Challenges of the pharmacological management of benzodiazepine withdrawal, dependence, and discontinuation

Anxiolytic effects of N-(4,5-dihydro-5-oxo-1,2-dithiolo-[4,3,b]-pyrrole-6-yl)-N-methylformamide, a pyrroloformamide isolated from a marine Streptomyces sp., in adult zebrafish by the 5-HT system

General anxiety disorders are among the most prevalent mental health problems worldwide. The emergence and development of anxiety disorders can be due to genetic (30-50%) or non-genetic (50-70%) factors. Despite medical progress, available pharmacotherapies are sometimes ineffective or can cause undesirable side effects. Thus, it becomes necessary to discover new safe and effective drugs against anxiety. This study evaluated the anxiolytic effect in adult zebrafish (Danio rerio) of a natural pyrroloformamide (PFD), N-(4,5-dihydro-5-oxo-1,2-dithiolo-[4,3,b]-pyrrole-6-yl)-N-methylformamide, isolated from a Streptomyces sp. bacterium strain recovered from the ascidian Eudistoma vannamei. The complete structure of PFD was determined by a detailed NMR analysis, including 1H-13C and 1H-15N-HBMC data. In addition, conformational and DFT computational studies also were performed. A group of fishes (n = 6) was treated orally with PFD (0.1, 0.5 and 1.0 mg/mL; 20 μL) and subjected to locomotor activity and light/dark tests, as well as, acute toxicity 96 h. The involvement of the GABAergic and serotonergic (5-HT) systems was investigated using flumazenil (a silent modulator of GABA receptor) and 5-HT1, 5-HT2A/2C and 5-HTR3A/3B receptors antagonists, known as pizotifen, granisetron and cyproheptadine, respectively. PFD was nontoxic, reduced locomotor activity and promoted the anxiolytic effect in zebrafish. Flumazenil did not inhibit the anxiolytic effect of the PFD via the GABAergic system. This effect was reduced by a pretreatment with pizotifen and granisetron, and was not reversed after treatment with cyproheptadine. Molecular docking and dynamics studies confirmed the interaction of PFD with the 5-HT receptor.Communicated by Ramaswamy H. Sarma.

Inhibition of fatty acid binding protein-5 in the basolateral amygdala induces anxiolytic effects and accelerates fear memory extinction

RATIONALE

The endocannabinoid (eCB) system critically controls anxiety and fear-related behaviours. Anandamide (AEA), a prominent eCB ligand, is a hydrophobic lipid that requires chaperone proteins such as Fatty Acid Binding Proteins (FABPs) for intracellular transport. Intracellular AEA transport is necessary for degradation, so blocking FABP activity increases AEA neurotransmission.

OBJECTIVE

To investigate the effects of a novel FABP5 inhibitor (SBFI-103) in the basolateral amygdala (BLA) on anxiety and fear memory.

METHODS

We infused SBFI-103 (0.5 μg-5 μg) to the BLA of adult male Sprague Dawley rats and ran various anxiety and fear memory behavioural assays, neurophysiological recordings, and localized molecular signaling analyses. We also co-infused SBFI-103 with the AEA inhibitor, LEI-401 (3 μg and 10 μg) to investigate the potential role of AEA in these phenomena.

RESULTS

Acute intra-BLA administration of SBFI-103 produced strong anxiolytic effects across multiple behavioural tests. Furthermore, animals exhibited acute and long-term accelerated associative fear memory extinction following intra-BLA FABP5 inhibition. In addition, BLA FABP5 inhibition induced strong modulatory effects on putative PFC pyramidal neurons along with significantly increased gamma oscillation power. Finally, we observed local BLA changes in the phosphorylation activity of various anxiety- and fear memory-related molecular biomarkers in the PI3K/Akt and MAPK/Erk signaling pathways. At all three levels of analyses, we found the functional effects of SBFI-103 depend on availability of the AEA ligand.

CONCLUSIONS

These findings demonstrate a novel intra-BLA FABP5 signaling mechanism regulating anxiety and fear memory behaviours, neuronal activity states, local anxiety-related molecular pathways, and functional AEA modulation.

300-fold higher neuro- and immunotoxicity from low-redox transformation of carbamazepine

Current challenges in (eco)toxicology are in understanding the transformation of (reactive) substances, and how transformation affects toxic modes of action. Empirical assessment of transformation products of, practically an infinite number of substances, via experimentation, is impossible. Predicting transformation products for (benchmarking) compounds from conditions, facilitates risk analyses. This study applied calculus to predict transformation products of an important environmental and medicinal/toxicological marker, carbamazepine. As radicals are ubiquitous in humans and the environment, we looked into radical-mediated transformations of carbamazepine as a benchmark. We calculated proportions of their speciation states as function of redox conditions, which we took as pH and O2 concentration, describing transformation via covalent and ionic interactions. Formation of ring-contracted products with neuro-immunological activity is thermodynamically favored under anaerobic conditions and at low pH. Experimentally observed product distributions and toxicities reflect that pattern. Our predictive method may support toxicity predictions for other substances and conditions 'similar' to the current case study via interpolation. This paves the way for a more coherent, effective and easier risk assessment of transformation products.

