Guidelines for the rational use of benzodiazepines. When and what to use

A sensitive and selective method for the detection of diazepam and its main metabolites in urine by gas chromatography–tandem mass spectrometry

A gas chromatography-tandem mass spectrometry method for detection of diazepam, nordazepam and oxazepam is presented. The method associates electron capture ionization and multiple reaction monitoring (MRM). No derivatization is performed; oxazepam undergoes thermal degradation during chromatographic injection and is thus quantified via its decomposition product. The negative molecular ions are so stable that they do not dissociate when collision is performed under "classical" conditions (i.e. with argon as collision gas). With xenon as collision gas, the energy transfer is sufficient to provide two product ions for diazepam and nordazepam and one product ion for the decomposition product of oxazepam. The sample preparation part involves liquid/liquid extraction with TOXI-TUBES A extraction tubes; it provides recovery yields between 68 and 95%, depending of the benzodiazepine considered, with coefficients of variation below 6% for 10 samples. The applicability of the method was demonstrated on urine extracts. From 1 mL of urine, the method provides quantitation limits of 0.15 ng/mL for diazepam, 1.0 ng/mL for nordazepam and 1.5 ng/mL for oxazepam. Mechanisms of dissociation of M*(-) ions of benzodiazepines are suggested.

Functional status in the elderly with insomnia

BACKGROUND

Insomnia causes psychological distress in the elderly. Besides primary insomnia (PI), illness, medications and psychosocial factors contribute to development of sleep disorders. Although elderly insomniacs usually complain of poorer daytime functioning, it is unknown whether the disorder affects capacity to carry out activities.

OBJECTIVE

To assess the relationship in the elderly between PI, level of physical functioning, depression and anxiety symptoms, state of psychological well-being and consumption of psychopharmaceuticals.

DESIGN

Cross-sectional, observational study.

SETTING

Populational.

SUBJECTS

About 424 non-institutionalized elderly patients.

METHODS

Subjects were interviewed at public Health Centres or at home. They were considered to have PI if DSM-IV criteria were met. The remaining variables measured were: depression and anxiety symptoms (The Goldberg's Depression and Anxiety Scale), cognitive state (Short Portable Mental Status Questionnaire), physical functioning (The Katz Index and the Instrumental Activities of Daily Living Scale), life satisfaction (The Philadelphia Geriatric Center Morale Scale), health problems, consumption of pharmaceuticals and sociodemographic variables.

RESULTS

About 34.2% of the elderly admitted to having problems with sleep, but only 20.3% (CI: 95%: 16.5-24.1) fulfilled the criteria for PI. The existence of an anxiety disorder, a score below the 50th percentile on The Philadelphia Geriatric Center Morale Scale (lower life satisfaction) and consumption of psychopharmaceuticals were variables associated with insomnia. Amongst the most common illnesses reported, only diabetes appeared with significantly higher frequency in the elderly with insomnia (24.4% vs. 14.7%) (p < 0.05). No statistically significant association was found between insomnia and level of dependence in carrying out basic or instrumental activities.

CONCLUSIONS

Approximately one fifth of the non-institutionalized elderly meet the criteria for PI. Those affected present a poorer state of psychological and social well-being, although level of autonomy for conducting basic and instrumental activities does not appear to be modified by the disorder. The existence of an anxiety disorder, low life satisfaction and consumption of psychopharmaceuticals constitute variables associated with PI in the population we studied.

[Appropriate use of benzodiazepines zolpidem and zopiclone in diseases attended in primary care]

OBJECTIVES

To estimate the proportion of benzodiazepine prescriptions that comply with the guidelines for appropriate prescription. To identify the variables associated with appropriate prescription.

DESIGN

Observational, cross-sectional study.

SETTING

Monóvar Health Centre in Area IV, Madrid, Spain.

SUBJECTS

Random sample of 270 active benzodiazepine prescriptions in adult patients from the prescriptions record of the OMI-AP V. 5.0 computer system.

MEASUREMENTS

The chosen dimensions for appropriate prescription were: a) correct diagnostic indication; b) absence of benzodiazepines with long half-life in the elderly; c) existence of support or monitoring visits; d) overall appropriateness or coexistence of correct diagnostic indications and monitoring visits. Independent variables were recorded in relation to patient, person prescribing and prescription.

RESULTS

Diagnostic indication, 75.6%; absence of benzodiazepines with long half-life in the elderly, 79.8%; existence of support visits, 63.3%; overall appropriateness, 53%. Main diagnoses: pure anxiety, 29%; anxiety related to other illness, 18.6%; insomnia, 14.8%; cardiovascular illness, 14.8%; alcohol and drug abuse, 4.5%; osteo-muscular illness, 4.4%; schizophrenia, 4.4%. Most prescribed substances: lorazepam, 27.8%; bromazepam, 23.7%. Average life of prescriptions: 18.58 months. Origins: health centre, 68.5%; out-patient psychiatry, 10%; hospital, 10%. The variable that is most closely associated with overall appropriateness, fitted with the rest of the variables, is out-patient psychiatry prescription (OR, 6.67; 95% CI, 1.92-23.18).

CONCLUSIONS

The mean duration of the prescriptions infringes all standards. The overall appropriateness or correct coexistence of adequate diagnostic indication with follow-up visits is associated with out-patient Psychiatry prescription.

Changes in neocortical and hippocampal GABAA receptor subunit distribution during brain maturation and aging

gamma-Aminobutyric acid type A (GABA(A)) receptors are the most important inhibitory receptors in the central nervous system, playing a pivotal role in the regulation of brain excitability. The pentameric receptor is commonly composed of different alpha, beta, and gamma subunits which mediate the function and pharmacology of the receptor and show regional- and temporal-specific expression patterns. Under varying physiological and pathophysiological conditions, this diversity allows a multitude of adaptive changes in subunit composition leading to distinct biological and pharmacological properties of the receptor. Here, we investigated the expression of five major GABA(A) receptors subunits (alpha1, alpha2, alpha3, alpha5, gamma2) in early postnatal, adult, and aged rat brains. Immunohistochemistry was performed at postnatal day 10, 30, 60, 90, 180, 360, and 540. Morphological and semi-quantitative evaluations of regional optical densities revealed specific regional and temporal expression patterns for all subunits. The study clearly demonstrated that changes in GABA(A) receptor distribution not only occur in the early postnatal cortex and hippocampal formation but also during later periods in the adolescent and aging brain. These findings contribute to a better understanding of age-related changes in brain excitability and further elucidate the distinct pharmacological effects of different GABAergic drugs in young and elderly patients.

Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program

OBJECTIVE

To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial.

METHOD

We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice.

RESULTS

Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95% CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95% CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95% CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95% CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence.

CONCLUSIONS

Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.

Modeling cumulative dose and exposure duration provided insights regarding the associations between benzodiazepines and injuries

BACKGROUND AND OBJECTIVES

Accurate assessment of medication impact requires modeling cumulative effects of exposure duration and dose; however, postmarketing studies usually represent medication exposure by baseline or current use only. We propose new methods for modeling various aspects of medication use history and employment of them to assess the adverse effects of selected benzodiazepines.

STUDY DESIGN AND SETTING

Time-dependent measures of cumulative dose or duration of use, with weighting of past exposures by recency, were proposed. These measures were then included in alternative versions of the multivariable Cox model to analyze the risk of fall related injuries among the elderly new users of three benzodiazepines (nitrazepam, temazepam, and flurazepam) in Quebec. Akaike's information criterion (AIC) was used to select the most predictive model for a given benzodiazepine.

