Multiple drug use and psychiatric comorbidity in patients admitted to the hospital with severe benzodiazepine dependence

Benzodiazepine high-doses: The need for an accurate definition

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.

Effects of CYP2C19*2 polymorphisms on the efficacy and safety of phenazepam in patients with anxiety disorder and comorbid alcohol use disorder

Introduction: Phenazepam therapy can often be ineffective and some patients develop dose-related adverse drug reactions. Aim. The purpose of this research was to study the effect of the CYP2C19*2 (681G>A, rs4244285) in patients with anxiety disorders and alcohol dependence taking phenazepam therapy. Materials & methods: Patients (175 males, average age: 37.16 ± 7.84 years) received phenazepam in tablet form for 5 days. Genotyping was performed by real-time polymerase chain reaction. Results: The statistically significant differences in the UKU Side-Effect Rating Scale scores on the fifth day of therapy: (CYP2C19*1/*1) 2.00 [1.00; 2.00), (CYP2C19*1/*2) 7.00 (7.00; 7.00), (CYP2C19*2/*2) 9.00 (8.00; 9.00), p < 0.001. Conclusion: This study demonstrated the different efficacy and safety of phenazepam in patients with different genotypes of CYP2C19*2.

Psychiatric Disorders and Alcohol Consumption Among Low-Income African Americans:Gender Differences

Background: Although cooccurrence of nonsubstance use disorders (non-SUDs) and substance use is well-established in the literature, most of what we know in this regard is derived from studies that have recruited predominantly White sample populations. As a result, there is a gap in knowledge on this link among low-income African Americans (AAs). There is also a need to understand how low-income AA men and women differ in these associations. Objective: To study whether there is an association between number of non-SUDs and amount of alcohol consumption by AA adults, and whether this association varies between AA men and women. Methods: This cross-sectional study recruited a nonrandom sample of 150 AA adults with non-SUDs (i.e., major depression, bipolar disorders, obsessive–compulsive disorder, paranoid disorder, panic disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder). The independent variable was the number of non-SUDs. The dependent variable was the amount of alcohol consumption. Age, socioeconomic status (educational attainment and household income), and self-rated health were covariates. Gender was the moderator. Linear regression models were used to analyze the data. Results: A higher number of non-SUDs was not associated with a higher amount of alcohol use in the pooled sample of AA adults. We, however, found a significant interaction between gender and number of non-SUDs on the amount of alcohol use, suggesting a stronger effect of non-SUDs on alcohol consumption in AA men than in AA women. Gender-stratified linear regression models showed a positive association between number of non-SUDs and amount of alcohol consumption in AA men but not in AA women. Conclusion: Non-SUDs impact alcohol use of AA men but not women. Future research should test whether AA men may have a higher tendency to turn to alcohol to regulate their emotions and cope with psychological pain due to multiple non-SUDs. The results also suggest that integration of services for SUDs and non-SUDs may be more relevant to provision of mental health services for AA men than AA women.

Review: Adjunctive pharmacologic approaches for benzodiazepine tapers

BACKGROUND

Many patients require discontinuation of benzodiazepines due to a reduction in drug efficacy over time, the development of a sedative use disorder, or unwanted side effects. Benzodiazepine discontinuation can pose a significant challenge for prescribing clinicians due to potential withdrawal symptoms and a recurrence of psychiatric complaints.

METHODS

A PubMed literature search was conducted using the medical subject heading of benzodiazepines in combination with the following key words: discontinuation, withdrawal, detoxification, cessation, dependence, addiction, substance use disorders, or long term. Twenty-one studies met the search criteria.

RESULTS

Few medications facilitated the successful discontinuation of benzodiazepines or relief from benzodiazepine withdrawal symptoms.

CONCLUSIONS

Studies were heterogeneous with respect to sample selection, sample size, and outcome measures. Medications targeting insomnia yielded mixed results. Similarly, studies of agents targeting anxiety symptoms demonstrated inconsistent findings in the reduction of anxiety, improvement in withdrawal symptoms, or enhancement of benzodiazepine completion rates. Anticonvulsants have supporting evidence from small case reports; carbamazepine shows some potential in assisting taper completion and reducing withdrawal severity. These conclusions should be considered in light of a number of inconsistencies across studies in the literature. The results of this review article highlight the need for additional research on optimal strategies for facilitating successful benzodiazepine tapers.

