肌甲A第鍔号証ハダ＞

MedicalReport（4）Re：WayneDouglas−BenzodiazeplneDependence

Preparedby：Dr．GraemeJudson

ClinicalDirector
MentalHealth＆AddictionServices

TaranakiDistrictHealthBoard
Preparedfor：TokyoHighCourt
ヽ︑■‖甘

′・．．一

／′⁚

﹂

′ ∫ ●

′フ∴﹁

Date：

f
Signature：

●

■

▲

●▲

●

●●

●

●

●

■

■

●

●

■

●

●

●

●

●

■●

●

●●

ContentsSe1

IntroductionaSubjectgp▲

Section2（1）Con丘rmationofPrescriptions l．l DiazepamConversions
3

l・2

ReasonsforDiffbringDiazepamConversions
3l・3

To丘sopam
4

FormalReductionHistoryBreakdown

Findings

2．1

DiagnosticProcedure

2・2

0riginalGroundsforDiagnosis（Etiology）

2・3

DSMJVTRBasedonhitialAssessment

2・4
2・5

7

l・9

0 0

PreviousHistoryofDrugUse

7

ClarificationofFileContent

l・8

〜

1．7

′ 0

BreakdownOfReductionAttempts

l・65（2）Diagnosis＆DSMIV−TR

AddictivenessofBenzodiazeplneS

l・5

4

l・4

SymPtOmSOnPresentation
Recovery（additionalinformation）

9

9

10〜13
13〜14
14〜15

15
（3）Di脆rentialDiagnosis

3・1・Dr・terHaar，sFile（HistoryofCo叩1aints）
3・2

3・3

Dr・mtWellsFile（HistoryofComplaints）

MentalHealth＆AddictionServices

16〜17
17〜19

19〜20

（HistoryofComplaints）（4）Prescribing，hformedConsent，

Monitoring

4・l PrescribingIssues

4．2

InformedConsent

4・3

Monitoring

4．4
4・5

CumulativeSummative／Conclusion

ClinicalConsiderations
Findings

21〜22
23〜24

24〜26
26〜28
28

29〜31

r三十iフ

霊慧霊監禁監禁慧慧還農芸慧竃慧慧憲霊漂Ch
FurthertoReport3，WhichfocusedmainlyonWayne，sBenzodiazq）inedependenceinrelationtothe

Patientmesfh）mJapan，inthisreportIwouldliketofocusmainlyonthepatientnles丘om・NewZealandandhowWayne，sdependencediagnosiswasinitiallydetemied．

Inaddition，IwouldliketotakethisopportunitytoadvanCemyOPinionwithregardstoprescribingissues，

informedconsentandmonitoringinWayne，scase・ThisisbecauseIwillbebusywithvarioushospital

COmitmentsoverthenextseveralmonthsandIunderstandthecourtproceedingspresentvarioustime
COnStraintsaswell．

Thisreportconsistsof4mainsectionsasfollows：

1・ConfirmationofPrescriptions（Diaz甲amequivalents）
2・Diagnosis＆DSM−IVTR（initialassessment）
3・DifftrentialDiagnosis（additionalinformationbasedonNZfiles）

4・Prescribing，InformedConsent，Momitoring

SectionOnelooksatcon丘mingtheexactdosesthatWaynewasprescribedandtheDiazepam

SectionTwolooksatthegroundsuponwhichImademyinitialdependencydiagnosis，includingthe

applicationoftheDSM−IVTR，andthesymPtOmSthatWaynepresentedwith．

SectionThreeprovidesadditionalinformationregardingthediffbrentialdiagnosisbasedonWayne，sPreVioushistorycontainedinhisNewZealandmedicalrecords．

SectionFourlooksatprescribing，informedconsentandmonitoringbasedonWayne，scaseinrelationto
reCOmmendationsoutlinedbytheWorldHealthOrgamizationandothergeneralprescribingguidelines．

Onceagain，thereferencenumberstoevidenceitemslodgedinthecoudwereprovidedtomebyWayne

andhislawyerandIhavenotbeenabletoverifythemBrsthand，however，ItruSttheyareconsistentwith
thecourtrecords．

1SectionOne

l・ConfirmationofPrescriptions

l・1迦epamConverslOIl＿寧

日・l BelowisabreakdownOftheDiazepamequivalentssuppliedbyMentalHealth＆AddictionServices・FurthertomyfirstReportl，WhichcoveredsimpleprescnptlOnhistory，IwouldliketoclarifytheconvertedDiazepamequlValentsoftheBenzodiazq）lneS

thatwereprescribedtoWayne・BelowisabreakdownfortheBenzodiazeplneCO叩Onent
Oftheprescriptions（dailydosage）：

Prescdbing Doctor （Hospital）

Pedod

PrescnptionDrugS

Trade Name

Diazepam Equiv （mg）

ChemicalName

Rivotril

遺i。，

Dose （mg）

Clonazepam

0．9

90

5／7／00 22／1／01
Chlordiazepoxide150 15Grandaxin ContolTo茄sopam（10％）

6TotalDiazepam

21

Dr．

1．2

23／1／01

8／4／01

Rivotril

ConstanClonazepam

Alprazolam

12

1．2

TotalDlaZePam

6

12

24

NB：AswedonotdealwithTofisopaminNewZealand，Wehavenoconversionratefor
thisdrug・Spbsequently，the，rateincludedabovewasbasedontheJapanesesourcesupplied

byLegalCounsel『■belowinA血Iel・1・2，aSthisdrugismorecommonly。SedinJqpan．

1・1・2BelowisabreakdownoftheDiazepamequivalentssuppliedbyLegalCounsel−

Prescdbing

PeriodDoctor

PrescnptionDrugS

Trade（Hospital）
Dr．

5／7／00

ContolGrandaxinDrl■膚』』■

p

o

（5）

Clonazepam

（mg）
15

10

0．25

6

75
18

31．5

Rivokil

Constan

AIprazolam

2

0．9

Equiv

150

23／1／01 8／4／01

TotalDiazepam

Diazepam

Rate

Chlordiazepoxide

To貢soamlO％
125

Conv

（mg）

Name

22／1／01
Rivotril

TotalDiazepam

Dose

ChemicalName

Clonazepam
1．2

1．2
0．8

0．25
7．5

31．5

24

1・2ReasonsforDi脆ri王将DiazepamConverslOnS

l・2・1TherateusedforconvertingDiazqpamequivalentstendstodifftrfromsourcetosource．
ThisisbecauseindividualvariationinclinicalresponsestoHequivalentdosescanVarySO

Closemonitoringofpatientresponsetosubstitutionisnecessarywhenconvertingfromone
BenzodiazeplnetOanOther．

1・2・2

ThesourceofconversionratesusedbyushereattheMentalHealth＆AddictionServices

isbasedontheASAMandTRANXguidelines．

1・2・3

TherateusedbyLegalCounselt■givesaslightlyhigherDiazepamCOnVerSionthanthe

rateusedbyushereatMentalHealth＆AddictionServices．However，itisnotunusualto
haveaslightvariationinconversionrangesandmoreimportantly，itdoesnotbyany

meansalterthefactthatWaynebecamedependenttothedosesthatwereprescribedtohim．

1．3Tofisopam

l・3・lIunderstandthedeftnseisclaimlngthatTofisopamisnon−addictive・Asmentionedabove，

WedonotdealwithTofisopaminNewZealand，however，ProfessorAshtonhasprovided
thefollowlnginformationwithregardstothis．

uJJgゐe占e形OdZα甲加e∫dre乃0朋eJecfived乃dαCfoMJJ妙e∫げGd朗伽彫OdねZ甲加e

rec甲fo和・拘わ以椚αCお0乃ααC砂虎姫∫αmereC甲わ作α∫属70乃qP乃ek乃e〝α乃reα∫0乃
血紬e乃ZO威αZ画乃e∫ろdVe∫0〝矧〝加古嘩re乃どぶfr〟的regね乃Of∫0〝7〟Cゐ血細りαCH）乃

頃砕re乃frec甲fo和伸印ゐ乃りあ㍑抽娩αg血加gco〝甲α乃吉田Cα乃CαJJJカe椚嘩re乃g
加が・乃りre椚α加Cゐem加砂丘e乃ZO成αZ甲加e∫桓Cゐe7乃gCdJ乃α椚可．d肋0喝ゐ班り∽町
句跨rf乃鋸乃威喝頑言乃砂カr血rec甲gO7等，pOfe乃叩，e勧めZα如乃fi椚e，egCリどろりdJJαCgO乃αJJ∫ ろcJd∫∫e∫げろe形0成α甲加rec甲わ和・d扉椚αJ∫如dお力αVeCO乃∫おお乃砂∫ゐow乃如才盛

e乃ZO成αZ甲乃甜dreC鱒α嵐kqr乃血桓クγ∫わねぎ加重pe乃滋乃C頑ercro乃わ
α加扉乃ねかαわ円．

乃e血喀7埴呼α〝佃αゐe乃ZOdねZ甲加ゐr加かe椚α乃乙的C如red加α加．乃ゐα∫
α乃血かおpr呼er如∫占以fね∫dfd乃OHOゐdVege血fgve，α乃如0乃Ⅶ血α砿Or〝7㍍∫CねrekXα乃f

pr呼er鹿∫・∫αVe乃0幻perね乃Ce叩頭娩ね訪〟g㍑日加α肋0∫gCerね乃頭協H乃∫0meゐ∫e∫

W油狛ゐefゐer呼e㍑鮎川乃評班e血gw肋お用0捌oあeα威力C如α乃戌拘gedわ乃gJerm，
WfJJcα〟∫eWffあかαWαJ即〝pfo〝は的乃−e彫0成dZ甲乃e∫Wわあ

αVe ee乃C血乃edo

αVe

平eCがC炉C出合祝C α∫Z呼たわ乃可 αVeぬけ乃edo以g O dVeαJ妨e∫α椚eαCわ乃∫α∫
8g乃ZOdfαZ甲わzeぶ，加cJ〟d加g卸e乃ゐ7Ce匝威力C如可α乃dw助かαWαJ弓辟Cエー．凡r班er乃70re，

α町訪喝班ααJ抑αね∫dmね秋作・g・α加妬みαr抽祝rαね∫α乃dg如eαr鮎r血刀曾山〃ねe叫由Ph旧∫Jcer出血focdM号やe乃由り撃主犯pmeクe甲吐血e乃α乃〟d甲′即∫α扉血がW鳥扇
柁Jねveα借ge砂Cα以∫eWgfあかαWα7号酔C怨Wろe乃呼野ed

1・3・2

EvenifinthecasethatTo丘sopamWaSnOtaddictive，thisargumentdoesnotbyanymeanS

alterthefactthatWaynebecamedependent，aShewasprescribedotherBenzodiazeplneS
aswell・Thatistosay，eVeniftheTo丘sopamwasremovedfromtheequation，theremainingDiazepamequivalentwasstillsu氏cientenoughtoformdependence．

