated patients, their families, and their physicians now wonder whether a person should be considered an abuser after taking these drugs for longer than a few weeks. Several reviews, however, generally support the conclusion that even long-term therapeutic use is rarely accompanied by inappropriate drug-taking or drug-seeking behavior (e.g., high and sustained dosage escalation; trying to obtain the drug from several physicians or illicitly; 4,5,6,7,8,9,10). An international group of experts considered the therapeutic dose, potential for dependence, and abuse liability of BZDs in the long-term treatment of anxiety disorders. They concluded that although the BZDs pose a higher risk of dependence than most potential substitutes, they pose a lower risk of dependence than older sedatives and recognized drugs of abuse (11). Although this may be correct, there appears to be a clear distinction between BZD abusers and therapeutic-dose users. Almost exclusively, the former are reported to also abuse other prescription or street drugs or alcohol; take BZDs in large doses for euphoriant effects or to potentiate other (usually illicit street) drugs; and prefer drugs other than BZDs when available. In contrast, patients who take a BZD continuously for more than 4 to 6 weeks may become dependent on the drug, but the vast majority:

• Do not drink more than social amounts of alcohol
• Do not have a history of dependence on other drugs
• Do not abuse BZDs
• Do not take more than the prescribed dosage
• Usually attempt to reduce dosage to avoid addiction
• Are able to successfully withdraw from BZDs without resorting to another dependence-inducing drug.

These distinctions are important because the advantages and the disadvantages of the therapeutic use of BZDs should not be confused with their abuse. [bold in the original]" The Sceptical Chymist (talk) 11:10, 22 June 2009 (UTC)

I think that this is important in the risks and advantages discussion. I would add extra precautions in slow metabolisers, previous drug abuse, and the elderly, where the risk and advantages may be altered. BNF licensed prescribed use may be necessarily cautious. Snowman (talk) 15:12, 22 June 2009 (UTC)

[Edit conflict with snowman]. I agree with most of what this text book says. It is true that most prescribed users do not develop problematic drug abuse/addiction. I agree that barbiturates and other older sedative hypnotics generally have a higher abuse potential. The problem with the word addiction is various experts have a different viewpoint on exactly what addiction means and can vary from country to country as well. Thing is it is true for other drugs as well, most prescribed amphetamine users don't abuse their drugs and same with opiates most prescrribed opiate users don't become problematic drug abusers. I will remove addiction from the lead.--Literaturegeek | T@1k? 15:23, 22 June 2009 (UTC)

I have added a comment about a similar point where long term use is mentioned on the FAR subpage. Snowman (talk) 15:35, 22 June 2009 (UTC)

• (edit conflict) All the review articles I have read point out to the lack of reliable data on long-term usage and the need for further studies. I think this needs to be taken into account in the article, given that the worry seems to be over long-term usage. Physicians readily prescribe these drugs [9] (in England 80% of 10 millian prescriptions were to the elderly in 2004). So the risk/benefit profile should address this age group and not "police detainees", as I notice one study mentioned above does. —Mattisse (Talk) 15:38, 22 June 2009 (UTC)

• I would have thought that there would have been a lot more information on their usage and safety aspects; anyway, if there is not, the article should reflect this. The numbers might have changed a lot from 2004, and prescribing might be different elsewhere. I have a recollection that the USA have a drug for anxiety working on GABA somewhere that is not licensed in the UK. Snowman (talk) 16:25, 22 June 2009 (UTC)

• There was an interesting point earlier about the therapeutic action on anxiety not developing tolerance, but I have not looked up the references. Snowman (talk) 16:25, 22 June 2009 (UTC)

• I believe that Alprazolam, a drug that is widely prescribed in the U.S. as a Schedule IV drug, along with all benzodiazepines and "Z-drugs", is considered more dangerous in the U.K. than other benzodiazepines and "Z-drugs", but I may be wrong.Mattisse (Talk) 17:22 22 June 2009 (UTC)

Even if USA it has a bad rep for drug abuse and withdrawal problems and USA. It is also bad in overdose.--Literaturegeek | T@1k? 21:07, 22 June 2009 (UTC)

Show me the hospitalization data on overdoses and serious effects from withdrawal. I think psychological dependence may be as much of a factor as physical dependence. Withdrawal is relatively minor compared to alcohol, barbiturates and opiates. I have never heard of a death from benzodiazepine overdose. Not saying that it never happens, but I think it is rare and that benzodiazepines are actually relatively safe and benign i.e. do not harm the body as does alcohol, opiates, etc. My belief is this is why doctors are so willing to prescribe them. In the U.K. too, according to that 2004 report. What is the death/hospitalization rate from benzodiazepine overdose or withdrawal? —Mattisse (Talk) 21:18, 22 June 2009 (UTC)

Here is a USA gov report on drug abuse, if you look at table 9 it has stats for ER visits due to drug class and broken down into individual drugs. It shows benzos ahead of all prescription drug classes except for opiates/opiods.[10] Most prescription drug abuse stats show benzos at the top or close to opiates.

This paper is interesting but whilst it is not focusing on overdoses but just general mortality overall in general populations it does give a quote for stats in England, here is a quote from abstract, "Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug."[11] I do think benzos are relatively safe in overdose but if you look at stats the safety and claim of death is "rare from benzos" is wrong and usually when authors make this claim it is not based on stats but on their assumption. I would say that overdose from benzos is "usually not fatal".

