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Ritvo AD, Foster DE, Huff C, Finlayson AJR, Silvernail B, Martin PR. Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey. PLoS One 2023; 18:e0285584. [PMID: 37384788 PMCID: PMC10309976 DOI: 10.1371/journal.pone.0285584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/27/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Acute benzodiazepine withdrawal has been described, but literature regarding the benzodiazepine-induced neurological injury that may result in enduring symptoms and life consequences is scant. OBJECTIVE We conducted an internet survey of current and former benzodiazepine users and asked about their symptoms and adverse life events attributed to benzodiazepine use. METHODS This is a secondary analysis of the largest survey ever conducted with 1,207 benzodiazepine users from benzodiazepine support groups and health/wellness sites who completed the survey. Respondents included those still taking benzodiazepines (n = 136), tapering (n = 294), or fully discontinued (n = 763). RESULTS The survey asked about 23 specific symptoms and more than half of the respondents who experienced low energy, distractedness, memory loss, nervousness, anxiety, and other symptoms stated that these symptoms lasted a year or longer. These symptoms were often reported as de novo and distinct from the symptoms for which the benzodiazepines were originally prescribed. A subset of respondents stated that symptoms persisted even after benzodiazepines had been discontinued for a year or more. Adverse life consequences were reported by many respondents as well. LIMITATIONS This was a self-selected internet survey with no control group. No independent psychiatric diagnoses could be made in participants. CONCLUSIONS Many prolonged symptoms subsequent to benzodiazepine use and discontinuation (benzodiazepine-induced neurological dysfunction) have been shown in a large survey of benzodiazepine users. Benzodiazepine-induced neurological dysfunction (BIND) has been proposed as a term to describe symptoms and associated adverse life consequences that may emerge during benzodiazepine use, tapering, and continue after benzodiazepine discontinuation. Not all people who take benzodiazepines will develop BIND and risk factors for BIND remain to be elucidated. Further pathogenic and clinical study of BIND is needed.
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Affiliation(s)
- Alexis D. Ritvo
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - D. E. Foster
- Benzodiazepine Action Work Group, Colorado Consortium for Prescription Drug Abuse Prevention, Aurora, Colorado, United States of America
| | - Christy Huff
- Benzodiazepine Information Coalition, Midvale, Utah, United States of America
| | - A. J. Reid Finlayson
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Bernard Silvernail
- Alliance for Benzodiazepine Best Practices, Portland, Oregon, United States of America
| | - Peter R. Martin
- Department of Psychiatry and Behavioral Sciences and Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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MacDonald T, Gallo AT, Basso-Hulse G, Hulse GK. Outcomes of patients treated with low-dose flumazenil for benzodiazepine detoxification: A description of 26 participants. Drug Alcohol Depend 2022; 237:109517. [PMID: 35688053 DOI: 10.1016/j.drugalcdep.2022.109517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Benzodiazepines are commonly prescribed for a variety of indications and can be employed in the short- and long-term. While they are efficacious, issues arise from long-term use with the emergence of dependence and tolerance to doses within the therapeutic range and beyond. Discontinuation from benzodiazepines can be problematic for patients and may result in a withdrawal syndrome, which can be protracted and last months to years. METHODS 26 participants received low-dose subcutaneous flumazenil infusions (4 mg/24 h for approximately eight days) as part of a randomised control crossover trial. Return to benzodiazepine use was assessed monthly for three months based on the benzodiazepine use in the previous week. Where data was not available, the treating psychiatrist examined patient files and clinical documents to determine benzodiazepine use. Withdrawal and craving scores were also measured. RESULTS Abstinence rates from benzodiazepines at one-, two-, and three-month follow ups were 65.4 %, 50.0 %, and 46.2 % respectively. When considering patient files and clinical documents for those lost to follow-up, abstinence rates were higher at 73.1 %, 65.4 % and 61.5 % at the one-, two-, and three-month follow ups respectively. Withdrawal and craving scores were higher in those that had returned to any benzodiazepine use. CONCLUSION Self-reported rates of abstinence from benzodiazepines at three months was between 46.2 % and 61.5 %. Flumazenil may yield greater success than benzodiazepine tapering from high dose benzodiazepine use (≥30 mg diazepam equivalent). Further research should compare abstinence rates after treatment with flumazenil compared to benzodiazepine tapering in high dose benzodiazepine users.
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Affiliation(s)
- T MacDonald
- Currumbin Clinic, Currumbin, Queensland, Australia; School of Medicine, Griffith University, Australia.
| | - A T Gallo
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia.
| | - G Basso-Hulse
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia
| | - G K Hulse
- Division of Psychiatry, Medical School, the University of Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Australia; Fresh Start Recovery Programme, Subiaco, Western Australia, Australia
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3
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Jones JD, Campbell AN, Brandt L, Metz VE, Martinez S, Wall M, Corbeil T, Andrews H, Castillo F, Neale J, Strang J, Ross S, Comer SD. A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder. Drug Alcohol Depend 2022; 237:109505. [PMID: 35709575 PMCID: PMC9472254 DOI: 10.1016/j.drugalcdep.2022.109505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically. METHODS PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training. RESULTS Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039). CONCLUSIONS All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.
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Affiliation(s)
- Jermaine D Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA.
| | - Aimee N Campbell
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Laura Brandt
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Verena E Metz
- Kaiser Permanente Division of Research, Center for Addiction and Mental Health Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Suky Martinez
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Melanie Wall
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Thomas Corbeil
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Howard Andrews
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Felipe Castillo
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - Stephen Ross
- Addictive Disorders and Experimental Therapeutics Research Laboratory, New York University Langone Health, New York, NY 10016, USA
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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A double-blind randomised crossover trial of low-dose flumazenil for benzodiazepine withdrawal: A proof of concept. Drug Alcohol Depend 2022; 236:109501. [PMID: 35644071 DOI: 10.1016/j.drugalcdep.2022.109501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Benzodiazepines (BZD) are a class of anxiolytics with varying uses, which primarily act on the GABAA receptor resulting in hyperpolarisation. BZDs are often a difficult drug class to cease once neuroadaptation has occurred; recommendations usually involve gradual dose reductions at variable rates. A growing body of evidence has suggested that low-dose flumazenil, a GABAA receptor antagonist, may be a useful agent to allow for rapid detoxification. AIM To collect pilot data on the safety and efficacy of low-dose subcutaneous flumazenil to reduce BZD use, withdrawal symptoms, and craving in participants taking above and below the therapeutic maximum diazepam equivalent of 30 mg to inform on sample size for future trials. METHOD In a randomised double-blinded crossover study design, participants received low-dose flumazenil first (4 mg/24 h for approximately eight days) or placebo first. Groups were divided into those taking < 30 mg diazepam equivalent and ≥ 30 mg diazepam equivalent at baseline. Main outcome measures were percentage reduction in daily diazepam use, withdrawal symptoms, and craving scores from baseline, difference in diazepam use across the placebo first group, and flumazenil related adverse events. RESULTS Twenty-eight participants were recruited and randomised to flumazenil first (n = 14) and placebo first (n = 14). In participants taking ≥ 30 mg diazepam equivalent at baseline (n = 15), flumazenil significantly reduced diazepam use by 30.5% (p = 0.024) compared to placebo. CONCLUSION Low-dose flumazenil may aid in BZD detoxification in participants taking daily diazepam equivalent doses greater than or equal to the therapeutic maximum (≥30 mg) by reducing the need for diazepam.