Reinforcing effectiveness of midazolam, ethanol, and sucrose: behavioral economic comparison of a mixture relative to its component solutions

Benzodiazepines (BZs) are relatively safe when administered alone. However, these drugs can produce severe side effects when coadministered with ethanol. Despite these adverse consequences, rates of concurrent BZ and ethanol misuse are increasing, and it is unclear whether this behavior is maintained by an enhanced reinforcing effect of the mixture. To address this issue, the current study compared the reinforcing effectiveness of sucrose solutions mixed with midazolam, ethanol, or both. Eight male rats were trained to orally self-administer solutions of either sucrose (S), sucrose+midazolam (SM), sucrose+ethanol (SE), or sucrose+midazolam+ethanol (SME). The response requirement was increased between sessions until the number of reinforcers earned was zero and the relationship between response requirement and reinforcers earned was analyzed using the exponential model of demand. Although baseline intake was similar across drug conditions, consumption of SM was least affected by increases in cost, indicating that it possessed the highest reinforcing effectiveness (i.e. least elastic). The reinforcing effectiveness of S, SE, and SME did not differ significantly. The finding that the reinforcing effectiveness of the SME was less than that of SM does not support the supposition that BZ and ethanol coadministration is maintained by a higher reinforcing effectiveness of the mixture.

Coadministration of disulfiram and lorazepam in the treatment of alcohol dependence and co-occurring anxiety disorder: an open-label pilot study

BACKGROUND

Anxiety is common among persons with alcohol use disorder during early abstinence from alcohol. Although benzodiazepines are effective for short-term treatment of anxiety, they are rarely used beyond acute detoxification due to concerns about misuse or interactions with alcohol.

OBJECTIVES

We conducted an open-label trial to explore the effects of coadministering lorazepam and disulfiram to alcohol-dependent patients with anxiety disorder symptoms. The rationale for this model is to minimize the risks of the benzodiazepine, while also potentially enhancing adherence to disulfiram.

METHODS

Forty-one participants with DSM-IV alcohol dependence who also met syndromal criteria for anxiety disorder with or without co-occurring major depressive syndrome initiated treatment with lorazepam (starting dose 0.5 mg three times daily) and disulfiram (starting dose 500 mg three times weekly). Participants received 16 weeks of monitored pharmacotherapy with manualized medical management.

RESULTS

Adherence to treatment decreased steadily with time (85.4% at 4 weeks, 36.6% at 16 weeks). Participants showed significant increases in percent abstinent days during treatment and at 24 weeks follow-up. Large reductions in anxiety, depression, and craving were observed during treatment, and improvement remained significant at 24 weeks. Duration of adherence with disulfiram strongly predicted abstinence at 16 weeks. There was no evidence of misuse of lorazepam or dose escalation during the study.

CONCLUSION

Lorazepam can be safely used for short-term treatment of anxiety in combination with disulfiram treatment of alcohol use disorder. However, it is not clear that making lorazepam dispensing contingent on adherence to disulfiram enhances retention in disulfiram treatment.

Treatment of co-occurring anxiety disorders and substance use disorders

Anxiety disorders commonly co-occur with substance use disorders both in the general population and in treatment-seeking samples. This co-occurrence is associated with greater symptom severity, higher levels of disability, and poorer course of illness relative to either disorder alone. Little research has been conducted, however, on the treatment of these co-occurring disorders. This gap may not only leave anxiety untreated or undertreated but also increase the risk for relapse and poor substance use outcomes. The aim of this article is to review the current state of the literature on treating co-occurring anxiety and substance use disorders. In addition to presenting a brief overview of the epidemiology of this co-occurrence, the article discusses the challenges in assessing anxiety in the context of a substance use disorder, the evidence for various treatment approaches, and recent advances and future directions in this understudied area. Also highlighted is the need for future research to identify optimal behavioral and pharmacologic treatments for co-occurring anxiety and substance use disorders.

Prevalence and socio-demographic risk factors associated with psychoactive substance use in psychiatric out-patients of a tertiary hospital in Nigeria

BACKGROUND

The co-morbidity of psychoactive substance use and other mental disorders is a major challenge to the management of both conditions in several parts of the world. There is relative dearth of information on co-morbidity and its predictors in Nigeria. This study determined the prevalence and socio-demographic risk factors associated with psychoactive substance use in the psychiatric out-patients of a tertiary hospital in Nigeria.

STUDY DESIGN

A cross-sectional study.