Rhabdomyolysis in the Context of Designer Benzodiazepine Misuse

Designer benzodiazepines belong to a class of lab-created psychoactive compounds, with limited federal regulation, no toxicity testing, and reported high potency, leading to substantial overdose risk and harmful clinical syndromes. Benzodiazepine misuse has been previously documented to be associated with rhabdomyolysis, with elevated creatine kinase (CK) during and after acute episodes of intoxication. Here, we present a case of profound rhabdomyolysis and associated acute kidney injury (AKI) after acute designer benzodiazepine intoxication. A 26-year-old male with a history of poly-substance misuse, including alcohol, psychedelics, opiates, kratom, and benzodiazepines, presented to the emergency department with altered mental status and agitation after an accidental overdose on liquid flubromazolam and clonazolam, designer benzodiazepines purchased online. He went on to develop seizure-like activity. Additional labs revealed AKI with creatinine 2.22 mg/dL (reference 0.74-1.35 mg/dL, baseline 0.88 mg/dL). He was discovered to have severe rhabdomyolysis that peaked at 131,920 U/L (reference 55-170 U/L) on the fourth day of admission. This case demonstrates the potential deleterious effects of the designer benzodiazepine class, including prolonged sedation, AKI, and severe rhabdomyolysis. In addition, seizure-like manifestations may occur during the intoxication or withdrawal phase. Designer benzodiazepines may produce rhabdomyolysis; however, the mechanism is unknown. Direct myotoxicity or prolonged immobilization may be contributors to rhabdomyolysis. More research is needed to elucidate the consequences of designer benzodiazepine misuse. Clinicians should be aware of their use given the ease of availability online and rising popularity.

Intravenous ketamine for benzodiazepine deprescription and withdrawal management in treatment-resistant depression: a preliminary report

We present the first evidence that sub-anesthetic ketamine infusions for treatment resistant depression (TRD) may facilitate deprescription of long-term benzodiazepine/z-drugs (BZDRs). Long-term BZDR prescriptions are potentially harmful yet common, partly because of challenging withdrawal symptoms. Few pharmacological interventions have evidence for facilitating BZDR discontinuation, and none in patients actively suffering from TRD. In this ambi-directional cohort study, discontinuation of long-term (>6 month) BZDRs was attempted in 22 patients with severe unipolar or bipolar TRD receiving a course of six subanesthetic ketamine infusions over four weeks. We investigated the rates of successful BZDRs deprescription, trajectories of acute psychological withdrawal symptoms, and subsequent BZDRs abstinence during a mean follow-up of 1 year (primary outcome). Clinically significant deteriorations in depression, anxiety, sleep, and/or suicidality during the acute BZDR discontinuation phase were measured by repeated standardized scales and analyzed by latent growth curve models and percent correct classification analysis. Of the 22 eligible patients, all enrolled in this study and 91% (20/22) successfully discontinued all BZDRs by the end of the 4-week intervention, confirmed by urinary analyses. Less than 25% of discontinuers experienced any significant worsening of anxiety, depression, sleep difficulties, or suicidality during treatment. During follow-up (mean [range] duration, 12 [3-24] months), 64% (14/22) of patients remained abstinent from any BZDRs. These preliminary results suggest that ketamine infusions for TRD may facilitate the deprescription of BZDRs, even in patients with active depressive symptoms and significant comorbidity. Further investigation is warranted into this potential novel application of ketamine.

Preclinical data on morpholine (3,5-di-tertbutyl-4-hydroxyphenyl) methanone induced anxiolysis

Trimetozine is used to be indicated for the treatment of mental illnesses, particularly anxiety. The present study provides data on the pharmacological profile of trimetozine derivative morpholine (3,5-di-tert-butyl-4-hydroxyphenyl) methanone (LQFM289) which was designed from molecular hybridization of trimetozine lead compound and 2,6-di-tert-butyl-hydroxytoluene to develop new anxiolytic drugs. Here, we conduct molecular dynamics simulations, docking studies, receptor binding assays, and in silico ADMET profiling of LQFM289 before its behavioral and biochemical assessment in mice within the dose range of 5-20 mg/kg. The docking of LQFM289 showed strong interactions with the benzodiazepine binding sites and matched well with receptor binding data. With the ADMET profile of this trimetozine derivative that predicts a high intestinal absorption and permeability to blood-brain barrier without being inhibited by the permeability glycoprotein, the oral administration of LQFM289 10 mg/kg consistently induced anxiolytic-like behavior of the mice exposed to the open field and light-dark box apparatus without eliciting motor incoordination in the wire, rotarod, and chimney tests. A decrease in the wire and rotarod´s fall latency coupled with an increase in the chimney test´s climbing time and a decrease in the number of crossings in the open field apparatus at the dose of 20 mg/kg of this trimetozine derivative suggest sedative or motor coordination impairment at this highest dose. The attenuation of the anxiolytic-like effects of LQFM289 (10 mg/kg) by flumazenil pretreatment implicates the participation of benzodiazepine binding sites. The lowering of corticosterone and tumor necrosis factor alpha (cytokine) in LQFM289-treated mice at a single oral (acute) dose of 10 mg/kg suggests that the anxiolytic-like effect of this compound also involves the recruitment of non-benzodiazepine binding sites/GABAergic molecular machinery.

Understanding psychosis

ABSTRACT

Psychotic behavior is often unpredictable; thus, there can be an increased risk of violence toward others and oneself. This article details the etiology and diagnosis of psychosis and nursing interventions to provide appropriate care.

