Benzodiazepine withdrawal: overview and implications for the treatment of anxiety

Impact of triplicate prescription program on psychotropic prescribing patterns in long-term care facilities

OBJECTIVE

To assess the impact of the effect of the New York state triplicate prescription program on psychotropic prescribing patterns in selected long-term care facilities over a one-year period.

DESIGN

Retrospective study for changes in psychotropic drug use patterns before and after implementation of the triplicate prescription program.

SETTING

Eight private and two public long-term care facilities in the western New York area.

PATIENTS

All residents in the long-term care facilities with complete medical records for a one-year period were reviewed.

OUTCOME MEASUREMENTS

Charts were reviewed for changes in psychotropic drug patterns and incidence in adverse events such as falls, hip fractures, hospital admission, signs or symptoms of benzodiazepine (BZD) withdrawal syndrome, or behavioral outburst.

MAIN RESULTS

BZD use declined precipitously from 25 percent of psychotropic drug orders to 10 percent six months after implementation of the program. The decline in BZD use was accompanied by an increase in the number of orders for alternative psychotropic agents. Although 22 percent of the patients previously receiving BZDs were discontinued from these drugs, more than half of these patients were switched to alternative therapy, including tricyclic antidepressants and antipsychotic drugs. The majority of patients who discontinued BZDs did so without tapering of the dosage; however, few experienced minor withdrawal symptoms and no patient experienced seizures or required hospitalization following discontinuation. The risk of falls, hospital admission for any reason, or combined events was not significantly altered despite a reduction in BZD use. There was a trend, however, for a reduction in falls after implementation of the program.

CONCLUSIONS

This study documents that psychotropic drug prescribing patterns were significantly affected by the triplicate prescription program. BZD use declined; however, use of alternative psychotropic drugs increased. Despite changes in psychotropic prescribing patterns, we found no significant risk of adverse events. Further study to evaluate the long-term effect of alternative psychotropic drugs is necessary.

Integrated treatment of panic disorder

The purpose of this article is to provide the nonpsychiatric physician with a practical approach to the treatment of panic disorder by reviewing the literature on treatment efficacy. The author reviews studies and uncontrolled case series on pharmacologic and nonpharmacologic treatment of panic disorder and presents a clinical approach based on these. Setting the stage for treatment by educating patients and obtaining a detailed description of their particular clinical syndrome is a vital, but frequently neglected, precursor to treatment. Treatment selection is based on a risk-benefit analysis of the individual treatment and the particular exigencies of the patient's clinical presentation. Both pharmacologic and nonpharmacologic therapies are highly effective for acute treatment. Because panic disorder is a chronic illness, long-term treatment or reinitiation of acute treatment at a later date is often required.

Theoretical and therapeutic considerations for the anxiety disorders

Everyone is familiar with that paralyzing state of dread known as anxiety. Although it is unpleasant, the experience of anxiety has adaptive aspects: it can serve as an impetus to effect beneficial life change and can facilitate psychological development. Anxiety becomes of clinical concern, however, when it interferes with intellectual function, or arrests normal social or vocational pursuits. Anxiety disorders are chronic illnesses. Treatment can eliminate many of the disease's debilitating features, but the underlying disorder is not usually cured. Discontinuation of treatment-pharmacological, behavioral, or both-often results in the recurrence of symptoms. The focus of treatment, therefore, generally centers on striking a balance between the goal of alleviating the patient's symptoms, and the need to avoid the deleterious effects which result from long-term treatment (1). The intention of this paper is to review theoretical and therapeutic considerations for four types of anxiety disorder: panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder. In doing this, emphasis will be placed on the physiological concomitants and, when possible, neuropsychological bases of these illnesses. Furthermore, pharmacological treatment will be related to the underlying substrata of the disorder whenever possible.