Withdrawal from sedative hypnotics is well known to be the most severe. The only drugs where the withdrawal can directly kill you are the GABAaergic acting sedative-hypnotics, alcohol, benzos, barbs etc. Convulsions are the most notable life threatening withdrawal symptom but usually only occur at the higher end of the therapeutic prescribing range. You can quit cocaine, heroin, nicotine cold turkey and you may get unpleasant withdrawal or "come down" in the case of stimulants symptoms but the withdrawals are not a direct threat on your life. Will get a ref for this.--Literaturegeek | T@1k? 22:55, 22 June 2009 (UTC)

But the conclusion in the abstract to your article referenced above is that results were mixed and that half of the six studies found (from a literature review going back to 1990) showed no increased risk of overdoes from "illicit" benzodiazepines use! —Mattisse (Talk) 23:04, 22 June 2009 (UTC)

No, you are mistaken. I explained the review meta-analysis was not assessing overdose, but general mortality/life expectancy. Basically what it is saying some studies found no increased mortality by any cause such as heart disease for example. Like alcohol is increased with increased mortality overall and is dose dependent as well. I only used that ref for the stats mentioned. The stats are collected nationally by only one source and that is the Home Office. They are talking about general mortality, i.e. general health. They were not disputing the statistics by the home office. I agree the conclusion of that paper that the effects of benzos on life expectency is not well researched. Read the abstract again. I have a feeling we are going a little off topic rather than editing the article. :)--Literaturegeek | T@1k? 23:31, 22 June 2009 (UTC)

PURPOSE: This paper will review literature examining the association of benzodiazepine use and mortality. METHODS: An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards. RESULTS: Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug. CONCLUSION: On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.[12]

It was a literature review in which only six studies were found to be relevant, even though they went back to 1990, half of which found no increased risk in the elderly. Only one found increased risk in those over 60. Increased compared to what? "[B]enzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug." How many people are "poisoned" by any drug? Were they looking at worldwide date, or only from the U.K? I think you need to go with the article's conclusions and not interpret "Tables" on your own. Stats need to take into account relative numbers. —Mattisse (Talk) 00:06, 23 June 2009 (UTC)

I am not trying to convince you that benzos shorten life expectancy, I agree with the conclusions of the author that the data is conflicting. This article does not talk about mortality/life expectany and benzos anyway, so think we are off-topic. Increased compared to normal life expectany or controls not on benzos it would have been comparing it to. Literature reviews and meta-analysis's are usually world wide or at least all english language publications.--Literaturegeek | T@1k? 00:14, 23 June 2009 (UTC)

Where is the evidence that use of this drug is dangerous to patients who use it over the long-term? —Mattisse (Talk) 00:44, 23 June 2009 (UTC)

What do you mean by dangerous? I interpret dangerous as meaning a threat to life or causing some serious medical disorder like heart failure, liver failure etc. The article does not imply that these drugs are dangerous. With long term use, at least at high dosage you would be at least in severe cases at risk of convulsions, psychosis, delerium if stopped abruptly. That would be the only notable medically dangerous adverse effect of benzodiazepines used long term. See answer 40 of this psychiatry text book.[13] The article does not talk about the drugs being dangerous drugs apart from mentioning convulsions.--Literaturegeek | T@1k? 02:41, 23 June 2009 (UTC)

To clarfify my views as well as interpretation of the literature, death from withdrawal of benzos is uncommmon but possible, most people who have convulsions from benzo withdrawal do not die but convulsions themselves are a dangerous side effect in themselves as they can cause brain damage (either directly due to the seizures or falling down and having a head injury etc) and are considered a medical emergency and I guess "dangerous". I have spoken personally to a couple of dozen people who have had seizures coming off of benzos but I have not personally known of anyone dying of seizures from benzodiaazepine withdrawal. Hope this helps answer your question.--Literaturegeek | T@1k? 02:50, 23 June 2009 (UTC)

Surely you have heard of the "DT's"? That is delerium tremens which can occur with GABAergic sedative hypnotics like benzos, barbs and alcohol. It is quite an infamous withdrawal symptom at least for alcohol. Delerium tremens is a serious medical disorder which is characterised by delerium and convulsions. I am not being biased about saying benzos can cause convulsions or delerium in abrupt withdrawal, I am just reporting the facts Mattisse. :-( I have not given any undue weight to this withdrawal effect, it is only mentioned I think once in the article.--Literaturegeek | T@1k? 03:12, 23 June 2009 (UTC)

I am not biased for saying sedative hypnotic withdrawal is more serious than opiate withdrawal, it is a factual and non-controversial statement in the medical literature. I feel like I am being accused wrongly of distorting the medical literature. :-(--Literaturegeek | T@1k? 03:17, 23 June 2009 (UTC)

I believe you are overemphasizing a standard but overly negative point of view that is without support in the literature, per WP:MEDRS. All studies I have seen are heavy on the short-term effects but say more research is needed and long-term effects are inconclusive. Yet, it is stated that there is not much recent research. I contest this statement: "sedative hypnotic withdrawal is more serious than opiate withdrawal, it is a factual and non-controversial statement in the medical literature." Also, what about heroin, which in my experience, is much more of a withdrawal problem with methadone causing its own problems and black market availability, and alcohol? Benzodiazepines, which you said most elderly who take them in the UK got hooked in the 60s and 70s, are benign by comparison.