RESULTS

The best-fitting model included a combination of cumulative duration and current dose for temazepam, and cumulative dose for flurazepam and nitrazepam, with different weighting functions. The window of clinically relevant exposure was shorter for flurazepam than for the two other products.

CONCLUSION

Careful modeling of the medication exposure history may enhance our understanding of the mechanisms underlying their adverse effects.

Efficacy of etifoxine compared to lorazepam monotherapy in the treatment of patients with adjustment disorders with anxiety: a double-blind controlled study in general practice

Adjustment Disorders With Anxiety (ADWA) account for almost 10% of psychologically motivated consultations in primary care. The aim of this double-blind randomised parallel group study was to compare (non-inferiority test) the efficacies of etifoxine, a non-benzodiazepine anxiolytic drug, and lorazepam, a benzodiazepine, for ADWA outpatients followed by general practitioners. 191 outpatients (mean age: 43, female: 66%) were assigned to receive etifoxine (50 mg tid) or lorazepam (0.5-0.5-1 mg /day) for 28 days. Efficacy was evaluated on days 7 and 28 of the treatment. The main efficacy assessment criterion was the Hamilton Rating Scale for Anxiety score (HAM-A) on Day 28 adjusted to Day 0. The anxiolytic effect of etifoxine was found not inferior to that of lorazepam (HAM-A score decrease: 54.6% vs 52.3%, respectively, p=0.0006). The two drugs were equivalent on Day 28. However, more etifoxine recipients responded to the treatment (HAM-A score decreased by >or=50%, p=0.03). Clinical improvement (based on Clinical Global Impression scale CGI, Social Adjustment Scale Self-Report SAS-SR, and Sheehan scores) was observed in both treatment arms, but more etifoxine patients improved markedly (p=0.03) and had a marked therapeutic effect without side effects as assessed by CGI, p=0.04. Moreover, 1 week after stopping treatment, fewer patients taking etifoxine experienced a rebound of anxiety, compared to lorazepam (1 and 8, respectively, p=0.034).

Anxiolytic–hypnotic drug use associated with trust, social participation, and the miniaturization of community: A multilevel analysis

The concept of social capital has gained wide interest in public health research in recent years. However, we suggest a concept that was introduced and developed by Fukuyama, named "miniaturization of community", as an alternative to that of social capital. The concept of miniaturization of community emphasizes that a high level of social participation can be accompanied by a low level of trust, both at the individual and at the community level, which may in turn result in social disorder and lack of social cohesion. When society becomes more disordered, people may tend to feel more insecure and anxious. Use of anxiolytic-hypnotic drugs (AHDs) could under such circumstances be a coping strategy. In this study, we first wanted to investigate whether the contextual component of the miniaturization of community concept (i.e. area high social participation and low trust) is associated with individual AHD use, over and above individual characteristics. Secondly, we aimed to study whether people living in the same municipality share a similar probability of AHD use, after adjusting for individual characteristics, and if so, how large this contextual phenomenon is. We used data on 20,319 women and 17,850 men aged 18-79 years from 58 municipalities in six regions in central Sweden, who participated in the Life & Health year 2000 postal survey. We applied multilevel logistic regression analysis with individuals at the first level and areas at the second level. Our results suggest that living in an area with a high level of miniaturization of community seems to be associated with individual AHD use, beyond people's individual characteristics including their own level of social participation and trust. The concept of miniaturization of community may be an extension of the classic concept of social capital and may increase our understanding of contextual effects on health.

Socioeconomic influences on benzodiazepine consumption in an Irish Region

Misuse of prescription sedatives is a significant problem for addiction treatment services. The aim of this study was to examine the prescribing of diazepam in disadvantaged Irish communities, and to identify factors which may predict diazepam consumption in that population. We examined prescribing trends for those aged 16-69 years in 2002 in a region of the state-funded General Medical Services Scheme. Material deprivation was based on the 2002 Small Area Health Research Unit (SAHRU) deprivation index. The average defined daily dose (DDD) was calculated and logistic regression analysis was used to predict diazepam use by age, gender and deprivation index. Results showed that patients living in the most-deprived areas were more likely to receive diazepam than patients living in the least-deprived areas (OR = 1.21, 95% CI 1.15-1.27). Female patients living in the most-deprived areas were also more likely to receive diazepam than those living in the least-deprived areas (OR = 1.36, 95% CI 1.18-1.57). It is concluded that there is a pattern of higher diazepam prescribing in areas of greatest deprivation, where prescription sedatives play a complex role within troubled families.

Regular prescriptions for benzodiazepines: a cross-sectional study of outpatients at a university hospital

OBJECTIVE

To investigate 1) the patterns of regular prescriptions for benzodiazepines among department clinics in a university teaching hospital, 2) the effects of patient's characteristics on regular benzodiazepine prescriptions, and 3) the patterns of benzodiazepine prescriptions among department clinics from the perspective of pharmacological half-life.

PATIENTS

Patients were 22,099 outpatients (51% female; mean age: 56 years) who were prescribed any drug three or more times.

METHODS

Cross-sectional study of patient-based data (July 2002 to August 2003) from the database of a computer ordering system at a university hospital. The patterns of regular prescriptions for benzodiazepines were compared among the clinical departments (i.e., Internal Medicine, Psychiatry, and Others). A logistic regression model was used to assess the effects of patient gender and age, and the clinic visited on the issuing of regular prescriptions for benzodiazepines.

RESULTS

Regular benzodiazepine users were 3,204 (14.5%). Benzodiazepines were more likely to be prescribed for women (61.3%) than for men and were prescribed most often by psychiatrists (31.7%), followed by internists (20.1%). Multivairate logistic regression model showed that being female and elderly, and being prescribed by a psychiatrist were significantly associated with regular benzodiazepine prescriptions. With regard to the pharmacological half-life, internists were more likely to prescribe short half-life benzodiazepines than were psychiatrists (p < 0.001).

CONCLUSION

A large number of outpatients at a Japanese university hospital appeared to be maintained on a regular supply of benzodiazepine drugs. Educational programs are needed to promote the rational prescribing of benzodiazepines.

Tapering off benzodiazepines in long-term users: an economic evaluation

BACKGROUND

Discontinuation of benzodiazepine usage has never been evaluated in economic terms. This study aimed to compare the relative costs and outcomes of tapering off long-term benzodiazepine use combined with group cognitive behavioural therapy (TO+CBT), tapering off alone (TOA) and usual care.

METHOD

A randomised controlled trial was conducted, incorporating a cost-effectiveness analysis from a societal as well as a pharmaceutical perspective. The cost of intervention treatment, prescribed drugs, healthcare services, productivity loss, and patients' costs were measured using drug prescription data and cost diaries. Costs were indexed at 2001 prices. The principal outcome was the proportion of patients able to discontinue benzodiazepine use during the 18-month follow-up. A secondary outcome measure was quality of life (Health Utility Index Mark III [HUI-3] and the Medical Outcomes Study 36-item Short-Form Health Survey [SF-36]).

RESULTS

A total of 180 patients were randomised to one of TO+CBT (n = 73), TOA (n = 73) or usual care (n = 34). Intervention treatment costs were an average of 172.99Euro per patient for TO+CBT and 69.50Euro per patient for TOA. Both treatment conditions significantly reduced benzodiazepine costs during follow-up compared with usual care. The incremental cost-effectiveness ratios (ICERs) showed that, for each incremental 1% successful benzodiazepine discontinuation, TO+CBT cost 10.30-62.53Euro versus usual care, depending on the study perspective. However, TO+CBT was extendedly dominated or was dominated by TOA. This resulted in ICERs of 0.57Euro, 10.21Euro and 48.92Euro for TOA versus usual care from the limited pharmaceutical, comprehensive pharmaceutical and societal perspective, respectively.