Severe chronic abuse of zolpidem for over 10 years: a case report and review of similar cases

Background

Insomnia is a major health issue, and zolpidem is an effective treatment for insomnia. However, high doses of zolpidem can cause dependence, abuse, and withdrawal symptoms, questioning its advantages.

Case presentation

A 39-year-old woman who has been divorced and unemployed for 2 years was referred to an addiction treatment center with a chief complaint of "seizure-like withdrawal symptoms after consuming high doses of zolpidem (up to 6,000 mg per day) for a decade." These symptoms were in the form of body tremors, nystagmus, stress, anxiety, hot flashes, and sweaty palms. She has been undergoing detoxification by clonazepam for almost 2 months. Except for the first few days, she did not have any withdrawal symptoms, and her insomnia caused by zolpidem has improved.

Conclusion

Chronic abuse of zolpidem can cause dependence, withdrawal symptoms, and abuse. High doses can lead to extreme cravings and dependence. Physicians must manage the withdrawal process.

Effects of acupuncture on earthquake survivors with major psychiatric disorders and related symptoms: A scoping review of clinical studies

BACKGROUND

This scoping review aimed to determine the current research status of acupuncture for major psychiatric disorder (MPD) in earthquake survivors.

METHOD

We followed the scoping review process described previously. A literature search on 14 electronic databases was conducted from inception to November 29, 2022. Data from the included studies were collected and descriptively analyzed to address our research question. Extracted data were collated, synthesized, and summarized the according to the analytical framework of a scoping review.

RESULT

This scoping review included nine clinical studies: four randomized controlled trials (RCTs) and five before-after studies. The most frequent MPD type among the included acupuncture studies was posttraumatic stress disorder (PTSD; 6/9, 66.67%). The most frequent acupuncture type was scalp electro-acupuncture (4/9, 44.44%), followed by manual acupuncture and ear acupressure/ear acupuncture (3/9, 33.33%). Studies using scalp electro-acupuncture all used common acupoints, including GB20, GV20, GV24, and EX-HN1. In general, the treatment period lasted between 4 and 12 weeks. Validated assessment tools for PTSD severity and accompanying symptoms were used for patients with PTSD, while the corresponding evaluation tools were used for patients with other diagnoses or clinical symptoms. Acupuncture-related adverse events were generally mild and temporary, such as mild bleeding and hematoma, and syncope was a rare but potentially serious adverse event (1/48 patients and 1/864 sessions over a treatment period of 4 weeks).

CONCLUSION

Acupuncture studies for MPD after an earthquake mainly focused on PTSD. RCTs accounted for around half of the included studies. Scalp electro-acupuncture was the most common acupuncture type, and EX-HN1 and GV24 were the most important acupoints in the acupuncture procedures for MPD. The included studies mostly used validated symptom assessment tools, though some did not. Clinical studies in this field need to be further expanded regardless of the study type.

PROTOCOL REGISTRATION

https://osf.io/wfru7/.

Chronic use of benzodiazepines: The problem that persists

Though clinical guidelines and policies discourage the chronic prescribing of benzodiazepines, rates of prescribing have continued to rise in the United States to the tune of an estimated 65.9 million office visits per year. Quietly, we have become a nation on benzodiazepines. There are numerous reasons for this discrepancy between official recommendations on the one hand, and actual clinical practice on the other. Drawing from the literature, we argue that while patients and providers both shoulder some of the responsibility, they also cannot be solely blamed. Rather, policies and guidelines regarding benzodiazepines have become out of touch with the clinical reality that benzodiazepines are now deeply entrenched in modern medicine. We propose that guidelines regarding benzodiazepines need to reconsider how to apply concepts such as harm reduction and other lessons learned in the opioid epidemic in order to help physicians manage this oft-deferred, but increasingly pressing problem affecting millions of Americans.

Application of gabapentinoids and novel compounds for the treatment of benzodiazepine dependence: the glutamatergic model

BACKGROUND

Current approaches for managing benzodiazepine (BZD) withdrawal symptoms are daunting for clinicians and patients, warranting novel treatment and management strategies. This review discusses the pharmacodynamic properties of BZDs, gabapentinoids (GBPs), endozepines, and novel GABAergic compounds associated with potential clinical benefits for BZD-dependent patients. The objective of this study was to review the complex neuromolecular changes occurring within the GABAergic and glutamatergic systems during the BZD tolerance and withdrawal periods while also examining the mechanism by which GBPs and alternative pharmacological therapies may attenuate withdrawal symptoms.

METHODS AND RESULTS

An elaborative literature review was conducted using multiple platforms, including the National Center for Biotechnology (NCBI), AccessMedicine, ScienceDirect, pharmacology textbooks, clinical trial data, case reports, and PubChem. Our literature analysis revealed that many distinctive neuroadaptive mechanisms are involved in the GABAergic and glutamatergic systems during BZD tolerance and withdrawal. Based on this data, we hypothesize that GBPs may attenuate the overactive glutamatergic system during the withdrawal phase by an indirect presynaptic glutamatergic mechanism dependent on the α₂δ₁ subunit expression.

