1
|
O'Carroll A, Duffin T, Collins J. Harm reduction in the time of COVID-19: Case study of homelessness and drug use in Dublin, Ireland. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102966. [PMID: 33166825 PMCID: PMC7647898 DOI: 10.1016/j.drugpo.2020.102966] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 11/29/2022]
Abstract
Dublin appears to have performed very well as compared to various scenarios for COVID-19 mortality amongst homeless and drug using populations. The experience, if borne out by further research, provides important lessons for policy discussions on the pandemic, as well as broader lessons about pragmatic responses to these key client groups irrespective of COVID-19. The overarching lesson seems that when government policy is well coordinated and underpinned by a science-driven and fundamentally pragmatic approach, morbidity and mortality can be reduced. Within this, the importance of strategic clarity and delivery, housing, lowered thresholds to methadone provision, Benzodiazepine (BZD) provision and Naloxone availability were key determinants of policy success. Further, this paper argues that the rapid collapse in policy barriers to these interventions that COVID-19 produced should be secured and protected while further research is conducted.
Collapse
Affiliation(s)
- Austin O'Carroll
- COVID-19 Clinical Lead for Homelessness in Dublin, Grangegorman Upper, Arran Quay, Dublin, Ireland
| | - Tony Duffin
- CEO of Ana Liffey Drug Project, 48 Middle Abbey St, North City, Dublin 1, D01 TY74, Ireland.
| | - John Collins
- Director of Academic Engagement, the Global Initiative Against Transnational Organized Crime, Schwarzenbergplatz 1, 1010 Vienna, Austria.
| |
Collapse
|
2
|
Franc A, Kubová K, Elbl J, Muselík J, Vetchý D, Šaloun J, Opatřilová R. Diazepam filled hard capsules intended for detoxification of patients addicted to benzodiazepines and Z-drugs. Eur J Hosp Pharm 2017; 26:10-15. [PMID: 31157089 DOI: 10.1136/ejhpharm-2016-001163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 11/04/2022] Open
Abstract
Objectives The abuse of benzodiazepines and Z-drugs reduces the quality of life of millions of addicted people worldwide. They cannot be discontinued abruptly due to harmful withdrawal symptoms. Detoxification is usually based on replacement of short/middle acting benzodiazepines or Z-drugs by diazepam and tapering the dose over time. In order to enhance patient adherence to an individual withdrawal plan, suitable diazepam dosage forms have to be available. Hard capsules containing an exact and uniform dose could be used for the relief of symptoms caused by altering the plasma level and overcoming psychogenic stress from the dose reduction. Methods This work demonstrates that capsules with a content of diazepam ranging from 2.125mg to 0.492 mg (dose decreasing always by 15%) cannot be easily prepared by standard mortar technology in a pharmacy. To meet mass and content uniformity European Pharmacopoeia criteria, capsules were prepared by improved technology based on the preparation of binary blends of calcium phosphate anhydrous and diazepam in descending concentrations in a high-speed mixer (time 30 s) and densification of about 10% during filling of the capsules. Results All batches (n=20) prepared by improved technology met the requirement for content uniformity compared with only nine batches prepared by standard mortar blender technology. Based on the process capability index, none of the samples prepared by standard technology fitted pharmacopeia limits at the statistically acceptable level. On the other hand, all batches prepared by improved technology exhibited acceptable process capability index. Conclusions We have shown that at least 99.73% of batches prepared by our improved technology would meet the pharmacopoeia limits for content uniformity and are suitable for treatment of this type of addiction.
Collapse
Affiliation(s)
- Aleš Franc
- Department of Pharmaceutics, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Kateřina Kubová
- Department of Pharmaceutics, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Jan Elbl
- Department of Pharmaceutics, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Jan Muselík
- Department of Pharmaceutics, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - David Vetchý
- Department of Pharmaceutics, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Jan Šaloun
- Department of Applied Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Radka Opatřilová
- Department of Chemical Drugs, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| |
Collapse
|
3
|
Wolter DK. [Discontinuation of benzodiazepines in old age : When and if so, how?]. Z Gerontol Geriatr 2017; 50:115-122. [PMID: 28105500 DOI: 10.1007/s00391-016-1171-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.