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Bias Discovery in Machine Learning Models for Mental Health. INFORMATION 2022. [DOI: 10.3390/info13050237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fairness and bias are crucial concepts in artificial intelligence, yet they are relatively ignored in machine learning applications in clinical psychiatry. We computed fairness metrics and present bias mitigation strategies using a model trained on clinical mental health data. We collected structured data related to the admission, diagnosis, and treatment of patients in the psychiatry department of the University Medical Center Utrecht. We trained a machine learning model to predict future administrations of benzodiazepines on the basis of past data. We found that gender plays an unexpected role in the predictions—this constitutes bias. Using the AI Fairness 360 package, we implemented reweighing and discrimination-aware regularization as bias mitigation strategies, and we explored their implications for model performance. This is the first application of bias exploration and mitigation in a machine learning model trained on real clinical psychiatry data.
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Abstract
BACKGROUND Anxiety disorders are highly prevalent affecting up to 33.7% of people over a lifetime. Although many treatment options are available, they are often associated with unacceptable side-effect profiles and approximately one in three patients are treatment resistant. Allopregnanolone, a neuroactive steroid acting as a positive allosteric modulator at the GABAA receptor, is synthesised in response to stress and acts to negatively modulate the hypothalamic-pituitary-adrenal axis. FINDINGS After chronic exposure to and withdrawal from allopregnanolone, an increase in α4β2δ GABAA receptors results in a reduced inhibitory effect of allopregnanolone, resulting in decreased inhibition and, therefore, increased neuronal excitability. The relationship between allopregnanolone and increased α4β2δ GABAA receptors has been demonstrated in animal models during methamphetamine withdrawal and puberty, events both associated with stress. The effect of allopregnanolone during these events is anxiogenic, a paradoxical action to its usual anxiolytic effects. Flumazenil, the GABAA receptor antagonist, has been shown to cause receptor internalisation of α4β2δ GABAA receptors, which may results in anxiolysis. CONCLUSION We propose that chronic stress and chronic exposure to and withdrawal from allopregnanolone in anxiety disorders result in alterations in GABAA receptor function, which can be corrected by flumazenil. As such, flumazenil may exhibit anxiolytic properties in patients with increased α4β2δ GABAA receptor expression.
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Affiliation(s)
- Alexander T Gallo
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Gary K Hulse
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.,Fresh Start Recovery Programme, Subiaco, WA, Australia
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Casari R, Metastasio A, Zamboni L, Biasioli M, Campagnari S, Lugoboni F. Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil. Front Psychiatry 2022; 13:857376. [PMID: 35432044 PMCID: PMC9008883 DOI: 10.3389/fpsyt.2022.857376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Since the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines. OBJECTIVE The aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU. METHOD In this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion. CONCLUSION To this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities.
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Affiliation(s)
- Rebecca Casari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | | | - Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy.,Department of Neurosciences, University of Verona, Verona, Italy
| | - Martino Biasioli
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Simone Campagnari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
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Cloos JM, Lim Cow CYS, Bocquet V. Benzodiazepine high-doses: The need for an accurate definition. Int J Methods Psychiatr Res 2021; 30:e1888. [PMID: 34331787 PMCID: PMC8633930 DOI: 10.1002/mpr.1888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/02/2021] [Accepted: 07/14/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES A clear definition of what we understand of high-dose misuse or of a 'markedly increased dose' (as stated by the DSM-5) is important and past definitions may be inadequate. The aim of this review is to describe the different definitions used and to test these definitions for their accuracy. METHODS A narrative PubMed literature review was conducted based on articles published between 1 January 1990 and 31 December 2020 describing benzodiazepines (in MeSH Terms or MeSH Major Topic) and high-dose (or high-dosage). Specific definitions were applied to a population sample to show how definitions affect high-dose benzodiazepine prevalence. RESULTS Multiples of an equivalent-diazepam dose or of the World Health Organization 'defined daily dosage' were used more frequently than the overstep of the recommended maximum therapeutic dosage as a cut-off point. CONCLUSION High-dose use is rare but the prevalence in the general population varies among studies, mainly due to different definitions, making both clinical and epidemiological comparisons between studies difficult. Defining a high-dose user as a person who takes at least a higher dose than the maximum usual therapeutic dose over a defined period of time therefore appears to be clinically more consistent.
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Affiliation(s)
- Jean-Marc Cloos
- Department of Psychiatry, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | | | - Valéry Bocquet
- Department of Public Health, Competence Centre in Methodology and Statistics, Luxembourg Institute of Health, Luxembourg.,Unité de Soutien Méthodologique, CHU La Réunion, Saint-Denis, France
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9
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Edinoff AN, Nix CA, Hollier J, Sagrera CE, Delacroix BM, Abubakar T, Cornett EM, Kaye AM, Kaye AD. Benzodiazepines: Uses, Dangers, and Clinical Considerations. Neurol Int 2021; 13:594-607. [PMID: 34842811 PMCID: PMC8629021 DOI: 10.3390/neurolint13040059] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/08/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Benzodiazepines (BZDs) are among one of the most widely prescribed drug classes in the United States. BZDs are a class of psychoactive drugs known for their depressant effect on the central nervous system (CNS). They quickly diffuse through the blood-brain barrier to affect the inhibitory neurotransmitter GABA and exert sedative effects. Related to their rapid onset and immediate symptom relief, BZDs are used for those struggling with sleep, anxiety, spasticity due to CNS pathology, muscle relaxation, and epilepsy. One of the debilitating side effects of BZDs is their addictive potential. The dependence on BZDs generally leads to withdrawal symptoms, requiring careful tapering of the medication when prescribed. Regular use of BZDs has been shown to cause severe, harmful psychological and physical dependence, leading to withdrawal symptoms similar to that of alcohol withdrawal. Some of these withdrawal symptoms can be life threatening. The current treatment for withdrawal is through tapering with clonazepam. Many drugs have been tested as a treatment for withdrawal, with few proving efficacious in randomized control trials. Future research is warranted for further exploration into alternative methods of treating BZD withdrawal. This call to action proves especially relevant, as those seeking treatment for BZD dependence and withdrawal are on the rise in the United States.