CONCLUSIONS

GBPs may benefit individuals undergoing BZD withdrawal, given that the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor current significantly increases during abrupt BZD withdrawal in animal studies. This may be a conceivable explanation for the effectiveness of GBPs in treating both alcohol withdrawal symptoms and BZD withdrawal symptoms in some recent studies. Finally, natural and synthetic GABAergic compounds with unique pharmacodynamic properties were found to exert potential clinical benefits as BZD substitutes in animal studies, though human studies are lacking.

Effect of acupuncture on patients with major psychiatric disorder and related symptoms caused by earthquake exposure: Protocol for a scoping review of clinical studies

Earthquakes have the greatest destructive effect among all natural disasters. Posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and anxiety disorder (AD) are major psychiatric disorders (MPD) that can be triggered by exposure to earthquakes. Conventional treatments such as pharmacological treatments have several limitations. Acupuncture therapy as a complementary integrative medicine may be an effective alternative treatment for these limitations. This study aimed to identify the status of the clinical evidence regarding acupuncture therapy for earthquake survivors with MPD. We will follow the scoping review process as previously described. The study question is as follows: "Which types of clinical research designs, study types, study durations, adverse events, and clinical outcomes have been reported regarding acupuncture therapy for MPD in earthquake survivors?" Medline, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, PsycArticles databases, and Chinese, Korean, and Japanese databases will be comprehensively searched electronically from their inception to November 2022. Data from the included studies will be collected and descriptively analyzed in relation to our research question. We will collate, synthesize, and summarize the extracted data according to the analytical framework of a scoping review. The protocol will conform with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extensions of Scoping Reviews to ensure the clarity and completeness of our reporting in the whole phase of the scoping review (Protocol registration: https://osf.io/wfru7/). The findings of this scoping review will provide fundamental data that will help researchers identify appropriate research questions and design further studies on the use of acupuncture for MPD management in earthquake survivors. These results will be helpful for developing disaster site-specific research protocols for future clinical trials on this topic.

Effect of discontinuation of lemborexant following long-term treatment of insomnia disorder: Secondary analysis of a randomized clinical trial

Discontinuing long-term pharmacotherapy for insomnia can result in rebound insomnia or withdrawal symptoms and suboptimal treatment. Post hoc analyses evaluated rebound insomnia and withdrawal symptoms among the subset of subjects from a phase III, 12-month, global, multicenter, randomized, double-blind, parallel-group study who completed 12 or 6 months of active treatment and follow-up period. Study E2006-G000-303 (Study 303) included adults (N = 655) with subjective sleep-onset latency ≥30 min and/or subjective wake-after-sleep onset ≥60 min at least three times weekly during the 4 weeks before enrollment. Subjects were randomized 1:1:1 to lemborexant 5 mg (LEM5) or 10 mg (LEM10) or placebo for 6 months. Thereafter, for an additional 6 months, LEM5- and LEM10-treated subjects continued lemborexant and the placebo group was rerandomized 1:1 to LEM5 or LEM10. Month 12 was followed by abrupt discontinuation and a 2-week end-of-study follow-up. Using daily electronic sleep diaries, patients reported (subjective) sleep end points (sleep-onset latency, wake-after-sleep onset, sleep efficiency, and total sleep time). Withdrawal symptoms were assessed using the Tyrer Benzodiazepine Withdrawal Symptoms Questionnaire (T-BWSQ). Sleep outcome improvements with lemborexant at month 12 were generally maintained throughout the 2-week off-treatment period wherein <20% of subjects experienced significant worsening of insomnia symptoms versus screening. There was no evidence of withdrawal symptoms by T-BWSQ following lemborexant discontinuation. This analysis demonstrates rebound insomnia is unlikely to occur with lemborexant, and its effectiveness is maintained after abrupt discontinuation without placebo replacement following 6-12 months of treatment.

Pharmacopuncture Effects on Insomnia Disorder: Protocol for a Multi-Site, Randomized, Acupuncture-Controlled, Clinical Trial

Insomnia is a common health problem that can lead to various diseases and negatively impact quality of life. Pharmacopuncture is a new type of acupuncture that involves applying herbal medicine extracts to acupoints. Korean medicine doctors frequently use it to treat insomnia disorder. However, there is insufficient evidence to support the effectiveness and safety of pharmacopuncture for insomnia disorder. We designed a pragmatic randomized controlled trial to compare the effectiveness of pharmacopuncture and acupuncture for insomnia disorder. This multi-site, randomized, acupuncture-controlled trial will enroll 138 insomnia patients. The subjects will be randomly assigned to one of two groups, pharmacopuncture or acupuncture, at a 2:1 ratio. For 4 weeks, the participants will receive ten sessions of pharmacopuncture or acupuncture treatment and will be followed up for 4 weeks after the treatment ends. The Pittsburgh Sleep Quality Index score is the primary outcome measure. Insomnia severity index score, sleep parameters recorded using actigraphy and sleep diaries, physical symptoms associated with insomnia, emotions, quality of life, medical costs, and safety are the secondary outcome measures. The findings of this trial willprovide evidence that will be useful in clinical decision-making for insomnia treatment strategies.