3

1・4些
1・4・1AsoutlinedinAdicle2・lofmy3rdrepon，ProftssorAshtonhasconfirmedthatitis
POSSibletodeveloptoleranCeanddq）endenceonminlmaltherapeuticdosesaslowas

l・4・2ItisoRenassumedthatwhenBenzodiazq）lneSarePreSCribedlegallytheymustbesaft．
However，thisisnotnecessarilythecase．

1・4・3BelowisaquotationfromprofessorMalcolmLader（ProftssorLaderisanadvisertothe
WorldHealthOrganisationondrugSuSedinpsychiatry）．

三善≡≒≒薫芋≒≠≒きま≒干害工＿．＿＝∫0拗ねrα地触叩摘veα脚血′府ro∂′e椚CO〝吻ば乃印とゐer呼Cは触Wf紬吻肘は砂伽wf肋Wα′如verw助dWeeんor∫0・…椚紬乃ZOゐZ甲瘍dpr呼Or如乃q存α加地goo乃わわ喝fer〝川地かαWαJ

1・5些迦塑主星
1・5・l BelowisabreakdownOfWayne・sattemptsatreduction．

No． ＃1Time Late

2000

＃2

TypeofAttempt （Stoppingor Reducing） Attemptatsto

OPg8，Article90fWayne，S 丘rststatement

Nov

ppmg （2consecutivedoses） Attemptatreduci

Mar 2001（lsingledose）

nsuccessfu1＃3 ＃4 27 Mar 2001 28 Attemptatstopplng （2consecutivedoses） Attemptatreducin

Mar
2001

g （lsingledose）

nsuccessfu1 U

Result U

Evidence−●SeeReport3，Article2．5．2

Dr．

●SeeReport3，Article2．3．4 OPglOof−patient■me （EvidenceKohA6）

Unsuccessful S．SeeReport3，A血cle2．3．6 ●Pgllofll■patientfile （EvidenceKohA6）

uccesshl， butsufRring Withdrawal（havlngPrOblemswith

Doctor

●Pg30fDr・Whitwell，S丘1e
Withdrawal）

Dr・¶■

n／a

Dr．
WhitwellDr・Whitwell，spatientBlesuppomsRepod3，A融e2・3・4becauseitshowsthatWayne

hadcontinuedtahngthedrugS3timesadayfollowinghis2ndunsuccessfulatbmptat
reductionunderDr．■despiteshowinganawarenessthattheywerelikelycausingharm．

4

1．6FormalReductionHistorvBreakdown

Mth

Date

Day

Mom （mg）

Noon （mg）

Ni岳ht （mg）

DzmEq （mg）

Notes

Mar 25仙 Sun 0．4／0．4 0．4／0．4 0．4／0．4 24 WayneretumedtoNZonO・4mg Clonazepam／0・4mgAIprazolam3xday Waynereports3rdattemptatstopplng Waynereducedtotwiceaday ←WayneapprqachedDr・Whitwell，aShe WaShavingdifBcultywithwithdrawal．Dr． WhitwellexplainedthatBenzodiazeplneS areaddictiveandproceededwitha reductionplanencouragingWayneto maintainareductionattwicedailydoses．
Mar

26th

Mar

Mon

0．4／0．4

27m

Mar

28m

Mar

29th

Mar
Mar

Apr

lSt

Tue

Wed

0．4／0．4

0．4／0．4

24

0．4／0．4

8

0．4／0．4

0．4／0．4

16Thu

0．4／0．4

0．4／0．4

16

30th

Fri

0．4／0．4

0．4／0．4

16

31St

Sat

0．4／0．4

0．4／0．4

16Sun．

0．4／0．4

0．4／0．4

16

Apr

2nd

Mon

0．4／0．4

0．4／0．4

16

Apr

3rd

Tue

0．4／0．4

0．4／0．416

Apr

4t血 ul

Wed Thu

ApI Apr Apr Apr Apr
6 tb

0．4／0．4

5 m

0．4／0．4

0．4／0．4

Fn Sat Sun

16

0．4／0．4

0．4／0．4

16

0．4／0．4

16

7

th

0．4／0．4

0．4／0．4

168

tn

0．4／0．4

0．4／0．4

16

9 Mon 0．25

0．5 7．5 ←Waynewasfurtherencouragedtoreduce andwasprescribedClonazepam（0．5mgx 45tabs）only・Hestartedtaking％mor干，1 night．HewasthenreferredtoourservlCeaS hewashavingtroublewithwithdrawal． Wayneselfreducedt0％tabtwicedaily

Apr

10th

Tlle

0．25

0．5

7．5

Apr

11th

Wed

0．25

0．5

7．5

Apr

12m

0．25

0．5

7．5

Apr

13ul

0．25

0．5

7．5

Apr
Apr

Thu
Fri

14m

Apr

Apr

Sat

Apr

Apr

15m

0．25
m

16 17也 18th 19也
Tue

Wed

Thu 0．25

Sun
Mon

0．25
0．25

0．25

5

0．25
0．25

5
5

0．25

0．25

5

0．25

0．25

5

0．25 5 Waynepresentedtous（nurseassessment） ←TsawWaynefbrthefirsttimeanda treatment（reduction）planwasdiscussed． WealsoprovidedinfoonBenzodiazeplneS andthenatureofwithdrawal．Although， Wayneshowedastrongdeterminationto StOP，WeenCOuragedhimtostayonhis Currentdosetoallowhisbodytorea句ust．

Apr

20也

Fri

0．25

0．25

5

Apr

21St

Sat

0．25

0．25

5

Apr

22nd

Sun

0．25

0．25

5

Apr

23rd

0．25

0．25

5

Apr

24m

0．25

0．25

5

Apr

25t山

0．25

5

0．25

5

Apr

Apr

26m

27m

Mon
Tue
Wed
Thu

Fri

0．25

0．25
0．25

2．5

Wayneselfreducedtoシちtabmom （estimatedtime）

Apr

28th

Sat

0．25

2．5

Apr

29th

Sun

0．25

2．5

皐pr

30m

Mon

0．25

2．5

←Follow−uPCOnSultation・Waynenoticed theworsenlngOfsomeofhissymPtOmS， however，heremaineddeterminedtostop andaplanWaSmadetoreducehisdrug intaketomiloverthefollowing2weeks．

May

lSt

Tue

0．25

2．5

May

2nd

Wed

0．25

2．5

May

3rd

Thu

0．25

2．5

May

4th

May

5th

May

6也

Fri

Sat

Sun

0．25

2．5

0．25

2．5

0

Waynehadstoppedhisdrugintake

May 21St Mon Afbllow−uPCOnSultationwasconducted・Waynewasexperienclngadditional withdrawalsymPtOmS，Whichheprovidedinlistform（Seepage220fMentalHealth＆ AddictionServicespatientfile）・Thenatureofwithdrawalwasdiscussedagainandhe WaSdischargedbacktohisGP，Dr．Whitwell．

5

1・7蜘
（1）DrugNames
1・7・10npage60ftheMentalHealth＆AddictionServicespatientBle，itsays：
CameoverfromJapanOn Rivotril（Clonazepam）1・2mgod

24mgDiazepam

脚B：Od＝OnCedaily）

鞄i．2mgod Equ㍍忘声

1・7・2Icancon丘mthatthedrugnameHLibrium（Chlordiaz甲OXide），，abovewasamistakeand
thatWaynewasinfacttakingHConstan（AIprazolam）的，thisisconfirmedintheentryby
Ourdetoxnurse（page16）．

1・7・3Thisisalsoconsistentwiththe

folIowlngreCOrds：

1）PagelO
Patientfile（Evidence

KohA6）
2）Page20fDr・Whitwell，spatientme

l・7・4Subsequently，IcanCOnfirmthathecameoverfromJapanOnthefollowlngPreSCnPtlOnS：

三三三二三三 三… 意烹喜‡壬…：二￣三三三
1・7・5TheconversionrateusedfordeterminingtheDiaz印amequivalentof24mginArticle
l・7．1abovewasasbllows：

三三三二；二幸三

三
24mg（2）PrescriptiOnChanges

l・7・60npage60ftheMentalHealth＆AddicdonServicespatientnle，itsays‥
EndofMarchseenGP

NochangeM

l・7・7ThisreftrstothefactthatDr・mtWelldidnotchangeWayne，sprescrlPtlOnSWhen
Wayne鮎stpresentedtohimon29thMarch2000．

（3）ReductiOnAmounts

l●7 8親…：呈諾慧慧篭慧諾浩二器諾意警慧禁㌫nt叩
1・7・9Icancon丘mthatthiswasthetotalamountoftabletsthathadbeenprescribedtoWayne

三三三ご三二三三寺三宝≒三三

Sentence，WhereitsaysHHassinceinthelastweekreducedhisowndosetoclonazepam

O・25mgBDM
6

（4）WeeuyUse
l・7・10Theweeklyuserecordedonpage120ftheMentalHealth＆AddictionServicespatient
mereferstotheweekleadinguptoWayne，spresentationattheA＆Dservice（SeeArticle
l・6above）．

1・7・11ThewordingHlastweekHreferstooneweek，stimeleadinguptothedayofWayne，sPreSentation−nOtaCalendarweek・Thisisconsistentwithherotherentry叩adethesame

dayonpage16，WhichsaysHHassinceinthelastweekreducedhisowndoseto

Clonazepamo・25mgBDH

l・8PreviousHistoryofDru寧せ準

1・8・1AsoutlinedinReportl，Articlel・2，WhenWaynepresentedtoourservice，boththedetox
nurseandIcamiedoutadetailedseriesofquestionswithregardstoWayme，shistoryof
druguSe．

1・8・2

Subsequently，itwasnotedthatWaynehadnopriorhallucinogenuse，nOhistoryoplateuSe，nohistoryofsoIventuseandnohistoryofstimulantuse（Seepage50fpatientfile）．

1・8・3

AsoutlinedinReportl｝Articlel・2・3，hedidhoweveracknOwledgethatheusedcarnabis

betweenagesof15and21，buthadnocannabissincetheageof21・Waynereportedthat
hesmokedaboutlmarリuanaClgarettebetweenabout5peopleatparties．

NB：Onpage50fthepatientfileitsaysfromage17．

1・8・40npage40fthepatientfileitsaysHCounsellorvisitedonceataschool．Decisionwasto

StOPCannabis・NoCamabissinceage21・MWaynereportsthistookplaceatage21（in1987），afterwhichhestopped．