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Affiliation(s)
- Amber N. Edinoff
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.N.); (J.H.)
- Correspondence: ; Tel.: +1-(318)-675-8969
| | - Catherine A. Nix
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.N.); (J.H.)
| | - Janice Hollier
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.A.N.); (J.H.)
| | - Caroline E. Sagrera
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.E.S.); (B.M.D.); (T.A.)
| | - Blake M. Delacroix
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.E.S.); (B.M.D.); (T.A.)
| | - Tunde Abubakar
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (C.E.S.); (B.M.D.); (T.A.)
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (E.M.C.); (A.D.K.)
| | - Adam M. Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA 95211, USA;
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA 71103, USA; (E.M.C.); (A.D.K.)
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10
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Characterization of the GHB Withdrawal Syndrome. J Clin Med 2021; 10:jcm10112333. [PMID: 34073640 PMCID: PMC8199158 DOI: 10.3390/jcm10112333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022] Open
Abstract
The gamma-hydroxybutyric acid (GHB) withdrawal syndrome can have a fulminant course, complicated by severe complications such as delirium or seizures. Detoxification by tapering with pharmaceutical GHB is a safe way to manage GHB withdrawal. However, a detailed description of the course of the GHB withdrawal syndrome is currently lacking. This study aimed to (1) describe the course of GHB withdrawal symptoms over time, (2) assess the association between vital signs and withdrawal symptoms, and (3) explore sex differences in GHB withdrawal. In this observational multicenter study, patients with GHB use disorder (n = 285) were tapered off with pharmaceutical GHB. The most reported subjective withdrawal symptoms (SWS) were related to cravings, fatigue, insomnia, sweating and feeling gloomy. The most prevalent objective withdrawal symptoms (OWS) were related to cravings, fatigue, tremors, sweating, and sudden cold/warm feelings. No association between vital signs and SWS/OWS was found. Sex differences were observed in the severity and prevalence of specific withdrawal symptoms. Our results suggest that the GHB withdrawal syndrome under pharmaceutical GHB tapering does not strongly differ from withdrawal syndromes of other sedative drugs. The lack of association between vital signs and other withdrawal symptoms, and the relative stability of vitals over time suggest that vitals are not suitable for withdrawal monitoring. The reported sex differences highlight the importance of a personalized approach in GHB detoxification.
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Gallo AT, Hulse G. Pharmacological uses of flumazenil in benzodiazepine use disorders: a systematic review of limited data. J Psychopharmacol 2021; 35:211-220. [PMID: 33426982 DOI: 10.1177/0269881120981390] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The estimated annual prevalence of drug use disorders is as high as 3%, underpinning the need to continually develop more effective treatments. Central nervous system dysregulation, contributing to acute and post-withdrawal syndromes, has traditionally been managed with benzodiazepines; however, a small but growing body of data indicate that the GABAA receptor antagonist, flumazenil, may offer some advantages over traditional management. AIM To review the literature on the safety and efficacy of flumazenil in benzodiazepine use disorders and identify gaps in the literature. METHOD A systematic method was used to identify randomised control trials. Where randomised control trials existed, non-randomised control trials were included to supplement findings. RESULTS Eleven flumazenil trials were included with varying doses, frequencies and routes of administration. The evidence for flumazenil alone showed generally a reduction in withdrawal symptoms with the exception of one study where withdrawal symptoms initially increased. Flumazenil plus benzodiazepine tapering was assessed in one randomised control trial and a series of non-randomised control trials. Randomised control trial results showed that flumazenil plus benzodiazepine tapering was superior at reducing withdrawal symptoms compared to benzodiazepine tapering alone and placebo. Flumazenil was associated with no serious adverse events; however there remains a risk of seizures. CONCLUSION Although flumazenil shows promising efficacy in the management of benzodiazepine use disorders and withdrawal, more randomized control trials are required before a definitive recommendation can be made around its use.
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Affiliation(s)
- Alexander T Gallo
- Division of Psychiatry, The University of Western Australia, Perth, Australia
| | - Gary Hulse
- Division of Psychiatry, The University of Western Australia, Perth, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
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12
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Basińska-Szafrańska A. Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring. Eur J Clin Pharmacol 2021; 77:795-808. [PMID: 33388822 DOI: 10.1007/s00228-020-03048-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 11/17/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Many harms secondary to benzodiazepine (BZD) dependence force users towards detoxification treatment. However, even strongly motivated patients tolerate the process badly or experience early relapse. The detoxification procedure has not yet been standardized. The objective of this paper is to examine the hypothesis that faulty detoxification routines may have caused some failures. METHODS The detoxification approaches found in the literature were compared stage by stage. The review was used to identify possible common, across-the-board systematic errors. RESULTS The presented literature review confirms that the widespread divergence in the BZD metabolism rate is effectively neglected during detoxification routines. Without laboratory measurements, these differences, additionally interfered with by auxiliary drugs, undermine not only the scheduled but even the symptom-driven procedures. An initial substitution with a long-acting BZD, although recommended, may lead to over-accumulation. This excess, varying between patients and incompatible with the current tapering stage, may lead to repeated overestimation of the patient's adjustments to reduced doses. Consequently, the patient's good clinical presentation at withdrawal, resulting in a conclusion of detoxification, may actually reflect a persistently high serum BZD concentration. The low-concentration stage, if shifted past the end of treatment, exposes patients to unexpected, unassisted withdrawal crises. With laboratory feedback, these crises, unlike the symptoms related to deficient re-adaptation mechanisms, could be prevented. Moreover, by minimizing the high-concentration phase, time can be saved for properly assisted low-concentration challenges. CONCLUSION A customized detoxification procedure driven not only by the intensity of withdrawal symptoms but also by serum BZD monitoring may prevent some failures. As the standard regimen, it would make detoxification from BZDs more reliable and effective.