Benzodiazepine Modulation of GABAA Receptors: A Mechanistic Perspective

Benzodiazepines (BZDs) are a class of widely prescribed psychotropic drugs that target GABA_A receptors (GABA_ARs) to tune inhibitory synaptic signaling throughout the central nervous system. Despite knowing their molecular target for over 40 years, we still do not fully understand the mechanism of modulation at the level of the channel protein. Nonetheless, functional studies, together with recent cryo-EM structures of GABA_A(α1)₂(βX)₂(γ2)₁ receptors in complex with BZDs, provide a wealth of information to aid in addressing this gap in knowledge. Here, mechanistic interpretations of functional and structural evidence for the action of BZDs at GABA_A(α1)₂(βX)₂(γ2)₁ receptors are reviewed. The goal is not to describe each of the many studies that are relevant to this discussion nor to dissect in detail all the effects of individual mutations or perturbations but rather to highlight general mechanistic principles in the context of recent structural information.

Revelatory Anxiety and Dissociative Disorders: An Existential-Humanistic Approach

This article argues that an existential-humanistic approach to anxiety provides crucial insight to certain dissociative disorders, namely, depersonalization/derealization disorder (DPR/DRZ). Although reports suggest that nearly 200,000 people in the United States experience DPR/DRZ episodes each day, DPR/DRZ has remained understudied and misunderstood by the psychiatric community. This article argues that an existential-humanistic approach to the disorder informed by the work of Sartre, Heidegger, and May allows DPR/DRZ sufferers to understand their dissociative episodes as ontological engagements with the human condition that provides a shared sense of being-in-the-world. As rates of anxiety disorders continue to reach unprecedented levels and treatment plans have become increasingly equated with medication, the second portion of this article argues that an existential-humanistic approach might produce better therapeutic results while allowing DPR/DRZ sufferers to generate meaning out of their anxiety. The argument extends outside of the therapeutic setting and suggests that existential modes of thinking can be employed by the broader public when dealing with everyday experiences of anxiety.

Midazolam nasal spray to treat intermittent, stereotypic episodes of frequent seizure activity: pharmacology and clinical role, a comprehensive review

An intranasal formulation of midazolam, Nayzilam, has been FDA-approved to treat intermittent, stereotypic episodes of frequent seizure activity. Nayzilam is easy to administer and can quickly treat seizures that occur outside of the hospital. The intra-nasal route of administration allows non-medical personal to administer the drug which makes it more accessible and user-friendly in the event of a seizure. Many studies have indicated quick cessation of seizures with Nayzilam compared to rectal diazepam, which has been the standard of care treatment. Nayzilam has been proven to be safe and effective for acute seizures in children, deeming it a revolutionary alternative in times where intravenous administration is not possible.

Daridorexant for the Treatment of Insomnia

Purpose of Review

Insomnia is a complex sleeping disorder that affects the lives of many individuals worldwide. Insomnia often occurs in the presence of coexisting comorbidities making it a complex disorder that requires a multifactorial approach to therapy. First-line therapy is cognitive-behavioral therapy for insomnia (CBT-I). Pharmacotherapy for insomnia falls into four classes based on mechanism of action: benzodiazepine receptor agonists (BZRAs), histamine receptor antagonists, melatonin receptor agonists, and dual orexin receptor antagonists (DORAs).

Recent Findings

Daridorexant is a dual orexin type 1 and types 2 (OX₁ and OX₂) receptor antagonist that was recently approved by the US FDA for the treatment of adults suffering from insomnia. It was shown to be effective in reducing insomnia symptoms, increasing daytime functioning, and improving the overall quality of sleep. Daridorexant offers patients relief from insomnia while avoiding the severe side effects and dependency issues of traditional treatments like benzodiazepines and sedatives.

Summary

In this article, we review the most recent data on insomnia treatments and summarize the safety and efficacy of daridorexant in treating insomnia.

Phenobarbital use in benzodiazepine and z-drug detoxification: a single-centre 15-year observational retrospective study in clinical practice

Given the increase in benzodiazepine (BZD) and Z-drug (ZD) use disorder, this study described the use of phenobarbital (PHB) as detoxification in clinical practice. A 15-year observational retrospective study was performed on medical records of BZD-ZD use disorder patients detoxified with PHB at the Toxicology Unit and Poison Centre, Careggi University Hospital, Florence (Italy). A multivariate logistic regression was used to estimate odd ratios (ORs) and related 95% confidence intervals (CI) of "treatment failure" considering demographic and pharmacological characteristics. "Hospitalisation length", "PHB discharge dose", and "BZD-ZD free status" at discharge were also calculated. During detoxification, out of 355 patients (57% of men), with a mean age of 42.92 years, only 20 (5.6%) treatment failures were recorded: 19 were discharged against medical advice or due to misbehaviour, and only one for PHB-related non-serious skin rash. Analysis showed a higher probability to be BZD-ZD free at discharge for subjects who reported to be employed (OR 2.29; CI 95% 1.00-5.24), for those who abused oral drops of BZD-ZD (OR 2.16, CI 1.30-3.59), and for those treated with trazodone (OR 2.86, CI 1.14-7.17) during hospital stay. A hospitalisation length of > 7 days was observed for patients with opioid maintenance therapy (OR 2.07, CI 1.20-3.58) for substance use disorder, and for those treated with more than 300 mg/day of PHB equivalents at hospital admission (OR 1.68, CI 1.03-2.72). Our results suggested that PHB can be considered a valuable detoxification option for different types of BZD and ZD use disorder patients.

A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder

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.

