Are patterns of benzodiazepine use predictable? A follow-up study of benzodiazepine users

Novel Designer Benzodiazepines: Comprehensive Review of Evolving Clinical and Adverse Effects

As tranquilizers, benzodiazepines have a wide range of clinical uses. Recently, there has been a significant rise in the number of novel psychoactive substances, including designer benzodiazepines. Flubromazolam(8-bromo-6-(2-fluorophenyl)-1-methyl-4H-[1,2,4]triazolo[4,3-a][1,4]benzodiazeZpine) is a triazolo-analogue of flubromazepam. The most common effects noted by recreational users include heavy hypnosis and sedation, long-lasting amnesia, and rapid development of tolerance. Other effects included anxiolysis, muscle-relaxing effects, euphoria, loss of control, and severe withdrawals. Clonazolam, or 6-(2-chlorophenyl)-1-methyl-8-nitro-4H-[1,2,4]triazolo[4,3-α]-[1,4]-benzodiazepine, is a triazolo-analog of clonazepam. It is reported to be over twice as potent as alprazolam. Deschloroetizolam (2-Ethyl-9-methyl-4-phenyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepine) is part of the thienodiazepine drug class, which, like benzodiazepines, stimulates GABA-A receptors. Meclonazepam ((3S)-5-(2-chlorophenyl)-3-methyl-7-nitro-1,3-dihydro-1,4-benzodiazepin-2-one) is a designer benzodiazepine with additional anti-parasitic effects. Although it has proven to be an efficacious therapy for schistosomiasis, its sedative side effects have prevented it from being marketed as a therapeutic agent. The use of DBZs has been a subject of multiple recent clinical studies, likely related to increasing presence and availability on the internet drug market and lack of regulation. Many studies have aimed to identify the prevalence of DBZs and their effects on those using them. This review discussed these designer benzodiazepines and the dangers and adverse effects that the clinician should know.

Continuation and discontinuation of benzodiazepine prescriptions: A cohort study based on a large claims database in Japan

Although benzodiazepines (BZDs) are often prescribed to treat a wide range of psychiatric and neurological conditions, they are also associated with various harms and risks including dependence. However the frequency of its continued use in the real world has not been well studied, especially at longer follow-ups. The aim of this study was to clarify the frequency of long-term BZD use among new BZD users over longer follow-ups and to identify its predictors. We conducted a cohort study to examine how frequently new BZD users became chronic users, based on a large claims database in Japan from January 2005 to June 2014. We used Cox proportional hazards models to identify potential predictors. A total 84,412 patients with new BZD prescriptions were included in our cohort. Among them, 35.8% continued to use BZD for three months, 15.2% for one year and 4.9% for eight years without ever attaining three months of no BZD prescription. The confirmed predictors for long-term BZD use were older age, psychiatrist-prescriber, regular use, high dose of BZD, and concomitant prescription of psychotropic drugs. When we consider BZD use, we have to keep in mind these figures and avoid these predictors as much as possible.

Determinants of initiated and continued benzodiazepine use in the Netherlands study of depression and anxiety

BACKGROUND

Longitudinal research on determinants of initiated and continued benzodiazepine (BZD) use is inconsistent and has identified many possible determinants. It is unclear which of those are most important in the prediction of BZD use. We aimed to identify the most important predictors of initiated and continued BZD use. Therefore, we analyzed the most consistently identified determinants from previous research plus some new determinants.

METHODS

We identified baseline and 2-year longitudinal predictors of initiated BZD use (vs nonuse) among 2205 baseline BZD nonusers and of continued use (vs discontinued use) among 369 baseline BZD users in the Netherlands Study of Depression and Anxiety using logistic regression analyses.

RESULTS

During follow-up, BZD use was initiated by 4.9% of BZD nonusers at baseline. Initiated use was predicted by insomnia (odds ratio [OR], 1.60), enduring anxiety symptoms (OR, 2.02), entering secondary care during follow-up (OR, 2.85), and past BZD use (OR, 3.57). Positive life events during follow-up reduced the likelihood of BZD initiation (OR, 0.76). Of BZD users at baseline, 54.2% continued use during the entire follow-up period. Continuation of BZD use was predicted by higher age (OR, 1.03), severe anxiety (OR, 1.85), and a long duration of BZD use (OR, 1.54). Leaving secondary care was associated with less continued BZD use (OR, 0.29).

CONCLUSION

Insomnia and anxiety were the main risk factors of initiated use, whereas advanced age and anxiety severity were the main risk factors of continued use. Sex, education, pain, and physical health seemed to be less important.