Chronic benzodiazepine administration. IX. Attenuation of alprazolam discontinuation effects by carbamazepine

Clinical studies suggest that carbamazepine may attenuate effects of alprazolam discontinuation. Since discontinuation of chronic alprazolam in a mouse model is associated with behavioral alterations and upregulation at the gamma-aminobutyric acidA (GABAA) receptor, we studied the effects of carbamazepine administration after alprazolam (2 mg/kg/day) discontinuation. Open-field activity was increased in mice 4 days after alprazolam discontinuation, but this effect was reduced significantly by continuous infusion of carbamazepine, 25 or 100 mg/kg/day. Benzodiazepine receptor binding in vivo was increased in cortex at 2 and 4 days after alprazolam discontinuation, and in hypothalamus at 4 days; with carbamazepine, 100 mg/kg/day, binding in both regions at these time points was similar to control values. Similar results were observed in cortex with benzodiazepine receptor binding in vitro. GABA-dependent chloride uptake was also increased at 4 days alprazolam administration. Treatment with carbamazepine attenuated (P less than 0.10) this increase. Carbamazepine alone after vehicle did not alter benzodiazepine binding or GABA-dependent chloride uptake. These results indicate that carbamazepine administration after alprazolam discontinuation attenuates behavioral and neurochemical alterations associated with discontinuation.

Pharmacological adjuncts for the treatment of withdrawal syndromes

Alternative explanations for symptoms that occur during the period of drug (medical or nonmedical) withdrawal are examined. These symptoms are not necessarily due to the discontinuation of the drug and should be considered when treating a patient for a withdrawal syndrome. The rationale behind treating withdrawal syndromes and criteria to consider for hospitalizing a patient during the withdrawal period are discussed. The main focus of this article is the appropriate use of prescription drugs for treating withdrawal syndromes. In addition, protocols of the Drug Detoxification, Rehabilitation, and Aftercare Project of the Haight Ashbury Free Clinics are reviewed in detail. Finally, information is provided on some potentially promising medications that are currently being investigated for the treatment of withdrawal.

[Benefits and risks of hypnotics]

Rationalisation of the war of hypnotics has recently been under discussion in France: a review of the benefits and risks of these substances may therefore be useful. Chronic insomnia is a result of multiple factors, among which individual characteristics of the personality play an important role. Hypnotic treatment is symptomatic; its beneficial influence on sleep progressively vanishes in few weeks, while some negative residual effects on daytime functioning (mood, alertness, performance, memory impairment) may persist. The main problems posed by hypnotic treatment with benzodiazepines are related to tolerance effects during the treatment period and to rebound insomnia and withdrawal phenomena after discontinuation. Practical issues for the treatment of insomnia, based on international consensus, are presented.

Regulation of benzodiazepine prescribing practices: clinical implications

In an effort to control prescription abuse of benzodiazepines, the New York State Department of Health (DOH) enacted a regulation requiring the use of triplicate prescriptions for these medications. DOH predicted that this regulation would reduce the overall abuse of benzodiazepines and eliminate widescale organized fraud and abuse without any negative impact or reduced availability to patients. Following implementation of the regulation, the authors reviewed all psychiatric emergency room cases and outpatient clinic walk-in evaluations over a 3-month period in an urban medical center and identified 59 cases in which the use of benzodiazepines was a significant presenting problem. Of these, 24 (41%) were judged to be directly related to the new triplicate regulation. In all but one of these cases the patient presented because of symptoms or concerns directly stemming from the refusal by a clinician to continue prescribing a benzodiazepine in a previously established pattern. Typically, abrupt discontinuation of benzodiazepine treatment led to a withdrawal syndrome and/or the unmasking of a previously treated anxiety disorder. In attempting to redress what are essentially criminal substance abuse problems through the regulation of legitimate clinical practice, regulatory agencies may ultimately deprive patients of appropriate, legitimate, and efficacious treatments.

Benzodiazepines: abuse and new use

Both abuse and new uses for benzodiazepines are reviewed. The pharmacology of benzodiazepines is summarized and statistics regarding their general use are given. The question of benzodiazepine abuse is reviewed in some detail and the question of rebound, recurrence of symptoms and physiological withdrawal is differentiated. Benzodiazepines are regarded as a very safe class of drugs and the abuse potential is felt to be negligible provided that they are prescribed for appropriate conditions and monitored carefully. The dangers of alternatives to benzodiazepines such as alcohol or barbiturates is emphasized. New uses for benzodiazepines are reviewed including the use of benzodiazepines in panic disorder, as well as an adjunct in the therapy of mania and some psychotic states. Rational prescribing of benzodiazepines is encouraged and the attitude that these are dangerous and addictive drugs is discouraged and put into perspective.