Concomitant Brain Injury and Spinal Cord Injury Management Strategies: A Narrative Review

Spinal cord injury (SCI) is a catastrophic event with multiple comorbidities including spastic paralysis, sensory loss, autonomic dysfunction with sympathetic blunting, neurogenic orthostatic hypotension, neurogenic restrictive and obstructive lung disease, neuropathic pain, spasticity, neurogenic bladder, neurogenic bowel, immobilization hypercalcemia, osteopenia/osteoporosis, neurogenic obesity, and metabolic dysfunction. Cervical and thoracic SCI is all too often accompanied by traumatic brain injury (TBI), which carries its own set of comorbidities including headaches, seizures, paroxysmal sympathetic hyperactivity, aphasia, dysphagia, cognitive dysfunction, memory loss, agitation/anxiety, spasticity, bladder and bowel incontinence, and heterotopic ossification. This manuscript will review the etiology and epidemiology of dual diagnoses, assessment of both entities, and discuss some of the most common comorbidities and management strategies to optimize functional recovery.

A double-blind randomised crossover trial of low-dose flumazenil for benzodiazepine withdrawal: A proof of concept

INTRODUCTION

Benzodiazepines (BZD) are a class of anxiolytics with varying uses, which primarily act on the GABA_A 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 GABA_A 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.

Systematic review of guidelines for managing physical health during treatment for substance use disorders: Implications for the alcohol and other drug workforce

ISSUES

Substance use disorders are associated with significant physical health comorbidities, necessitating an integrated treatment response. However, service fragmentation can preclude the management of physical health problems during addiction treatment. The aim of this systematic review was to synthesise the recommendations made by clinical practice guidelines for addressing the physical health of people attending alcohol and other drug (AOD) treatment.

APPROACH

An iterative search strategy of grey literature sources was conducted from September 2020 to February 2021 to identify clinical practice guidelines. Content pertaining to physical health care during AOD treatment was extracted. Quality of guidelines were appraised using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) tool.

FINDINGS

Thirty-three guidelines were included for review. Fourteen guidelines were considered high quality based on AGREE-II scores. Neurological conditions (90.9%) and hepatitis (81.8%) were the most frequent health problems addressed. Most guidelines recommended establishing referral pathways to address physical health comorbidities (90.9%). Guidance on facilitating these referral pathways was less common (42.4%). Guidelines were inconsistent in their recommendations related to oral health, tobacco use, physical activity, nutrition and the use of standardised assessment tools.

IMPLICATIONS AND CONCLUSIONS

Greater consistency and specificity in the recommendations made for integrating physical health care within addiction treatment is needed. Ensuring that recommendations are applicable to the AOD workforce and to treatment services limited by funding and resource constraints should enhance implementation. Future guideline development groups should consider increased consultation with the AOD workforce and inclusion of clinical tools and decision aids to facilitate referral pathways.

Discontinuation of chronic benzodiazepine use in primary care: a nonrandomized intervention

BACKGROUND

Chronic benzodiazepine use is a challenge in primary care practice. Protocols to support safe discontinuation are still needed, especially in countries with high utilization rates.

OBJECTIVES

To evaluate the feasibility, effectiveness, and safety of a benzodiazepine discontinuation protocol in primary care setting.

METHODS

Nonrandomized, single-arm interventional study, at primary care units. Family physicians (FPs) recruited patients (18-85 years-old) with benzodiazepine dependence and chronic daily use ≥3 months. Patients with daily dosages ≥30 mg diazepam-equivalent, taking zolpidem, with a history of other substance abuse or major psychiatric disease were excluded. After the switch to diazepam, the dosage was gradually tapered according to a standardized protocol. Primary endpoint was the percentage of patients who stopped benzodiazepine at the intervention last visit. Dosage reduction, withdrawal symptoms, patients' and FPs' satisfaction with the protocol were evaluated.

RESULTS

From 66 enrolled patients (74% female; 66.7% aged >64 years; median time of benzodiazepine use was 120 months), 2 withdrew due to medical reasons and 3 presented protocol deviations. Overall, 59.4% of participants successfully stopped benzodiazepine (60.7% when excluding protocol deviations). Men had higher probability of success (relative risk = 0.51, P = 0.001). A total of 31 patients reported at least 1 withdrawal symptom, most frequently insomnia and anxiety. Most of participating FP considered the clinical protocol useful and feasible in daily practice. Among patients completing the protocol, 77% were satisfied. For the patients who reduced dosage, 85% kept without benzodiazepines after 12 months.

CONCLUSION

The discontinuation protocol with standardized dosage reduction was feasible at primary care and showed long-term effectiveness.