I think you should say up front in the introduction that, although benzodiazepines continue to be popular and prescribed liberally, there is very little research on the long term effects. I would prefer this to the vague statements in the article about harmful effects and withdrawal problems unsupported by recent data. —Mattisse (Talk) 12:56, 23 June 2009 (UTC)

This is all original research and I think that you got your education in addiction medicine from the newspapers. I have worked in addictions and been reading the peer reviewed literature for most of my adult life and have helped uncountable people off of drugs, thousands of benzo people. So I really don't need to refute your original research. You prove to me that heroin withdrawal is more medically dangerous that benzos. I would love to see the citation for that.--Literaturegeek | T@1k? 13:02, 23 June 2009 (UTC)

Oh and another thing, what on EARTH does it matter about this opiate versus benzos. The article says nowhere about benzos being worse than opiates so why are you engaging me in POINTLESS original research arguments which are totally irrelevant to the production of this article?--Literaturegeek | T@1k? 13:06, 23 June 2009 (UTC)

Possible omissions

I think that more of the newer sedative drug classes should be included to put their modern use into perspective. Snowman (talk) 16:05, 22 June 2009 (UTC)

Benzodiazepines have a black-market, which could be added to the article. Snowman (talk) 16:05, 22 June 2009 (UTC)

It is unclear to me if "Z-drugs" are an improvement in safety and efficacy, as implied in the article by the statement that they are replacing the benzodiazepines. In the U.S., they are considered to be generally in the same class, and I don't think they are "replacing" benzodiazepines as much as being considered an additional option. The standard benzodiazepines are still more widely prescribed I believe (without having any data one way or another to support my statements). —Mattisse (Talk) 17:27, 22 June 2009 (UTC)

Some say they are, some say they have the same risks and benefits. There are also differences between the Z drugs, like zolpidem and zaleplon have a higher affinity for the alpha1 subunit containing GABAa receptors which is responsible for hypnotic effects. Zopiclone is relatively unnselective in its binding profile.--Literaturegeek | T@1k? 20:15, 22 June 2009 (UTC)

We're not seeing a huge uptake in Z drugs at all really, and Stilnox got alot of bad press here so has declined in sales I think. Also WRT black market, people don't ilicitly make benzos, but buy and sell them (especially alprazolam), and go doctor shopping to get as many as possible. Casliber (talk · contribs) 20:24, 22 June 2009 (UTC)

One or two are quite popular in the UK, and have been for years since the price went down. Snowman (talk) 10:57, 23 June 2009 (UTC)

I examined the sources cited to support the lead's claim

"Now benzodiazepines are beginning to be replaced by the nonbenzodiazepines, especially for treatment of insomnia"

and the body's corresponding claim

"A newer class of drugs called the nonbenzodiazepines (sometimes referred to as Z-drugs) are now beginning to replace the benzodiazepines in the treatment of insomnia".

Unfortunately, the sources do not seem to directly support these claims.

• The 1st cited source, Jufe 2007 (PMID 18265473), is rather a weak one (published, in Spanish, in a journal that's not available online as far as I can tell: has any editor actually read the full article as opposed to just the abstract? if not, we should not cite it). The abstract of this source does not say that the Z-drugs are beginning to replace benzos for insomnia; instead, it says that Z-drugs are "most widely prescribed" for insomnia, which is quite different from "beginning to replace" for insomnia, and which says nothing about use of benzos for conditions other than insomnia, nor does it say anything about nonbenzos other than Z-drugs.
• The 2nd cited source (in the body only), Ashton & Young 2003 (PMID 12870563), disagrees with the claim. It is not primarily about Z-drugs, so it is not a good source either, but it says "Attempts have been made to introduce non-benzodiazepine hypnotics, such as zopiclone, zolpidem and zaleplon. These drugs also act at GABA_A receptor sites, albeit with slightly more specificity for the α₁ subunit of the receptor, and have also been shown to cause tolerance, dependence, withdrawal reactions and abuse" which is hardly a ringing endorsement for Z-drugs, nor is it a claim that nonbenzos are beginning to replace (or have replaced) benzos.

I also see that some new text has been added to the lead about nonbenzodiazepines, I guess in order to provide some balance:

"although research into the safety of nonbenzodiazepines and their long term effectiveness has been recommended" (citing Benca 2005, PMID 15746509).

But this new text doesn't really belong in the lead, as it's not about benzos; also, it causes the lead to cite a source which the body does not, which is not a good practice.

To try to work around the problem I made this change, which causes the lead to say this:

"More recently other drugs have become more popular than benzodiazepines for treatment of insomnia."

and the body to say this:

"For treatment of insomnia, benzodiazepines are now less popular than nonbenzodiazepines, which include zolpidem, zaleplon, eszopiclone, and ramelteon."

in both cases citing Tariq & Pulisetty 2008 (PMID 18035234), a better source for this topic than either Jufe or Ashton & Young. Eubulides (talk) 06:39, 23 June 2009 (UTC)

I have no disagreement with your changes. I think we have enough on the nonbenzos, we don't need to go too much into detail about them as we don't want to go too off-topic. :)--Literaturegeek | T@1k? 06:50, 23 June 2009 (UTC)

• The "overdose" section:

The section refers to "toxic effects" too much without summarizing what they are. The section needs to say more about what an OD does do, as in; Benzodiazepine_overdose#Signs_and_symptoms. I have added "coma" to the introduction. Snowman (talk) 10:44, 23 June 2009 (UTC)

I have addressed this issue snowman.--Literaturegeek | T@1k? 04:01, 24 June 2009 (UTC)

Asking about this reference

• This reference is cited three times in the article, twice in the lead, and it is not a meta-analysis from what I can tell. Is it an opinion piece? I cannot access the whole article

• Lader MH (1999). "Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified?". Eur Neuropsychopharmacol. 9 (Suppl 6): S399–405. doi:10.1016/S0924-977X(99)00051-6. PMID 10622686.