Alprazolam and diazepam: addiction potential

Alprazolam and diazepam, the two most prescribed benzodiazepine anxiolytics in the United States, have potential for addictive use. The Drug Abuse Warning Network (DAWN) indicates they are the most mentioned benzodiazepines, and the National Household Survey indicates significant abuse of tranquilizers. Both drugs are rapidly absorbed and enter the brain tissue rapidly, leading to reinforcement. Alprazolam has a shorter half-life, which may lead to more withdrawal symptoms than diazepam. In experimental conditions, they are among the most reinforcing benzodiazepines. Each causes a withdrawal syndrome, but alprazolam withdrawal may be more severe and may occur after a shorter period of use. Adverse effects from their use are said to be rare, yet subtle negative consequences may be seen with some regularity. Alprazolam deserves special caution because of its relative newness, great popularity, reinforcing capabilities, relatively severe withdrawal syndrome, and reports of addiction and negative consequences of use.

Adverse effects of benzodiazepines

The growing realisation that the benzodiazepines have potential for causing serious harm has caused concern due to their wide and common use. This paper is a review of the adverse effects of benzodiazepines, and concentrates on four areas of particular concern: drug dependence with the consequent withdrawal symptoms; psychological effects while on the drugs; use by the elderly; and tolerance to the drug effects. Although the phenomenon of a benzodiazepine withdrawal syndrome is generally accepted, there is still controversy over the frequency amongst users. A number of major studies are reviewed here, and the main methodological issues are discussed. These include definition of the withdrawal symptoms, selection of subjects, and use of double-blind, placebo-controlled conditions. The studies investigating psychological impairment with benzodiazepine use deal mainly with motor performance and co-ordination, although there is a large group of studies looking at the effect of the drugs on memory. Although the studies reviewed make a considerable contribution to the understanding of the effects of benzodiazepines, they focus on physiological and specific psychological variables, rather than more global measures of functioning and behaviour. It is suggested here that this emphasis needs to change in order to obtain a clearer picture of how benzodiazepines affect quality of life. Future studies should also be prospective in design, and include clear criteria for the selection of subjects and for the definition of withdrawal symptoms.

Treatment of benzodiazepine withdrawal symptoms with carbamazepine

In 18 patients with a benzodiazepine (BZD) dependency the drug was withdrawn. The dose of BZD was gradually reduced in nine of the patients, while the others were additionally treated with carbamazepine (CBZ) for a further 15 days after BZD discontinuation. Withdrawal symptoms were assessed every third day during the study period. When comparing results in both groups, a clear trend towards less severe withdrawal symptoms could be observed in the group treated with CBZ. Some of the differences were statistically significant on days 9-12 after BZD withdrawal. Fundamental withdrawal symptoms (like hypersensitivity to sensory stimuli, abnormal perception of movement, depersonalisation or derealisation) were also less severe in the group treated with CBZ compared with the group not receiving that treatment. These findings support the results of previous reports indicating a therapeutical effect of CBZ in BZD withdrawal.

Medical and psychosocial factors predictive of psychotropic drug use in elderly patients

The purpose of this study was to investigate medical and psychosocial factors that may be used to identify patients at risk of psychotropic drug use. Population-based surveys were completed by 278 elderly health maintenance organization (HMO) patients in August 1984. Physical and mental health status and social support were measured in the survey. Automated prescription records from the year prior to and the year after the survey were linked to data from the survey. Patients received 737 prescriptions for psychotropic drugs during the two-year period under study. Doxepin (20.2 percent), flurazepam (15.2 percent), and diazepam (14.8 percent) were dispensed most frequently. Nearly 30 percent of the patients received a prescription for at least one psychotropic drug during the two-year period, and 14 percent received at least one prescription during both years. Three significant predictors of subsequent psychotropic drug use were: prior use (odds ratio = 17.2, 95% CI = 6.25, 47.33), the number of physical impairments (OR = 1.73, 95% CI = 1.05, 2.84), and the respondent's rating on the Alameda Health Scale (OR = 1.65, 95% CI = 0.99, 2.75). Patients' self-reported mental health status and sociodemographic characteristics were not significant predictors of subsequent use.