1・8・5IhavebeeninformedthatWayne，shistorythereafterhasalsobeenenteredintothe
evidence・Waynesaysthatafterdistancinghimselffromuntowardpeerpressureandassociatedcannabisuse，hedecidedtotakeadvantageOfagovemmentimitiativetoretum
toschool，aSanadultstudentin1990・Afterthis，hebeganstudyingatuniverslty，Wherehe

excelledinleamingJq）aneSe・andapparentlywentontorepresentNewZealandina
SCholarshiptourofJapan・Ⅰunderstandthathealsowentontoreceivenumerousaccolades

forhisworkinthefieldofintemationalrelationsinJapan・Thishistoryisconsistentwith

thenoteinthepatientfileonpage13，WhereitsaysH0nlyasteenager，SmOkingdope・Rebuiltlifb・Sincenoproblems．H7

l・9・l Wayne，shistorydoesnotsuggestthathehasanaddictivepersonalityandthatheindeed

hadasubstanCefreehistorywithexceptionofthecarnabisusethatwasmentioned．

1・9・2TheonlyhistoryofnotewithWayneregardingsubstanceusewastheBenzodiazeplne
regimethathewasinitiallyprescribedbyDr．1−in2000．

1・9・3

AsoutlinedinReport3，Articlel・3，WeCandetemiethattherewasatleasta50〜100％

ChancethatWaynewasdependentsimplybasedonthedurationanddosagesofhis
PreSCnPtlOnSalone−beforeweevenlookattheoverallclinicalpictureortheapplication

1・9・4Further，regardlessofthedi脆rencesinDiazq）amCOnVerSionsmentionedabove，the
OVerallamountSWereStillsufficientenoughtoformdqpendence，aSCOn丘medby
ProfbssorAshton，WhohasobservedthedevelopmentoftoleranCeanddependencein
Patientsonminimaltherapeuticdosesaslowas2・5〜5mgofDiazepam（Report3，Arlicle

2．1）．

8

つ

SectionTwo

2．Diagnosis＆DSM−ⅠVTR
BelowisaneXPlanationofhowwewereabletodetemineWayne，Sinitialdependencydiagnosis
basedontheinformationwehadinournlesbeforetheproceedingsforcompensationcommenced．

NB：AsaresultofWayne，slegalcaseforcompensation，mOreandmorequestionshavebeenasked，
andsubsequently，alotofadditionalinformationhassurfacedafterthefact，SuChasthecontentofthe

PatientmesfromJ叩an・Mostofthisadditionalinformationwasconsideredandappliedtothe
d印endencydiagnosisinReport3・Althoughalotoftheadditionalinformationretrievedafterthefact
actuallysupportsthedependencydiagnosis，inthissectionofReport4，Iwouldliketofocusonthe
methodusedinmakingtheinitialdependencydiagnosisuponWayne，spresentationtoourservicein

Apd12001．
2・1Dia寧nOStlCPrOCedurQ

RefertoReportl，Articles2・1・1〜4forexplanationofthis．

2・2g蝮inalGroundsforDia印OSis（Etiolog勇2・2・1AsexplainedinReportl，OneOfthefirstthingswedidwastoconsiderthereferralform
ffomWayme，sGP，Dr・Whitwell・NotedinthisreferralwasthefactthatWaynehada
VeryStrOngdesiretostopandyetwashavingdifficultyreducing・Thisisevidentwhere
itsaysHattemptlngreductionwithoutcompletesuccess・Patientverykeentogetoff
thesemedsH．

2・2・2

NotedinWayne，shistoryuponpresentationwasthefactthathehadbeenprescribed

multiplecombinationsofBenzodiazeplneSandatncyclicantidepressantforalmosta10
monthperiodbythetimehewasassessedatourservice・Subsequently，WeWereabletodeteminethattherewasatleasta50〜100％chancethathewasdependentsimplybased
Onthedurationanddosagesofhisprescriptionsalone．

2・2・3

BasedontheinterviewswithWayne，WeWereabletoformtheinitialoverallclinical

Picture（Reportl，Article2．2）．Throughtheseinterviewswewerealsoablet。determine
thefactthatWaynedidnothaveanaddictivepersonality・Thiswasmadeevidentbyhis
keennesstodistanCehimselffromtheBenzodiazepineregimeandhishistory（Seepage

50fpatient丘le）．

2・2・4

AIsotakenintoconsiderationwastheapplicationoftheDSM−IVTR（Seenextpage）．

NB：Wealsocamiedoutsometestsincludingthyroidfunctiontest，bloodglucosetest

andfullbloodcount（Seepage170fpatientfile）．Theseweredonetocheckiftherewas
anyotherreasonthatcouldhaveexplainedhisfeelingofHlousy・・・Iusuallydotheseto

mieoutmorecommonformSOftiredness，WhichIwasabletodoinWayne，scase．AIso
doneatthetimewereU＆E（checkrenalfunction），LFT−S（checkliverfunction）andall

resultsdidcomeinthenormalrange・

9

2・3

QSMrIVTRBasedon！由辿麺

2・3・l TheDSM−IVTRcriteriacanbeqppliedtoWayne，sinitialassessment，aSfollows：

TolerancewasevidentinthefactthatWaynereportedsomesettlingofhissymptoms，
butsoonafterwardshissymptomsstartedtoretumalongwithothers・Thisissupported

bythecon皿entOnPage30fWayne，stypednotesuponpresentationtoourservice（page90fthepatientme）whereitsaysHAlthoughmyconditionhadstabilizedtoa
Certainextent（imitially），Icontinuedtosu脆rfとommostoftheaforementi。ned

SymPtOmS・・・・FurthermOre，additionalsymptomsbegantoappear・．．M

Further，aSOutlinedinReport3，Article2・1，thefhctthatWayneproducedwithdrawal
SymPtOmSuPOnreductionatourservicealSoconfirmsthathehaddevelopedtolerance．

ThisisduetothefactthatwithdrawalandtoleranCeareinterTelatedbecauseifapatient
doesnothavetoleranCe，thenthereisnoneuro−adaptation，andthusnowithdrawalswill

OCCur（Report2，Pagel）．

NB：ReftrtoReport3，Article2・lforadditionalinformationregardingtheapplication
OfthecriteriaforTolerance．

2■3

2墨慧範㌶詑慧悪霊慧1慧忠君慧芸慧誌

bothmyselfandtheDetoxNurseintypedfbrm（Seepages7〜llofpatientme）．Itwas

notedthatmanyofthesymPtOmSCOntainedinthishistorywereconsistentwith
Benzodiaz甲lneWithdrawalandorsideeffbcts．

2・3・3AsoutlinedinReportl｝Article2・3−2，inWayne，scase，aShehadbeenprescribed

BenzodiazepinesongoingforalmostlOmonthsbythetimehewasreviewedatour
Service，itwasverylikelythathewouldhavehadwithdrawalsymPtOmSSimplybased

OnthelengthoftimehewasprescribedBenzodiazeplneSfor．

2・3・4Waynemetthecriteriafbrwithdrawal，Whichwasmadeevidentbythefollowlng
SymPtOmS，WhicheitherinitiallyemergedduringthecourseofhistreatmentduetotoleranCe（Report3，Article2・2・3）orinitiallygotworseorfirstdevelopedonreduction

OfhisoveralldoseasrecordedinthepatientBleandshownbelow：

10

No．

WithdrawalSymPtOmSOutlinedin
Report3，Article2．2．9

1

Tinglingsensationoverface

2

Lossincoordination

3

MyoclonlCjerks

457（hitialAssessment）

Pg22

Pg22（arm＆hand）

Pg22（involuntarymovements）

Oilysmellinbodyodour

Pg22（increasedhypersensitivity）

hcreasedjointpalnS

6

CorrespondencetoPatientFile

Pg22

Tighteningofmuscles

Pg18（21／5／01）＆Pgs2ト22

WorsenlngOfdizziness

Pg18（30／4／01）

8

WorsenlngOfpulsatlngtemPOral arterleS

Pg18（30／4／01）

9WorsenlngOfvisualdistufbanCeS

Pg18（21／5／01）＆Pg21

10

Increaseinemotionalinstability

PgslO〜11（Feelonbrinkofhaving nervOuSbreakdown）

11

Increasedpalpitations

12

Tighteninginchest

Pgll

13

Flushing

PglO

14

Hypersensitivity

PglO

PglO（hyperandnervy）

2●3■4慧監慧怨霊慧霊謡震誤霊豊監禁nOnWhattheyareprescribedfor，howtheywork，thenatureofside−effbctsand

WithdrawalandhowtoidentifythesymPtOmS．

2・3・5

WiththisincreasedawareneSS，Waynewasabletoidentifyseveralotherwithdrawal

SymPtOmS，Whichheprovidedbywayofatypedlistathisfulalconsultationon21May
2001（Seepages21〜22pfpatientBle）・ThislistofwithdrawalsymPtOmSincludedthosethathehadfirstdevelopedduringthedrugtreatmentandnewonesthathedeveloped
afterstopplngCOmPletelyon5May2001・

NB：hmylettertoDr・Whitwell，dated5thJune2001，ImentionedthatwhenWayne
reducedhisdosagehenoticedthesymPtOmSOfdizziness，PulsatlngtemPOralartery，andheadachesretumed，buttheyquicklysettledoverthefollowlng缶vedaysafterreduction．

ThismeanSthatthesymPtOmShadsettledbacktotheleveltheywerebeforethe
PreVioussteplnreduction−itdoesnotmeantheysettledcompletely・

Toexplainfurther，thisrefbrstothefactthateachtimeWaynereduced，heexperienced

aworsenlngOfsymPtOmS・HealsohadnumerousotherwithdrawalsymPtOmSin
additiontotheabove（SeepageslO，11，21，220ffile）andmanyofthemdidnotbegin
tosettlecompletelyuntilafterabout6monthsfollowlngCOmPletecessation．Thisis

SuPPOrtedbytheentryinDr・Whitwell，spatientBleinNovember2001，Whereitsays
HslowimprovementinmostareasHandagalninJanuary2002，WhereitsaysHSymPtOmS−mOStimprovlngeXCePtOCularH・AIsonotedinJanuary2002wasthefactthatWa）ne，S

Pulseratehadretumedto68（normal）

from90（tachycardia）recordedonpage30fthe
Patient別e．

NB：RefertoR甲Ort3，Article2・2foradditionalinformationregardingtheapplication

OfthecriteriaforWithdrawal．
11

（4）LossofContro1

2・3・6

Regardingthecriteriaforlossofcontrol，itwasnotedinDr・Whitwell，sreftrralformto

OurServicethatWaynewasHattemptingreductionwithoutcompletesuccessM（Seepage

230fMentalHealth＆AddictionServicespatientfile）．

NB：OnecanseethefollowlngentrymadebyDr・Whitwellinhispatientmeon9也

Apri12001．

Tired

on

AIprazolam
Rivotlil

Havingproblemswithwithdrawal

0．4mglbd
O・4mglbd

Control鱒蝕等？？lookathomedetox

ThissupportsArticle2・30fReport3forLossofControl．

Further，thisisconsistentwithArticle2・30fReport3，WhichhighlightsthefactthatDrlwasalsonotsurewhetherorpottoreduceWayne，sintakefrom3to2timesaday
becauseofthesymPtOmSWOrSenlng・