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Morbioli L, Lugoboni F. High-dose benzodiazepine dependence among health-care professionals: A neglected phenomenon. MEDICINE, SCIENCE, AND THE LAW 2021; 61:42-45. [PMID: 33591879 DOI: 10.1177/0025802420928650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Chronic use of benzodiazepines (BDZs) is a widespread phenomenon which can lead to side effects such as tolerance, dependence and cognitive impairment, as well as resulting in accidents at work. High-dose BDZ dependence (HD-BDZ) is little studied, and it is mainly attributed to major psychiatric disorders and polydrug abuse. To date, few studies have investigated HD-BDZ among active workers, with none among health-care professionals (HPs). Tapering from high doses of BDZs can cause severe withdrawal symptoms, including seizures. The Addiction Unit of the University Hospital in Verona uses a protocol based on flumazenil slow infusion (FLU-SI), the safest and most effective treatment for HD-BDZ. Since 2003, 1281 patients have been detoxified from long-term use of high doses of BDZ using FLU-SI. The sample includes 139 (10.8%) HPs. Mean daily doses were 336 mg diazepam equivalent among HPs and 365 mg diazepam equivalent among non-HPs (no statistically significant difference). HPs are at higher risk of sleep disorders and work-related stress. Most of these HPs experience difficulties at work due to cognitive impairment, but they are often afraid of the potential legal implications and too ashamed to ask for help. It is important to study the prevalence of HD-BDZ among HPs and to investigate the impact on their working skills and working eligibility.
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Affiliation(s)
- Laura Morbioli
- Integrated University Hospital of Verona, Addiction Unit, Italy
| | - Fabio Lugoboni
- Integrated University Hospital of Verona, Addiction Unit, Italy
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Artur de la Villarmois E, Pérez MF. Cognitive interference as a possible therapeutic strategy to prevent expression of benzodiazepine withdrawal. Eur J Neurosci 2019; 50:3843-3854. [PMID: 31299121 DOI: 10.1111/ejn.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 01/04/2023]
Abstract
Benzodiazepines are usually prescribed for anxiety and sleep disorders in long-term schedules that may cause drug dependence. Discontinuation after prolonged administration may lead to withdrawal expression, being anxiety the most predominant sign. The context-dependent associative learning process that underlies diazepam dependence can be interfered by pre-exposure to the drug administration context, an effect known as latent inhibition. Considering this background, the primary aim of the present investigation is to develop a therapeutic strategy to prevent diazepam withdrawal in male Wistar rats by interfering with this learning process. Nitric oxide is a crucial player in learning and memory, hippocampal synaptic transmission and in diazepam withdrawal. Then, a secondary goal is to determine how latent inhibition could alter functional plasticity and neuronal nitric oxide synthase enzyme (NOS-1) expression within the hippocampus, by using multi-unitary cell recordings and Western blot, respectively. Our results indicate that chronic diazepam treated animals under latent inhibition did not show anxiety, or changes in hippocampal synaptic transmission, but a significant reduction in NOS-1 expression was observed. Accordingly, pharmacological NOS-1 inhibition resembles behavioral and electrophysiological changes induced by latent inhibition. Contrary, diazepam treated animals under Control protocol expressed anxiety and evidenced an increased hippocampal-plasticity, without alterations in NOS-1 expression. In conclusion, manipulation of the contextual cues presented during diazepam administration may be considered as an effective non-pharmacological tool to prevent the withdrawal syndrome. This behavioral strategy may influence hippocampal synaptic transmission, probably by alterations in nitric oxide signaling pathways in this structure.
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Affiliation(s)
- Emilce Artur de la Villarmois
- Departamento de Farmacología, Facultad de Ciencias Químicas, IFEC-CONICET, Universidad Nacional de Córdoba, Ciudad Universitaria, Córdoba, Argentina
| | - Mariela Fernanda Pérez
- Departamento de Farmacología, Facultad de Ciencias Químicas, IFEC-CONICET, Universidad Nacional de Córdoba, Ciudad Universitaria, Córdoba, Argentina
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Votaw VR, Geyer R, Rieselbach MM, McHugh RK. The epidemiology of benzodiazepine misuse: A systematic review. Drug Alcohol Depend 2019; 200:95-114. [PMID: 31121495 PMCID: PMC6639084 DOI: 10.1016/j.drugalcdep.2019.02.033] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research. METHODS PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse. RESULTS The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment. CONCLUSIONS Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.
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Affiliation(s)
- Victoria R. Votaw
- Department of Psychology, University of New Mexico, MSC 03-2220, Albuquerque, NM, USA,Corresponding author: Victoria R. Votaw, Clinical Psychology Ph.D. Student Department of Psychology, University of New Mexico, Logan Hall, 1 University of New Mexico, Albuquerque, NM 87131,
| | - Rachel Geyer
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA, USA
| | - Maya M. Rieselbach
- Department of Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA
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Lugoboni F, Mirijello A, Morbioli L, Faccini M, Casari R, De Cosmo S, Gasbarrini A, Addolorato G. Zolpidem high-dose abuse: what about the liver? Results from a series of 107 patients. Expert Opin Drug Saf 2019; 18:753-758. [DOI: 10.1080/14740338.2019.1628216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Fabio Lugoboni
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Antonio Mirijello
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Laura Morbioli
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Marco Faccini
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS Research Hospital, Rome, Italy
| | - Giovanni Addolorato
- Department of Internal Medicine and Gastroenterology, Catholic University of Rome, Rome, Italy
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS Research Hospital, Rome, Italy
- "Alcohol Use Disorder and Alcohol Related Disease" Unit, Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario "A. Gemelli" IRCCS Research Hospital, Rome, Italy
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Cook B, Creedon T, Wang Y, Lu C, Carson N, Jules P, Lee E, Alegría M. Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse. Drug Alcohol Depend 2018; 187:29-34. [PMID: 29626743 PMCID: PMC5959774 DOI: 10.1016/j.drugalcdep.2018.02.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Benzodiazepines (BZDs) are widely prescribed during psychiatric treatment. Unfortunately, their misuse has led to recent surges in overdose emergency visits and drug-related deaths. METHODS Electronic health record data from a large healthcare system were used to describe racial/ethnic, sex, and age differences in BZD use and dependence. Among patients with a BZD prescription, we assessed differences in the likelihood of subsequently receiving a BZD dependence diagnosis, number of BZD prescriptions, receiving only one BZD prescription, and receiving 18 or more BZD prescriptions. We also estimated multivariate hazard models and generalized linear models, assessing racial/ethnic differences after adjustment for covariates. RESULTS In both unadjusted and adjusted analyses, Whites were more likely than Blacks, Hispanics, and Asians to have a BZD dependence diagnosis and to receive a BZD prescription. Racial/ethnic minority groups received fewer BZD prescriptions, were more likely to have only one BZD prescription, and were less likely to have 18 or more BZD prescriptions. We identified greater BZD misuse among older patients but no sex differences. CONCLUSIONS Findings from this study add to the emerging evidence of high relative rates of prescription drug abuse among Whites. There is a concern, given their greater likelihood of having only one BZD prescription, that Blacks, Hispanics, and Asians may be discontinuing BZDs before their clinical need is resolved. Research is needed on provider readiness to offer racial/ethnic minorities BZDs when indicated, patient preferences for BZDs, and whether lower prescription rates among racial/ethnic minorities offer protection against the progression from prescription to addiction.