GABAA receptor subtypes and benzodiazepine use, misuse, and abuse

Benzodiazepines have been in use for over half a century. While they remain highly prescribed, their unfavorable side-effect profile and abuse liability motivated a search for alternatives. Most of these efforts focused on the development of benzodiazepine-like drugs that are selective for specific GABA_A receptor subtypes. While there is ample evidence that subtype-selective GABA_A receptor ligands have great potential for providing symptom relief without typical benzodiazepine side-effects, it is less clear whether subtype-selective targeting strategies can also reduce misuse and abuse potential. This review focuses on the three benzodiazepine properties that are relevant to the DSM-5-TR criteria for Sedative, Hypnotic, or Anxiolytic Use Disorder, namely, reinforcing properties of benzodiazepines, maladaptive behaviors related to benzodiazepine use, and benzodiazepine tolerance and dependence. We review existing evidence regarding the involvement of different GABA_A receptor subtypes in each of these areas. The reviewed studies suggest that α1-containing GABA_A receptors play an integral role in benzodiazepine-induced plasticity in reward-related brain areas and might be involved in the development of tolerance and dependence to benzodiazepines. However, a systematic comparison of the contributions of all benzodiazepine-sensitive GABA_A receptors to these processes, a mechanistic understanding of how the positive modulation of each receptor subtype might contribute to the brain mechanisms underlying each of these processes, and a definitive answer to the question of whether specific chronic modulation of any given subtype would result in some or all of the benzodiazepine effects are currently lacking from the literature. Moreover, how non-selective benzodiazepines might lead to the maladaptive behaviors listed in DSM and how different GABA_A receptor subtypes might be involved in the development of these behaviors remains unexplored. Considering the increasing burden of benzodiazepine abuse, the common practice of benzodiazepine misuse that leads to severe dependence, and the current efforts to generate side-effect free benzodiazepine alternatives, there is an urgent need for systematic, mechanistic research that provides a better understanding of the brain mechanisms of benzodiazepine misuse and abuse, including the involvement of specific GABA_A receptor subtypes in these processes, to establish an informed foundation for preclinical and clinical efforts.

Benzodiazepines and Related Sedatives

Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.

Ketamine: A Potential Adjunct for Severe Benzodiazepine Withdrawal

Following the abrupt cessation of benzodiazepine therapy, patients can present with acute life-threatening withdrawal. Medical management of benzodiazepine withdrawal is typically undertaken with benzodiazepines either through loading dose with gradual taper or symptom triggered treatment, though adjuvant anxiolytics and anticonvulsants are often used. Ketamine, increasingly utilized as an adjunct in the treatment of alcohol withdrawal, may represent an effective medication in the treatment of benzodiazepine withdrawal. In this case report, a 27-year-old male with a history of benzodiazepine and opioid abuse presented to our emergency department with a chief complaint of drug withdrawal. Despite standard treatment with large amounts of benzodiazepine, barbiturate, opioid, and adjunctive medications, the patient remained with severe withdrawal syndrome until an infusion of ketamine (0.5mg/kg in 30 minutes) was administered resulting in significant improvement of the patient symptoms. This case demonstrates the potential role of ketamine as an adjunct medication in the treatment of benzodiazepine withdrawal.

Anesthetic Considerations for Patients on Psychotropic Drug Therapies

Psychotropic drugs are used in the treatment of psychiatric and non-psychiatric conditions. Many patients who are on psychotropic medications may present for procedures requiring anesthesia. Psychotropic medications can have dangerous interactions with drugs commonly used in anesthesia, some of which can be life-threatening. In this review, we describe the current anesthetic considerations for patients on psychotropic drug therapies, including antidepressants, antipsychotics, mood stabilizers, anxiolytics, and stimulants. The pharmacology, side effects, and potential drug interactions of the commonly prescribed psychotropic drug therapies with anesthetic agents are described. Further, we highlight the current recommendations regarding the cessation and continuation of these medications during the perioperative period.

Superlatives in news articles reporting non-FDA approved indications for use of cannabis and cannabis products with a focus on psychiatric disorders: a cross-sectional analysis

The exaggerated language used in news articles to describe the benefits of cannabis for conditions without FDA indications may mislead the public and healthcare providers. Thus, this study's objective was to investigate the use of exaggerated language in news articles focused on cannabis and cannabis-derived products. Using a cross-sectional study design, we searched Google News from March 3, 2020, and September 3, 2019 for 11 prespecified superlative terms along with the search terms "cannabis," "cannabidiol," "pot," "marijuana," "weed," and "CBD." Articles were evaluated for these exaggerative terms describing cannabis and cannabis-derived products along with additional news article characteristics. Screening and data extraction occurred in a masked, duplicate fashion. We identified 612 superlative terms in 374 different news articles focused on cannabis and cannabis-derived products from 262 news outlets. Only 26 (of 374, 7.0%) news articles provided clinical data. In total, superlative terms were used to describe cannabis and cannabis-derived products for the treatment of 91 medical conditions, of which only 2 are FDA approved. The most common psychiatric disorder indicated was anxiety disorder appearing in 88 news articles. Superlatives in news articles covering the treatment of psychiatric illnesses with cannabis and cannabis-derived products are common.

Benzodiazepines: Uses, Dangers, and Clinical Considerations

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.

Delayed crises following benzodiazepine withdrawal: deficient adaptive mechanisms or simple pharmacokinetics? Detoxification assisted by serum-benzodiazepine elimination tracking

Objective

Rapid relapses after successful withdrawal occur even in apparently motivated benzodiazepine (BZD)-dependent patients. Regardless of known personality or biological (re-adaptation) issues, the aim of this open-label, single-arm, seminaturalistic study was to search for any detoxification errors contributing to failures.

Methods

The data came from 350 inpatients. Based on serum-BZD evolution criteria, the procedure was divided into four stages: substitution, accumulation, elimination and post-elimination observation. After switching the patients to a long-acting substitute (diazepam), to prevent data falsification due to unwanted overaccumulation, the doses were expeditiously reduced under laboratory feedback until accumulation stopped. With the start of effective elimination, the tapering rate slowed and was individually adjusted to the patient’s current clinical state. The tracking of both serum-BZD concentration and the corresponding intensity of withdrawal symptoms was continued throughout the entire elimination phase, also following successful drug withdrawal. Detoxification was concluded only after the patient's post-elimination stabilization.