Diazepam (Valium): its dependency liability

Reports of the withdrawal syndrome following discontinuation of diazepam and drug dependence fears have contributed to diazepam's displacement as the most popular anxiolytic agent. Reports of the withdrawal syndrome, the factors involved in withdrawal, and the remedies proposed for diazepam withdrawal symptoms are reviewed.

The use of benzodiazepines in the workplace

Benzodiazepines differ from many of the other abused substances in that there are legitimate medical indications for their use. Any prescription for benzodiazepines must be preceded by a careful risk-benefit analysis that considers the specifics of an individual's particular life situation, personality style, and psychiatric diagnosis. The risk of benzodiazepine abuse by chemically dependent individuals and the problems of cognitive and/or psychomotor impairment and dependence for all individuals have to be balanced against the therapeutic benefits of these drugs for patients who experience disabling anxiety disorders or anxiety that accompanies chronic medical illness. Problems of dependence can be minimized by utilizing a variety of pharmacologic and psychotherapeutic strategies to ameliorate withdrawal symptoms that might accompany the discontinuation of long-term benzodiazepine treatment.

Chronic administration of benzodiazepines--V. Rapid onset of behavioral and neurochemical alterations after discontinuation of alprazolam

Discontinuation of chronic treatment with alprazolam may cause a characteristic clinical syndrome. To assess the basis of this syndrome, mice were treated with alprazolam, 2 mg/kg, for 7 days, a regimen associated with the development of tolerance and downregulation of receptors. Effects on motor activity and the binding and function of GABA receptors were evaluated 1, 2, 4 and 7 days after discontinuation. Motor activity was similar to controls 1 day after cessation of alprazolam, increased from days 2 to 4 after-alprazolam, and returned to control values by 7 days. The binding of benzodiazepines in vivo and in vitro was increased in the cortex 2 and 4 days after alprazolam and in the hypothalamus at 4 days after alprazolam. Binding returned to control values in all areas by 7 days. Binding at the chloride channel, using [35S]t-butylbicyclophosphorothionate, was not significantly altered after discontinuation. Muscimol-stimulated uptake of [36Cl-] in cortical synaptoneurosomes was increased at 4 days after alprazolam, compared to days 1, 2 and 7. Thus, behavioral and neurochemical alterations was associated with the discontinuation of alprazolam. These alterations were qualitatively similar to those observed following discontinuation of lorazepam but occurred more rapidly and with differing regional specificity.

A practical approach to benzodiazepine discontinuation

Non-medical use of benzodiazepines is rare among patients with anxiety disorders. Numerous studies have found that non-medical use, or abuse, of benzodiazepines occurs usually among patients with histories of alcohol and drug abuse--those who use those drugs to get "high". This article distinguishes between medical and non-medical use of benzodiazepines in clinical practice, and offers practical approaches to discontinuation of benzodiazepine treatment for both medical and non-medical users of those medicines. The major barrier to clear thinking about the abuse of benzodiazepines is the confusion of "addiction" and "withdrawal". Addiction means high, unstable dosing outside medical and social boundaries for "recreational" purposes, loss of control over use, and continued use despite clear evidence of harm. Alcoholism and heroin addiction are typical examples of addiction (Kalant, 1989). In contrast, withdrawal is a pharmacological consequence of discontinuation of a substance on which a person has become dependent. Many drug-addicted people have only minor withdrawal symptoms when they stop drug use. Many medical patients, with no evidence of addiction, have withdrawal symptoms when they stop treatment, especially when they stop abruptly (e.g. surgical patients using narcotic analgesics and epileptics using benzodiazepines or barbiturates in their treatment). Addiction to benzodiazepines, in the sense of loss of control over use and continued despite harm, is virtually limited to people with pre-existing drug or alcohol abuse, while withdrawal symptoms after prolonged daily use are common among medical users of benzodiazepines. The serious nature of both drug abuse and anxiety disorders is not emphasized sufficiently during medical school or in the professional literature. The distress and disability from which both groups of patients and their families suffer is profound. Fortunately, both drug abuse and anxiety patients receive tremendous benefit from successful treatments, both pharmacological and nonpharmacological (DuPont, 1986a; DuPont, 1984). This article discusses the use of benzodiazepines in two distinct populations--drug abusers and patients with anxiety disorders--and helps clinicians distinguish between the use of benzodiazepines in the two groups. The central distinction made in this article is reflected in the common use of the words "drugs" and "medicines". The former term often denotes non-medical substance use, while the latter term refers to traditional pharmacotherapy.