Collapse
Affiliation(s)
- Dirk K Wolter
- Gerontopsykiatrisk Afdeling, Psykiatrien, Kresten Philipsens Vej 15 B, 6200, Aabenraa, Dänemark.
| |
Collapse
|
4
|
Bakker A, Streel E. Benzodiazepine maintenance in opiate substitution treatment: Good or bad? A retrospective primary care case-note review. J Psychopharmacol 2017; 31:62-66. [PMID: 28072037 DOI: 10.1177/0269881116675508] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Co-prescribing benzodiazepines to patients in opiate substitution treatment is controversial and often alleged to increase mortality. In an inner-London general practice, patients with problematic benzodiazepine co-dependence were allowed benzodiazepine maintenance treatment (BMT) since 1994, providing an opportunity for analysis. METHOD 1) Case-note review of all 278 opiate substitution treatment patients, accruing 1289 patient treatment years; 46% had concurrent BMT. 2) National Health Service database search for patients who died after leaving accrued a further 883 years of information; only patients who left the UK were unaccounted for (4%). Three groups were studied: 1) never obtained benzodiazepine prescription (NOB): n=80); 2) briefly/occasionally prescribed benzodiazepines (BOP): n=71; 3) BMT: n=127. OUTCOMES MEASURED Treatment retention (months); deaths/100 patient treatment years; deaths after leaving the service/100 years of information. RESULTS Treatment retention: NOB: 34 months; BOP: 51 months; BMT: 72 months. In-treatment mortality: NOB: 1.79/100 patient treatment years; BOP: 0.33/100 patient treatment years; BMT: 1.31/100 patient treatment years. Deaths after leaving service: NOB: 2.24/100 years of information, BOP: 0.63/100 years of information. However, mortality for previously BMT-patients increased by 450% to 5.90/100 years of information. DISCUSSION BMT patients had longer treatment retention than NOB or BOP and lower mortality than NOB patients. It is unlikely that patients had access to prescribed benzodiazepines on leaving the service because of restrictions in the national guidelines but co-dependent patients are a high-risk group who may stand to gain most benefit from opiate substitution treatment if combined with benzodiazepine-maintenance.
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Darker CD, Sweeney BP, Barry JM, Farrell MF, Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Database Syst Rev 2015; 2015:CD009652. [PMID: 26106751 PMCID: PMC11023022 DOI: 10.1002/14651858.cd009652.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Benzodiazepines (BZDs) have a sedative and hypnotic effect upon people. Short term use can be beneficial but long term BZD use is common, with several risks in addition to the potential for dependence in both opiate and non-opiate dependent patients. OBJECTIVES To evaluate the effectiveness of psychosocial interventions for treating BZD harmful use, abuse or dependence compared to pharmacological interventions, no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL- the Cochrane Library issue 12, 2014) which includes the Cochrane Drugs and Alcohol Group Specialized Register; PubMed (from 1966 to December 2014); EMBASE (from 1988 to December 2014); CINAHL Cumulative Index to Nursing and AlliedHealth Literature (1982 to September 2013); PsychINFO (1872 to December 2014); ERIC (Education Resources Information Centre, (January 1966 to September 2013); All EBM Reviews (1991 to September 2013, Ovid Interface); AMED (Allied & Alternative Medicine) 1985 to September 2013); ASSIA (Applied Social Sciences Index & Abstracts (1960 to September 2013); LILACS (January 1982 to September 2013);Web of Science (1900 to December 2014);Electronic Grey Literature Databases: Dissertation Abstract; Index to Theses. SELECTION CRITERIA Randomised controlled trials examining the use of a psychosocial intervention to treat BZDs versus pharmacological interventions,no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures outlined in Cochrane Guidelines. MAIN RESULTS Twenty-five studies including 1666 people met the inclusion criteria. The studies tested many different psychosocial interventions including cognitive behavioural therapy (CBT) (some studies with taper, other studies with no taper), motivational interviewing (MI),letters to patients advising them to reduce or quit BZD use, relaxation studies, counselling delivered electronically and advice provided by a general practitioner (GP). Based on the data obtained, we performed two meta-analyses in this Cochrane review: one assessing the effectiveness of CBT plus taper versus taper only (575 participants), and one assessing MI versus treatment as usual (TAU) (80 participants).There was moderate quality of evidence that CBT plus taper was more likely to result in successful discontinuation of BZDs within four weeks post treatment compared to taper only (Risk ratio (RR) 1.40, 95% confidence interval (CI) 1.05 to 1.86; nine trials, 423 participants) and moderate quality of evidence at three month follow-up (RR 1.51, 95% CI 1.15 to 1.98) in favour of CBT (taper)for 575 participants. The effects were less certain at 6, 11, 12, 15 and 24 months follow-up. The effect of CBT on reducing BZDs by> 50% was uncertain for all time points examined due to the low quality evidence. There was very low quality evidence for the effect on drop-outs at any of the time