Also, it is a 1999 reference - 10 years old. —Mattisse (Talk) 22:01, 22 June 2009 (UTC)

• Further, the article says, "Although short-term efficacy is established, long-term efficacy remains controversial ...". —Mattisse (Talk) 22:04, 22 June 2009 (UTC)

• Since there has been no response, I am going to take the liberty and remove this reference, per WP:MEDRS. —Mattisse (Talk) 00:42, 23 June 2009 (UTC)

There has been a response, I deleted the ref 5 mins ago from the lead. Just looking for replacement refs for its other cited instances.--Literaturegeek | T@1k? 00:43, 23 June 2009 (UTC)

But you replaced it with another 1998 reference. Please note the age of that reference. (My god, that was before the world ended and the housing market crashed!) Per WP:MEDRS, sources should not be over 5 years old. —Mattisse (Talk) 00:48, 23 June 2009 (UTC)

Please see #Catalog of sources above for the issue of age of reviews. As far as ages of sources goes, the article is much better than it used to be; benzodiazepines do not seem to be as actively researched and reviewed as they were decades ago, so some older sources may be needed. PS. I refactored Mattiesse's comment to fix the problem Mattisse noted with its citation; hope that's OK. Eubulides (talk) 01:49, 23 June 2009 (UTC)

I agree, a lot of work went into getting newer reviews and getting rid of older ones. We did come to a consensus though that a small number should be kept as their removal worsened the article.--Literaturegeek | T@1k? 03:08, 23 June 2009 (UTC)

WP:NPOV: A refresher

Now I see that Matisse also detected a "subtle systemic bias". I suggest that LG reads and re-reads WP:NPOV, especially WP:YESPOV and WP:ASF (reading WP:AGF also would not hurt ;)).

Some highlights for the lazy.

None of the views should be given undue weight or asserted as being judged as "the truth", in order that the various significant published viewpoints are made accessible to the reader, not just the most popular one. It should also not be asserted that the most popular view, or some sort of intermediate view among the different views, is the correct one...

The neutral point of view is a point of view, not the absence or elimination of viewpoints. The elimination of article content cannot be justified under this policy on the grounds that it is "POV". Article content should clearly describe, represent, and characterize disputes within topics, but without endorsement of any particular point of view. Articles should provide background on who believes what and why, and which view is more popular; detailed articles might also contain evaluations of each viewpoint, but must studiously refrain from taking sides.

When reputable sources contradict one another and are relatively equal in prominence, the core of the neutral point of view policy is to let competing approaches exist on the same page: work for balance, that is: describe the opposing viewpoints according to reputability of the sources, and give precedence to those sources that have been the most successful in presenting facts in an equally balanced manner.

Wikipedia describes disputes. Wikipedia does not engage in disputes.

A matter that is both verifiable and supported by reliable sources might nonetheless be used in a way that is not neutral. For example, it might be:

• cited selectively
• painted by words more favorably or negatively than is appropriate
• made to look more important or more dubious than a neutral view would present
• subject to other factors suggestive of bias

Also read WP:Writing for the enemy, WP:Avoiding constant disputes.

The Sceptical Chymist (talk) 11:09, 23 June 2009 (UTC)

Look Sceptical you are using primary sources within a review to cast doubt on the conclusions of the review article. I honestly just want to cancel this FA article. There is no rule which says "delete systemic reviews", perform original research by reviewing a review to cast doubt on the conclusions by citing primary sources in the review. You are giving undue weight to uncontrolled questionaire based studies and edit warring by deletinng systemic reviews of the literature because you don't like it. As far as pitting Mattisse against me she also criticised you for doing original research which you have just went ahead and redone it.--Literaturegeek | T@1k? 12:27, 23 June 2009 (UTC)

Look I don't fully agree with you other edits but hey I can compromise with them. This edit, however, I cannot accept because it is based on systemic reviews of the literature.[14] Your only evidence is a review on uncontrolled questionaire studies performed by the manufacturers of the drug. To use uncontrolled clinical trial review, to delete a stronger evidencce base is really not fair. There could be an argument for deleting the uncontrolled trials suggesting no tolerance as this is an FA article but for neutrality I compromised and said ok lets have both views but you don't want both views, you only want one view, your uncontrolled trials.--Literaturegeek | T@1k? 12:33, 23 June 2009 (UTC)

Sceptical it really is totally hypocritical to bombard me with Wiki policies when you are making totally biased edits like this,[15] to remove the other stronger evidence base. The policy you cite says no undue weight, hmmm you delete systemic reviews of the literature and only "allow" your view on tolerance, haha, almost laughable. I site both sides you only allow one side.--Literaturegeek | T@1k? 12:40, 23 June 2009 (UTC)

Besides even if you have found a friend who has bought into your nonsense of doing original research and screaming biased because both sides are cited in an article, I ddon't care if necessary I will get a request for comments on all editors here doing original research and edit warring over high quality refs like you have done. Mattisse was bombarding me with original research yesterday as well and insisting that I provide high quality proof to refute her original research, it went way off topic and I made little progress on the article addressing colin's concerns because of it. This disruption must stop. Please don't do biased deletions and edit war over this sentence again to make the tolerance section only say what you want it to say.[16]--Literaturegeek | T@1k? 12:45, 23 June 2009 (UTC)