MATERIALS AND METHODS

From routine clinic visits over a 4-month period, each consecutive 4(th) adult patients (>18 years) who had previously attended the clinic at least for 1 year, completed a socio-demographic and semi-structured drug use questionnaires and interview with the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) to generate substance use diagnosis. Data was analysed using the statistical package for social sciences (SPSS), version 16. Level of significance was set at P < 0.05.

RESULTS

The lifetime prevalence for the use of substance was 29.3%, while that for multiple substances was 17.7%. The most commonly used substances were alcohol, cannabis and tobacco and they were also the ones mostly used in combination with one or the other. A total of 10.1% of the patients had a psychoactive substance use disorder. Being male, married with at least primary education and unemployed were significant risk factors for substance use.

CONCLUSION

Psychoactive substance is common among the psychiatric outpatients of the hospital with males, those with formal education, the married and unemployed being at high risk of substance use.

The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome

BACKGROUND

To date, no screening tools for alcohol withdrawal syndromes (AWS) have been validated in the medically ill. Although several tools quantify the severity of AWS (e.g., Clinical Institute Withdrawal Assessment for Alcohol [CIWA]), none identify subjects at risk of AWS, thus missing the opportunity for timely prophylaxis. Moreover, there are no validated tools for the prediction of complicated (i.e., moderate to severe) AWS in the medically ill.

OBJECTIVES

Our goals were (1) to conduct a systematic review of the published literature on AWS to identify clinical factors associated with the development of AWS, (2) to use the identified factors to develop a tool for the prediction of alcohol withdrawal among patients at risk, and (3) to conduct a pilot study to assess the validity of the tool.

METHODS

For the creation of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), we conducted a systematic literature search using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines for clinical factors associated with the development of AWS, using PubMed, PsychInfo, MEDLINE, and Cochrane Databases. Eligibility criteria included: (i) manuscripts dealing with human subjects, age 18 years or older, (ii) manuscripts directly addressing descriptions of AWS or its predisposing factors, including case reports, naturalistic case descriptions, and all types of clinical trials (e.g., randomized, single-blind, or open label studies), (iii) manuscripts describing characteristics of alcohol use disorder (AUD), and (iv) manuscripts dealing with animal data (which were considered only if they directly dealt with variables described in humans). Obtained data were used to develop the Prediction of Alcohol Withdrawal Severity Scale, in order to assist in the identification of patients at risk for complicated AWS. A pilot study was conducted to assess the new tool's psychometric qualities on patients admitted to a general inpatient medicine unit over a 2-week period, who agreed to participate in the study. Blind to PAWSS results, a separate group of researchers retrospectively examined the medical records for evidence of AWS.

RESULTS

The search produced 2802 articles describing factors potentially associated with increased risk for AWS, increased severity of withdrawal symptoms, and potential characteristics differentiating subjects with various forms of AWS. Of these, 446 articles met inclusion criteria and underwent further scrutiny, yielding a total of 233 unique articles describing factors predictive of AWS. A total of 10 items were identified as correlated with complicated AWS (i.e., withdrawal hallucinosis, withdrawal-related seizures, and delirium tremens) and used to construct the PAWSS. During the pilot study, a total of 68 subjects underwent evaluation with PAWSS. In this pilot sample the sensitivity, specificity, and positive and negative predictive values of PAWSS were 100%, using the threshold score of 4.

DISCUSSION

The results of the literature search identified 10 items which may be correlated with risk for complicated AWS. These items were assembled into a tool to assist in the identification of patients at risk: PAWSS. The results of this pilot study suggest that PAWSS may be useful in identifying risk of complicated AWS in medically ill, hospitalized individuals. PAWSS is the first validated tool for the prediction of severe AWS in the medically ill and its use may aid in the early identification of patients at risk for complicated AWS, allowing for prophylaxis against AWS before severe alcohol withdrawal syndromes develop.

Nicotine dependence among clients receiving publicly funded substance abuse treatment

BACKGROUND

Smoking and nicotine dependence (ND) are prevalent among substance abusers but little is known about characteristics of ND in this population. This information would help identify those most in need of smoking cessation programs. This study evaluated the associations of socio-demographic, tobacco- and substance use-related, and health/mental health factors to ND in adults receiving publicly funded substance abuse treatment in Tennessee.