2・3・7

0therunsuccessfu1attemptsatreductionbecameclearafterproceedingsfor

COmPenSationhadcorrmenced（SeeArticlel・5・1above）．

NB：RefertoR印Ort3，Article2・3foradditionalinformationregardingtheapplication

OfthecriteriaforLossofControl，（6）ImpactonLifb
2・3・8WhenWaynepresentedtoourservice，itwasclearthathehadsufftredaninTPaCtOnhis
lifbduetothefactthathewasnolongerabletowork．

2・3・9

AsoutlinedinReport2，0fparticularnotewasthefhctthathewasstillabletoworkin

Japan，albeitonlightduties，beforethetreatmentbegan，buthestruggledtoco叩lete
hiscontractdmingthecourseofthetreatment（subsequentlycutshort），afterwhichhe
endeduplnaStateWherehewasunabletoworkatallagainfbroveroneyear．

NB‥RefertoReport3，Article2・4foradditionalinformationregardingtheqpplication

OfthecriteriaforImpactonLift．

12

（7）ContinuedUSeDespiteKnowledgeofEarm
2・3・10AsoutlinedinReport3，Article2・5・1，thefactthatWaynealwaysproduceddetailed

notesregardinghisconditionuponconsultationshowsthatheisthetypeofpersonwho
isawarehiscondition．

2・3・llNotedinthehistorythatWaynepresentedtoourservicewasthelistofadditional
SymPtOmSthathedevelopedfollowlngaPPrOXimately4monthsofdrugtreatment．
Further，aftershowingawarenessthathehaddevelopedthesenewsymPtOmS，heendeavouredtoseekaltemativehelpfromanotherhospital（SeepagelOofpatient丘le）．

23・12DesplteShowingawarenessthatthedrugSWerePOSSiblycauslnghimharm，heCOntinuedtouse，WhichsupportsthecriteriaforContinuedUseDespiteKnowledgeof

NB：ReftrtoRq）Ort3，Article2・5foradditionalinformationregardingtheqpplication

OfthecriteriaforContinuedUseDespiteKnowledgeofHarm．

2・4

5ymptomsonPresentatio！！

2・4・1AIsotakenintoconsiderationuponWayne，spresentationtoourservicewasthelistof

SymPtOmSCOntainedinhistypednotes（SeepageslO〜1lofpatientnle）．Inotethatthe
SymptOmSCOntainedinthislistareconsistentwiththosereftrredtoinReport3，Article

2・1・3／EvidenceKohA12，andArticle2．2．3／EvidenceKohA26．

2・4・2Ialsonotethattherearesomeslightvariations・ForexamPle；aCCOrdingtoEvidence

KohA12，Wayne丘rstdevelopedthepalpitationsfollowlngl・5monthsof
Benzodiazq）lneeXPOSure，butaccordingtohistypednoteonpagelOofthepatientnle，

hedevelopedpalpitationsfromOctober．

2・4・3

AIso，OnPage20fWayne，stypednotes（page80fpatientfile）helists

3awpainMunderthegroupofsymPtOmSaSat16thMay2000，followlnghisinitialvertlgOaaaCk・Wayne

inwrittencommunicationhassincereportedthatthiswasamistakeandthathedidnot
developanytightnessinhisjawuntilaboutOctober2000，Whenitstartedtolockup
andwasaccompamiedbyageneralsti晩ningofmusclesencompassinghisentirebody（R甲Ort3，Article3．3．17）．
2・4・4Thisisconsistentwiththefactthatthereisnomentionofjawpain／st臆leSSinanyOf
theotherdocumentation，includinganyofthepatientfiles，beforeitwasfirstnotedin

WayneshandwrittennotetoDr■■■inDecember2000（R甲Ort3，A，ticle2．2．3／

EvidenceKohA26）．
2・4・5

AccordingtoWayne，sfirststatement（Page8，A血cle7），hedidnotbringthe

PSyChologicalsymPtOmS（thathedevelopeddmingthetreatment）totheattentionofDr，−forfbarofbeingcomi

edtoapsychiatriCinstituti。ninac。untrydiff6，e。t

丘ombisown．

13

2・4・6

However，hedidcomplainofthesesymPtOmSqPOnPreSentationtoourservice．These

includedfeelingsofbeinghyperandnervy，emOtionalinstability，（chmiC）anxiety，
ftelingsofbeingonthevergeofhavingafit／goingmad，mOOdswings，（chronic）

d印reSSion，feelingsofhavinganervOuSbreakdownandconfusion（Seepage2lof
PatientBle）．

2・4・7

ThemoodswlngSandaggressivenesswerealsonotedinstatementsfromfHendsand

family（Report3，Articles2．4．3〜4）．

2・4・8Thepanicattackswereimitiallydescribedasepisodesofbeinghyperandnervy，

emotionalinstability，beingonthevergeofhavinga丘tetc，butwerenotrecogmizedas

beingpanicattacksassuchuntilaftermostofWayme，sothersymPtOmShadsubsided
andafterhehadlearntmoreabouttheuntowardefftctsofBenzodiazq）inedependency

throughvariouspublicationsandthroughourfollow−uPdiscussionsatthetime。f
WntlngReportl．

2・4・9AsoutlinedinReport3，Articlel・2，Whendetermlnlngadiagnosisford印endence，itis
notsufBcientenoughtosimplyanalyze．SymPtOmS，rathereverythingneedstobe
COnSideredincontextincluding；thepatlentbackground／history，0Verallclinicalpicture，

applicationoftheDSM−IVTRcriteriaandthecombinedr軸tionshipofthis
information．

2・5

Recoverv（additionalinformal塾由2・5・lItwasnotedinReport3，Article3・1・2，thatWaynerecoveredfrommostofhis

SymPtOmSWithinthenrstyearofcessationwithmanySymPtOmSSubsidingwithinthe
first3monthS・ItwasalSonotedinA血clellofthesummarythatheHrecoveredfrom

芸豊慧慧芸…慧概慧y。fhissymPtOmSStartedtoimprove3monthsafterthat，itwouldmeanthathewasstarting

toshowslgnSOfrecoveryafterabout6monthsofstopplng・

2

5

2

2・5・3

霊宝慧慧慧慧霊慧rhtwell

snleonl或November2001，0

Further，thefactthatWaynecontinuedtomakeasteadyrecoverywithtimeissupported

bytheentrymadeinDr・Whitwell，sfileon8thJanuary2002，Whereitsays…SymPtOmS−mOStimprovlngeXCq）tOCular・IslookingatgoingbacktoworkM．

2・5・4Asoutlinedinmyfirstletter，datedlOSq）tember2004，WhenIsawWayneagainin
January2003andagalninApri12003，itwasapparentthathehadbeenmakinga

Slgnificantimprovementinhisstateofoverallphysicalandpsychologicalhealthsincehewasfirstreftrredtoourservice・ThisissupportedbytheentrymadebyPsychologist

AlanGuy，WhichsaysHPresentedlookingverywell＋r甲OrtlngaStableincreased
Weightthanwhenlastseenhere・NoobviousmooddisorderM．AIso，nOtedwasthefact

thehehadremainedBenzodiazeplnefreesincehewasdischargedbackinMay2001（SeeMentalHealth＆AddictionServicespatientnle，Page19）．

14

2・5・5Further，WhenIsawWayneagalninSeptember2004，itwasapparentthathiscondition

COntinuedtoimproveintheabsenceofBenzodiazeplneS・Thiswasnotedintheme

WhereitsaysHTodayheishealthier＆fitterthanbefore（Apri12003）．WaynelookswellinappearanCe−benchpresses180kgM・

NB：Waynehassinceinformedmethathewasactuallysquattlng180kg，andbench
PreSSlngOVerlOOkg・Nonetheless，itwasaslgniBcantimprovementconsideringthathe

WaShavingdifficultyjustwalkingwhenwe丘rstsawhim．

2．6

Records

2・6・l YouwillnotethatmyconsultationswithWaynewererecordedintheMentalHealth＆AddictionServicespatientfileasfaras8th2004．

2・6・2

AlloftheadditionalworkdoneregardingWayne，scaseforcompensationsincethenhasbeendoneonavolunteerbasisinmyowntime・Subsequently，nOhospitalrecords

regardingWayne，scaseweremaintainedafterSeptember2004．

15

SectionThree

3・DifftrentialDiagnosis（AdditionalInformationBasedonNZPatientFiles）

3・1⊇工L麺こ迦地y吐卿
3・1・l BelowisalistofcomplaintstakenfromWayne，shistoryunderDr・terHaarthatmaybe
usedtotryandruleoutcertainsymPtOmSaSSOCiatedwithhisBenzodiazepinedependence．
Subsequently，Iwouldliketotakethisopportunitytodifftrentiatebetweentheseprevious

COmplaintsandthedependencysymPtOmSin2000〜2001．

伊g・1‥Lowbackpain）
3・1・2WeknOwthatWaynehadaprevioushistoryof盛衰lowerbackpainsincestraininghis
backliningheavylumberinMarch1989（discussedinArticle3・3・170fRepoH3）．

ItmaybearguedthattheHmusclestiffhessHWayneexperiencedduringthedrugtreatment、一in2000〜2001wasa

ributabletohispreviousepisodesof

AsmemionedinReport3，the…musclestifhesslowbackpainH．

associatedwiththedq，endencewasnot

localizedorlimitedtoonearea；ratheritencompassedhisentirebody・Thisgeneralall

OVer

muSClestifhessMissupportedbythefactthatWaynebeganaCOurSeOfregularfu11−

bodyde甲tissuemassage丘omNovember2000（following4〜6monthsofBenzodiazepine
exposure）atalocalphysiotherapyclinicinSaitamatohelptryandalleviatethis．NB：I

havebeeninformedthatthephysiotherapyclinichassuppliedWaynewithaletter
explainingthismusclestiffhessandsubsequentcourseoffu11−bodymassagetherapy・

伊g・1：Leftshoulderpain）
3・1・3WaynesuffbredfiomrecurrlngleftshoulderdislocationsfollowlngaSPOrllngincidentin

1985・Thiscontinuedtocausehimdiscomfortuntilafterhehadrecoveredfromthe
Subsequentoperationdonebyorthopedicsurgeon，TimAstley，in1991．

ItmaybearguedthattheadditionalHshoulderstiffhess（R印Ort3，Article2．1，3／Evidence

KohA12）Wayneexperiencedduringthedrugtreatmentin2000〜2001wasattributabIe
tohispreviousdislocationsandsubsequentoperation．