CONCLUSIONS

TO+CBT and TOA both led to a reduction in benzodiazepine costs. However, it remains uncertain which healthcare utilisation has a causal relationship with long-term benzodiazepine consumption or its treatment. Although the ICERs indicated better cost effectiveness for TOA than for TO+CBT, the differences were relatively small. The addition of group CBT to tapering off had no clinical or economic advantages. Extrapolation of our data showed that the investment in TOA was paid back after 19 months when corrected for treatment gain with usual care.

Sleep maintenance insomnia: strengths and weaknesses of current pharmacologic therapies

BACKGROUND

Although insomnia is highly prevalent, sleep disturbances often go unrecognized and untreated. When insomnia is recognized, considerable emphasis has been placed on improving sleep onset; however, there is growing evidence that improving sleep maintenance is an equally important treatment goal.

METHODS

A MEDLINE literature search was performed using the search parameters "insomnia," "zolpidem," "zaleplon," "flurazepam," "estazolam," "quazepam," "triazolam," and "temazepam," as these agents are FDA-approved for the treatment of insomnia. Per reviewer comments, the search criteria was later expanded to include lorazepam. A literature search using the terms "trazodone" and "insomnia" was also performed, as this is the second-most commonly prescribed agent for treating insomnia. Sleep efficacy endpoints from randomized, placebo-controlled clinical trials in adult populations and key review articles published between 1975 and 2004 were included in this review. As only one randomized placebo-controlled trial evaluated trazodone use in primary insomnia, the trazodone search was expanded to include all clinical trials that evaluated trazodone use in insomnia. Relevant texts and other articles that evaluated side effect profiles of these agents were also included, one of which was published in January of 2005. In all publications, impact of treatment on sleep maintenance parameters (wake time after sleep onset, number of awakenings) and measures of next-day functioning were evaluated, in addition to sleep onset parameters (sleep latency, time to sleep onset/induction) and sleep duration data (total sleep time).

RESULTS

Many of the currently available agents used to treat insomnia, including the antidepressant trazodone, the non-benzodiazepine hypnotics zolpidem and zaleplon, and some of the benzodiazepines, have not consistently demonstrated effectiveness in promoting sleep maintenance. Furthermore, the benzodiazepines with established sleep maintenance efficacy are associated with next-day sedation, the risk of tolerance and dependence, or both.

CONCLUSIONS

New agents that offer relief of sleep maintenance insomnia without residual next day impairment while improving next day function are needed. Several compounds currently under development may offer clinicians a more effective and safer treatment for this common disorder.

Anti-conflict effects of benzodiazepines in rhesus monkeys: relationship with therapeutic doses in humans and role of GABAA receptors

RATIONALE AND OBJECTIVES

Conflict procedures are used to study mechanisms underlying the anxiolytic effects of benzodiazepines (BZs). We established a conflict procedure with rhesus monkeys in order to examine the role of GABAA receptors in the anxiolytic-like effects of BZs.

METHODS

Four rhesus monkeys responded under a two-component multiple schedule in which responding was maintained under a fixed-ratio schedule of food delivery in the absence (non-suppressed responding) and presence (suppressed responding) of response-contingent electric shock.

RESULTS

Conventional BZs (alprazolam, flunitrazepam, clonazepam, nitrazepam, lorazepam, bromazepam, diazepam, flurazepam, clorazepate, chlordiazepoxide) engendered increases in the average rates of suppressed responding at low to intermediate doses and decreased the average rates of non-suppressed responding at higher doses. Positive correlations were observed when the therapeutic potencies of BZs in humans were compared with potencies to increase the rates of suppressed responding (R2=0.83) or decrease the rates of non-suppressed responding (R2=0.60). The 5-HT1A agonist buspirone increased the rates of suppressed responding, although the effects were modest, whereas the opioid morphine lacked anti-conflict effects. The BZ antagonist flumazenil also modestly increased the rates of suppressed responding. A relatively low dose of flumazenil enhanced, while a high dose blocked, alprazolam's anti-conflict effects. Compounds selective for alpha1 subunit-containing GABAA receptors (zolpidem, zaleplon, CL218,872) engendered relatively weak increases in the rates of suppressed responding.

CONCLUSIONS

A rhesus monkey conflict procedure was established with predictive validity for therapeutic doses in people and provided evidence that anxiolytic-like effects of BZs can occur with relatively low intrinsic efficacy at GABAA receptors and are reduced by alpha1GABAA receptor selectivity.

Psicofármacos en el anciano

Based on the following realities, general knowledge on the management of psychodrugs in the elderly population is necessary for any physician: high prescription of psychodrug in this population, up to 25% of the elderly may require this treatment at any time, and good therapeutic response. To achieve good compliance to the psychiatric treatment by the elderly patient, the pharmacokinetic characteristics and interactions in this population must be well known to avoid the appearance of significant side effects. These side effects may induce the patient to drop out of the treatment or to even have at risk side effects. A review on the pharmacodynamic and pharmacokinetic characteristics related with psychodrugs in the elderly is done in this article. Based on this, the three large groups of anxiolytic, antidepressive and antipsychotic psychodrugs are reviewed.

Simultaneous determination of clobazam and its major metabolite in human plasma by a rapid HPLC method

A rapid and specific HPLC method has been developed and validated for simultaneous determination of clobazam, the anticonvulsant agent, and its major metabolite in human plasma. The sample preparation was a liquid-liquid extraction with tuloene yielding almost near 100% recoveries of two compounds. Chromatographic separation was achieved with a Chromolith Performance RP-18e 100 mm x 4.6mm column, using a mixture of a phosphate buffer (pH 3.5; 10mM)-acetonitrile (70:30, v/v), in isocratic mode at 2 ml/min at a detection wave-length of 228 nm. The calibration curves were linear (r(2)>0.998) in the concentration range of 5-450 ng ml(-1). The lower limit of quantification was 5 ng ml(-1) for two compounds studied. The within- and between-day precisions in the measurement of QC samples at four tested concentrations were in the range of 0.89-9.1% and 2.1-10.1% R.S.D., respectively. The developed procedure was applied to assess the pharmacokinetics of clobazam and its major metabolite following administration of a single 10mg oral dose of clobazam to healthy volunteers.

Flunitrazepam: psychomotor impairment, agitation and paradoxical reactions

Benzodiazepines are sedatives used for anxiolysis, hypnosis, muscle relaxation and the treatment of epilepsy. Paradoxical reactions including agitation, talkativeness, confusion, disinhibition, aggression, violent behavior and loss of impulse control may, however, occur in some subjects. It has been claimed that high doses of flunitrazepam may cause aggression on a more regular basis in all individuals. The present study makes use of a Norwegian forensic toxicological database containing analytical results from drivers suspected of driving under the influence and suspects of violent crime to analyze the relationship between behavior and blood flunitrazepam concentration. Four-hundred and fifteen cases of drivers suspected of driving under the influence and seven cases of suspects of violent crime were studied. These selected cases had flunitrazepam as the only drug in blood samples and had been evaluated by a clinical test for impairment (CTI) performed by a police physician at the time of blood sampling. The impaired drivers had higher blood flunitrazepam concentrations than the not impaired drivers. Multivariate analysis revealed that both blood flunitrazepam concentration and age of the suspected drivers had independent impact on impairment, indicating tolerance with age. Most of the effects measured were sedative effects of flunitrazepam and these effects were related to flunitrazepam level. Possible paradoxical reactions were observed in a subgroup of 23 individuals (6%), but these reactions did not relate to blood flunitrazepam concentration. The suspects of violent crime showed similar degree impairment and had not more paradoxical reactions than the suspected drugged drivers. The findings were in agreement with other research that claims paradoxical reactions should be viewed as a reaction in certain individuals, and does not support the notion that flunitrazepam in high concentration produces aggression in all individuals taking the drug.