METHODS

All Tennessee residents who received federal block grant-funded substance abuse treatment during July-December, 2004 were invited to participate in a 6 month post-intake telephone follow-up interview. Socio-demographic characteristics, perceived health and mental health, tobacco use history and patterns, and ND, assessed by the Fagerstrom Test of Nicotine Dependence (FTND), were obtained at follow-up. Alcohol and illicit drug use and smoking status prior to treatment were assessed at intake. This paper analyzes data for 855 clients who were current cigarette smokers at both intake and follow-up.

RESULTS

Sixty three percent of smokers were ND (FTND score ≥ 4). Correlates of ND included older age, poorer self-rated overall health, earlier age of onset of cigarette smoking and substance abuse, fewer smoking quit attempts in past year, single substance use (alcohol or illicit drug, vs. multiple substances) at intake, use of opiates/narcotics and sedatives, and past month self-reported depression.

CONCLUSION

ND was highly prevalent and correlated with specific types and patterns of substance abuse and depression. These results suggest that intensive smoking cessation interventions, involving behavioral support, pharmacotherapy, and mood management, are needed to effectively assist this population.

Benzodiazepine use among patients in heroin-assisted vs. methadone maintenance treatment: findings of the German randomized controlled trial

Benzodiazepine (BZD) use has been found to be associated with poorer psychosocial adjustment, higher levels of polydrug use and more risk-taking behaviors among opioid dependent patients. The aim of this paper is to analyze the correlation between BZD use, BZD prescription and treatment outcome among participants in the German trial on heroin-assisted treatment. 1015 patients who participated in the study comparing heroin-assisted and methadone maintenance treatment (HAT & MMT) for 12 months were included in the analysis. Analyses were carried out to assess the association of treatment outcome with baseline BZD use, with ongoing BZD use and with different patterns of BZD prescription. Baseline BZD use correlated with lower retention rates but not with poorer outcome. Ongoing BZD use correlated with poorer outcomes. Significantly better outcomes were found in the course of phobic anxiety symptomatology for those with regular prescription of BZD. The percentage of BZD positive urine tests decreased more in HAT than in MMT. Poorer outcome for benzodiazepine users may be mediated by a higher severity of addiction. Cautious prescribing of benzodiazepines may be beneficial due to the reduction of overall illicit use.

Medication errors in psychiatry: a comprehensive review

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. Our primary focus was to examine patient-, provider- and system-related factors that contributed to medication errors. Due to differences in research design and denominators used to determine error rates, the reported prevalence rates of medication errors in psychiatry vary widely. Patient-related factors identified as contributing to medication errors included non-adherence to medication, failure of patients to inform their various care providers about the medications they are taking and symptoms of psychiatric illnesses. Provider-related factors identified as contributing to medication errors were also identified and included clinical practices associated with prescribing, transcription, dispensing, administration and monitoring. Finally, the healthcare system also has a major role to play in reducing medication errors by ensuring seamless continuity of care, mandating medication reconciliation programmes, ensuring adequate clinical pharmacy services and supporting a nonpunitive medication error reporting system. Although the literature raises awareness of these specific contributing factors, there is still a great need for more systematic evaluations of the problem including root cause analysis. Medication errors in psychiatry have been studied almost exclusively in the inpatient setting and thus little is known about the incidence and significance in outpatient and community settings.

Zopiclone misuse: an update from Dublin

The prevalence of zopiclone misuse in clients attending a methadone maintenance programme in Dublin through detection of its degradation product, 2-amino-5-chloropyridine (ACP) on urinalysis is outlined. Urine samples from all 158 clients were tested for the presence of ACP, opiates, benzodiazepines, cocaine, alcohol and cannabis. Of the 37 (23%) clients who tested positive for ACP, 23 (62%) were interviewed. A profile of zopiclone misusers is outlined, including details of demographics, drug history, viral status, recent urinalysis results and opinions on zopiclone. Of the 14 (38%) clients who were not interviewed, information was obtained from their clinical casenotes and documented urinalysis results. The prevalence of zopiclone misuse was reported as 23%. Benzodiazepines were the most popular drug of misuse with zopiclone followed by heroin/opiates. Zopiclone is being misused by drug users in Dublin in the context of many other drugs. Prescribing of zopiclone should be restricted, especially among drug misusers.