However，thepalnaSSOCiatedwiththeabove，hadalreadyresolveditselffollowlngaCOurSe
OfstrengthenlngeXerCisesandphysiotherapybefbreWaynetravelledtoJapanin1999．

Thisissupportedbytheentryonpage40fDr・terHaar，spatientfHe，WhereitsaysHGood
resultfromshoulderrepairM・Further，thepalnaSSOCiatedwiththeshoulderdislocations，

WaSlimitedtotheleftsideonly・TheHmusclestifhessHassociatedwiththedependence，
however，included，nOtOnlybothshoulderareas，buttheentirebody，aSeXPlainedabove．

16

3・1・4

WecanSeefromtheabovehistory，anumberofWayme，spreviouscomplaintsoccurredas

SeParateindividualcases，underdi脆rentcircumstancesatdiffbrentperiodsintime，and

WerenOtaCCOmPaniedbyothergroupsofsymPtOmS．

Whereas，thedq）endencysymPtOmSalloccurredunderthesameCircumstancesatthesame
timeandwereaccompaniedbyothersymPtOmSCOnSistentwithdependence・Further，allof
thesymPtOmSaSSOCiatedwithWayne，sdependencylnCreaSedagainduringthewithdrawal

PrOCeSSandthentheylmproveda鮎rthedrugShadbeenremoved．

3・1・5

Consideringtheabovewithincontextoftheoverallclinicalpicture（Reportl，Article2．2）

andthefactthatWaynemet5CriteriaoftheDSMIV−TRwithinthesame12monthperiod，
itisclearthatWayne，sprevioushistorywasnotacontributingfactortohisconditionin
2000〜2001，ratheritwascausedbyBenzodiazeplnedependency・

NB：WaymeWaSaregularpatientofDr．BarryterHaarfrom9Mar1989〜18Jun1996．
HethentravelledtoJapaninJuly1996toundertakeapublicrelationsjob．
After，heretumedinAugust1998，herelocatedtoWaitaraandsubsequently，becamearegularpatientof

Dr・Whitwellfrom4Sep1998（Seebelow）．

3・2Dr・mtWell

sFile−HistoryofComplaints（4Sep1998〜1May2002）

3・2・1BelowisalistofcomplaintstakenfromWayne，shistoryunderDr・Whitwellthatmaybe
usedtotryandruleoutcertainsymptomsassociatedwithhisBenzodiazepinedependence．

Subsequently，Iwouldliketotakethisopportunitytodi脆rentiatebetweenthese．

0｝g・3：LongHistoryofSlightlyStiffNeck）
3・2・2
WeknowthatWaymehadaprevioushistoryof幽neckpain，Whichaccordingto
Wayne，firstdevelopedinlate1997whilstdoingprolongeddeskworkusingalaptop

COmPuterWithPoorergonomicsattheMiyazakiLocalGovernmentOfBce（discussedin

Article3・3・170fReport3）・NB：Dr・terHaar，spatientfileaboveshowsthatWaynehadno
historyofneckpainpnorto1997・

ItmaybearguedthattheHmusclestifhessHWayneexperiencedduringthedrugtreatmentin2000〜2001wasattributabletohis

longhistory（3years）ofslightlystiffneck

However，OnCeagaln，theHrrmsclesti放leSSHassociatedwiththedependencewasnot

localizedorlimitedtoonearea；ratheritencompassedhisentirebodyandhadworsenedto

thedegreethathisjawbeganlockingup．

17

（Pg・3：Paininbetweenshoulderblades）
3・230n4thseptember1998WaynealSocomplainedofHpaininbetweenshoulderblades（leadinguptoneck）．

ItmaybearguedthattheHmusclestifhessMWayneexperiencedduringthedrugtreatmentin2000〜2001wasattributabletothisHpalninbetweenshoulderbladesH

However，aSWithpreviousmuscularcomplaints，thiswaslocalized，Whereas，theHmuscle

StifhessHassociatedwiththedependencyencompassedhisentirebody・Funher，Wayne

reportsthattheepisodesofHpalninbetweenshoulderbladesHareperiodicinnatureand
aretnggeredonlybystrenuousexercise，WhichissupportedbythenoteinDr．Whitwell，sPatientmewhereitsaysHLiftingweightsatgym．

（Pg・3：LongHistoryMiIdLowerBackPain）
3・2・4

RefertoArticle3・1・2abovefordiscussiononthis．

3・2・5監芸龍三諾監禁慧禁諾言霊ぎ慧dingmie。dqressivep，。blem ，WhichmaysuggestthatWayne，sanxietysymPtOmSWereCauSedbyanunderlyinganxiety

COndition・AIso，thereareseveralotherentriesthroughoutDr・Whitwell，spatientfile
refbmingtoanxietyanddepressionsymptoms．

3・2・6IwouldagreethatWaynewassu飴ringfromanxietySymPtOmS；howevermostofthe
SymPtOmShepresentedwithtoourserviceinApri12000，Werelikelycausedor
exacerbatedbyBenzodiazqinedependencyandnotanunderlyinganxietycondition．The

reasonsforthisareasfollows：

1・Waynespriorhistory，SPaminglOyears（includingDr・Whitwell，sfile）showsthathe

hadnopreviouspsythologicalconditions（includinganyanxietyproblems）Or

neurologicalcomplaintspnortotravellingtoJapanin1999documentedinhisavailable
medicalnotes．

2・BenzodiazeplneSCanCauSeSimplestresssymptomstoworsen，andcanleadtothe
developmentofpamicattacksetcduringthetreatment，Whichiswelldocumentedinthe
literature（Report3，Article3．3．15）．

3・ThefactthatWayne，sconditionworsenedduringthetreatmenttothepolntWherehe

4・LikehisotherdependencesymPtOmS，theanXietyanddepressiontypesymPtOmS
intensi丘edagainduringtheformalreductionprocess，andlikehisotherdependence
SymPtOmS，theanxietyanddepressiontypesymPtOmSCOntinuedtoinprovefollowlng
COmPletionoftheinitialwithdrawalphaseofhisfomalwithdrawalprogram−inthe
absenceofBenzodiazeplneS，although，manySymPtOmSdidwaxandwaneforseveral
months，Whichisconsistentwithaprotractedwithdrawalsyndrome．

5・WaynehassincebeenabletomakeareturntolivingandworkinginJapan，anddesplte

beingunderconsiderablemorestressonthisoccasionwithhisongolngCaSefor
COmPenSation，hecontinuestomaintainamuchbetterstateofhealth．

18

（Findings）

3・2・7

ThereisnoquestionthatWaynehadsynvtomsofamietyanddepressionin2000〜2001．

蓋慧冨慧詫芸墨霊由麺
3・2・8

Basedontheaforementionedreasons，andthereasonsoutlinedinReport3，Article3．3．12，

itismostlikelythatthem勾0rityofWayne

SanXietytypesymPtOmSuPOnPreSentationto

OurServicewerecausedbyBenzodiazepinedependency・

3・2・9

Theoneexcq）tlOntOWayne，srecoveryfromthesesymPtOmSfollowinghisabstinence蝕）mBenzodiazeplneSWaSthathedidcontinuetosuffbrfrompanicattacks，albeittoa
lesserdegreeovertime・However，thisneedstobeanalyzedtakingintoconsiderationthe

longterme脆ctsincluding；PrOtraCtedwithdrawal，thetraumaOfthedependence
experience，andtheadditionalpressuresofhissubsequentcaseforcompensation．

3・2・10Wedoknow，however，thatWaynehadnohistoryofpanicattacksbeforebeingexposedto
BenzodiazeplneS．

3・2・11Thedifncultyofbeingabletodi脆rentiatebetweensymPtOmSOfamietyandthoseof

dependencylSOneOfthebigproblemswithBenzodiazeplneSbecauseitoftenresultsinthe
OVerPreSCribingofthesedrugS・QuiteoRen，theformationofdependencyisoverlooked，
resultingindoctorsthinkingthatthepatient，SanXietyconditionhasworsened．The
Patient，sprescnptlOnSareSOmetimesincreasedfollowedbyatemporaryalleviationof

SymPtOmS；however，thisoftenleadstothecompoundingofthedependencyproblem．

3・2・12Inadditiontotheabove，Whenputintocontextoftheoverallclinicalpicture（Reportl，

Article2・2）andconsideringthefactthatWaynemet5CriteriaoftheDSMIV−TRwithin
thesame12monthperiod，itbecomesclearthatmostofthe（chronic）anxietyand（chromiC）depressionsymPtOmSWaynehadin2000〜200lweremostlikelycausedor
exacerbatedbyBenzodiazepinedependency・

3・3MerltalHealth＆AddictionServlCeS−HistoryofCompla圭担

げg．8：Depression）
3・3・10npage20fWayne

stypednotesuponpresentationtoourservice（page80ftheMental

Health＆AddictionServicespatientme）thereisalist，Whichcorrespondswiththaton

Page120fDr・−spatientfileunderthetitle

3・3・2

NB

．

WecanSeethereisanadditionalcommentincludedinthislist，Whichwasnotonglnally

includedintheversiongivenfODr・1−・Thisadditionalcommentis：

Havestartedto

fteldepressedandclosedinslnCeVertigoattack．H

3・3・3

WaynereportsthatfollowinghisinitialvertlgOattaCkandsubsequentbalanceproblem，hehadsomedifncultygolngOutandsocializing，aSheusuallywould．

3・3・4

Subsequently，itmaybearguedthattheHlmpactonLifbMoutlinedinA血cle2・40fReport

3，WaSCauSedbytheinitialvertigoattackandbalanceproblemthereafter，aSOPPOSedto

Benzodiazq）inedq）endency．

19

3・3・5Howevel・，OnCeagain，thisneedstobeconsideredincontext・Forexample，WeknOwthat
WaynewasstillabletoworkinJapan，albeitonlightduties，beforetheBenzodiazepine
heatmentbeganandduringtheearlystagesofthetreatment，butfollowlngmorethan4−6
mOnthsofBenzodiazeplneexposure，hisconditioncontinuedtodeteriorateandevenhally

heendedupinastatewherehewasunabletoworkatallagainfbraperiodexceedingone

3・3・6ThissuggeststhattheBenzodiazq）inedependencyhadthegreaterimpactbecausewayne

WaSStillabletowolkfollowlnghisimitialComplaintofvedigoandsubsequentbalance
PrOblem，buthewasnotabletoworkfollowinghisdrugtreatment．

3・3・70npage170fthepatient恥thereisanentryon30thApri12001saylngthatWaynehadrequeStedgeneralcounselingasopposedtospecialistD仏（Drug＆AIcohol）Counseling．

3・3・8Wayneinwri

encommunicationhasrq）Onedthatthereasonwhyherequestedgeneral

COunSelingwasbecause，aRerhavingbeenbrieftdonthenatureofBenzodiazeplneS，includingdependenceandwithdrawal・hefdtheknewwhatneededtobedoneasfhras
StOPPlngWaSCOnCemed，andsubsequently，didnotfeelthatheneededanyextra