Another problem Sceptical is that your ref is ONLY on clonazepam so actually is not even relevant to this article because you are doing original research to say that this applies to ALL benzodiazepines. Alprazolam has antidepressant actions,[17] and works on beta-adrenergic receptors.[18] Tolerance does not occur to antidepressants in general like benzos so perhaps this is why alprazolam "might" remain effective "long term" in panic disorder, not due to benzodiazepine actions but to additional actions at other receptor sites which other benzos don't work on.--Literaturegeek | T@1k? 15:33, 23 June 2009 (UTC)

I have read studies where clonazepam enhances serotonin function similar to antidepressants as well. This could be a unique moderate antidepressant effect which helps these drugs to be effective for some people wiith panic disorder. I can find these studies if necessary.--Literaturegeek | T@1k? 15:44, 23 June 2009 (UTC)

On a side note I am happy enough with your edits to the cognition section and will not be opposing them.--Literaturegeek | T@1k? 15:54, 23 June 2009 (UTC)

Here is a ref for clonazepam, quote "Clonazepam is a partial benzodiazepine agonist and serotonin agonist,"[19]

So there you go both clonazepam and alprazolam have moderate antidepressant like effects, so that is probably why they have antipanic properties long term. You are using a study into clonazepam to mass generalise across the whole benzodiazepine drug class which is original research.--Literaturegeek | T@1k? 17:40, 23 June 2009 (UTC)

Please answer my points rather than ignoring them so that we can find dispute resolution.--Literaturegeek | T@1k? 17:40, 23 June 2009 (UTC)

Stop vandalising this article mr Sceptical Chymist

You have deleted a systematic review for about the 30th time and only allowed a discussion of weak uncontrolled trials in therapeutic dose section. If necessary I will have requests for comments. There is NO DEFENSE for your disruptive trolling on talk pages and vandalism and ignoring of my appeals for discussion. This is harmful to the project and article.--Literaturegeek | T@1k? 11:32, 24 June 2009 (UTC)

Why no one intervening here with their comments? This has been going on for weeks and people have just abandoned this situation so consensus on this repeated deletion of the systematic reviews NICE and only allowing reviews by Pollack. I get article sorted out for FA, then it gets vandalised and original research.--Literaturegeek | T@1k? 11:41, 24 June 2009 (UTC)

RfC: Is is right to keep deleting systematic review and clinical guidelines?

Sceptical Chymist has kept deleting National Institute of Clinical Excellence systematic review and clinical guideline recommendations and only allowing weak uncontrolled trials review article (a non-systematic review) with cherry picked sources. His source only actually focuses on one benzodiazepine rather than the drug class and this article is on the drug class. I have appealed and tried to have some sort of a dispute resolution but my comments get ignored, he will quote edits or comments out of context, edit war bombard me with wiki policies of NPV and accuse me of POV because I want both sides cited and so forth, he does this to preempt me because he knows he is being biased. He is being very combative. I have tried being really nice to him on talk page to resolve dispute. He also keeps inserting original research into the article like declaring the controversy is great. He doesn't like the systematic reviews because they talk about tolerance which he has tried tirelessly to delete with rather weak reviews, like reviews which will quote a single clinical trial from the 1980's but in his eyes only these reviews are allowed because they say what he wants. I have opened up this RfC as a last resort as I don't want to get into an edit war and all other measures have failed. So I would like comments on whether a systematic review should be minimised or deleted entirely and more weight should be given to weaker sources. There are multiple other issues but will address those later.Literaturegeek | T@1k? 12:03, 24 June 2009 (UTC)

The other problem is Sceptical abuses policies like NPOV by doing original research to make things "neutral".--Literaturegeek | T@1k? 12:35, 24 June 2009 (UTC)

Mediation any volunteers

I have closed RFC. What is needed is mediation, not an RFC, it is beyond an RfC. We need a mediator with medical knowledge who feels themselves to be independent/neutral on the subject matter. Someone who understands basic wiki policies like NPOV and reliable sources, medical articles and what is needed for FA articles.--Literaturegeek | T@1k? 14:55, 24 June 2009 (UTC)

One of the problems is the editors I feel don't understand basic medical and pharmacology and the subject matter. Fior example I tried to point out that a CT scan didn't measure neurons but measured brain structure changes but was ignored and Sceptical continued to edit war and do original research to delete parts referring to protracted withdrawal/post withdrawal effects, using totally irrelevant refs. We really need mediation from someone medical to resolve this. The idea is to get this article to FA but this constant inserting of original research, taking refs out of context, even faking refs to, taking weak refs out of context to make clinical guidelines and systematic reviews sound like they are extremist is beyond the pale and has ruined this FA nomination. If anyone wants to mediate great. I admit I did wrong by breaking 3revert, all I can say in my defense was I was enthusiastic to get article to FA and saw all mine and others efforts going down the drain.--Literaturegeek | T@1k? 15:00, 24 June 2009 (UTC)

I'm willing to try to mediate if both sides are willing, or you can ask at WP:MEDCAB. Physchim62 (talk) 16:49, 24 June 2009 (UTC)