Adjunctive benzodiazepine treatment of hospitalized schizophrenia patients in Asia from 2001 to 2008

Benzodiazepines are commonly prescribed to patients with schizophrenia in many countries, but as little is known about such treatment in Asia, we evaluated their adjunctive use for 6761 in-patients diagnosed with schizophrenia in nine Asian countries using a cross-sectional study design in 2001, 2004 and 2008. Multivariate logistic regression and multivariate linear regression analyses were performed to assess predictors of benzodiazepine use and dose, respectively. Overall, 54% of the patients received adjunctive benzodiazepines at an average daily dose equivalent to 30.3 mg diazepam, with minor changes over the years sampled. Benzodiazepine use was highest in Taiwan and Japan, lowest in Thailand and China, and was associated with fewer years ill, presence of delusions (OR 1.24), hallucinations (OR 1.22), disorganized speech (OR 1.17), social or occupational dysfunction (OR 1.16), and use of mood stabilizers (OR 3.15), antiparkinsonian (OR 1.79) or antidepressant drugs (OR 1.33), and lower doses of antipsychotics (all p=0.016 to <0.001). Benzodiazepine doses were highest in Taiwan and China, lowest in Korea and Singapore; higher doses were associated with being young, male, physically aggressive, receiving mood stabilizers, and having electroconvulsive treatment (all p=0.019 to <0.001). Benzodiazepine use was associated with neurological and systemic adverse effects. In conclusion, benzodiazepine use was common in Asian patients with schizophrenia. Predictors of benzodiazepine use and dose differed in this population. Critical clinical guidelines should be developed specifically for Asian countries to address sound practices in regard to use of benzodiazepines for psychotic disorders.

Benzodiazepine use in the elderly: an indicator for inappropriately treated geriatric depression?

OBJECTIVE

To measure the prevalence of benzodiazepine (BZD) use and to explore associated demographic and clinical variables of BZD use within a cohort of 75-year- old inhabitants of an urban district of Vienna.

METHODS

This is a prospective, interdisciplinary cohort study on aging. Our investigation is based on the first consecutive 500 subjects that completed the study protocol. Demographic and clinical characteristics, benzodiazepine and antidepressant use were documented using a standardized questionnaire. Affective status was assessed using the Hamilton Depression Rating Scale (HAMD), the Geriatric Depression Scale (GDS), and the Spielberger State-and Trait Anxiety Inventory subscales (STAI).

RESULTS

Prevalence of BZD use was 13.8%. Compared to non-users, BZD users had significantly higher mean scores at the HAMD (p = 0.001), the GDS (p = 0.026), and the Spielberger State-and Trait Anxiety Inventory subscales (p = 0.003; p = 0.001). Depression was found in 12.0% (HAMD) and 17.8% when using a self-rating instrument (GDS). Less than one-third of depressed subjects were receiving antidepressants. Statistically equal numbers were using benzodiazepines.

CONCLUSIONS

Inappropriate prescription of BZD is frequent in old age, probably indicating untreated depression in many cases. The implications of maltreated geriatric depression and the risks associated with benzodiazepine use highlight the medical and socioeconomic consequences of inappropriate BZD prescription.

Determinants of chronic benzodiazepine use in the elderly: a longitudinal study

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

* The risk of adverse events due to chronic benzodiazepine use is high in the elderly. * Cross-sectional studies have shown that increasing age, female gender and poor physical and mental health are associated with benzodiazepine use. * When users were re-examined some years later, chronic somatic disease, pain and stress seemed to contribute to the continuation of benzodiazepine use.

WHAT THIS STUDY ADDS

* This is the first longitudinal study that analyzed the determinants of new-onset chronic benzodiazepine use in community-dwelling elderly. * Symptoms of depression, hypertension, pain related joint complaints and the perception of poor physical health predicted new-onset chronic use. Living alone was found to decrease the risk of chronic use.

AIMS

The risk of adverse events due to chronic benzodiazepine use is high in the elderly. Clinicians need to be able to identify those persons who are at risk of chronic benzodiazepine use, but little is known about the determinants. This study determined social and health related factors that predict new-onset chronic benzodiazepine use in community-dwelling elderly.

METHODS

This study was embedded in an ongoing cohort study among 5364 persons aged >or=57 years. Drug-dispensing medication records were available for the period between 1991 and 2003. We defined chronic benzodiazepine use as use during at least 180 days in a period of 365 consecutive days. The association of various social, psychiatric and somatic variables with new-onset chronic benzodiazepine use was studied with a Cox proportional hazards analysis.

RESULTS

Symptoms of depression, hypertension, pain related joint complaints and the perception of poor physical health predicted new-onset chronic use. In the subsample of participants who had filled at least one prescription in the follow-up period, of these variables only pain related joint complaints increased the risk of new-onset chronic use. Living alone protected against chronic benzodiazepine use.

CONCLUSIONS

The elderly with poor mental and physical health are at an increased risk of chronic benzodiazepine use. Living alone was found to decrease the risk of chronic use, which suggests that social factors may determine drug usage patterns. Very few characteristics predicted chronic benzodiazepine use once patients had received their first prescription. For clinicians, identification of patients at high risk is therefore not straightforward.