COunSelingforthis・Rather，hewishedtoseekadviceregardinggriefetc・withregardsto
hissituationatthetime．

3・3・9hmyletbrtoDr・Whitwell，dated5thJune2001，ImentionedthatWaynewasencouraged

tOlookatalternativerelaxationtechniquestohelphimcopewithsomeofthestressorshe
haddescribed・Thesest托SSOrSreftrtothepreviousworkrelatedsbessathisjobin
Shizuokainlate1999／eady2000，thefacthesuffbredfhjmanundiagnosedverhgoathck

thathadlefthimwithaongoingbalanceproblemforaperiod，andthefhctthathehadbeen
SufftringkomBenzodiazepinedependency，Whichhadsubsequentlyimpactedonhislifb
includinghisabilitytowork．

げg・22：VisualI）isturbances）

3・3・10FurthertoAmicles3・3・16〜2lofRepon3，Whichgaveexarpplesonhowsomeofthe
SymptomsrelatingtoWayne，soriginalC？mPlaint（musclestifhessandhypersensitivity）
WOrSenedinthepresenceofBenzodiazeplneS，theworsenlngOfvisualdisturbancesgives

3・3・11PagellofDr・t■，SpatientBlFShowsthatWaypewasexperiencingsensitivitytolightandnickeringinhis／visionfollowlnghisinitialvertlgOauack．

3・3・12However，WeCanSee丘omthenotesonpage2loftheMentalHealth＆Addiction
Servicespatient丘1ethatWaynelatercomplainedofan堕望堅些inlightsensitivity，COlournashes，eXaggeratedaRerimages，naShes，Staggeredfocusetcfollowing4〜6monthsof
Benzodiazq31neeXPOSure・Thisworserungofvisualsymptomsisalsosuggestiveof
Withdrawal．

20SectionFour

4・PrescribingJnfbrmedConsent）Monitoring

4．1PrescribinEIssues

4・1・1Belowaresomecontributingfactors，Whichwouldhaveincreasedtherisksregardingthe
forrmngofdependenceinWayne，scase．

1・ProlongedprescnptlOnS
2・Multi−PreSCribing

3・Suitabilityofprescriptions

4・Informedconsent（SeeArticle4．2）

5・Monitoring（SeeA血cle4．3）（1）ProlongedPrescriptions

4・1・2

AsmentionedinReport3，andinpreviOusreports，theriskfactorwithregardstothe

formngofdependencyinWayne，scasewouldhaveincreasedbyabout50〜100％simply
basedontheprolongedperiodoftheprescnptlOnS・（2）Multi−preSCribing
4・1・3

AsmentionedinReport3，andinpreviOusreports，theaboveriskfactorwouldhave

increasedyetevenfurther，basedonthefactthatWaynewasprescribedmultiple
COmbinationsofBerrzodiazq31neS・ThisisbeczrLWeBenzodiazeplneSdonotmixwell，andWhentheyaremixed，thereiianincreasedpossibilityofside−effbctsanddependency

bm皿g．

（3）SuitabilityofPrescriptions
4・1・4

Firstly，inordertohelpdeterminethesuitabilityofthedrugSthatwereprescribedto

Wayne，WeShouldconsiderthereasonwhytheywereprescribedtobeginwith．

4・1・5

Regardlessoftheirpotency，SPeedofeliminationordurationofef托cts，thetherapeutic

actionsofa11Benzodiazepinesarevirtuallythesame，aSfollows：●

Anxiolytic（reliefofanxiety）●

Hypnotic（promotionofsleep）．Myorelaxant（rmsclerelaxation）

4・1・6

●

Anticonvulsant（controlfitsconvulsions）●

Amesia（sedationforsurgiCalprocedures）

WeknowfromtheevidencethatDr・『■■diagnosedWayneaihaving

Sylviani三三二三三‥三三≡三宝己呈−！千三三三三千千■
Waynelater，bothsuspecteda

LvestibularPrOblem21．

4・1・7Withregardstothetherapeutice脆ctsofBenzodiazeplneSaSaSuitablemeansoftreatment
foreitherofthesediagnoses，Dr・Hutchinson，SuPPliedthefollowlnginformationinhis

letter，datedllFeb2008．

TWZr相野ee−血ゐCわ77αg鹿−助重ねJぬ肋加増布川。∫拍呵′力。d。乃甲如ゐげdc如e掩∫地′／呼α頻れ吻2000．
uJ

α7ヲgeげ77eZげ0ゐ錘αJco痛わ77∫的′・α叩′e−Ce7−eゐe伽ゆrc如77刷物′e∫CJeJ・叫Cα777777777gCdc地据わge′・α肋・匝′■αJ勉励J呼α勅如α〝α′・ee血fdedo′・椚α滋veJγ

Z〝血相血か一血几飢cc

昭昭加加

明

・ed血わ77e吻7匝ゆ極刑e∫才力e

J−eCのノe7γ娩e′・匝′・αhe∫血払・舟7C如77か7卯触紙用油dc地裾肋・α′蝕画才・αJ柁血J呼物j・加e77ねαre∫07

ぬ7e∫αね0αd77わ7ぬe抽7・αVe770乙相通α乃dα77〜〜−

乃e桝V血卸e血Cゆ7如77雨′■α′・eα77d∫e伽7g77CO祝助・e如77770あ7777g乙〝・0秘αJ

prαCgfce・dJ加地柁∫e肌ゐ∫乃翔′一乙′α7γ200叩妨77g卵油g鹿野′・e∫∫加・勘ル加

卸e血Cゆ血777e〆肋頼∫g2jα血加わ7CeJ瑚一棚0乃恒α′・加わ∫如恒α∫g20

γed和・加重77わα即77

か0′77eWゐ0∫eβ励′・e∫加′血ve摘Cα7gαZeJ・打沈如乃，αろ乃抑77αJ

押批′γ′・eαC如玖仰e′・J励・e加C如α乃dco乃Ve聯乃C糾一eかαC細りe〃70脚7g血肋α匝須0？VeJ都72Ceα乃d血1γあ抽乃777秒血00cc祝′・・勘ル加叩e血cg平め777e
以∫〟α砂occ紀和〃7クα励伯山飢加地d砂血フ呼ゐα∫祝川ゐ0∫e血独占eco777e的血〆．

∫廃Jecα∫eJ′甲0璃αVeα血0ぬC壷d班e印加′雨クα血加雌＝助・α鋸的rcgo乃∫，777嘩ね∫CJero∫出力ぬ77わあ脚70〝一触g石〟7770椚〜乃班e錘eかegわ巌77加7血eJ・α7

777励めゐ∫加∫夕・肋加喝わざ御αre融少成加0柏のノe班eα如eco破七拗ね77げ
77e〟7・0わggcαわな乃∫適才7770reg77卯r加砂旭∂r血必打∫Cα77朗770才∫ゐow妙0呼肋∫07′叩0血ゐorあWゐgcゐCα77p′・0血ce蝕みルfα乃dg以e血Cゆ乃如〃7e．

週讐主軸如777e成。α払刑
wo〟〟 ゐdVeゐαdα 7−Oe加娩e かeα加7g乃g
770gカαVeかeα加柁乃gJ一gね∫α77d 如ve乃0 CJeαrJ′OJe

0770gゐee4・1・8必′ヱ）0祝α乃g〜−e777gよね

侮fgろ〟わわかeαめ7

カα血∫Or娩eo娩erWithregardstothetherapeutice脆ctsofBenzodiazqplneSaSaSuitabletreatmentfor

anxiety，theyareeffbctivefortheshort−termtreatmentOfacutetrauma（fbrnotmorethan

about2〜4weeks）；however，theyarenotsuitableasameansoflongtermregulartreatment，duetothefactthatdependencecanberapidlyformed．

乃eCo777777g触ア乃極少〆肋批わze∫α乃細eRq′αgCo〃聯好物C肋・ぬ如ろeUだ
9077CJ以ゐd玩Vα770㍑∫∫gα励e旭〃夕β紬7dJタ夕方班α血′は。成。Z印加即。′・e〟那〟加ろわあ，．
ーge7−7乃〟∫eα乃d班α 娩e ∫力0以Jdか7
eJ一わめ0 2−41〝ee恕
QZZhz・（SeeBenzodiazepines：

HowTheyWorkand HowtoWithdrawal．Prof二C．H．

Ashton・RevisedAugust2002−Chapter2，Page2／100fonlineversion）．

4・1・9Subsequently，regardlessofthereasonwhythesedrugSWereprescribed，Whetheritwasfor
treatinganXietyorSylvianAqueductSyndrome，Wayme，streatmentcannotbeconsidered
asideal，andoveraprolongedperiod，itultimatelyledtothefbrmationofBenzodiazeplne

dependency・

22

tt

4．2

王nformedConsent

4・2・1Belowaresomeindicatorsthatwouldsuggestwaynewasnotgivenadequateinformed
COnSentWithregardstohismultipleprescnptlOnSOfBenzodiazeplneS・

1・Dr・−■，sdiagnosisdidnotincludeanXiety
2・ReportedreABOnforprescriptions（duringmediation）
3・Effbrtstoseekdrugrelatedinformation

4・Dr・Whitwell，spatientnle
5．Presentationtoourservice（1）Dr・−，sDiagnosisDidNotIncludeAnⅩiety
4・2・2

Firstly，40utOfthe5drugSthatwereprescribedtoWayneareuSedinthetreatmentof

aruiety，including3di脆rentkindsofBenzodiazepinesandltricyclicantidepressant．

However，Dr・1−，spatient丘leclearlyshowsthattherewasnodiagnoFismade
regardingananXiety，COndition，nOrWaSthereanyemiesmadeinhispatlentfilerelating
tothetreatmentofa猥ietyfortheentirethedurationofthetreatment．

Thissupportswayne，svetbalreportsthattherewasneveranydiscussionregardingthe
treatmentofanxiety．

（2）ReportedReasonfbrPrescriptions（DuringMediation）

4・2・3Ihavebeeninformedthatwhenaskedduringmediationwhythe3difftrentkindsof
BenzodiazepinesFndltricyclicrltidepressantwerebeingprescribed，Dr．『■■respondedbysaylng

AcutevertlgOattaCksarescaryandareoftenaccompaniedbya

SenSeOfanXiousnessandso，adecisionwasmadetoHaddalittlesomething

intothePreSCnPtionsforthisM．

TousethewordsHaddalittlesomethingMseemstobequlteanunderstatement．Thisis

because，OnCeagaln，themqorityofthedrugSPreSCribedwereforthepurposeoftreatlng

anxiety，andtherefore，Wayneshouldhavebeengivenadequateinformedconsentwith
regardstothis，tOgetherwithanexpknationofthepossiblerisksandaltemativeoptions，atthetimeofhisvery鮎stconsultation−beforethetreatmentbegan・（3）EffbrtstoSeekDrugRelatedInfbrmation
4・2・4