Benzodiazepines and injury: a risk adjusted model

BACKGROUND

Benzodiazepines (BZD) are one class of medications that are generally acknowledged to be a risk factor for injuries.

OBJECTIVE

Our objective was to link outpatient prescription data with clinical data in order to develop a risk adjusted binary model that associates BZD usage with the risk for a healthcare encounter for an injury.

METHODS

In total, 3 years of outpatient BZD prescription data, totaling 133 872 outpatient BZD prescriptions for 13 745 patients for a VA medical center, were combined with data from inpatient and outpatient administrative databases. The model incorporated Elixhauser comorbidity measures with 1-year look back period, along with hospital discharges, marital status, age, mean arterial pressure and body mass index. The model also included the dose of the drug, converted to valium equivalents and its duration. The model was analyzed using generalized estimation equations (GEE).

RESULTS

Dose, duration, discharges and various comorbidities were associated with an increased risk for injury, while being married reduced the risk. Increased body mass was associated with increased injury risk. Increased mean arterial pressure was associated with decreased risk.

CONCLUSIONS

These findings offer guidance on how specific combinations of risk factors and potential protective effects may impact accidental injury risk. Clinicians prescribing or adjusting BZDs can use these results to more accurately tailor medication regimens for a patient. Our findings suggest that clinicians should also consider the nature of the social support system available to the patient in assessing total injury risk.

Influence of inflammatory nociception on the anxiolytic-like effect of diazepam and buspirone in rats

RATIONALE

The effect of anxiety on nociception has been evaluated but not that of nociception on anxiety.

OBJECTIVE

The study was conducted to analyse the influence of nociception on basal levels of anxiety-like behaviour and on the action of anxiolytic drugs.

METHODS

Nociception was induced by an intra-articular injection of uric acid at 3.75 or 7.5%. Experimental anxiety was determined in the rat burying behaviour and the elevated plus maze tests. To separate specific anxiety-related drug actions, a spontaneous ambulatory test was included. The anxiolytics, buspirone (2.5 and 5.0 mg/kg, i.p.) and diazepam (0.5, 1.0 and 2.0 mg/kg, i.p.), were used.

RESULTS

In the nociception test, the pain-induced functional impairment rat model, uric acid at 3.75 and 7.5% had an effect of around 35 and 75%, respectively. Uric acid (UA) at the lower dose (3.75%) lacked an effect on burying behaviour but significantly increased the time spent and number of entries to the open arms; the higher UA dose (7.5%) produced a significant increase in the time spent and number of entries to the open arms and a statistically significant reduction in cumulative burying. Diazepam and buspirone produced a clear dose-dependent reduction in cumulative burying. In the plus maze, diazepam also induced an increase in the time spent and number of entries to the open arms. In the burying behaviour test, rats with a mild level of nociception (uric acid at 7.5%) were insensitive to the anxiolytic-like effect of these anxiolytic drugs. In the plus maze test, the anxiolytic-like effect of diazepam (1.0 mg/kg) was blocked under both levels of nociception.

CONCLUSIONS

These data demonstrate that nociception modifies the response to anxiolytic drugs. The role of factors with anxiogenic properties produced during inflammation, which may modify diazepam and buspirone effects, is discussed.

Effects of kava-kava extract on the sleep-wake cycle in sleep-disturbed rats

RATIONALE

Kava-kava extract may be useful as an herbal medicine for treatment of insomnia and anxiety.

OBJECTIVES

The present study was undertaken to investigate the effects of kava-kava extract on the sleep-wake cycle in comparison with that of flunitrazepam using sleep-disturbed rats.

METHODS

Electrodes for measurement of electroencephalogram (EEG) and electromyogram (EMG) were implanted into the frontal cortex and the dorsal neck muscle of rats. EEG and EMG were recorded with an electroencephalogram. SleepSign ver.2.0 was used for EEG and EMG analysis. Total times of wakefulness, non-rapid eye movement (non-REM) and REM sleep were measured from 09:00 to 15:00.

RESULTS

A significant shortening of the sleep latency in sleep-disturbed rats was observed following the administration of kava-kava extract at a dose of 300 mg/kg, while no effects were observed on the total waking and non-REM sleep time. On the other hand, flunitrazepam showed a significant shortening in sleep latency, decrease in total waking time and increase in total non-REM sleep time. Although the effects of flunitrazepam were antagonized by the benzodiazepine receptor antagonist flumazenil, the effect of kava-kava extract was not antagonized by flumazenil. Kava-kava extract showed a significant increase in delta activity during non-REM sleep in sleep-disturbed rats, whereas a significant decrease in delta power during non-REM sleep was observed with flunitrazepam. Flumazenil caused no significant effect on the changes in delta activity induced by both kava-kava extract and flunitrazepam.

CONCLUSIONS

Kava-kava extract is an herbal medicine having not only hypnotic effects, but also sleep quality-enhancement effects.

The epidemiology of long-term benzodiazepine use

Recommendations for benzodiazepine (BZD) use suggest durations of no more than a few weeks, but studies report use for months, years, or even decades. This article examines the who (who are long-term users), why (why do they use BZD), what (what are patterns of long-term use) and how (how do they compare to all BZD users). The study population is from the National Population Health Survey in Canada which interviewed respondents four times at two-year intervals, asking about specific drugs use as well as demographic, lifestyle and health-related questions. Long-term BZD use was defined as BZD use for two successive cycles. Four percent of the Canadian population used BZD at any one time, half of whom also reported use in the previous cycle. Benzodiazepine users were more likely to be female, elderly, smokers, to prefer speaking a language other than English, to have insurance coverage for medication, and to have completed high school education. Almost none of these determinants predicted long-term use. Persons reporting BZD use in 2000 had an odds ratio (OR) of 38.6 for also using BZD in 1998, were more likely to use antidepressants (OR=8.5) and suffer from conditions such as poor health, stress, and pain. Most of these determinants had no association with long-term use or if they did at a considerably lower OR. Of the 395 BZD users in 2000, almost 48.4% also used BZD in the previous cycle and 17% in all three previous cycles. Benzodiazepine use in any previous cycle made BZD use in 2000 more likely, with use determined by how recent and the frequency of reported use, culminating in a very high OR of 83.3 for use in all three previous cycles. Continued use for any of the individual BZD tended to be largely for the same BZD. We conclude that: (1) the overriding determinant for BZD use was that of previous use; and (2) long-term use was not determined by the same factors as overall use, which is significant in developing approaches to dealing with long-term BZD use.

Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study

Minimal intervention strategies to decrease long-term benzodiazepine use have not yet been evaluated in large primary care based studies with a blinded control condition and a long follow-up period. The purpose of this study was to assess the effects of a letter with a discontinuation advice sent to long-term benzodiazepine users in family practice followed by an evaluation consultation offer. The experimental group consisted of 2425 long-term benzodiazepine users, 1707 of whom were addressed by a discontinuation letter and an evaluation consultation offer. The control group consisted of 1821 long-term users. Primary endpoints were the number of prescribed daily dosages (PDD) and the percentage of subjects without prescription (quitters). At 21 months a reduction in benzodiazepine prescription of 26% was observed in the experimental group, versus 9% in the control group (PDD difference=12.5; 95%-ci: 8.2-16.8). In the experimental group 13% and in the control group 5% of the study completers were benzodiazepine prescription free through the full follow-up period (RR=2.6; 95%-ci: 2.0-3.4). The percentage of quitters at short-term (6 months) was 24% in the experimental group versus 12% in the control group (RR=2.1; 95%-ci: 1.8-2.4). It is concluded that this intervention strategy steadily reduces long-term benzodiazepine use in family practice.

Mental disorders associated with benzodiazepine use among older primary care attenders--a regional survey

BACKGROUND

Benzodiazepines (BDZs) are among the most commonly prescribed drugs in the elderly and their use is often too prolonged according to current international guidelines.

METHODS

We investigated the pattern of use of BDZs among 65- to 84-year-old attenders at 40 Italian primary care practices who answered positively in a questionnaire on the use of anxiolytic/hypnotic drugs and successfully completed the PRIME-MD questionnaire. The survey lasted 6 months, from February to July 2001.

RESULTS

Of the 1,156 subjects who completed the PRIME-MD, 748 subjects were positive for at least one psychiatric diagnosis. A depressive disorder was present in 36.5% of all PRIME-MD completers and in about one-third of cases represented by major depression, whereas anxiety disorders, somatoform disorders and alcohol abuse accounted for 18.2%, 8.1% and 1.7% of all PRIME-MD completers, respectively. Most patients were first prescribed BDZs by their General Practitioners (GPs) for each diagnostic group. However, patients with pure anxiety started BDZ treatment during hospitalisation more often (19.7%) than patients with depressive disorders (13.7 %). Moreover, patients with comorbid anxiety and depressive disorders (CADD) were most likely to receive their first BDZ prescription from a psychiatrist (15.7 %). Sleep disturbances were present in at least 50% of cases (and up to 86 %) in each diagnostic group. About 75% of prescriptions concerned anxiolytic BDZ or medium/long-acting BDZ. Most patients with anxiety, CADD and depression used night-time BDZ (65.2%, 56.9 % and 60.5%, respectively). The prevalence of chronic use of BDZs was equally high in all categories of psychiatric disorder (about 90 % for each), showing that the vast majority of patients, irrespective of the diagnosis, had been using BDZs for years.

CONCLUSIONS

BDZs are widely prescribed for elderly people by their GPs, often for a considerable length of time. The evidence that many BDZ consumers suffer from a depressive or an anxiety disorder, or both, could be a starting point for encouraging a rational prescription in accordance with international guidelines.

Initial benzodiazepine use and improved health-related quality of life

OBJECTIVE

The health-related quality of life (HRQOL) of initial benzodiazepine users was measured over time. Furthermore, benzodiazepine usage characteristics as determinants of change in mental and physical health status of the benzodiazepine users were examined.

METHODS

In the only pharmacy of a Dutch community of 13,500 and during four months from November 1994, all patients with a benzodiazepine prescription and no history of benzodiazepine use over a period of 12 months before inclusion, were invited to participate. A total of 106 initial benzodiazepine users were matched for age and gender. In a six-month follow-up study, HRQOL was measured with the RAND-36. Consequently, in a nested case control design, determinants of change in mental and physical functioning over the six-month period were analysed using the Mental Component Summary and the Physical Component Summary.

RESULTS

At baseline, initial benzodiazepine users showed a lower HRQOL as compared to reference subjects. After six-month follow-up, benzodiazepine users presented an absolute increase in HRQOL, while the reference subjects maintained a stable HRQOL. Diazepam and the male gender were associated with an increase in physical functioning over time. Younger age, a lower daily dose (DDD < 0.75) and a period of use between 16 and 60 days were associated with better mental functioning over time.

CONCLUSION

This study is one of the first to associate improvement in HRQOL over time of starting benzodiazepine users with specific usage characteristics, such as limited duration of use and a low dosage.

Hypnotic Activities of Chamomile and Passiflora Extracts in Sleep-Disturbed Rats

In the present study, we investigated hypnotic activities of chamomile and passiflora extracts using sleep-disturbed model rats. A significant decrease in sleep latency was observed with chamomile extract at a dose of 300 mg/kg, while passiflora extract showed no effects on sleep latency even at a dose of 3000 mg/kg. No significant effects were observed with both herbal extracts on total times of wakefulness, non-rapid eye movement (non-REM) sleep and REM sleep. Flumazenil, a benzodiazepine receptor antagonist, at a dose of 3 mg/kg showed a significant antagonistic effect on the shortening in sleep latency induced by chamomile extract. No significant effects were observed with chamomile and passiflora extracts on delta activity during non-REM sleep. In conclusion, chamomile extract is a herb having benzodiazepine-like hypnotic activity.

Effect of Concomitant Use of Benzodiazepines and Other Drugs on the Risk of Injury in a Veterans Population

BACKGROUND

Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related health care episode.

METHODS

A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13,745 patients at a Veterans Administration hospital system over a 3-year period (1999-2001). We analysed 1,33,872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in 'major' interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related health care episode within a 30-day period when taking both a benzodiazepine and another drug with a 'major' severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment.

RESULTS

Of the 1,110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk.

CONCLUSIONS

This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with health care utilisation for injuries.

Generalized anxiety disorder: acute and chronic treatment

Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.

Sub-chronic administration of zolpidem affects modifications to rat sleep architecture

Gamma-aminobutyric acidA receptor (GABAAR) modulators constitute the majority of clinically relevant sedative-hypnotics. Animal studies have clearly demonstrated sedative efficacy for these compounds in acute studies. However, relatively less is known regarding their efficacy under brief periods of repeat administration or following intermittent dosing. Therefore zolpidem, a short-acting GABAAR modulator with selectivity for the type-I (omega1) benzodiazepine receptor, was studied for efficacy in altering rat sleep architecture as determined by electrocorticogram (ECoG) and electromyogram (EMG) activity over a 7-day sub-chronic administration period. Zolpidem caused significant reductions in wakefulness entries and rapid eye movement (REM) sleep entries and duration, with increases in Delta sleep duration throughout the administration period. Examination of sleep architecture 24 h after cessation of sub-chronic zolpidem administration revealed a decrease in Delta sleep, suggesting that repeated zolpidem administration might elicit enduring modifications to sleep organization. This was not seen following similar dosing of diazepam. The efficacy of sub-chronic administration of zolpidem to alter sleep architecture was enhanced when the administration regimen was repeated following a 7-day hiatus. Significant increases in Delta sleep duration, with significant decreases in light sleep and wakefulness were observed during the repeated exposure to zolpidem. Therefore, sub-chronic administration of zolpidem affected lasting modifications in sleep organization that appeared both 1 day following administration and during reiterated administration without eliciting tolerance.