Self-injection of flunitrazepam alone and in the context of methadone maintenance in baboons

Patients in methadone maintenance programs use benzodiazepines to "boost" methadone's subjective effects, and flunitrazepam has been prominent in this context. Self-administration of flunitrazepam (0.001-0.32 mg/kg i.v.) alone and during daily oral methadone administration was evaluated in three baboons. Flunitrazepam maintained self-injection as an inverted U-shaped function of dose at rates higher than those maintained by most other benzodiazepines under the same procedure. In the context of demonstrated physical dependence on 3.2 mg/kg/day p.o. methadone, flunitrazepam doses on the ascending limb of the dose-effect curve maintained greater rates of self-injection than before methadone in two baboons. When the methadone dose decreased to 1.8 mg/kg/day, self-injection remained higher for those baboons and became higher than before methadone for the third baboon. Self-injection remained higher when methadone decreased to 1.0 mg/kg/day, except self-injection of the lowest flunitrazepam dose returned to or below the pre-methadone rate for two baboons. After methadone was discontinued, the dose-effect curve shifted to the right in one baboon but remained to the left in two. Flunitrazepam thus served as a reinforcer alone and in the context of methadone maintenance. Lower doses maintained higher self-injection during and shortly after methadone maintenance. Further research should explore the duration of higher self-injection rates following methadone maintenance.

Eyes wide shut?--A conceptual and empirical critique of methadone maintenance treatment

BACKGROUND

Methadone maintenance treatment (MMT) has been the 'gold standard' pharmacotherapy treatment for illicit opioid dependence for over 30 years. It has been widely evaluated, and is generally claimed to be 'effective'.

METHODS

The objective of this paper is to review the rationale of MMT as an intervention for a biomedical disorder with primary social objectives as well as the methodological quality and evidence of MMT outcome research. Data sources included opioid dependence treatment practice, review and outcome research literature (1965-2001) in the form of peer-reviewed articles, books, monographs and reports that are preeminently cited and reviewed international studies on MMT. RESULTS/DATA SYNTHESIS: Rigorous and appropriate evaluation (i.e., RCTs, intent-to-treat, patient-centered) methods in MMT evaluations are rare. Evidence of MMT's effectiveness on primary treatment objectives is mixed and appears to be largely partial and short-term. Positive outcomes may be the result of selection effects of compliant patients and loss in proportion when more rigorous standards of analysis are applied.

CONCLUSIONS

The quality of existing MMT research, and evidence for its general effectiveness are limited. Key concepts of self-medication and psychiatric comorbidity are largely ignored in MMT treatment and research frameworks, although they may serve to explain MMT's limited treatment success. Emerging new opioid pharmacotherapies require the fundamental review of the existing MMT paradigm as well as the application of rigorous and appropriate evaluation methods for future treatment.

Predictors of benzodiazepine discontinuation in subjects manifesting complicated dependence

We described characteristics of subjects with benzodiazepine dependence that was typically complicated by harmful and hazardous alcohol use or high benzodiazepine doses, and assessed predictors of successful discontinuation of benzodiazepines for this group. Seventy-six patients who participated in a randomized clinical trial of two different gradual withdrawal treatment approaches were assessed. The trial was conducted between February 1995 and July 1999. The mean age +/- SD of subjects was 40.0 +/- 9.6 years, 55% were male, 38% were married or cohabiting, and 70% had received more than nine years of education. The median benzodiazepine dose was 35 mg/day (range 2.5-180) in diazepam equivalents. The median duration of benzodiazepine use was 84 (range 8-360) months. Subjects with lower benzodiazepine doses and no previous withdrawal attempts were more successful at benzodiazepine discontinuation. Cluster B personality/borderline personality disorder was associated with an inability to stop benzodiazepine use and with "dropping out" of treatment. Alcohol use-related disorders or other psychiatric diagnoses were not associated with outcome. Further studies on predictors of successful benzodiazepine discontinuation in different populations are required. Patients manifesting cluster B personality/borderline personality disorder and benzodiazepine dependence may need concomitant treatment for their personality disorders to benefit from benzodiazepine discontinuation treatment.

Correlates of benzodiazepine use in individuals with insomnia

BACKGROUND AND PURPOSE

Although benzodiazepines (BZDs) are commonly used in the treatment of insomnia, there is little information about psychological, health, and sociodemographic correlates associated with their use.

OBJECTIVE

This study examined correlates of benzodiazepine use for sleep in a clinical sample of patients seeking treatment for insomnia at a sleep disorders clinic.