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Affiliation(s)
- Benjamin Cook
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA.
| | - Timothy Creedon
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Ye Wang
- Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
| | - Chunling Lu
- Harvard School of Public Health 677 Huntington Ave., Boston, MA 02115, USA
| | - Nicholas Carson
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Piter Jules
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Esther Lee
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, 1035 Cambridge St., Cambridge, MA, 02141, USA
| | - Margarita Alegría
- Department of Psychiatry, Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA
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Lugoboni F, Mirijello A, Morbioli L, Arzenton E, Leone R, Faccini M, Casari R, De Cosmo S, Gasbarrini A, Addolorato G. Does high-dose benzodiazepine abuse really produce liver toxicity? Results from a series of 201 benzodiazepine monoabusers. Expert Opin Drug Saf 2018; 17:451-456. [DOI: 10.1080/14740338.2018.1457646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Fabio Lugoboni
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Antonio Mirijello
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Laura Morbioli
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Elena Arzenton
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Roberto Leone
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Marco Faccini
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Department of Medicine, Verona University Hospital, Verona, Italy
| | - Salvatore De Cosmo
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Gastroenterology and Hepatology, Catholic University of Rome, Rome, Italy
| | - Giovanni Addolorato
- Department of Internal Medicine, Gastroenterology and Hepatology, Catholic University of Rome, Rome, Italy
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Tamburin S, Faccini M, Casari R, Federico A, Morbioli L, Franchini E, Bongiovanni LG, Lugoboni F. Low risk of seizures with slow flumazenil infusion and routine anticonvulsant prophylaxis for high-dose benzodiazepine dependence. J Psychopharmacol 2017; 31:1369-1373. [PMID: 28613124 DOI: 10.1177/0269881117714050] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
High-dose benzodiazepine (BZD) dependence represents an emerging and under-reported addiction phenomenon and is associated with reduced quality of life. To date there are no guidelines for the treatment of high-dose BZD withdrawal. Low-dose slow flumazenil infusion was reported to be effective for high-dose BZD detoxification, but there is concern about the risk of convulsions during this treatment. We evaluated the occurrence of seizures in 450 consecutive high-dose BZD dependence patients admitted to our unit from April 2012 to April 2016 for detoxification with low-dose slow subcutaneous infusion of flumazenil associated with routine anticonvulsant prophylaxis. In our sample, 22 patients (4.9%) reported history of convulsions when previously attempting BZD withdrawal. Only four patients (0.9%) had seizures during ( n = 2) or immediately after ( n = 2) flumazenil infusion. The two patients with seizures during flumazenil infusion were poly-drug misusers. The most common antiepileptic drugs (AEDs) used for anticonvulsant prophylaxis were either valproate 1000 mg or levetiracetam 1000 mg. Our data indicate that, when routinely associated with AEDs prophylaxis, low-dose slow subcutaneous flumazenil infusion represents a safe procedure, with low risk of seizure occurrence.
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Affiliation(s)
- Stefano Tamburin
- 1 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Marco Faccini
- 2 Department of Medicine, Addiction Medicine Unit, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- 2 Department of Medicine, Addiction Medicine Unit, Verona University Hospital, Verona, Italy
| | - Angela Federico
- 1 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Laura Morbioli
- 2 Department of Medicine, Addiction Medicine Unit, Verona University Hospital, Verona, Italy
| | - Enrica Franchini
- 1 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | - Fabio Lugoboni
- 1 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Faccini M, Leone R, Opri S, Casari R, Resentera C, Morbioli L, Conforti A, Lugoboni F. Slow subcutaneous infusion of flumazenil for the treatment of long-term, high-dose benzodiazepine users: a review of 214 cases. J Psychopharmacol 2016; 30:1047-53. [PMID: 27166362 DOI: 10.1177/0269881116647505] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Despite the first reports concerning benzodiazepine dependence being published in the early 1960s literature, the risk of benzodiazepine addiction is still greatly debated. The severe discomfort and life threatening complications usually experienced by long-term benzodiazepine users who suddenly interrupt benzodiazepine intake have led to the development of several detoxification protocols. A successful strategy used by our Addiction Unit is abrupt benzodiazepine cessation by administering flumazenil slow subcutaneous infusion (FLU-SSI) with an elastomeric pump. Although some studies proved the efficacy of flumazenil infusion more than 20 years ago, only a few centres in the world offer this method to their patients. This paper reports the data related to 214 subjects addicted to high doses of benzodiazepine and treated with the FLU-SSI method between 2012 and 2014. This technique is less invasive and requires less nursing intervention than intravenous infusion. Our data support FLU-SSI as a possible efficient strategy for the treatment of patients with long-term, high-dose benzodiazepine addiction, and could become a routine therapy as long as the necessary further studies on dose, duration of infusion and safety issues are carried out.
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Affiliation(s)
- Marco Faccini
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Roberto Leone
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Sibilla Opri
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Chiara Resentera
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Laura Morbioli
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
| | - Anita Conforti
- Department of Diagnostics and Public Health, Pharmacology Unit, Verona University Hospital, Verona, Italy
| | - Fabio Lugoboni
- Department of Internal Medicine, Addiction Unit, Verona University Hospital, Verona, Italy
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Cosci F, Mansueto G, Faccini M, Casari R, Lugoboni F. Socio-demographic and clinical characteristics of benzodiazepine long-term users: Results from a tertiary care center. Compr Psychiatry 2016; 69:211-5. [PMID: 27423363 DOI: 10.1016/j.comppsych.2016.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/03/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE The use of benzodiazepines (BDZs) represents a critical issue since a long-term treatment may lead to dependence. This study aimed at evaluating socio-demographic and clinical characteristics of BZD long-term users who followed a detoxification program at a tertiary care center. METHOD Two hundred-five inpatients were evaluated. Socio-demographic (e.g., gender, age, education) and clinical information (e.g., BZD used, dose, reason of prescription) was collected. BZDs dose was standardized as diazepam dose equivalents and was compared via the Defined Daily Dose (DDD). Chi-square, Fisher test, ANOVA and Bonferroni analyses were performed. RESULTS Females were more frequently BDZ long-term users than males. Hypnotic BZDs were frequently prescribed for problems different from sleep disturbances. Lorazepam, alprazolam, and lormetazepam were the most prescribed drugs. Lorazepam was more frequently used by males, consumed for a long period, in pills, and prescribed for anxiety. Lormetazepam was more frequently consumed by females with a high school education, having a psychiatric disorder, taken in drops and prescribed for insomnia. Lormetazepam had the highest DDD. CONCLUSION A specific profile of BZD long-term user seems to exist and presents different socio-demographic and clinical characteristics according to the benzodiazepine taken into account.
