Physician failure to record alcohol use history when prescribing benzodiazepines

Long-term use of benzodiazepines in participants with comorbid anxiety and alcohol use disorders

BACKGROUND

Although the only widely accepted role for benzodiazepines in alcohol dependence is the treatment of withdrawal syndromes, they are frequently prescribed outside of this clinical setting. There is little empirical evidence to guide the rational use of benzodiazepines in the common clinical situation where anxiety disorders are comorbid with alcohol use disorders (AUD). Since January 1989, the Harvard Anxiety Research Program has naturalistically monitored the prospective clinical course of people with anxiety disorders, some of whom had a history of AUD. Earlier research showed that the use of benzodiazepines was not significantly associated with the presence or absence of a history of an AUD over the first year of follow-up. This report extends that investigation.

METHODS

Using standard parametric analytic methods, patterns of benzodiazepine use (routinely prescribed medication and as-needed [PRN] use) among participants receiving benzodiazepine treatment was prospectively examined over the course of 12 years. Differences in benzodiazepine usage patterns were examined in each year of follow-up between participants who did (n=120) and did not (n=425) have a new episode of AUD. Using proportional hazards regression analysis, benzodiazepine usage levels were examined as predictors of recovery and recurrence of AUD. Additionally, random-effects regression analyses were used to examine the patterns of benzodiazepine use before and after the onset of a prospectively observed episode of AUD.

RESULTS

Benzodiazepine usage levels remained stable for the full sample over the course of the 12 years. Benzodiazepine use did not distinguish participants who had a new AUD from those who did not. Over the 12 years of follow-up, participants who had an AUD used more PRN medication in years five to eight. This difference reached statistical significance but was not clinically significant. Benzodiazepine usage levels did not predict recovery or recurrence in AUD subjects. Neither the total dose nor the PRN usage of benzodiazepines was significantly associated with the onset of AUD, but when combined into a measure of any benzodiazepine use, a relationship between increased use and the onset of AUD emerged.

CONCLUSIONS

For participants in the Harvard Anxiety Research Program with comorbid alcohol dependence and anxiety disorders, there was little association between the use of benzodiazepines and the occurrence of a new AUD. Neither was there a temporal relationship between the use of benzodiazepines and the onset of a new AUD. Whether or not this finding extends to a broader patient population or a group of people who present to addictions treatment awaits further investigation.

alpha2-gamma-Aminobutyric acid (GABA)A receptors are the molecular substrates mediating precipitation of narcosis but not of sedation by the combined use of diazepam and alcohol in vivo

Classical benzodiazepines such as diazepam are widely used tranquillisers and hypnotics in various neuropsychiatric diseases including alcohol-related disorders. One of the major drawbacks of benzodiazepine therapy, however, is an exacerbation of the sedative and hypnotic effects associated with alcohol intake, even at low doses. Even though the gamma-aminobutyric acid (GABA)A receptor complex is a common target for the actions of both classes of drugs, the molecular mechanisms underlying the enhanced pharmacological properties of the combined use of benzodiazepines and alcohol remain to be identified. The present experiments aimed at clarifying which of the GABAA receptor subtypes mediate the augmented hypnotic-like and sedative effects of combined diazepam and alcohol using the righting reflex and motor activity assays, respectively, in histidine-to-arginine point mutated mice that possess diazepam-insensitive alpha1-, alpha2-, alpha3- or alpha5-GABAA receptors. The combination of diazepam (2 or 3 mg/kg) and ethanol (3 g/kg) induced loss of righting reflex with a significantly dose-dependent increase of the latency to its full recovery in wild-type, alpha1(H101R), alpha3(H126R) and alpha5(H105R) but not in alpha2(H101R) mice. A combined treatment with diazepam (1 mg/kg) and ethanol (2.5 g/kg) precipitated motor inhibition similarly in wild-type and alpha2(H101R) mice. Responsiveness of the alpha2(H101R) mice to ethanol alone was similar to that of wild-type mice. These results demonstrate that induction of loss of righting reflex by combined diazepam and alcohol is closely dependent on the activation of the alpha2-GABAA receptors by the benzodiazepine whereas precipitation of sedation involves GABAA receptors other than the alpha2-GABAA receptors.

Acute performance-impairing and subject-rated effects of triazolam and temazepam, alone and in combination with ethanol, in humans

The acute behavioural effects of triazolam (0.125 and 0.25 mg), temazepam (15 and 30 mg), and placebo, alone and in combination with ethanol (0 and 0.5 g/kg), were assessed in 10 volunteers. Ethanol alone did not impair performance and produced only a few subject-rated drug effects. Triazolam and temazepam alone produced some performance impairment and a few subject-rated drug effects. These effects tended to be dose-dependent and were comparable for the two drugs across the range of doses tested. The triazolam-ethanol and temazepam-ethanol combinations produced robust performance impairment and sedative-like subject-rated drug effects that were similar in magnitude. The findings of the present study suggest that even a moderate amount of ethanol in combination with a clinical dose of triazolam or temazepam can cause performance impairment that might diminish an individual's ability to respond adequately to unexpected demands (e.g. smoke alarms or middle-of-the-night child care).

A Pilot Project: Continuing Education for Pharmacists on Substance Abuse Prevention

The American Association of Colleges of Pharmacy advocates that pharmacists can have a significant impact on substance abuse prevention provided they receive adequate training. Continuing education programs are needed to enable practicing pharmacists to augment their limited education. This paper examines the process the Society of Teachers of Family Medicine (STFM) used to develop a pilot continuing education program for pharmacists. With limited literature and a small number of pharmacy teaching about substance abuse, input on topics and training methods was obtained from a convenience sample of practicing pharmacists to enhance the information from the pharmacist faculty regarded as content experts. Results of this pilot study revealed lack of agreement between faculty and practicing pharmacists regarding the prioritizing of content and educational methods. Consequently, input must be obtained from targeted audiences instead of relying solely on the advice of identified academic content experts when designing continuing educational programs. Other professions should consider this process when designing continuing education programs. Pharmacists are poised to play an important role in the prevention of substance abuse problems, but they need continuing education about substance abuse.

Prescription drug abuse. A question of balance

The current American medical practice paradox of concomitant overprescribing and underprescribing of controlled drugs is within the power of physicians to correct. It requires actively seeking education in traditionally neglected areas and avoiding prescribing controlled drugs to patients with either substance abuse histories or vague clinical indications. Attempts to limit prescribing to short therapeutic time courses, refusal to prescribe if pushed, and careful chart documentation practices are important. By increasing knowledge about chemical dependence and about chemically dependent patients' abnormal relationships with scheduled drugs, the current clinical reality can be reversed. This reversal will result in marked decreases in prescribing to the minority of patients (those with chemical dependence) and increases in prescribing to the majority of patients who are currently often undertreated.

Screening and diagnosis of "alcohol abuse and dependence" in older adults

A literature review reveals that research is warranted to improve screening for "alcohol abuse" in older adults and women. An examination of diagnostic criteria for "alcohol abuse dependence" reveals that older adults provide unique challenges to classification systems. There is a need to evaluate the sensitivity and specificity of several new screening instruments for the identification of "alcohol abuse" in the elderly. Routine screening of elderly and women presenting in primary care settings should be a priority for researchers and clinicians.