Thank you Physche. From your profile you are a chemist so would be familar with pharmacology which will be of value. I still feel that we need a medical person though due to disruptive tactics with refs and literature misused being hard to spot. Do you have a good knowledge on benzos or good knowledge of medicine? If not we can recruit someone from wikimed but on't do that until we see if Sceptical is interested in resolving this or not. To be honest I have lost my motivation to get the article up to FA status but will contribute to any mediation with Sceptical. I will get diffs to show the faking of refs if need me as this will need to be resolved if mediation proceeds. I think this will be a lengthy mediation, lots to be resolved. Have a good day.--Literaturegeek | T@1k? 18:49, 24 June 2009 (UTC)

I would gladly help, but I am not exactly an uninvolved party and benzos are not at all my area of expertise (and no, I am not a "medical person" :) Still, if I can be of assistance... Fvasconcellos (t·c) 23:13, 24 June 2009 (UTC)

Thanks FV, :) chemist and a pharmacist, now we need a med doc or psychiatrist. :) To be honest though best things wait. Need to see if Sceptical is interested in resolving conflicts and accusations or not. MastCell is looking into things over the next few days to get familar with the background. Dunno if he is going to help mediate or just investigate user conduct. :) Keep article on your watch list though for developments.--Literaturegeek | T@1k? 23:32, 24 June 2009 (UTC)

Please stop

Sceptical, you are making controversial changes, some of which may be valid but are mixed in with original research and faking or misrepresenting refs. Please stop making massive poor edits to the article which editors, not just me had worked very hard to get up to FA standard. Please discuss things instead of combative editing.--Literaturegeek | T@1k? 13:31, 24 June 2009 (UTC)

You are doing harmful edits, you are saying things like intermediary view is,, then quote the opinion of a doctor as if to say clinical guidelines and systemic reviews etc are "extremist" and the opinion of a few doctors who may or may have a COI is the "normal" or "moderate" opinion thus casting doubt on systematic reviews and review articles about tolerance. Citing the fact some doctors believe in long-term use is fine but to go debunking clinical guidelines and deleting systematic reviews is bang out of order mate.--Literaturegeek | T@1k? 13:55, 24 June 2009 (UTC)

I am stopping reverting

I will not be reverting what I regard as abuse of refs and original research anymore as it is now an edit war and will end up in a block. I suggest that you don't revert either Sceptical. I urge you to quit ignoring my appeals on the talk page and to sit down and discuss changes. We really need a mentor here or a 3rd party here who could mediate, preferably someone with medical knowledge. I cannot compromise and reach consensus if you refuse to respond to me on talk page. DO NOT keep IGNORING ME.--Literaturegeek | T@1k? 14:07, 24 June 2009 (UTC)

I just now looked into this article and see that a near edit-war has occurred between User:Literaturegeek and User:The Sceptical Chymist, with the current state being unchanged from the state 30 versions ago. This is hardly a productive use of editors' time. Some thoughts:

• The Sceptical Chymist made zero comments on the talk page during this period, which is unfortunate: the bold, revert, discuss practice of Wikipedia requires discussion on the talk page to work.
• The most recent change, which is a revert by Literaturegeek of The Sceptical Chymist's changes, does appear to be an improvement, as the previous version contains phrases like "An intermediate, empirical, position" which are not supported by the cited sources, and contains other claims like "if the prolonged treatment is necessary, the patient reports sustained benefits from a benzodiazepine and no signs of misuse are visible, there is no harm from this practice" which are contradicted by the cited sourcs.
• I urge The Sceptical Chymist to discuss concerns and proposed changes on the talk page first, instead of directly editing the article, when the proposed changes are likely to be controversial.
• An article like this must stick close to what reliable sources say. There is should be no need for any original research, or any synthesis of previous work, as the area is well-covered by reliable review sources.

Eubulides (talk) 17:49, 24 June 2009 (UTC)

I've protected the page for 24 hours to encourage discussion. If the edit-warring resumes after expiry of the protection, then blocks would be the next step. I think an agreement can probably be reached if all involved parties begin participating here, though. MastCell ^Talk 18:15, 24 June 2009 (UTC)

It is unfortunate that LG have chosen to revert any additions I did. I was trying to make a balanced description of the controversy but LG reverted even the piece where I added some details on the views of a prominent BD critic Ashton. In particular, I have taken care not to delete any references. There was an unwarranted misinterpretation which I deleted; however, the corresponding reference was cited elsewhere and so it remained.

It is also strange to hear accusations in ownership and edit warring from somebody who is ready to editwar over commas. LG removed several serial commas and introduced run-on sentences.[20]. Casliber returned many of those the commas back [21][22][23], and I returned one [24]. LG reverted my comma, while leaving Casliber's intact [25]. This is sad... The Sceptical Chymist (talk) 00:46, 25 June 2009 (UTC)

Perhaps you can help remedy this "sad" situation by explaining exactly what is being "misrepresented" in a new section. WhatamIdoing (talk) 01:09, 25 June 2009 (UTC)

More importantly, will you agree to participate in, and abide by, a formal mediation? Looie496 (talk) 01:11, 25 June 2009 (UTC)

This dispute is not over commas; it is over substantive changes, such as Literaturegeek's most recent edit, which reverted The Sceptical Chymist. Let's not be distracted by week-old minor edits when day-old major edits are the real issue. I second WhatamIdoing's suggestion to explain the misrepresentation problem. Eubulides (talk) 07:32, 25 June 2009 (UTC)