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Affiliation(s)
- F Cosci
- Department of Health Sciences, University of Florence, via di San Salvi 12, 50135, Florence, Italy.
| | - G Mansueto
- Department of Health Sciences, University of Florence, via di San Salvi 12, 50135, Florence, Italy
| | - M Faccini
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - R Casari
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - F Lugoboni
- Addiction Unit, Verona University Hospital, piazzale Aristide Stefani 1, 37126, Verona, Italy
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Kacirova I, Grundmann M, Silhan P, Brozmanova H. A Case Report of Clonazepam Dependence: Utilization of Therapeutic Drug Monitoring During Withdrawal Period. Medicine (Baltimore) 2016; 95:e2881. [PMID: 26945373 PMCID: PMC4782857 DOI: 10.1097/md.0000000000002881] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Clonazepam is long-acting benzodiazepine agonist used in short-acting benzodiazepine withdrawal; however, recent observations suggest the existence of its abuse. We demonstrate a 40-year-old man with a 20-year history of psychiatric care with recently benzodiazepine dependence (daily intake of ∼60 mg of clonazepam and 10 mg of alprazolam). High serum levels of both drugs were analyzed 3 weeks before admission to hospitalization (clonazepam 543.9 ng/mL, alprazolam 110 ng/mL) and at the time of admission (clonazepam 286.2 ng/mL, alprazolam 140 ng/mL) without any signs of benzodiazepine intoxication. Gradual withdrawal of clonazepam with monitoring of its serum levels and increase of gabapentin dose were used to minimize physical signs and symptoms of clonazepam withdrawal. Alprazolam was discontinued promptly. Clinical consequences of the treatment were controllable tension, intermittent headache, and rarely insomia. It is the first case report showing utilization of therapeutic drug monitoring during withdrawal period in the patient with extreme toleration to severe benzodiazepine dependence.
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Affiliation(s)
- Ivana Kacirova
- From the Department of Clinical Pharmacology (IK, MG, HB), Faculty of Medicine, University of Ostrava; Department of Clinical Pharmacology (IK, HB), Department of Laboratory Diagnostics; and Department of Psychiatry (PS), University Hospital Ostrava, Czech Republic
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Liebrenz M, Schneider M, Buadze A, Gehring MT, Dube A, Caflisch C. Attitudes towards a maintenance (-agonist) treatment approach in high-dose benzodiazepine-dependent patients: a qualitative study. Harm Reduct J 2016; 13:1. [PMID: 26743909 PMCID: PMC4705614 DOI: 10.1186/s12954-015-0090-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 12/11/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND High-dose benzodiazepine dependence constitutes a major clinical concern. Although withdrawal treatment is recommended, it is unsuccessful for a significant proportion of affected patients. More recently, a benzodiazepine maintenance approach has been suggested as an alternative for patients' failing discontinuation treatment. While there is some data supporting its effectiveness, patients' perceptions of such an intervention have not been investigated. METHODS An exploratory qualitative study was conducted among a sample of 41 high-dose benzodiazepine (BZD)-dependent patients, with long-term use defined as doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use, such as mixing substances, dose escalation, recreational use, or obtainment by illegal means. A qualitative content analysis approach was used to evaluate findings. RESULTS Participants generally favored a treatment discontinuation approach with abstinence from BZD as its ultimate aim, despite repeated failed attempts at withdrawal. A maintenance treatment approach with continued prescription of a slow-onset, long-acting agonist was viewed ambivalently, with responses ranging from positive and welcoming to rejection. Three overlapping themes of maintenance treatment were identified: "Only if I can try to discontinue…and please don't call it that," "More stability and less criminal activity…and that is why I would try it," and "No cure, no brain and no flash…and thus, just for everybody else!" CONCLUSIONS Some patients experienced slow-onset, long-acting BZDs as having stabilized their symptoms and viewed these BZDs as having helped avoid uncontrolled withdrawal and abstain from criminal activity. We therefore encourage clinicians to consider treatment alternatives if discontinuation strategies fail.
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Affiliation(s)
- Michael Liebrenz
- Department of Forensic Psychiatry, Institute of Legal Medicine, University of Bern, Bern, Switzerland.
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
| | - Marcel Schneider
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Anna Buadze
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
| | | | - Anish Dube
- University of Pennsylvania Health System, Philadelphia, USA.
| | - Carlo Caflisch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland.
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Abstract
The large class of CNS-depressant medications-the benzodiazepines-have been extensively used for over 50 years, anxiety disorders being one of the main indications. A substantial proportion (perhaps up to 20-30 %) of long-term users becomes physically dependent on them. Problems with their use became manifest, and dependence, withdrawal difficulties and abuse were documented by the 1980s. Many such users experience physical and psychological withdrawal symptoms on attempted cessation and may develop clinically troublesome syndromes even during slow tapering. Few studies have been conducted to establish the optimal withdrawal schedules. The usual management comprises slow withdrawal over weeks or months together with psychotherapy of various modalities. Pharmacological aids include antidepressants such as the SSRIs especially if depressive symptoms supervene. Other pharmacological agents such as the benzodiazepine antagonist, flumazenil, and the hormonal agent, melatonin, remain largely experimental. The purpose of this review is to analyse the evidence for the efficacy of the usual withdrawal regimes and the newer agents. It is concluded that little evidence exists outside the usual principles of drug withdrawal but there are some promising leads.