Use of benzodiazepine drugs and perceived job stress in a cohort of working men and women in Belgium. Results from the BELSTRESS-study

The aim of the Belstress Study was to see whether use of benzodiazepines is associated with perceived job stress as measured by Karasek's job-strain model. This model has as its central tenet that the most adverse health outcomes are to be expected in high strain jobs characterized by high job demands and low job control. An extension of the model states that the most noxious combination is high job demands, low control and low social support at work. Sample subjects were recruited from 25 Belgian companies between 1994 and 1998, and cover a wide range of occupations. A 5.6% of 16,094 men and 9.3% of 5012 women aged 35-59 years report use of benzodiazepines during the last month. A clear association is displayed between self-reported use of benzodiazepines and a high strain job compared to a low strain job (men: OR=1.93, 99% CI=1.4-2.6; women: OR=1.66, 99% CI=1.0-2.7), after adjustment is made for socio-demographic confounders (age, level of education, occupational group, employment sector, living situation). The independent association with quartile level of job demands is a striking feature (men: OR of highest quartile compared to lowest quartile group=1.91, 99% CI=1.4-2.6; women: OR=1.99, 99% CI=1.3-3.1). In men, an inverse association with quartile level of job control is observed (OR= 0.65, 99% CI=0.5-0.9) whereas in women a clear tendency in that direction is displayed (OR=0.62, 99% CI=0.4-1.1). The association with low social support is less clear; an independent association between use of benzodiazepines and iso-strain was observed particularly in men.

The prevalence, key causes and management of insomnia in palliative care patients

In a prospective audit, the prevalence, key causes and treatment of insomnia prior to admission were evaluated in a population of hospice patients using a questionnaire based on a review article of key features related to insomnia in the palliative care setting. Seventy-four patients completed the questionnaire. Fifty-two (70%) patients had insomnia symptoms. Uncontrolled physical symptoms, most often pain (15 patients), were the commonest cause of insomnia, cited by 31 (60%) sleep-disturbed patients. Thirteen (62%) of 21 patients who had been prescribed hypnotic medication reported an improvement with the prescribed medication. Twenty (38%) of the 52 patients with insomnia suggested that improved symptom control would improve their sleep, and only two (4%) suggested the need for more hypnotic medication. We conclude that insomnia is a common symptom in terminally ill patients and that improved symptom control should be a priority in the management of insomnia in this group of patients.

[Evaluation of the medical orientation for the benzodiazepine side effects]

OBJECTIVES

Benzodiazepines are among the most prescribed drugs indicated as anxiolytics, hypnotics, myorrelaxants or antiepileptics. Their main side effects are: reduced psychomotor activities, interaction to other drugs, like alcohol, and the development of dependence. In the present study it was evaluated the quality of the medical directions given to patients about those side effects.

METHODS

One hundred and twenty patients (39 men and 81 women), mean age of 48 years old, who visited pharmacies in Curitiba to buy prescribed benzodiazepines, were interviewed by an open or directive questionnaire designed to obtain the medical directions about benzodiazepines side effects.

RESULTS

Directions about the three main benzodiazepines side effects were observed only in 13% of the patients, 27% had received at least two and 40% only one, while 19% reported no directions. It suggested that the medical orientation was precarious and its quality was not influenced by the patients' educational level, the kind of medical attendance or the specialty of the physician. The main orientation cited was "don't drink" (85%), followed by "don't drive or operate machines" (46%), while few orientations about the risk to develop dependence on benzodiazepines was observed (31%).

CONCLUSION

This suggests that physicians were worried about the alcohol interaction risk, which can be dangerous for the patients. The high number of patients using benzodiazepines continuously for more than one year (61%), the unsuccessfully attempt to stop using BZD (94%) and the poor information about the duration of the treatment (22%) were all related to the low medical worry about dependence on benzodiazepines.

Effects of after-midnight intake of zolpidem and temazepam on driving ability in women with non-organic insomnia

BACKGROUND

Occasionally, insomniac patients may take a sleeping pill after midnight. This may have consequences on their ability to drive a car and result in an increased risk of car accidents.

METHODS

This double-blind, randomized, placebo-controlled, three-treatment three-period cross-over study investigated the effects of two frequently prescribed hypnotics of different classes in a real life condition on driving performance and psychomotor skills in insomniac women. Single doses of zolpidem 10 mg (Z), temazepam 20 mg (T) or placebo (P) were administered at 2:00 a.m. to 19 women aged 35-60 years in three treatment periods separated by wash-out periods of 3-14 days. After polysomnography at baseline and each treatment night, patients underwent, 5.5 h after drug intake at 7:30 a.m. on the next morning, a STISIM driving simulator test, and a subsequent neuropsychological test (FePsy).

RESULTS

Eighteen insomniac women were included in the analysis (mean age 50 years, mean weight 69 kg, mean BMI 25.6 kg/m2). There were no differences between treatments for the primary outcome measure (mean time to collision; baseline: 0.120 s, P: 0.124, T: 0.118, Z: 0.124; P> or =0.12 for all pairwise comparisons). No differences were recorded for speed deviation and reaction time to tasks for the verum treatments, however, lane position deviation was greater after administration of zolpidem in comparison to both placebo and temazepam (P=0.025 and 0.05, respectively). There were no differences between treatments in the FePsy test. Both medications were well tolerated.

CONCLUSIONS

5.5 h after drug administration there were no major differences in psychomotor performances between both zolpidem and temazepam compared to placebo, which indicates the absence of significant residual effects at that time. However, certain patients were more susceptible than others to the drug effects (two patients with high number of collisions). This underlines the necessity to strongly advocate against the late intake of hypnotics if patients intend to drive a car early the next morning.

Interdose elevation in plasma cortisol during chronic treatment with alprazolam but not lorazepam in the elderly

Benzodiazepines (BZPs) have been shown to reduce hypothalamic-pituitary-adrenal (HPA) axis activity acutely in normal humans. In contrast, the effects of chronic BZP treatment on the HPA axis have not been well studied, especially in the geriatric population. This study examined the acute and chronic effects (3 weeks) of alprazolam and lorazepam on plasma cortisol in 68 subjects (60-83 years) who received 0.25 or 0.50 mg b.i.d. alprazolam, or 0.50 or 1.0 mg b.i.d. lorazepam, or placebo orally according to a randomized, double-blind, placebo-controlled parallel design. Memory assessment and blood samples for plasma cortisol were obtained prior to the morning dose on days 0, 7, 14, and 21, and at 1, 2.5, and 5 h postdrug on days 0 and 21. Assessments of anxiety and depression were carried out at days 0, 7, 14, and 21 before drug administration. Plasma cortisol was affected compared to placebo only by the 0.5 mg alprazolam dose. During the first and the last day of treatment, there was a significant drop in cortisol at 2.5 h after alprazolam compared to placebo. The predose cortisol levels increased significantly during chronic alprazolam treatment, and correlations were found between these cortisol changes and changes in depression, anxiety, and memory scores. These findings suggest that even a short period of chronic treatment with alprazolam, but not lorazepam, may result in interdose HPA axis activation in the elderly, consistent with drug withdrawal. If confirmed, this effect may contribute to an increased risk for drug escalation and dependence during chronic alprazolam treatment.

Pediatric sleep pharmacology: you want to give my kid sleeping pills?

There is a need for greater information about the pharmacologic management of sleep disorders in children. Pharmacologic guidelines must be developed specifically for sleep disorders in children. Ideally, these guidelines should be approved by the Food and Drug Administration for a specific sleep disorder or for the pediatric age range. This approval prevents physicians from being forced to prescribe medications as an "off label" indication. Development of easy-to-swallow, chewable, or liquid forms of these medications would be well received by parents everywhere. When these are not available, instructions for compounding these medications into a suspension by pharmacists are needed. Integration of behavioral and pharmacologic treatments may yield better patient outcomes. This approach requires pediatricians to have a comprehensive understanding of clinical sleep disorders in children. Training programs should play the lead role in enhancing pediatricians' knowledge of the pharmacologic treatment of sleep disorders in children.

