Does routine screening for benzodiazepines help to diagnose dependence in psychiatric inpatients?

Psychoactive substance use among patients admitted to an acute psychiatric ward: laboratory findings and associations with clinical characteristics

BACKGROUND

Estimates of psychoactive substance use among acutely admitted psychiatric patients vary among studies, and few have used comprehensive laboratory methods.

AIMS

This study used chromatography-based analyses of blood and urine to identify the rates of substance use among acute psychiatric admissions, and to study the associations with socio-demographic variables, clinical characteristics and patients' reports of symptoms, substance use and need for treatment.

METHODS

A cross-sectional study was conducted in 2006/2007 in Oslo, Norway. Blood and urine samples were collected from 298 acute psychiatric admissions and extensively analysed for alcohol, medicinal and illicit drugs. Psychotic symptoms were assessed with the positive subscale of the Positive and Negative Syndrome Scale. Patient self-report questionnaires included the Alcohol and Drug Use Disorder Identification Tests. Patients were also asked if they needed professional help for substance use.

RESULTS

Psychoactive substances were detected in 63% of the 298 admissions, medicinal drugs in 46%, alcohol in 12% and illicit drugs in 28%. Patients using alcohol had a high suicidal risk score at admission and the shortest length of stay (median 1 day). Use of illicit drugs was associated with psychotic symptoms and readmission. Self-report questionnaires indicated harmful use of alcohol for half of the patients and of other substances for one-third. A need for professional help for substance use was reported by one-third of patients.

CONCLUSION

Given the high rates of substance use and the important clinical associations, drug screening seems warranted in acute psychiatric settings. Interventions designed for substance-using patients should be developed and integrated.

Anxiolytic and hypnotic use in 376 psychiatric inpatients. GERMED Neuropsychotropics Group

This objectives of this study were three-fold: retrospectively evaluate anxiolytic/hypnotic consumption by psychiatric inpatients, identify the risk factors of prolonged intakes, and prospectively measure the impact of hospitalisation on the use of those drugs. Three hundred and seventy-six patients hospitalised in 11 psychiatric departments in the Paris region were studied using a structured interview for the anxiolytic/hypnotic treatments, DSM-III-R criteria, GHQ-12, HAD, Spiegel's questionnaire, COVI's anxiety scale and the CGI. Eighty-five per cent of the patients had taken one anxiolytic/hypnotic or more in the 3 months preceding hospitalisation. Hospitalisation induced little change in anxiolytic/hypnotic use: dosage frequency increased from 77% to 84% between the week preceding hospitalisation and that preceding discharge; 26% of consumers were taking at least two anxiolytics or two hypnotics in the first period vs. 23% in the second. The absence of withdrawal during hospitalisation was related to the high age and a diagnosis of depression rather than schizophrenia, to the existence of continuous intake over the 3 months preceding hospitalisation and to higher drug doses during the 7 days preceding hospitalisation. Prescription of treatment at the end of hospitalisation in previously non-user subjects was related to a higher HAD anxiety score at discharge.

High prevalence of benzodiazepine dependence in out-patient users, based on the DSM-III-R and ICD-10 criteria

Despite the fact that there have been many reports on benzodiazepine (BZD) dependence, consensus about its definition has not been reached. Reliable prevalence data to estimate the dependence liability of BZDs are therefore lacking. This study is the first to assess the prevalence of BZD dependence in out-patient BZD users (115-general practice (GP) patients, 124 psychiatric out-patients and 33 self-help patients) on the basis of the DSM-III-R and ICD-10 substance dependence criteria. Past year and lifetime diagnoses of BZD dependence were made by means of the Schedules for Clinical Assessments in Neuropsychiatry (SCAN). High prevalence figures were found, ranging from 40% in the GP patients (DSM-III-R past year) to 97% in the self-help patients (ICD-10 lifetime), indicating that BZD users run a high risk of developing BZD dependence. The clinical management of BZD use could benefit from further development of diagnostic instruments such as a self-report questionnaire which reflects the severity of BZD dependence.

Abuse liability of flunitrazepam

Flunitrazepam is among the most frequently prescribed hypnotics in many countries. Although it was never marketed in the United States, flunitrazepam, in recent years, has been smuggled into the country, and reports of abuse--including alleged use of the drug to facilitate "date rape"--have attracted a great deal of scrutiny. It has been suggested that flunitrazepam may have greater liability for abuse than other benzodiazepines; such suggestions are supported by surveys of opioid abusers, many of whom report a distinct preference for flunitrazepam over other benzodiazepines. Experimental studies of animals and normal human subjects indicate that, although flunitrazepam has high efficacy and is very potent, it is pharmacologically similar to most other benzodiazepines. Although the studies are limited in number and scope, the data show no apparent differences between flunitrazepam and other benzodiazepines in ability to produce drug-taking or drug-seeking behavior, in capacity to produce physiologic dependence, nor in the characteristics of withdrawal after administration of an antagonist or discontinuation of treatment. Similar to other benzodiazepines, flunitrazepam produces dose-dependent effects on psychomotor performance and recall. Flunitrazepam does not seem to be involved in medical emergencies more often than other benzodiazepines, and there is no indication that flunitrazepam is more toxic than other benzodiazepines when taken in overdose by drug abusers or other individuals. Survey research among typical patient populations suggests that flunitrazepam is characteristic of benzodiazepines in that it is used appropriately and conservatively, with low liability for abuse. Thus the reported preference for flunitrazepam among opioid abusers seems to be the only way in which flunitrazepam is distinguished from other benzodiazepines; it is unclear what characteristics of the drug may be responsible for this reported preference. The evidence considered in this review indicates that abuse of flunitrazepam in this special population is not associated with any distinctive threats to the health of the general public.

Psychiatric diagnoses and perceived health problems in a sample of working Swedes treated with psychoactive medications

Findings of formal and subjective mental health problems among Swedish employees are presented as well as reviews of current Swedish policies on substance abuse and drug screening in the workplace. The focus is on the potential violation of medical confidentiality for employees with legitimate psychoactive drug medications and the lack of evidence linking the detection of various substances with impaired work performance. Data are drawn from a study of a sample of working Swedes, which revealed that approximately 3% reported taking psychoactive medications regularly. This was correlated with increases in long-term sick leave, periods of unemployment, and frequent job changes by both sexes. These workers also scored high for neuroticism, and had high rates of inpatient psychiatric treatment and suicide. With these high rates of formal mental health problems among employees who self-medicate with psychoactive drugs, discriminatory personnel management, including drug screening, jeopardizes confidentiality of treatment and civil rights.