Increased sensitivity to benzodiazepine antagonists in rats following chronic treatment with a low dose of diazepam

The effects of benzodiazepine (BZ) antagonists on operant behavior were examined in rats chronically administered a low dose of diazepam (DZ). The low maintenance dose of DZ (5 mg/kg twice daily) was selected as more closely associated with its anxiolytic effects than the higher treatment doses previously used to study BZ dependence. Food-restricted rats were trained to press a lever for food reinforcement under a FR20 schedule of reinforcement prior to the start of DZ administration. Acute administration of DZ caused a dose-dependent reduction of response rates, with 5 mg/kg causing a 50% decrease. Rats treated chronically with DZ became tolerant to its rate-suppressant effects as shown by a 5-fold increase in the dose of DZ required to reduce FR20 response rates by 50%. The BZ antagonist flumazenil (formerly Ro 15-1788; 10-56 mg/kg) suppressed rates of responding in rats treated chronically with DZ. The suppression of operant responding was obtained when flumazenil was given up to 3 h, but not 18 h, after the last treatment with DZ. In contrast, only the highest dose of flumazenil (56 mg/kg) caused reductions of operant responding when given to rats treated with saline. The BZ antagonist CGS 8216 (3.3-33 mg/kg IP), given 10 min prior to the session, was similarly more potent and effective at suppressing operant responding in rats treated chronically with DZ than saline. This procedure may provide a model for the clinical problem of physical dependence to chronically-administered low, anxiolytic doses of BZ tranquilizers.

Chronic benzodiazepine administration. IV. Rapid development of tolerance and receptor downregulation associated with alprazolam administration

The triazolobenzodiazepine compound alprazolam may have unique clinical effects compared to other benzodiazepines, and both behavioral and neurochemical studies have indicated unusual results after acute doses of alprazolam. To determine the effects of chronic dosage in mice, alprazolam (2 mg/kg/day) was administered via osmotic pumps for 1-14 days, and open-field activity, plasma and brain concentrations, benzodiazepine receptor binding in vivo and in vitro, [35S]t-butylbicyclophosphorothionate ([35S]TBPS) binding, and muscimol-stimulated chloride uptake were determined. Alprazolam decreased motor activity after 1 and 2 days, but tolerance developed by day 4 and persisted to day 14. Plasma and brain concentrations remained constant during the 2-week period. Benzodiazepine receptor binding in vivo was decreased at day 4 compared to day 1 in cortex (CX) and hypothalamus (HYPO), and remained depressed to day 14 in CX but not HYPO. Benzodiazepine binding in vitro and [35S]TBPS binding were decreased in CX at day 7. Muscimol-stimulated [36Cl-] uptake was decreased at days 4 and 7 compared to day 1, but at day 14 uptake was similar to day 1. These results indicate that behavioral tolerance and receptor downregulation develop rapidly during chronic alprazolam administration. Behavioral and neurochemical changes were similar to those associated with lorazepam administration, but occurred more rapidly and with different regional specificity.

Lorazepam discontinuation promotes 'inverse agonist' effects of benzodiazepines

1. The effects of lorazepam discontinuation on responses to benzodiazepine agonists and antagonists were studied in mice. 2. The convulsant dose of pentylenetetrazol was decreased after an acute dose of lorazepam (0.5 mg kg-1) at 4 days after drug discontinuation, compared to 1 or 7 days after discontinuation or to vehicle treatment. 3. The percentage of mice undergoing convulsions after an acute dose of FG 7142 (40 mg kg-1) was increased at 4 days after lorazepam discontinuation, compared to 1 or 7 days after discontinuation or to vehicle treatment. 4. After an acute dose (0.5 mg kg-1), lorazepam concentrations in cortex tended to be greater in lorazepam-treated compared to vehicle-treated mice at 4 days after discontinuation compared to 1 and 7 days. 5. These data indicate a shift toward reduced agonist sensitivity and increased inverse agonist sensitivity in mice 4 days after lorazepam discontinuation.