I support Eubulides' suggestion and I urge Sceptical Chymist to respond directly to the major substantive issues raised by LG on this talk page. It is unfair to all of those who invested so much effort in trying to bring this article to Featured Article Status not to make a good faith effort to resolve this dispute through dialog on this talk page. Boghog2 (talk) 08:13, 25 June 2009 (UTC)

The editwarring over commas exemplifies the pattern of abusive and nonconstructive behavior by LG. Read the examples below to understand why I ignore what LG writes. I should ignore the abuse according to behavioural guidelines, right? The Sceptical Chymist (talk) 12:26, 25 June 2009 (UTC)

Stop intentionally faking data [26], which you grossly worsened by adding fake facts which you grossly worsened by adding fake facts [27], refs being faked [28], someone who does not understand the medical literature has formed an opinion using original research and are fighting systemic reviews with weak reviews and taking refs out of context [29], faking refs [30], falsifying of the refs [31], Faking refs, making them say the opposite of what they say or distorting them [32], fake data [33], he got caught faking refs... He really is a carbon copy of Mwalla and scuro. WP:DISRUPT is what is going on [34], totally hypocritical [35], bought into your nonsense...Mattisse was bombarding me with original research ...This disruption must stop [36] you got your education in addiction medicine from the newspapers [37], I am under attack by medically illiterate people... Mattissa is attacking me with her original research...this gibberish [38], These disruptive editors engage in character assassination [39], There is NO DEFENSE for your disruptive trolling on talk pages and vandalism [40],SEVERE trolling from Sceptical Chymist...OWNERSHIP trolling Sceptical Chymist...his VANDALISING editing [41], obsessive distorting the evidence [42], Sceptical ... an obsessive guy [43], Sceptical abuses policies like NPOV [44], got trolled ... original research by Sceptical Chymist [45], weeks of trolling by Sceptical Chymist [46], smears of this troll...a battle with a troll [47], fighting faked references [48], Matisse ... faking refs [49], faking [50], faking refs [51], he was trolling, intentionally faking refs [52], faking of refs [53], mattissee ...seemed to buy into medical nonsense sceptical was saying [54], it was absolute hypocracy [55], faked refs...disruptive with the intent on wrecking the FA...sceptical's fake refs...he who was faking refs...I got totally trolled for no reason other than I think kicks [56], this trolling [57], trolled [58], this is all more trolling what sceptical is claiming [59].The Sceptical Chymist (talk) 12:25, 25 June 2009 (UTC)

You should be a politician, that was quite a good distortion of what really happened. :)--Literaturegeek | T@1k? 13:01, 25 June 2009 (UTC)

Nice try Sceptical, but in reality if you check out Sceptical's talk page and the archives the amount of time that I spent trying to be nice to Sceptical, appealing to him, trying to get him to address my points diplomatically one will see that the examples Sceptical is showing were after extensive provocation where I made such statements. You didn't just ignor me but you combatively edited, tried to make it look like it was me who the disruptive editor who was faking or misrepresenting refs. You made the editing environment intolerable and it was obvious that you were trying to sabotage the FA from the start, who knows why, for kicks perhaps.--Literaturegeek | T@1k? 12:35, 25 June 2009 (UTC)

I spent about 6 hours responding to Mattissee's original research having to dig out refs to debunk her original research which was attacking my edits on talk page, I lost my cool with her after being constantly criticised for 6 hours back and forth. I am cool with Mattisse and I have asked the admin investigating this not to drag her into it because the disruption she caused was temporary and she did help contribute to the article productively. I believe Mattissee was well intentioned. Because you were constantly bombarding the talk page with wiki policies that I was alledgedly violating she couldn't see what was going on and got sucked into the disruption. Also she criticised you for doing original research and misrepresenting refs. I never got any such accusation.--Literaturegeek | T@1k? 12:57, 25 June 2009 (UTC)

I can assure you I did not edit war over comma's LOL. Lots of new content was getting added, I was giving it a once over to get FA, with everything that was going on and dozens and dozens of edits I was not following who was adding comma's. Also if you carefully check sceptical's diffs you will see his diffs are mostly bogus with no "comma war" or comma change as they were new comma's added, not deleted ones replaced, two diffs do show a comma deleted and replaced but who cares, really. I can't even believe I am giving this the time of day. I worked very well and agreed to a large, major deletions of text from article from almost all sections, see crime section, pregnancy section and elderly section. For examples before article went to FAC, see here. This is all more trolling what sceptical is claiming.--Literaturegeek | T@1k? 01:32, 25 June 2009 (UTC)

I knew early on the article was being trolled and sceptical was trying to ruin it and posted on FA director's page requesting it be closed. People are welcome to research this through archives, userpages and FA archive. I can defend myself. I was apart from 3rr honorable and really tried hard to get this to FA but like I say knew sceptical was trying to wreck it but no one would listen even 3 weeks ago, just thought it was a editot dispute. Sceptical I believe had no interest in getting this article to FA.

You won, Sceptical.--Literaturegeek | T@1k? 01:32, 25 June 2009 (UTC)

I accepted most of scepticals edits and the edits I opposed were mostly faked refs, original research, and other such edits which were disruptive with the intent on wrecking the FA as I stated early on and why I tried to close FA early on. See archive here and see how I was ignored, edit warred, was blanked.Talk:Benzodiazepine/Archive_3#Withdrawal_section After challenging sceptical's fake refs he would then retaliate by then shoving verification failed all over the article to then make editors think that it was I and not he who was faking refs. I am sorry but I got totally trolled for no reason other than I think kicks. First mwalla, then scuro and now sceptical. Wikipedia ahas too many strange people on it.--Literaturegeek | T@1k? 01:43, 25 June 2009 (UTC)

Show the door to trolls, vandals, and wiki-anarchists, who, if permitted, would waste your time and create a poisonous atmosphere here.