intervals; post-treatment (RR 1.05, 95% CI 0.66 to 1.66), three month follow-up (RR 1.71, 95% CI0.16 to 17.98) and six month follow-up (RR 0.70, 95% CI 0.17 to 2.88).Based on the very low quality of evidence available, the effect of MI versus TAU for all the time intervals is unclear; post treatment(RR 4.43, 95% CI 0.16 to 125.35; two trials, 34 participants), at three month follow-up (RR 3.46, 95% CI 0.53 to 22.45; four trials,80 participants), six month follow-up (RR 0.14, 95% CI 0.01 to 1.89) and 12 month follow-up (RR 1.25, 95% CI 0.63 to 2.47).There was very low quality of evidence to determine the effect of MI on reducing BZDs by > 50% at three month follow-up (RR 1.52,95% CI 0.60 to 3.83) and 12 month follow-up (RR 0.87, 95% CI 0.52 to 1.47). The effects on drop-outs from treatment at any of e time intervals between the two groups were uncertain due to the wide CIs; post-treatment (RR 0.50, 95% CI 0.04 to 7.10), three month follow-up (RR 0.46, 95% CI 0.06 to 3.28), six month follow-up (RR 8.75, 95% CI 0.61 to 124.53) and 12 month follow-up(RR 0.42, 95% CI 0.02 to 7.71).The following interventions reduced BZD use - tailored GP letter versus generic GP letter at 12 month follow-up (RR 1.70, 95%CI 1.07 to 2.70; one trial, 322 participants), standardised interview versus TAU at six month follow-up (RR 13.11, 95% CI 3.25 to 52.83; one trial, 139 participants) and 12 month follow-up (RR 4.97, 95% CI 2.23 to 11.11), and relaxation versus TAU at three month follow-up (RR 2.20, 95% CI 1.23 to 3.94).There was insufficient supporting evidence for the remaining interventions.We performed a 'Risk of bias' assessment on all included studies. We assessed the quality of the evidence as high quality for random sequence generation, attrition bias and reporting bias; moderate quality for allocation concealment, performance bias for objective outcomes, and detection bias for objective outcomes; and low quality for performance bias for subjective outcomes and detection bias for subjective outcomes. Few studies had manualised sessions or independent tests of treatment fidelity; most follow-up periods were less than 12 months.Based on decisions made during the implementation of protocol methods to present a manageable summary of the evidence we did not collect data on quality of life, self-harm or adverse events. AUTHORS' CONCLUSIONS CBT plus taper is effective in the short term (three month time period) in reducing BZD use. However, this is not sustained at six months and subsequently. Currently there is insufficient evidence to support the use of MI to reduce BZD use. There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus TAU, and relaxation versus TAU could be effective for BZD reduction. There is currently insufficient evidence for other approaches to reduce BZD use.
Collapse
Affiliation(s)
- Catherine D Darker
- Department of Public Health & Primary Care, Trinity College Dublin, Dublin, Ireland.
| | | | | | | | | |
Collapse
|
8
|
Schuman-Olivier Z, Hoeppner BB, Weiss RD, Borodovsky J, Shaffer HJ, Albanese MJ. Benzodiazepine use during buprenorphine treatment for opioid dependence: clinical and safety outcomes. Drug Alcohol Depend 2013; 132:580-6. [PMID: 23688843 PMCID: PMC3916951 DOI: 10.1016/j.drugalcdep.2013.04.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 04/02/2013] [Accepted: 04/04/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prescribing benzodiazepines during buprenorphine treatment is a topic of active discussion. Clinical benefit is unclear. Overdose, accidental injury, and benzodiazepine misuse remain concerns. We examine the relationship between benzodiazepine misuse history, benzodiazepine prescription, and both clinical and safety outcomes during buprenorphine treatment. METHODS We retrospectively examined outpatient buprenorphine treatment records, classifying patients by past-year benzodiazepine misuse history and approved benzodiazepine prescription at intake. Primary clinical outcomes included 12-month treatment retention and urine toxicology for illicit opioids. Primary safety outcomes included total emergency department (ED) visits and odds of an ED visit related to overdose or accidental injury during treatment. RESULTS The 12-month treatment retention rate for the sample (N=328) was 40%. Neither benzodiazepine misuse history nor benzodiazepine prescription was associated with treatment retention or illicit opioid use. Poisson regressions of ED visits during buprenorphine treatment revealed more ED visits among those with a benzodiazepine prescription versus those without (p<0.001); benzodiazepine misuse history had no effect. The odds of an accidental injury-related ED visit during treatment were greater among those with a benzodiazepine prescription (OR: 3.7, p<0.01), with an enhanced effect among females (OR: 4.7, p<0.01). Overdose was not associated with benzodiazepine misuse history or prescription. CONCLUSIONS We found no effect of benzodiazepine prescriptions on opioid treatment outcomes; however, benzodiazepine prescription was associated with more frequent ED visits and accidental injuries, especially among females. When prescribing benzodiazepines during buprenorphine treatment, patients need more education about accidental injury risk. Alternative treatments for anxiety should be considered when possible, especially among females.