PATIENTS AND METHODS

The sample consisted of 97 individuals evaluated at a sleep disorders clinic for a presenting complaint of insomnia. Two groups were formed, including one with 61 patients who had been using BZDs for sleep for an average of 56.6 months (SD=68.0), and another with 36 patients who had insomnia but were not using BZDs or any other sleep aid. Logistic regressions, adjusting for an age difference between the user and non-user groups, were performed to examine variables associated with BZD use. Independent variables included demographic, medical, insomnia-related and psychological parameters and subjective sleep-wake characteristics. Unadjusted regression analyses were performed to identify factors associated with a pattern of long-term use (>12 months) within the user group.

RESULTS

Age was a significant predictor of BZD use (OR=1.84, P = 0.0002). Significant age-adjusted predictors of BZD use included perceived insomnia severity (OR=1.17, P = 0.038), depressive symptoms, (OR=1.108, P = 0.009) and state and trait anxiety symptoms (OR=1.062, P = 0.016; OR=1.084, P = 0.005, respectively). Significant predictors of long-term use (>12 months) were age of insomnia onset (OR=0.951, P = 0.0214), more frequent BZD use (OR=3.284, P = 0.0221), and higher state-anxiety (OR=1.106, P = 0.0471).

CONCLUSIONS

Age, psychological variables and perceived sleep disturbances severity, are associated with BZD use in patients with insomnia.

Drug injection cessation among HIV-infected injecting drug users

This article reports findings from a cohort study that investigated drug injection cessation over an 18-month period among HIV-infected injecting drug users followed up in a clinical setting. At 18th month visit, individuals reporting persistent injection practices were compared with individuals who reported drug injection cessation for at least 12 months. Crude and adjusted odds ratios were used to assess the impact of change in addictive and sexual behaviors, contacts with the drug network, depression, negative life events, clinical status, HIV therapy, and drug maintenance treatment (DMT) on drug injection cessation. After multiple adjustment, a general decrease of addiction practices (alcohol and cannabis) and of unsafe sexual behaviors significantly accompanied injection cessation. Individuals with higher education level, still in contact with the drug network, and not yet treated for their HIV disease were significantly more likely to persist injecting behaviors. These results underscore the importance and the need of monitoring addiction practices and unsafe sexual behaviors among HIV-positive individuals to properly address primary and secondary prevention in the era of highly active antiretroviral treatments (HAART).

Prescription opioid abuse in patients presenting for methadone maintenance treatment

To characterize prescription opioid dependent patients in a methadone maintenance treatment (MMT) program, a detailed retrospective chart review of new admissions (1997-1999, n=178, mean age=34.5+/-0.7 years, 65% male) was conducted. At admission most patients (83%) had been using prescription opioids (+/-heroin). Four groups were identified: 24% had used prescription opioids only; 24% used prescription opioids initially and heroin later; 35% used heroin first and prescription opioids subsequently; and 17% had used heroin only (this group was significantly younger: mean age 26+/-1 years, P=0.0001). Subjects reported regular use of prescription opioids at higher than therapeutic dosages. For example, in the 'prescription opioid only' group the reported mean (+/-S.E.) number of codeine or oxycodone-containing tablets consumed daily was 23 (+/-6) tablets and 21 (+/-3) tablets, respectively. There were no significant differences found amongst the groups in measures of social stability. Those dependent on prescription opioids alone were less likely to use illicit non-opioid drugs or to be associated with injection drug use. Those that used prescription opioids only or initially were more likely to have ongoing pain problems and to be involved in psychiatric treatment. Further research is required to better elucidate the complex relationships between pain, mental health and addiction in order to develop optimal prevention and treatment strategies for prescription opioid dependence.

Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data

AIMS

The non-benzodiazepine hypnotics zolpidem and zopiclone, which are indicated for short-term treatment of insomnia, were considered originally by physicians as almost devoid of abuse and dependence potential. Several recent publications, however, have suggested that both agents carry a significant risk of abuse. To substantiate and re-evaluate this situation, the world literature was reviewed for cases of dependence of both agents; these cases were analysed in order to identify certain underlying patterns, if evident.

METHODS

A systematic review based on a Medline literature search was conducted including the years 1966-2002 to assemble all available clinical case reports that were analysed for typical features of abuse and dependence according to prespecified criteria. Only case reports were of interest, and clinical studies were excluded. No limitations as to language or publication year were applied. The terms 'zolpidem', 'zopiclone' and 'abuse', 'dependence', 'addiction', 'withdrawal' and 'intoxication' were used to identify relevant publications. Potentially relevant citations were retrieved and assessed for inclusion independently by two authors.