Le traitement cognitivo-comportemental de l’insomnie et son utilisation lors de l’arrêt des hypnotiques

L’insomnie constitue un problème de santé très répandu menant souvent à l’utilisation d’hypnotiques. Parmi les agents pharmacologiques disponibles pour traiter l’insomnie, les benzodiazépines (BZD) sont les plus prescrites. Bien qu’efficaces pour améliorer le sommeil à court terme, les BZD présentent certains effets indésirables, entraînent des risques de tolérance et de dépendance, et augmentent le risque d’accidents de la route, de chutes et de fractures chez les personnes âgées. Le traitement cognitivo-comportemental (TCC) de l’insomnie, qui met l’accent sur les facteurs psychologiques et comportementaux jouant un rôle dans le maintien des difficultés de sommeil, est efficace pour améliorer le sommeil des personnes aux prises avec un trouble d’insomnie primaire. Il peut représenter une alternative à la pharmacothérapie ou encore être un complément thérapeutique facilitant lors de l’arrêt des hypnotiques. Le TCC de l’insomnie peut inclure différentes composantes, telles que le contrôle par le stimulus, la restriction du sommeil, la relaxation, la restructuration cognitive et l’hygiène du sommeil. Chez les personnes dépendantes aux BZD ou autres hypnotiques, un sevrage supervisé, basé sur l’atteinte d’objectifs successifs, s’ajoute généralement au TCC de l’insomnie.

Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach

The aim of this study was to identify risk factors for benzodiazepine (BZD) dependence, such as sociodemographic variables, characteristics of BZD use, and psychiatric parameters, which to date have been found to relate inconsistently to indicators of BZD dependence such as chronic BZD use and BZD withdrawal symptoms. The Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ), Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and Symptom Checklist-90 (SCL-90) were administered to 599 outpatients using BZDs. Regression analyses were conducted using BZD dependence diagnoses and severity scales as dependent variables. BZD dependence diagnoses were only predicted by being a self-help patient and long BZD elimination half-life (for only the DSM-III-R). The main predictors of BZD dependence severity, as measured by the ICD-10, DSM-III-R scales, and Bendep-SRQ Rasch scales, were in decreasing order: (1) being a self-help patient; (2) higher BZD dose, longer duration of BZD use, younger age; and (3) non-native cultural origin, lower level of education, being in outpatient treatment for alcohol and/or drug dependence, and the interaction of BZD dose with duration of BZD use. We conclude that a limited number of recognizable risk factors appear to predict the severity of BZD dependence. Additional administration of a specific BZD dependence instrument is recommended to confirm suspected BZD dependence and guide further clinical decision-making.

[Prescription patterns and quality of information provided for consumers of benzodiazepines]

The long-time benzodiazepine use by a considerable part of the population and its adverse consequences such as somatic and cognitive side effects, interactions with other drugs and alcohol and its possible impairment of quality of life has provoked a critical discussion about the practice of prescribing benzodiazepine and the information provided by physicians. We therefore investigated these issues in admitted patients of a general hospital. All patients having been admitted to the department of Internal Medicine and taking benzodiazepine were asked by means of a semi-structured interview, which was repeated after 1 year. In 90% of later benzodiazepine discontinuers and in almost 50% of benzodiazepine continuers, tranquilisers were first prescribed during hospital admission. Only 2% of all patients estimated the information provided by the prescribing physicians as satisfying and about 2/3 reported that they did not get any information at all. 66% of all patients were informed about dependency risks. This information was mainly provided by pharmacies, friends and patient information leaflets; only about 20% of all patients were informed by the prescribing physician. Guidelines for tranquiliser prescription only seem to have a poor impact on the clinical practice. The education of physicians about the risks of low-dose dependencies and especially about complementary therapy methods needs to be improved.

Potential adverse outcomes of psychotropic and narcotic drug use in Canadian seniors

Potential adverse outcomes (falls, impaired cognition, impaired self-care) of psychotropic (benzodiazepines, antidepressants, antipsychotics) and narcotic medication use were examined in a large sample of Canadians 65 years of age and older. We examined rates of reported falls, Digit Symbol Substitution Test (DSST) scores, and mean number of self-care impairments for those consuming psychotropic and/or narcotic drugs as compared to non-users. Use of psychotropic drugs and/or narcotics was associated with an increased prevalence of falls, lower DSST scores, and/or number of self-care difficulties. For example, in subjects who were cognitively normal, the frequency of falls was 60% greater in benzodiazepine users and 120% greater in users of antidepressants as compared to non-users. Adverse outcomes increased with the number of classes of psychotropic or narcotic medications used. These effects were most pronounced in cognitively normal subjects where the prevalence of falls increased from 13.9% in those consuming none of the medication classes to 42.6% for users of two or more classes. In subjects with mild dementia the use of these medications was not associated with any significant differences in the outcomes measured. Regression models showed that benzodiazepine, antidepressant, and narcotic use remained significant explanatory variables for potential adverse outcomes even after simultaneously considering the effects of several other variables. Although further work is necessary, our results suggest that individuals with better cognitive function may be at particular risk for adverse effects with use of these medications.