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Affiliation(s)
- Malcolm Lader
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, Denmark Hill, London, SE5 8AF, UK.
| | - Andri Kyriacou
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neurosciences, King's College London, Denmark Hill, London, SE5 8AF, UK
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Liebrenz M, Schneider M, Buadze A, Gehring MT, Dube A, Caflisch C. High-Dose Benzodiazepine Dependence: A Qualitative Study of Patients' Perceptions on Initiation, Reasons for Use, and Obtainment. PLoS One 2015; 10:e0142057. [PMID: 26556055 PMCID: PMC4640837 DOI: 10.1371/journal.pone.0142057] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 10/16/2015] [Indexed: 12/15/2022] Open
Abstract
Background High-dose benzodiazepine (BZD) dependence is associated with a wide variety of negative health consequences. Affected individuals are reported to suffer from severe mental disorders and are often unable to achieve long-term abstinence via recommended discontinuation strategies. Although it is increasingly understood that treatment interventions should take subjective experiences and beliefs into account, the perceptions of this group of individuals remain under-investigated. Methods We conducted an exploratory qualitative study with 41 adult subjects meeting criteria for (high-dose) BZD-dependence, as defined by ICD-10. One-on-one in-depth interviews allowed for an exploration of this group’s views on the reasons behind their initial and then continued use of BZDs, as well as their procurement strategies. Mayring’s qualitative content analysis was used to evaluate our data. Results In this sample, all participants had developed explanatory models for why they began using BZDs. We identified a multitude of reasons that we grouped into four broad categories, as explaining continued BZD use: (1) to cope with symptoms of psychological distress or mental disorder other than substance use, (2) to manage symptoms of physical or psychological discomfort associated with somatic disorder, (3) to alleviate symptoms of substance-related disorders, and (4) for recreational purposes, that is, sensation-seeking and other social reasons. Subjects often considered BZDs less dangerous than other substances and associated their use more often with harm reduction than as recreational. Specific obtainment strategies varied widely: the majority of participants oscillated between legal and illegal methods, often relying on the black market when faced with treatment termination. Conclusions Irrespective of comorbidity, participants expressed a clear preference for medically related explanatory models for their BZD use. We therefore suggest that clinicians consider patients’ motives for long-term, high-dose BZD use when formulating treatment plans for this patient group, especially since it is known that individuals are more compliant with approaches they perceive to be manageable, tolerable, and effective.
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Affiliation(s)
- Michael Liebrenz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
- Department of Forensic Psychiatry, Institute of Legal Medicine, University of Bern, Bern, Switzerland
- * E-mail: (ML)
| | - Marcel Schneider
- Department of Surgery, Division of Visceral and Transplantation Surgery, University Hospital, Zurich, Switzerland
| | - Anna Buadze
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | | | - Anish Dube
- University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States of America
| | - Carlo Caflisch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
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Janhsen K, Roser P, Hoffmann K. The problems of long-term treatment with benzodiazepines and related substances. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:1-7. [PMID: 25613443 DOI: 10.3238/arztebl.2015.0001] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 10/28/2014] [Accepted: 10/28/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Benzodiazepine abuse and dependence have been recognized and widely discussed for more than 40 years. With more than 230 million daily doses prescribed in Germany per year, the burden of reimbursement on the statutory health insurance carriers is high, albeit with a slight decline from year to year. At present, about 50% of all prescriptions in Germany are issued privately, even for patients who have statutory health insurance. METHODS We selectively review the literature on the epidemiology and treatment of benzodiazepine dependence and abuse in Germany. RESULTS Estimates of the number of benzodiazepine-dependent persons in Germany range from 128 000 to 1.6 million. Most estimates take no account of the large number of private prescriptions (i.e., those that are not reimbursed by the statutory health insurance scheme), while many exclude prescriptions for elderly persons, for whom these drugs are frequently prescribed. For the outpatient treatment of benzodiazepine withdrawal, it is recommended that the drug should first be switched to an equivalent dose of another benzodiazepine with an intermediate or long-acting effect; the dose should then, in general, be reduced weekly. In case of consumption of a high dose (≥ 20 mg diazepam equivalent), hospitalization and the additional administration of carbamazepine or valproic acid are recommended. Flumazenil treatment can improve with - drawal symptoms and leads to higher abstinence rates. Antidepressants should be given only if the patient is depressed. The dependence potential of nonbenzodiazepine drugs such as zolpidem and zopiclon must also be borne in mind. CONCLUSION Benzodiazepines are generally highly effective when first given, but they should generally be given only for strict indications and for a limited time. If these drugs still need to be given beyond the short term, timely referral to a specialist is indicated, and possibly also contact with the addiction aid system.
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Affiliation(s)
- Katrin Janhsen
- LWL-Klinik Bochum, Department of Psychiatry, Psychotherapy, Psychosomatic and Preventive Medicine, Ruhr University Bochum, Faculty of Health (Department of Medicine), Witten/Herdecke University
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Liebrenz M, Gehring MT, Buadze A, Caflisch C. High-dose benzodiazepine dependence: a qualitative study of patients' perception on cessation and withdrawal. BMC Psychiatry 2015; 15:116. [PMID: 25968120 PMCID: PMC4443548 DOI: 10.1186/s12888-015-0493-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/29/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benzodiazepine withdrawal syndrome has been reported following attempts to withdraw even from low or therapeutic doses and has been compared to barbiturate and alcohol withdrawal. This experience is known to deter patients from future cessation attempts. Research on other psychotropic substances shows that the reasons and motivations for withdrawal attempts - as well as the experiences surrounding those attempts - at least partially predict future efforts at discontinuation as well as relapse. We therefore aimed to qualitatively explore what motivates patients to discontinue this medication as well as to examine their experiences surrounding previous and current withdrawal attempts and treatment interventions in order to positively influence future help-seeking behavior and compliance. METHODS To understand these patients better, we conducted a series of 41 unstructured, narrative, in-depth interviews among adult Swiss patients with a long-term dependent use of benzodiazepines in doses equivalent to more than 40 mg diazepam per day and/or otherwise problematic use (mixing benzodiazepines, escalating dosage, recreational use or illegal purchase). Mayring's qualitative content analysis was used to evaluate findings. RESULTS These high-dose benzodiazepine-dependent patients decision to change consumption patterns were affected by health concerns, the feeling of being addicted and social factors. Discontinuation attempts were frequent and not very successful with fast relapse. Withdrawal was perceived to be a difficult, complicated, and highly unpredictable process. The first attempt at withdrawal occurred at home and typically felt better than at the clinic. Inpatient treatment was believed to be more effective with long term treatment (approaches) than short term. Patients preferred gradual reduction of usage to abrupt cessation (and had experienced both). While no clear preferences for withdrawal were found for benzodiazepines with specific pharmacokinetic properties, participants frequently based their decision to participate in treatment on the availability of their preferred brand name and furthermore discarding equivalent dosage rationales. CONCLUSIONS Our findings provide greater understanding of the factors that motivate high-dose benzodiazepine-dependent individuals to stop taking these medications, and how they experience withdrawal and treatment strategies. They underscore how patients' perceptions of treatment approaches contribute to compliant or non-compliant behavior.