RESULTS

A total of 36 cases for zolpidem were identified, most of them reported in recent years, and 22 cases for zopiclone. Both sexes were involved to a similar extent; and cases were reported in all age groups. In extreme cases, dose increases reached a factor of 30-120 above the recommended doses. The majority of patients had a history of former drug or alcohol abuse and/or other psychiatric conditions.

CONCLUSION

On the basis of world-wide prescription numbers, which are approximately twofold higher for zolpidem (1,338,774,000 tablets from June 2001 to June 2002 in Europe, Japan and United States) than for zopiclone (664,897,000 tablets during the same period in Europe and Japan), the relative incidence of reported dependence similar for both drugs and remarkably lower than that of benzodiazepines used for the treatment of disturbed sleep. The findings offer the conclusion that zolpidem and zopiclone are relatively safe drugs. However, as both drugs are psychotropic drugs, patients with a history of abuse or dependence and those with psychiatric diseases seem to be at increased risk of abuse of these agents.

Long-term outcome after benzodiazepine withdrawal treatment in subjects with complicated dependence

BACKGROUND

The study aimed to monitor subjects with benzodiazepine (BZ) dependence after withdrawal treatment in order to evaluate long-term outcome and predictors of remaining BZ-free. Subjects with high-dose dependence or co-occurring alcohol problems were not excluded.

METHOD

Seventy-six participants in an earlier, randomized, controlled trial of outpatient BZ discontinuation were interviewed, and documents from their treatment settings obtained, along with urine and serum samples for BZ use. Long-term outcomes for a cognitive-behavioral treatment group and a treatment-as-usual group were measured.

RESULTS

BZ discontinuation treatment outcomes were maintained in both treatment groups. No between-group differences were found. At the end of the study 25% of the subjects were BZ-free, and the median dose decrease from pre-treatment levels was 16.1 mg in diazepam equivalents. Subjects with pre-treatment doses exceeding 40 mg were able to maintain their doses at therapeutic levels through the follow-up. Pre-treatment low BZ dose, no previous withdrawal attempts, and high life satisfaction predicted success in staying BZ-free.

CONCLUSIONS

In subjects with complicated BZ dependence, the benefits of BZ discontinuation treatment may persist, but more studies are needed.

Divalproex sodium (Depakote) for alcohol withdrawal and relapse prevention

This pilot study evaluates the safety and efficacy of divalproex sodium (Depakote) for alcohol withdrawal and relapse prevention. Sixteen patients in moderate alcohol withdrawal were randomized to receive a standard benzodiazepine detoxification, depakote detoxification, or depakote detox plus maintenance. Symptom reduction occurred more rapidly and consistently in the depakote treated patients than in the benzodiazepine control group, and at six-week follow up a greater percentage of patients in the depakote maintenance group were completely abstinent than either detox-only group. There were no significant differences in sociodemographic or drinking data amongst the three cohort samples at baseline. Our findings suggest that the anticonvulsant divalproex sodium (Depakote) may be a safe and efficacious alternative to benzodiazepines for the treatment of alcohol withdrawal. It may be an advantageous alternative for outpatient detoxification, as it has no abuse potential, pharmacologic synergy with alcohol, or substantial cognitive or psychomotor side effects.

Assessment of benzodiazepine dependence in alcohol and drug dependent outpatients: a research report

In this study on 99 outpatients who were being treated for alcohol and/or drug dependence and also using benzodiazepines (BZDs), prevalence rates of DSM-III-R and ICD-10 substance dependence diagnoses were ascertained and scalability, reliability and validity of the scales of the Benzodiaepine Dependence Self-Report Questionnaire (Bendep-SRQ) were assessed. The latter properties were investigated by Rasch analyses, discriminability coefficients, test-retest coefficients and factor analyses. BZD dependence was found to be a prevalent additional diagnosis. The psychometric findings appear to support the use of the Bendep-SRQ at outpatient addiction centers, which could contribute to a more differentiated treatment for poly-substance dependence.