Disturbed sleep predicts hypnotic self-administration

OBJECTIVES

To evaluative whether polysomnographically determined sleep variables in a large group of subjects reflecting a wide range of sleep disturbance would be predictive of the self-administration of capsules before sleep.

METHODS

Sixty-four healthy men and women with and without insomnia (aged 21-55 years) were given an opportunity to self-administer placebo or triazolam (0.25 mg) capsules (single-choice method - available capsule or no capsule) before sleep in three separate studies. All qualified using the identical criteria based on a standard nocturnal polysomnogram. Screening sleep measures then were used to predict subsequent placebo and triazolam self-administration.

RESULTS

The percent of placebo and triazolam choices did not differ between or within the three studies. Persons with persistent psychophysiologic insomnia self-administered more capsules than persons with sleep state misperception or normals, with the subject groups not differing in placebo vs. active drug preference. Screening polysomnographic measures predicted percent of capsule choices. The single best predictor was the ratio of minutes of stage 3-4 sleep to minutes of wake plus stage 1 sleep with R=0.44. The addition of % stage 3-4 sleep, wake before sleep and total sleep time increased R to 0.49. On morning mood ratings less ability to concentrate and greater fatigue (Profile of Mood States) predicted percent of capsule choices with R=0.36.

CONCLUSIONS

These results show that the extent of sleep disturbance predicts the likelihood of self-administering a capsule before sleep regardless of whether it is placebo or active drug.

Testing for benzodiazepine inebriation--relationship between benzodiazepine concentration and simple clinical tests for impairment in a sample of drugged drivers

OBJECTIVE

To study how the various 25 subtests and observations of the Norwegian clinical test for impairment related to the blood benzodiazepine concentrations of apprehended drivers suspected of driving under the influence of benzodiazepines. The impact of single-dose intake in non-daily users of benzodiazepines on the clinical picture of inebriation was also studied.

METHODS

Included in the study were 818 drivers suspected of driving under the influence of non-alcoholic drugs with blood samples containing only one benzodiazepine. We determined which of the 25 subtests and observations of the clinical test for impairment related significantly to the blood benzodiazepine concentrations.

RESULTS

Significantly related to blood benzodiazepine concentrations were 13 subtests and observations. Of these, 9 withstood adjustment for a variety of background variables. Single dose intake in non-daily users only influenced 3 subtests and observations after adjustment for blood benzodiazepine concentration and background variables. Romberg's test, 1 observation concerning alertness (oriented for time and place), 4 tests on motor and coordination (walk and turn on line, finger-to-nose and finger-to-finger tests), 2 observations on speech (articulation and content) and 1 observation regarding appearance (general conduct) were related to blood benzodiazepine concentrations.

CONCLUSION

Many of these simple clinical tests are included in the standardized field sobriety test and are of value in revealing benzodiazepine impairment. The present study offered some possible additions. Combinations of these robust tests can also be used to reveal benzodiazepine inebriation in other contexts.

[Treatment of insomnia in children: pharmacological aspects]

In the last few years topics related to sleep in children have aroused increased interest. Most hypnotic drugs and sedatives used to treat adult insomnia are not recommended in children. Even so, 56% of pediatricians use medication to treat childhood sleep disorders. We review the different causes of insomnia in children from birth to school age. The various therapeutic options are discussed and the therapeutic methods that have been demonstrated to be most effective in the various types of insomnia. The most frequent hypnotic drugs used in insomnia treatment are benzodiazepines and non-benzodiazepine hypnotics such as imidazopyridine, pyrazolopyrimidine and cyclopyrrolone. Few studies have been published on the use of melatonin in insomnia although several reports suggest that is useful and relatively safe in the treatment of insomnia in school-aged children. In children with insomnia, pediatricians should first of all obtain information about the characteristics of insomnia and the environmental characteristics surrounding the child and his/her family. Once an organic cause has been ruled out, treatment should be based on informing the parents about sleep physiology and on training them in sleep hygiene and the acquisition of sleep habits. When pharmacological treatment is required, it should be carefully selected using the smallest effective doses. Melatonin seems to have a promising future in insomnia treatment in healthy children and in those with neurological disorders.

The use of hypnosedative drugs in a university hospital setting

OBJECTIVE

The use of hypnosedatives (HSs) in the hospital and at home before admission was registered. Also, the incidence of HSs newly started in the hospital and the incidence of withdrawal in chronic users while in hospital was recorded.

METHODS

The study population consisted of 517 consecutively admitted patients recruited from 10 wards of the Ghent University Hospital; 493 of them received a questionnaire and were interviewed concerning the use of HSs at home and in the hospital, about the cause and duration of treatment, the type of HSs used, the presence and nature of any concomitant sleep or anxiety disorder. Main outcome measures were the actual use of HSs during hospitalisation as compared with the reported use, the influence of hospitalisation on use of HSs and the assessment of cause and duration of use of HSs.

RESULTS

Twenty-nine percent of the study sample took HSs at home and 45.2% while in the hospital. HSs were prescribed to 28.6% of the patients not habituated to chronic use of HSs at home. In contrast, 14.0% of the patients habituated to chronic use of HSs received no sleep medication while in hospital. Patients older than 60 years used more HSs than younger patients. Previous administration of HSs, sleep problems during hospital admission and female sex were predictive of HS-use. The main reason for prescription of HSs in the hospital was continuation of HSs taken at home. The most prescribed HSs were: lormetazepam, lorazepam, alprazolam, diazepam and zolpidem. Almost 10% of the patients were not informed on treatment with HSs. Among the subjects in whom HSs were newly started, 16.0% intended to continue this medication after discharge. Eleven percent took combinations of hypnosedative drugs.

CONCLUSIONS

The prevalence of prescription of HSs in the university hospital setting is high. Appropriate guidelines are needed to control the use of HSs during hospitalisation and to ensure withdrawal from these drugs upon discharge.

Transtorno de estresse pós-traumático e transtorno de humor bipolar

O Transtorno Bipolar (THB) não é somente uma condição endógena. Severos eventos negativos durante a vida influenciam o desenvolvimento do primeiro episódio e alteram o curso do THB durante a vida. O Transtorno de Estresse Pós-Traumático (TEPT) é uma severa e incapacitante doença mental que afeta uma significativa parcela da população, em algum momento de suas vidas. A presença concomitante de TEPT e THB parece mais freqüente que anteriormente sugerido, e pacientes psicóticos com história de trauma tem sintomas mais severos e maior tendência a abusar de substância psicoativas ilícitas. Pensamentos intrusivos e pesadelos ocorrem com freqüência nos pacientes com TEPT e têm sido associados aos transtornos de humor. O tratamento farmacológico dessa comorbidade ainda está relacionado a estudo empíricos ou não-controlados. Neste artigo, são revisados aspectos atuais relacionados a essa comorbidade e enfatizados aspectos referentes à epidemiologia, etiologia, curso e tratamento farmacológico da comorbidade entre TEPT e THB. Especialmente, este estudo enfatiza a importância de avaliar sistematicamente a história de trauma em pacientes com THB.