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Affiliation(s)
- Michael Liebrenz
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA. .,Psychiatric University Hospital, Lenggstrasse 31, 8032, Zurich, Switzerland.
| | | | - Anna Buadze
- Psychiatric University Hospital, Lenggstrasse 31, 8032, Zurich, Switzerland.
| | - Carlo Caflisch
- Psychiatric University Hospital, Lenggstrasse 31, 8032, Zurich, Switzerland.
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Hood SD, Norman A, Hince DA, Melichar JK, Hulse GK. Benzodiazepine dependence and its treatment with low dose flumazenil. Br J Clin Pharmacol 2014; 77:285-94. [PMID: 23126253 DOI: 10.1111/bcp.12023] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 10/30/2012] [Indexed: 11/29/2022] Open
Abstract
Globally benzodiazepines remain one of the most prescribed medication groups, especially in the primary care setting. With such high levels of prescribing it is not surprising that benzodiazepine dependence is common, cutting across all socioeconomic levels. Despite recognition of the potential for the development of iatrogenic dependence and the lack of any effective treatment, benzodiazepines continue to be widely prescribed in general practice. Conventional dependence management, benzodiazepine tapering, is commonly a protracted process over several weeks or months. It is often associated with significant withdrawal symptoms and craving leading to patient drop out and return to use. Accordingly, there is a worldwide need to find effective pharmacotherapeutic interventions for benzodiazepine dependence. One drug of increasing interest is the GABAA benzodiazepine receptor antagonist/partial agonist, flumazenil. Multiple bolus intravenous infusions of low dose flumazenil used either with or without benzodiazepine tapering can reduce withdrawal sequelae, and/or longer term symptoms in the months following withdrawal. Preliminary data suggest that continuous intravenous or subcutaneous flumazenil infusion for 4 days significantly reduces acute benzodiazepine withdrawal sequelae. The subcutaneous infusion was shown to be tissue compatible so the development of a longer acting (i.e. several weeks) depot flumazenil formulation has been explored. This could be capable of managing both acute and longer term benzodiazepine withdrawal sequelae. Preliminary in vitro water bath and in vivo biocompatibility data in sheep show that such an implant is feasible and so is likely to be used in clinical trials in the near future.
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Affiliation(s)
- Sean David Hood
- School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
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Lugoboni F, Quaglio G. Exploring the dark side of the moon: the treatment of benzodiazepine tolerance. Br J Clin Pharmacol 2014; 77:239-41. [PMID: 23617374 DOI: 10.1111/bcp.12148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 02/05/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Fabio Lugoboni
- Medical Service for Addictive Disorders, University of Verona, GB Rossi Hospital, 37134, Verona, Italy
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Lugoboni F, Mirijello A, Faccini M, Casari R, Cossari A, Musi G, Bissoli G, Quaglio G, Addolorato G. Quality of life in a cohort of high-dose benzodiazepine dependent patients. Drug Alcohol Depend 2014; 142:105-9. [PMID: 25001277 DOI: 10.1016/j.drugalcdep.2014.06.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Benzodiazepines (BZD) are among the most widely prescribed drugs in developed countries. Since BZD can produce tolerance and dependence even in a short time, their use is recommended for a very limited time. However, these recommendations have been largely disregarded. The chronic use of BZD causes a number of serious side effects, i.e., cognitive impairment, falls, traffic accidents, dependence and tolerance. The aim of the present study was to evaluate quality of life (QoL) in a cohort of 62 consecutive high-dose BZD-dependent patients seeking a BZD detoxification. METHODS Patients seeking BZD detoxification were evaluated using the General Health Questionnaire (GHQ-12) and the short form-36 questionnaire (SF-36). RESULTS Patients showed a significant reduction of QoL as measured by either SF-36 or GHQ-12. In particular, the greater impairment was observed in the items exploring physical and emotional status. Physical functioning was the item more influenced by the length of BZD abuse. Female patients showed a greater reduction of QoL compared to male, at least in some of the explored items. Social functioning scores were greatly reduced. CONCLUSIONS The present study shows for the first time that high-doses BZD dependent patients have a reduced QoL and a reduced social functioning, along with high levels of psychological distress.
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Affiliation(s)
- Fabio Lugoboni
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Antonio Mirijello
- Alcohol Addiction Unit, Department of Internal Medicine, Catholic University of Rome, Rome, Italy
| | - Marco Faccini
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Rebecca Casari
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Anthony Cossari
- Department of Economics, Statistics and Finance, University of Calabria, Rende, Italy
| | - Gessica Musi
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Giorgia Bissoli
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Gianluca Quaglio
- Addiction Unit, Department of Medicine, Verona University Hospital, Verona, Italy
| | - Giovanni Addolorato
- Alcohol Addiction Unit, Department of Internal Medicine, Catholic University of Rome, Rome, Italy.
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Lin SK. Rapid detoxification of benzodiazepine or Z-drugs dependence using acetylcholinesterase inhibitors. Med Hypotheses 2014; 83:108-10. [PMID: 24774720 DOI: 10.1016/j.mehy.2014.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 03/27/2014] [Accepted: 03/28/2014] [Indexed: 10/25/2022]
Abstract
Dependence on benzodiazepines (BZDs) or Z-drugs (zolpidem, zopicline and zaleplon) is a common clinical phenomenon. Traditional detoxification of BZDs dependence includes tapering used dose gradually and using equivalent doses of long-acting BZDs as substitutes. This kind of regimen tends to take a long time (up to 4weeks) and may require hospitalization. Acetylcholinesterase inhibitors have been shown to reverse BZDs induced sedation. We propose that oral form acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) also posses the effect of inhibiting GABA receptors, and act as indirect antagonist, to be applied in the rapid detoxification treatment of BZDs and Z-drug dependence.
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Affiliation(s)
- Shih-Ku Lin
- Department of Psychiatry, Taipei City Hospital and Psychiatric Center, Taiwan; Department of Psychiatry, College of Medicine, Taipei Medical University, Taiwan.
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Moreno LCGEAI, da Silva Oliveira GZ, Cavalcanti IMF, Santos-Magalhães NS, Rolim HML, de Freitas RM. Development and evaluation of liposomal formulation containing nimodipine on anxiolytic activity in mice. Pharmacol Biochem Behav 2014; 116:64-8. [DOI: 10.1016/j.pbb.2013.10.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/13/2013] [Accepted: 10/26/2013] [Indexed: 12/29/2022]
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