Defining patterns of benzodiazepine use in older adults

Benzodiazepines are disproportionately prescribed to older adults. Elderly adults with comorbid medical and psychiatric conditions, elderly adults taking multiple medications, and elderly women are the most likely adults to continuously use benzodiazepines. These are also the groups of elderly who are likely to experience adverse effects, including falls, accidents, and motor vehicle crashes. Despite recommendations for short-term treatment and the potential risks of long-term use, some patients continue to receive benefit for extended time periods, occasionally years. Future research needs to be directed at improved identification of which patients will benefit from intermittent versus continuous treatment while minimizing risk for adverse side effects. In order to advance the study of the risks and benefits of benzodiazepine use, we have proposed a set of definitions for classification of use. These definitions can be used to develop clinical guidelines based on empirically derived clinical research models.

Long-term benzodiazepine therapy does not result in brain abnormalities

Studies on the association between long-term benzodiazepine use and brain abnormalities have yielded conflicting results. The computed tomographic (CT) scans of 20 long-term users of benzodiazepine (65% men; mean age +/- SD [range], 42 +/- 12.1 years [23-59]; mean daily benzodiazepine dose [diazepam equivalents], 19.5 +/- 16.2 mg [2.5-70]; mean cumulative benzodiazepine exposure, 55.2 g [1.8-198]) were compared with 36 age- (+/-3 years) and sex-matched controls. Controls were prospectively recruited from 96 patients attending a neurology clinic and were interviewed to screen for alcohol and substance use disorders and other conditions possibly leading to brain atrophy. Three neuroradiologists blindly assessed each CT scan for atrophy and measured ventricles (V1, V2, V3), sulci, fissures, cisterns, and folia. Reliability among observers ranged from 0.92 to <0.1, in which case deleting one observer increased all reliabilities to >0.45. No difference in atrophy was found between benzodiazepine users and controls. V1 measures were significantly higher for benzodiazepine users than for controls (mean +/- SD, 12.1 +/- 1.3 vs. 11.1 +/- 2.0;p = 0.02), but measures of third and fourth largest sulci were significantly higher in controls than in benzodiazepine users. Right third and fourth largest sulci (mean +/- SD), respectively, were the following: controls, 0.72 +/- 0.4 and 0.74 +/- 0.7; benzodiazepine users, 0.51 +/- 0.3 and 0.46 +/- 0.3 (p < 0.02). Left third and fourth largest sulci, respectively, were the following: controls, 0.77 +/- 0.6 and 0.65 +/-0.3; benzodiazepine users, 0.53 +/- 0.3 and 0.5 +/- 0.3 (p < 0.02). Long-term benzodiazepine therapy does not result in brain abnormalities that can be demonstrated on CT scans.

Characteristics of dependent and nondependent regular users of codeine

Although codeine is a widely used medication, the problems of codeine abuse and dependence have not been well-studied. This study characterized regular codeine users (using at least 3 days per week for 6 months, excluding those using codeine for the treatment of cancer pain) through a self-completed questionnaire. Recruitment through newspaper advertisements resulted in a total of 339 eligible questionnaires. Thirty-seven percent of subjects met DSM-IV criteria for codeine dependence. Dependent subjects (mean age, 40 +/- 10 years) were using an average of 179 (+/-171) mg of codeine per day. Codeine was predominantly used in the form of combination products with acetaminophen. Dependent subjects identified specific problems causally related to their codeine use such as depression (23%), anxiety (21%), and gastrointestinal disturbances (13%). The dependent subjects reported problems with other drugs more than did nondependent users (alcohol, 57% vs. 26%; cannabis, 23% vs. 5%; sedative/hypnotics, 33% vs. 12%; and heroin, 11% vs. 2%, respectively). Most were taking codeine primarily for a chronic pain problem (81%), although the dependent subjects currently found codeine less effective for treating pain than did the nondependent subjects and were more likely to use codeine for pleasurable effects, to relax, or to prevent withdrawal symptoms. This study showed that dependence is associated with the regular use of codeine. Pain is a key issue with these users; however, they are probably not receiving optimal treatment. There is a need to identify individuals experiencing problems with their codeine use and to develop optimal prevention and treatment strategies.

Addiction to benzodiazepines

Benzodiazepines are sedative hypnotic medications that can induce a state of dependence. Dependence however is not the same as addiction. The development of dependence is a predictable phenomenon, influenced by dose, duration of treatment, and a number of other factors including individual characteristics of the benzodiazepine user. It is unclear whether there are meaningful differences among benzodiazepines in producing a state of dependence. Benzodiazepine dependence is also characterized by a predictable discontinuation syndrome. Benzodiazepines are rarely abused by non-substance abusers. The regulation of benzodiazepines although the legitimate therapeutic use has been significantly reduced.