WaynereportsthatftomaboutOctober2000，Whenhisconditionstartedtodeteriorate

mOrenOtably，hebeganmakingvariouseffortstoseekinformationaboutthedrugSthathad

beenprescribedtohimbyDr・『−

4・2・5TheseeffbrtshtClu禦makinginqugesやthedispensaryusedbyDr．『■，aSking

fami1yandworkcolleaguestoseewhat theycould丘nd，andlater
fL＿＿．▲二1＿＿

＿

＿

＿1

thedispensaryatthe

gettlnginformationfrom

NB‥WaynesaysthathehascopleSOftheinformationhereceivedasaresultoftheabove
research．

23

4・2・6ThefactthatWaynewasmakingeffbrtstoseekinfbrmationaboutthedrugSisfurther
Suggestivethathedidnotreceive，WhatWaynewouldconsider，adequateinformation
duringhisconsultations．

4・2・7ThereferralfbmtoourservicehmDr・Whitwell，datedlOApri12001，SaySHhe（Wayme）
SaySthese（thedrugS）wereprescribedinJapanwithoutinformedconsentH．

WaynereportsthatafterleamlngOftheaddictivenatureofBenzodiazeplneSfronlDr．

Whitwell，hefeltsulPrisedthathehadnotbeentoldthisatanystageund。rDr．■■andSubsequently，reSPOndedbymakingtheabovecomment．

NB：Onemustalsoconsiderthatatthispolntintime，Wayne，sonlyconcemWaSWith
gettlngWellagain・Hehadabsolutelynothoughtsofpursulnglitigation｝andtherefore，had

nootherreasonforsaylngthathehadnotbeenglVeninformedconsent，aParth・Omthat
actuallybeingthecase．

（5）PresentationtoOurService
4・2・8Uponpresentationtoourserviceitwasclearthatdespitetheeffbrtsabove（4・2．4〜6）

WayneknewverylittleaboutthenatureofthedrugSandthereasonwhytheyhadbeen
PreSCribed・Asfarasheknew，allofthedrugS，includingthe3difftrentkindsof

BenzodiazeplneSandltricyclicantidqpressanthadbeenprescribedasameansof
treatmentforHSylvianAqueductSyndromeH．

NB：UponlearmngaboutthenatureofBenzodiazeplneSWayneshowedatremendous

desireandcommitmenttostopplng，Whichfurthersupportsthefactthathedoesnothave
anaddictivetypepersbnality・Subsequently，hadhebeenproperlyinformed，aStOthe
natureandpotentialrisksofBenzodiazeplneS，itispossiblethatWaynemayhavechosen
tolookataltemativeoptionsinstead．

4・3・1BelowaresomeindicatorsthatwouldsuggestWayne，sBenzodiazeplnetreatmentwasnot
monitoredsufnciently・

1・TheFormationofdependence
2・ReportedadmissionofHinadequateknOwledgeHduringmediation
3・SignsoftoleranCeWereOVerlooked

4・WithdrawalSymPtOmSWereOVerlooked
5・Givenauth0rizationtodrinkalcoho1
6・Norecordsofmonitoringfordq）endence

24

（1）TheFormationofDependence
4・3・2

ThesimplefactthatWaynehadformeddependencesuggeststhatthemonltoringwasnot

adequate．

（2）ReportedAdmissionof

InadequateKnowledge

DuringMediation

4・3・31havebeeninformedthatwhenLegalConsul■■askedDr．−duringmediationifhe
knewwhattolookforwithregardstorecognlZlngWhenapatientisfomingdependence，

4・3・4Toknowwhattolookforandtobeabletorecognizewhenapatientmaybeformlng
dependence，isafundamentalresponsibilityforanydoctorprescribingBenzodiazeplneS．

4・3・5

Further，theyshouldalsoinformthepatientaboutwhattolookforandaskthepatientto

reportimmediatelyanyChangeSintheircondition（anynewsymPtOmSetC）．

（3）SignsofToleranceWereOverlooked

4・3・6

AsoutlinedinArticle2・lofmy3rdreport，WaynewasshowingslgnSOftoleranCeafter

aboutl・5monthsoftreatment・Hadtherebeenanappropnatemonitonngsysteminplace，
thiscouldhavebeendetectedandthetreatmentreassessedaccordingly・

4・3・7

AccordingtoWayne，Sstatement，Whenhecomplainedofdevelopingpalpitationsin

August（followingaboutl・5monthsoftreatment），Dr・−respondedbysaying

Don，tdrinkcoldwaterdirectlyaftertakingabathHandHDon，tfillthebathwateroveryour
Chest・hresponsetoWayne
sdeterioratingappetite，Dr・−respondedbysaying
YouneedtoeatmoreH・Overthemonthsthatfollowed，OtherresponsesmadetoWayne，sCOmPlaintsabouthisdeterioratmgconditionincluded

You，reprobablyfbelingworse

becauseofrecentbadweathef，andHYouhavetotoughenupM

4・3・8

TheabovecorrmentssupportthenotedadmisionmadebyDr．−duringmediati。nWithregardstonotknowingwhattolookforwhenapatientisform1ngaStateOf
dependence．

（4）WithdrawalSymptomsWereOverlooked

4・3・9

AsoutlinedinArticle2・20fmy3rdr印Ort，WaynewasdeveloplngSymPtOmSOf

Withdrawalduetotolerancefollowlngabout4〜6monthsoftreatment．Hadtherebeenan
approprlatemOnitoringsysteminplace，thiscouldhavebeendetectedandthetreatment
reassessedwithaviewtoimplementlngaCOntrOlledreduction．

（5）GivenAuthorizationtoDrinkAIcohoI
4・3・10WaynereportsthatWhenDr・■｝■madethe丘rstprescription，headvisedthatitwas
OkaytoconsumealcohoIwhilsttakingthedrugtreatment．
NB：ThisisconsistentwiththeentrymadeinDr・『■■spatientBle，Whe，eitsays
Drinkingalcoholonceaweek （SeepagelO）．

25

4・3・11However，COntrarytOthisadvice，Patientsshouldbeadvisedtoavoidalcoholandthey
Shouldbeinformedaboutthepotentialriskofadditivee飴ctsandincreasedsideefftcts．

箸e乃ZO成αZ甲玩e∫αVeα成如ve脾CかW抽0娩erC相和re∫∫α略〜乃CJ㍑動gogろer

護蓋蛮嚢姦∫
BenzodiazepineUse・Pro￡C・H・Ashton・Page2／120fonlineversion）．

（6）NoRecordsofMonitoringfbrI）ependence

4・3・12Dr・−，spatientalecontainsnorecordsofmonitoringforpotentialdrugdependency，Whichfurthersupportsthefactthatthemonitoringwasinsufncientandultimatelyresulted
intheformationofBenzodiazepinedependencyinWayne（EvidenceOtsuAl）．

4・4蓑虫icalConside嘩！旦型

Belowisalistofconsiderationsregardingprescribing，informedconsentandmonitoring・Mostof
thesearebasedonexamplesinaccordancewithNewZealandlaw，andrecommendations

establishedbytheWorldHealthOrganization・AsIamnotfamiliarWithJapaneselaw，Iam
unabletomakereftrencewithregardstotheguidelinesinJapan；however，IamsurethatWayne，slawyerwillbeabletoclarifythis．

4・4・l Asoutlinedinpreviousreports，itisrecommendedthatBenzodiazeplneSShouldnotbe

PreSCribedforanylongerthan2〜4weeksasd甲endencecanberapidlyformed．
（SeereferenceinArticle4．1．8）
4・4・2

BenzodiazeplneSarehighlyaddictivedrugSthatcanproducemanyadversereactions

includingtolerance，Withdrawal，Side−efftctsandd甲endency・Subsequently，When
PreSCribinganymedication，unlessmanagedproperly，SOmePreSCnPtlOnShavethe
POtentialtocausedifBcultiesforthepatient，theirfamilies，theirworkandothersar0und

4・4・3

Forthisreason，inpnnciple，thepatienthasthefundamentalrighttobeinformedoftherisksbeforebeingprescribedBenzodiazeplneS，SOthattheymaybeabletomakean
informeddecisionregardingtheirhealthandwell−being・

4・4・4Thisincludesanexplanationofhisorhercondition，aneXPlanationofwhytheproposed
medicationisconsideredsuitablefortreatingtheircondition，aneXPlanationoftheoptlOnS
available，includinganassessmentofexpectedrisks，Sidee脆ctsandcostofeachoption．

NB：InthecaseofNewZealand，thisoutlinedbytheMedicalCouncilofNewZealand

InformationandConsentApri12002・TheserightsarealsoconsistentwiththeWHO（1994，
2000）

GuidetoGoodPrescribing，aPracticalManual．

4・4・5Further，WhendoctorsprescribeaddictivedrugS，theyneedtokeq，inmindandmomitorfor
thedevelopment，Ormanagementofpotentialdrugd甲endency・26

NB：ThisisarequlrementOftheMedicalCouncilofNewZealandanditisalsoconsistentWithguidelinesdevelopedbyothercountriese・g・HongKong（HongKongcollegeof
PSyChiatrist1997），USA（PrinciplesofAddictionMedicine，BenzodiazepinePrescribing
GuidelineWorkSession，Maine）．

4・4・6Thewn0（1994，2000）＝GuidetoGoodPrescribing，APracticalManualHgivesanOutline
Oftheprocessofrationaltreatment／prescribingofmedication・Itdefines6stepsas

hllows：

1・Definetheproblem
2・Specifythetherapeutico句ective

3・Verifythesuitabilityoftheprescription
4・Giveinformation，instruCtions＆warmngS
5．Startthetreatment

4・4・7Toexpandfurtheronstep4（inforTation，instruCtionsandwamings），neCeSSaryPrOVision
Ofinformationincludesthefollowlng：

1・AdescriptioTOftheefftctsofthedrug（whichsy叩tOmSWilldisqppearandwhen；how
importantislttOtakethedrug；Whathappensifitisnottaken）
2・Sideeffbcts（whichsideeffbctsmayoccur；howtorecognizethem；howlongtheywill

remain；howserioustheyare；Whattodoiftheyoccur）
3・InstruCtions（whentotake；howtostore；howlongtocontinuethetreatment；Whattodo
incaseofproblems）

4・Wamings（whatnottodo；maXimumdose；theneedtocontinuetreatment）
5・Nextappointment（whentocomeback；Whentocomebackearlier）