Larry Sanger on Wikipedia:Etiquette

--Literaturegeek | T@1k? 01:44, 25 June 2009 (UTC)

The thing about this trolling is you have to gather the diffs, then persuade people to read the refs to show they are faking it read loads and loads of talk page comments, edit diffs etc and only then can you show what is happening. So the victim is totally disadvantaged. Further, most uninvolved editors, admins or even the person who was trolled can't be bothered going through all of the diffs. Anyway, I am just frustrated.--Literaturegeek | T@1k? 01:51, 25 June 2009 (UTC)

It is clear that the following two things need to happen in order to resolve this dispute:

• LG needs to stop with the name calling.
• SC needs to stick to the central issue being discussed.

Boghog2 (talk) 15:32, 25 June 2009 (UTC)

Boghog, give me a break.Imagine yourself in my shoes. As you can see from the post above yours, the "name-calling" continues unabated, and now Matisse is also accused in being disruptive, although "temporary" ("her original research which was attacking my edits... I lost my cool with her after being constantly criticised for 6 hours back and forth... the disruption she caused was temporary"[60]). It is all but impossible to get to real issues through the thicket of abuse. The Sceptical Chymist (talk) 16:57, 25 June 2009 (UTC)

It's definitely going to be "impossible to get to real issues" if you keep refusing to get started. You've got a bunch of eyes on this page right now, and most of them are experienced editors. If you want to address real issues, your window of opportunity opened yesterday. It won't be open forever. I suggest that you take advantage of it immediately. WhatamIdoing (talk) 17:23, 25 June 2009 (UTC)

WhatamIdoing you are rude. The Sceptical Chymist (talk) 18:04, 25 June 2009 (UTC)

If that's your definition of being on task, then I cheerfully accept that. This is not the proper forum for protracted complaints about user conduct.

You haven't (yet) explained why your version is better than LG's (i.e., why this was worth an edit war). Please add that information as well. WhatamIdoing (talk) 18:19, 25 June 2009 (UTC)

Some people just cannot help being rude. You tolerated multiple LG's personal attacks on me and Matisse on this page. All of a sudden, even a minimal defense against these personal attacks is unacceptable because "this is not the proper forum for protracted complaints about user conduct". The Sceptical Chymist (talk) 18:27, 25 June 2009 (UTC)

I think you'll find that m:DICK is a handier way to link to that page.

I don't recommend that you make any assumptions about why I'm ignoring LG at this time -- especially if you're inclined to interpret it as supporting anyone complaining about user behavior instead of focusing on content. WhatamIdoing (talk) 18:49, 25 June 2009 (UTC)

Thank you, I got your point. The Sceptical Chymist (talk) 18:59, 25 June 2009 (UTC)

Refute the evidence base both scientific and wikipedia

Just like I asked you to accurately represent refs, not to misrepresent refs and not to do original research and use good quality sources, I would like you to also refute this evidence base. I invite everyone to read my collection of the evidence.--Literaturegeek | T@1k? 18:36, 25 June 2009 (UTC)

You have caused me immense harm Sceptical, I look like a trouble maker to many editors, you ruined an FA article and I suspect that you did this on purpose. Even from the get go you lied to me. You claimed you had experience from editing featured articles but a review of your contribs show no interaction on FA articles.User_talk:Literaturegeek#Benzodiazepine_FAC.--Literaturegeek | T@1k? 18:38, 25 June 2009 (UTC)

Address the evidence instead of ignoring it sceptical.--Literaturegeek | T@1k? 18:40, 25 June 2009 (UTC)

LG, please stop the name calling. The above is not helping to resolve this dispute. SC made a good first step. The ball is now in your court. Boghog2 (talk) 18:58, 25 June 2009 (UTC)

Where is the name calling? Oh do you mean in my evidence? I will remove that. I am not seeing any signs of dispute resolution. Any points I bring up get ignored and I get demonised by Sceptical. I will not use the T word but will refer to it as "disruption".--Literaturegeek | T@1k? 19:11, 25 June 2009 (UTC)

Mast Cell is investigating the matter so I created evidence rather than just type accusations back and forth.--Literaturegeek | T@1k? 19:13, 25 June 2009 (UTC)

"Disruption" is still name calling, IMHO. And why do you need to use this word, if you discuss the content and not the contributor? The Sceptical Chymist (talk) 19:17, 25 June 2009 (UTC)

Well you just linked to the word "dick" to describe me in above section in your last post so practice what you preach. I don't think disruption is an uncivil word and is not name calling.--Literaturegeek | T@1k? 19:23, 25 June 2009 (UTC)

I shall not be name calling you from now on but please also don't call me a "dick".--Literaturegeek | T@1k? 19:32, 25 June 2009 (UTC)

LG, why do you think that everything in this world is about you? It was about WhatIamDoing, and she was remarkably forgiving. I apologize to her, though, for being rude in turn. The Sceptical Chymist (talk) 21:29, 25 June 2009 (UTC)

SC, please stop trying to pit editors against me. This combative type approach to editing this article is what led to this dispute in the first place I feel.--Literaturegeek | T@1k? 12:23, 27 June 2009 (UTC)