Collapse
Affiliation(s)
- Zev Schuman-Olivier
- Harvard Medical School, United States; Massachussets General Hospital, United States.
| | - Bettina B. Hoeppner
- Harvard Medical School, United States,Massachussets General Hospital, United States
| | - Roger D. Weiss
- Harvard Medical School, United States,McLean Hospital, United States
| | - Jacob Borodovsky
- Tufts University, United States,Cambridge Health Alliance, United States
| | - Howard J. Shaffer
- Harvard Medical School, United States,Cambridge Health Alliance, United States
| | - Mark J. Albanese
- Harvard Medical School, United States,Cambridge Health Alliance, United States
| |
Collapse
|
9
|
Hawkins EJ, Malte CA, Imel ZE, Saxon AJ, Kivlahan DR. Prevalence and trends of benzodiazepine use among Veterans Affairs patients with posttraumatic stress disorder, 2003-2010. Drug Alcohol Depend 2012; 124:154-61. [PMID: 22305658 DOI: 10.1016/j.drugalcdep.2012.01.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/04/2012] [Accepted: 01/07/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although the Veterans Affairs and Department of Defense (VA/DoD) clinical guidelines for management of posttraumatic stress disorder (PTSD) recommend against routine benzodiazepine use, little is known about the trends and clinical and prescription profiles of benzodiazepine use since these guidelines were released in 2004. METHODS This retrospective study included 64,872 patients with a PTSD diagnosis received from care at facilities in VA Northwest Veterans Integrated Service Network (VISN 20) during 2003-2010. Annual prevalence of any use was defined as any prescription for benzodiazepines, and long-term use was defined as >90 days' supply, in a year. Gender-specific logistic regressions were fit to estimate any and long-term benzodiazepine use, test for linear trends over 8-years and explore factors associated with trends. RESULTS The trend of age-adjusted benzodiazepine use over 8-years rose significantly from 25.0 to 26.8% among men and 31.2 to 38.8% among women. Long-term use in men and women increased from 15.4 to 16.4% and 18.0 to 22.7%, respectively. Comorbid psychiatric and alcohol use disorders (AUD) were associated with a greater increase in long-term use of benzodiazepines. In 2010, 61% of benzodiazepine users received >90 days' supply. Among those prescribed benzodiazepines long-term, 11% had AUD and 47% were also prescribed opioids long-term. CONCLUSION Despite VA/DoD clinical guidelines recommending against routine use of benzodiazepines for PTSD, the adjusted prevalence of long-term use increased among men and women with PTSD in VISN 20. Widespread concomitant use of benzodiazepines and opioids suggests risk management systems and research on the efficacy and safety of these medications are needed.
Collapse
Affiliation(s)
- Eric J Hawkins
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA 98108, United States.
| | | | | | | | | |
Collapse
|
10
|
|
11
|
Darker CD, Sweeney BP, Barry JM, Farrell MF. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009652] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
12
|
Abstract
AIMS To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010. METHODS A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse. RESULTS Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized. CONCLUSIONS The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.
Collapse
Affiliation(s)
- Malcolm Lader
- Addiction Research Centre, Institute of Psychiatry, King's College London, London, UK.
| |
Collapse
|
13
|
Affiliation(s)
- Michael Liebrenz
- Research Group on Substance Use Disorders, Psychiatric University Hospital Zurich, Zürich, Switzerland.
| | | | | | | |
Collapse
|