The use of music to promote sleep in older women

Fifty-two women over the age of 70 participated in a study to investigate the use of an individualized music protocol to promote sleep onset and maintenance. They were recruited from the practices of physicians and nurse practitioners, and met the inclusion and exclusion criteria of the International Classification of Sleep Disorders (1990), and the Diagnostic and Statistical Manual of Mental Disorders (1994). Results indicated that the use of music decreased time to sleep onset and the number of nighttime awakenings. Consequently, it increased satisfaction with sleep. Nurses may wish to recommend the use of music at bedtime to older women with insomnia.

The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).

Clonazepam treatment of lysergic acid diethylamide-induced hallucinogen persisting perception disorder with anxiety features

An unique and intriguing characteristic of lysergic acid diethylamide (LSD) and LSD-like substances is the recurrence of some of the symptoms which appear during the intoxication, in the absence of recent intake of hallucinogens. Hallucinogen persisting perception disorder (HPPD) is a condition in which the re-experiencing of one or more perceptual symptoms causes significant distress or impairment in social, occupational or other important areas of functioning and may be extremely debilitating. Benzodiazepines are one of the recommended agents for the treatment of HPPD but it is unclear which of them may be more helpful. The goal of our investigation was to assess the efficacy of clonazepam in the treatment of LSD-induced HPPD. Sixteen patients fulfilled entrance criteria. All complained of HPPD with anxiety features for at least 3 months and were drug free at least 3 months. They received clonazepam 2 mg/day for 2 months. Follow-up was continued for 6 months. They were weekly evaluated during the 2 months of clonazepam administration and monthly during the follow-up period using the Clinical Global Impression Scale, a Self-report Scale and Hamilton Anxiety Rating Scale. Patients reported a significant relief and the presence of only mild symptomatology during the clonazepam administration. This improvement was clearly sustained and persisted during a 6-month follow-up period. This study suggests that high potency benzodiazepines like clonazepam, which has serotonergic properties, may be more effective than low-potency benzodiazepines in the treatment of some patients with LSD-induced HPPD.

Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature

Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.

Seminars on controversial issues. A review of the pharmacological approach to the management of dental anxiety in children

This paper aims to review the existing literature on the pharmacology of a number of sedative drugs used in the management of dental anxiety in the conscious child patient. Pharmacological agents may be used as a complement to behavioural techniques to assist in the management of anxiety in some paediatric dental patients. Their use may also be especially indicated in children with disabilities. These agents are usually sedative in action and do not, in themselves, eliminate anxiety but merely enhance patient acceptance by reducing arousal and modifying anticipation of danger. The agents used are varied and diverse and include nitrous oxide, benzodiazepines and narcotics. Nitrous oxide has proved to be of particular value but carries a degree of risk for the operating staff. Amongst the benzodiazepines, Midazolam has been used more frequently in recent years. It may be given by a variety of routes, including intra-nasally. Dentists who employ sedative agents and techniques should be familiar with the pharmacology of the agents selected, be cognisant of the risks and benefits of the technique employed and be able to manage any adverse events that may arise through their use.

Personality traits and socio-epidemiological status of hospitalised elderly benzodiazepine users

OBJECTIVE

to define personality traits and socio-epidemiological status of hospitalised elderly chronic benzodiazepine (BZD) users.

METHODS

this case controlled study assessed psychological characteristics (using the Millon Clinical Multiaxial Inventory-MCMI-I) and socio-epidemiological status (sex, age, education, marital status and housing) in 40 hospitalised geriatric patients taking BZDs for at least 3 months and 40 non-users, excluding dementia.

RESULTS

comparisons between groups: Compulsive personality pattern was more pronounced in the control group (p = 0.008). Severe personality pathology: a predisposition to borderline disorder was stronger among the BZD-users (p = 0.001). Clinical syndromes: anxiety, dysthymic disorder (p < 0.001) and tendency to alcohol dependence (p = 0.020) prevailed in the BZD-users. No severe syndromes were found. Widowed persons were more prevalent between the BZD-users (p = 0.03). All significant differences resulted from disparities between females. Predictors of BZD-use and clustering of traits: Dysthymic disorder was predictive of BZD-use (odds ratio (OR) 6.3 [95% confidence intervals (CI) 2.2-18.2]). It was strongly correlated with anxiety (r(s) = 0.93) and somatoform disorder (r(s) = 0.71). Dysthymic disorder and alcohol dependence predicted BZD-use in women (OR 15.3 [CI: 2.4-95.7] and OR 9.1 [CI: 1.2-64.9], respectively). There were no specific predictors in men.

CONCLUSIONS

chronic elderly BZD-users are typically widowed females with dysthymic disorder, anxiety, predisposition to alcohol dependence and borderline disorder. Before prescribing BZDs, it is important to recognize the nature of the elderly population at risk for BZD-use and to consider a broader-ranging therapeutic management of the predisposing personality traits.

Sensitive method for the detection of 22 benzodiazepines by gas chromatography-ion trap tandem mass spectrometry

A gas chromatography-ion trap tandem mass spectrometry method for simultaneous detection of 22 benzodiazepines is presented. Four operating modes were first optimized: the electron impact ionization and chemical ionization modes were compared on both underivatized and trimethylsilylated drugs. Results were compared in terms of sensitivity in MS-MS experiments. The trimethylsilylation of benzodiazepines including a protic functional group allows decreasing their detection threshold by a factor of 10-100. In terms of sensitivity, the comparison between both ionization modes shows that the most efficient one depends on the benzodiazepine considered. The use of an ion trap analyzer allows switching from an ionization mode to another one during the chromatographic process. It also provides a great selectivity owing to the MS-MS and multiple reaction monitoring acquisition modes. The detection thresholds are in the range 10-500 pg/microl for all the studied benzodiazepines but the three "triazolo" ones: estazolam, alprazolam and triazolam, have a detection threshold of 1 ng/microl. The applicability of the method on whole blood and urine extracts was demonstrated on an example implying five benzodiazepines among the most frequently encountered in forensic toxicology: nordazepam, oxazepam, bromazepam, flunitrazepam and prazepam.

The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues

BACKGROUND

Although symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder, the pathophysiologic, theoretical, and clinical significance of their co-occurrence has not been well studied.

METHODS

The epidemiological and clinical studies that have assessed the overlap of bipolar and anxiety disorders are reviewed, with focus on panic disorder and obsessive-compulsive disorder (OCD), and to a lesser extent, social phobia and post-traumatic stress disorder. Potential neural mechanism and treatment response data are also reviewed.

RESULTS

A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder. Psychobiological mechanisms that may account for these high comorbidity rates likely involve a complicated interplay among various neurotransmitter systems, particularly norepinephrine, dopamine, gamma-aminobutyric acid (GABA), and serotonin. The second-messenger system constituent, inositol, may also be involved. Little controlled data are available regarding the treatment of bipolar disorder complicated by an anxiety disorder. However, adequate mood stabilization should be achieved before antidepressants are used to treat residual anxiety symptoms so as to minimize antidepressant-induced mania or cycling. Moreover, preliminary data suggesting that certain antimanic agents may have anxiolytic properties (e.g. valproate and possibly antipsychotics), and that some anxiolytics may not induce mania (e.g. gabapentin and benzodiazepines other than alprazolam) indicate that these agents may be particularly useful for anxious bipolar patients.

CONCLUSIONS

Comorbid anxiety symptoms and disorders must be considered when diagnosing and treating patients with bipolar disorder. Conversely, patients presenting with anxiety disorders must be assessed for comorbid mood disorders, including bipolar disorder. Pathophysiological, theoretical, and clinical implications of the overlap of bipolar and anxiety disorders are discussed.