6・Makesureeverythingiscl由rtothepatient．

NB：Aswiththeprescribingofanymedication，yOuneedtoconsiderwhetherthepatientis
OnanyOthermedicationandifthereisapossibilityofdruginteractions，eSPeCiallywhen
multi−PreSCribing・

4・4・8AsBenzodiazq）inesarehighlyaddictivedrugSthatcanPrOducemanyadversereactions，
MonitoringHisnecessarywhenprescribingthesedrugS・

4・4・9Monitoringshouldincludethefollowing（wnOGuidetogoodprescribing，aPraCticalguide1997）：
1・Regularobservationstoseewhethertheilhessiscured．

NB：Whenitis，thetreatmentshouldbestopped・

2・Regularobservationstoseewhetherthetreatmentise脆ctive．

NB：Ifitis，buttheillnessisnotyetcured，thentheprescribingdoctorshouldincludein
theirreviewofthepatient；areViewofanySideefftctsandifserious，thetreatment
Shouldbereassessed．

3・Regularobservationstoseewhetherthetreatmentisine脆ctive．
NB：Ifitis，thetreatmentshouldbereviewed．

27

4・4・10GoodmedicalpracticedictatesthatmonitoringlSneeded，aSOutlinedabove，tOenSurethat
thepatientdoesnotsuffbrfromanyadversereactionsasaconsequenceofthetreatment．

4・4・11MonitoringshouldinvoIveregularreviewsofthepatienttoascertainwhetherthe

medicationisstillneededandifthereareanymintendedeffbctsoccumngasresultofthe

4・4・12Belowisalistofappropnatemeasuresthatneedtobetakenwhenapatientexhibitssigns

thattheymaybeformingastateofBenzodiazepined甲endence（basedonWHOGuideto
GoodPrescribing，APracticalManual，1997）．

1・Reviewdiagnosis
2・Reviewtherapeutico句ectives

3・Reviewsuitabilityoftreatmentforthispatient

4・ReviewwhetherthedrugWaSCOrreCtlyprescribed
5・Reviewwhetherthepatientunderstoodthetreatmentcorrectlyandwhethertheytook

thedrugCOrreCtly
6・Reviewwhetherthepatientwascorrectlymonitored

4・5・1TheaforementionedevidenceclearlyshowsthatWaynewasnotglVenadequateinformed
COnSentwithregardstotheprescnptions・Therewasnoexplanation／informationglVen

WithregardstotreatingsymPtOmSOfanxiety，nOrWerethereanyeXPlanations／informationglVenWithregardstowhytheproposedmedicationwasconsideredsuitable
fortreatingWayne，scondition・AsfarasWayneknew，basedontheinformationhehad
beengiven，theprescrlPtlOnSWereforthesolepurposeoftreating…SylvianAqueduct

4・5・2ThePctthatDr・『■ovedookedsignsoftolerance．andthedevelopmentofsymPtOmS
COnSIStentWithwithdrawalalsosuggeststhatthemonltOringwasinadequate，andthat

Waynewasnotadequatelyadvisedwithregardstothepossibilityofdependencyandside−
efRcts，Whatthesignsare，andwhattodoshouldtheyoccur．

4・5・3

Dr・『■■

spatientfileclearlyshowsthattherewasnomonitoringsysteminplacefor

detectingpotentialdependency・Asaresult，Vitalsignswereoverlooked，andthe
OPPOrtunitytoreviewthetreatmentwasmissed．

4・5・4Subsequently，theappropriatemeasures（outlinedinArticle4・4・12above）werenottaken，
anddespiteWayne，seffbrtstodrawattentiontohisdeterioratlngCOndition，hewas

COntinuouslyglVenrePeatPreSCnPtlOnSOfBenzodiazeplneSreSultinginthecompounding
Ofhisdrugd印endency・28

CumulativeSummary／Conclusion

BelowisacumdativesummarybasedontheevidenceoutlinedinbothReport3andthisReport4・

1）In1999，WaynetraveledtoJapaningoodhealthwithnoprevioushistoryrelatingtopsychological
COnditions（includinganyanXietyproblems）orneurologiCalComplaints．

2）Inlate1999，hedevelopedsomestresssymPtOmSWhilstworkingatastressfuljobinShizuoka，聖CharereCOr聖0PPa琶eS12〜130f聖￣「二甲T＿PatientPleヰd中Clや聖＆e／lethargy，PreSSurelntemPleareas，SWellingoftemporalveins，Shortnessofbreath，SleepdistufbanCeS・3）WaynesubsequentlychangedjobsinlateMarch2000andreportedthathereallylikedhisnewjob，Whichwasalsonotedonpage130fthe二■￣『二￣l ENTpatientfi1e・4）Onll也May2000，hesuddenlyawokeat2am．withanattaCkofverdgo，WhichleRhimwithan
OngOlngbalanCePrOblem−unSteadinessingalt．

5）W禦竺WaSinigYSP竺at＿the二二￣二▼Hospitaland竺qerWentaSeriesoftestsincluding
anMRIscan，allofwhichshowedupnegative・Neurologist，Dr・ヽ■whosawWayneinitially，and
Neurologist，Dr・Hutchinson，WhosawWaymelater，bothsuspecteda

vestibularproblem．

6）WaynebegantOdevelopftelingsofanxiousnessovernotbeingabletoreceiveacleardiagnosisfor

hisvertlgOattaCkandthebalanCePrOblemthatfollowed．

7）InJune2000，hedecidedtogetarefbrraltoseeDr・−whospecializesinbalanCePrOblems．

8）Dr・−diagnosedWaymeaShaving

FSylvianAqueductSyndrome．Anxietywasnotincludedin

hisdiagnosis．

9）Dr・｝−beganPreSCribingmultipledrugSincluding3diffbrentkindsofBenzodiazepines（anxiolyticdrugS）andltricyclicantidepressantforovera6monthperiodwithoutanyChangein
dosage．

10）ThisprolongedprescribingofmultipleBermdiazepineswouldhaveincreasedthelikelihoodof
Waynebecomlngdependenttoal）Out50〜100％．

11）AccordingtoinformationsuppliedbyNeu∫Ologist，Dr．Hutchinson，Benzodiaz甲ineswouldnothave
beensuitablefortreatlngeitherHSylvianAqueductSyndromeH，Ora

LvestibularproblemH，and

neitheraretheysuitableforthelongtermtreatmentofstresssymPtOmSduetothefactthat
dependencecanberapidlyfbrmed．

12亘可』■didnotinformWayneastothereasonwhythedrugS（3di脆rentkinds。fBenzodiazepinesandltricyclicantidq）reSSant）werebeingprescribed．AsfarasWayneknew，these

drugSWerebeingprescribedasameansoftreatmentforHSylvianAqueductSyndromeMandhehad
noideathattheywereBenzodiazq，lneSOrWhatBenzodiazqplneSaredesignedfor・2913）WayneshowedsignsofdevelopingtheearlystagesoftoleranCefouowingaboutl．5monthsof

treatmentwhichwasevidentinthatsomeofhissymPtOmSSetdedinidallyandthenretumedalong
withthedevelopmentofothersincludingpalpitations．

14）Thiswasfurthercompoundedbyseveralmoremonthsofdailydosing，afterwhich，Wayne

developedseveralmorenewsymptomsthatwereconsistentwithtoleranceandwithdrawal（followingabout4〜6monthsofprescriptions）．

15）Inresponse，tOthesecomplaints，includingthepalpitations，Waynereportsthathewastoldnotto

drinkcoldwaterdirectlyaftertakingabath，nOttOmlthebathwateroverhischest，heneededtoeat
more，hewasprobablyftelingworsebecauseofrecentbadweather，andthathehadtotoughenup．

16）Fouowingabout4JmonthsoftreatmenちWhenWayne，scondidonwasdeteriorating，hisfriends
beganVOiclngtheirconcernsregardinghisweubeing・17）Feelingconcemedforhisweubeing，WaynereportsthathetriedunSuCCeSSfullytostophisdrug
intakeinlateNovember2000．

18）慧監禁3篭芸慧慧三豊・熱theJ￣二二二Hospitalon13也
19）WaynethenbegantomakeahstofnewsymPtOmS，dated18thDecember2000，SOthathecould…芸言霊器霊慧三雲∑慧諾慧濫慧慧；烹禁yo地20）Subsequendy，WeCaneStimatethatWaynehadlikelydevelopedBenzodiazepinedependence
fouowingAbout4〜6monthsoftreatment，Whichbasedonstatistics，isatypicaltime鮎mefordependencetoform（Seereferenceonpage130fReportOne）．

21）AfterhavinglostfaithinDr・1−andhistreatmentwaynedecidedtochangehospitalS．Athis

血alconsultadonheaskedforinformadonal

utthedrugSthathewasbeingprescribedtoserveaS

futurereftrence，Whichwasrefused．

22）SoonafterchanginghospitalS，areductionplanWaSnegOdatedwithDr．1■Inacc。rdancewiththisPlan，WaynemadeasecondunSuCCeSSfulattemptatreduction．

23）FouowingthisanempちWaynedecidedtoretumtONewZealandoneweekshortofcompletinghis
employmentCOntraCtWherehemadean0therurmccessfulattemptatstopplng・24）Dr・Whitweudeclaredhimunnttoworkandreftrredhimtoourserviceforprofessionalhelp，aShe

WaShavingproblemswithwithdrawal．
25）Duringtheformalreducdonprogram，hissymPtOmSintensiBedagainalongwiththedevelopmentof

OtherwithdrawalSymPtOmS．
26）Waynemadeasteadyrecoveryfrommostofhissymptomsfouowingabout3monthsofcompleting

theimidalwithdrawalphaseofthereducdonprogram（6monthsfouowingcessadon）．0ther
SymPtOmStOOkuptolyeartorecoverfromgraduallyi叩rOvingovertime，Whichissuggesdveofa
PrOtraCtedwithdrawalsyndrome．
3027）FollowPgcompletionofthereductionprogram，Waされ？WaSabletomakeagradualretumto
recreatlOnalactivities，WherehemadesignifiCantgainslnWeight，Strengthandstamina，Whichwas

madeapparentbyhisabilitytolaterretumtOWOrkasanadventuretourguideandyardman．

28）HehassincebeenabletomakearetumtolivingandworkinginJapan，anddespitebeingunder
COnSiderablemorestressonthisoccasionwithhisongolngCaSeforcompensation，hecontinuesto
maintainamuchbetterstateofhealth．

29）Afterreviewingthenotes，Icanconfirmthat50fthe7DSM−IVTRcriteriacanbeappliedto
Wayne，sinitialdependencydiagnosisbasedontheinformationwehadinourfilesbefore

PrOCeedingsforcompensationbegan・30）Further，theadditionalinformationthatsurfacedlater，aSareSultofWayne，slegalcasefor
COmPenSation，includingthepatientmesfromJapan，doesnotdetract丘omthefactthatWaynemet
these5criteria．

31