Results

Regardless of various initial serum-BZD concentration levels and the customized dose-reduction rate, and despite the novel lab-driven actions preventing initial overaccumulation, elimination was systematically proven to be protracted and varied within the 2- to 95-day range after the final dose. Within this period, withdrawal syndrome culminated several times, with varying combinations of symptoms. The last crisis occurrence (typically 2–3 weeks after withdrawal) correlated with the final serum-BZD elimination. The factors that prolonged elimination and delayed the final crisis were patient age, duration of addiction, adjunct valproate medication and elimination stage start parameters growing with former overaccumulation.

Conclusions

The low-concentration detoxification stage is critical for patients’ confrontations with recurring withdrawal symptoms. Underestimated elimination time following drug withdrawal and premature conclusions of detoxification expose patients to unassisted withdrawal crises. Concentration tracking defines proper limits for medical assistance, preventing early relapses.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03205-x.

Is there a link between the use of benzodiazepines and related drugs and dementia? A systematic review of reviews

PURPOSE

Benzodiazepines (BZDs) and related drugs (BZRDs) are commonly used to treat diverse psychiatric disorders due to their anxiolytic, hypnotic and sedative properties, despite their known associated side effects, including acute consequences on cognition. Recently, some studies have also suggested that long-term cognitive effects may coexist, as the increased risk of cognitive decline and dementia. This review aims to appraise and summarise published synthesis studies on the risk of dementia development due to BZDs/BZRDs use.

METHODS

A comprehensive systematic search was carried out in PubMed, Web of Science, Cochrane Library and Epistemonikos databases. Grey literature and hand search of the studies' reference lists were undertaken. Meta-analysis, systematic and non-systematic reviews were included. Neither language nor date restrictions were applied. Search results other than synthesis studies were excluded. The methodological quality of the included reviews was analysed with AMSTAR-2 and SANRA tools.

RESULTS

Overall, 877 records were initially retrieved and 15 complied with the inclusion criteria. From these, five were systematic reviews with meta-analysis, two were systematic reviews and eight were non-systematic reviews. Most of the primary studies included in the analysed reviews found an association between BZDs/BZRDs use and subsequent dementia, with meta-analysis studies reporting an increased risk for users (ORs ranging from 1.38 to 1.78). However, the considerable clinical and methodological heterogeneity of the primary studies makes it difficult to establish a causal relationship.

CONCLUSION

Although hampered by the heterogeneity between the studies, the present findings suggest an association between BZDs/BZRDs use and increased risk of dementia in older adults.

Fast Anxiolytic-Like Effect Observed in the Rat Conditioned Defensive Burying Test, after a Single Oral Dose of Natural Protein Extract Products

Anxiety appears among the most frequent psychiatric disorders. During recent years, a growing incidence of anxiety disorders can be attributed, at least in part, to the modification of our eating habits. To treat anxiety disorders, clinicians use benzodiazepines, which unfortunately display many side effects. Herein, the anxiolytic-like properties of two natural products (αS1–casein hydrolysate and Gabolysat^®) were investigated in rats and compared to the efficacy of benzodiazepine (diazepam). Thus, the conditioned defensive burying test was performed after a unique oral dose of 15 mg/kg, at two time-points (60 min and then 30 min post oral gavage) to show potential fast-onset of anxiolytic effect. Both natural products proved to be as efficient as diazepam to reduce the time rats spent burying the probe (anxiety level). Additionally, when investigated as early as 30 min post oral gavage, Gabolysat^® also revealed a fast-anxiolytic activity. To date, identification of bioactive peptide, as well as how they interact with the gut–brain axis to sustain such anxiolytic effect, still remains poorly understood. Regardless, this observational investigation argues for the consideration of natural compounds in care pathway.

Evaluation of risk mitigation measures for people with substance use disorders to address the dual public health crises of COVID-19 and overdose in British Columbia: a mixed-method study protocol

INTRODUCTION

The COVID-19 pandemic was preceded by an ongoing overdose crisis and linked to escalating drug overdose deaths in British Columbia (BC). At the outset of these dual public health emergencies, the BC government announced interim Risk Mitigation Guidance (RMG) that permitted prescribing medication alternatives to substances, including opioids, alcohol, stimulants and benzodiazepines, an intervention sometimes referred to as 'safe supply'. This protocol outlines the approach for a study of the implementation of RMG and its impacts on COVID-19 infection, drug-related and systemic harms, continuity of care for people with substance use disorder (SUD), as well as their behavioural, psychosocial and well-being outcomes.

METHODS AND ANALYSIS

We conducted a parallel mixed-method study that involved both analysis of population-level administrative health data and primary data collection, including a 10-week longitudinal observational study (target n=200), a cross-sectional survey (target n=200) and qualitative interviews (target n=60). We implemented a participatory approach to this evaluation, partnering with people with lived or living expertise of drug use, and researchers and public health decision-makers across the province. Linked population-level administrative databases will analyse data from a cohort of BC residents with an indication of SUD between 1996 and 2020. We will execute high-dimensional propensity score matching and marginal structural modelling to construct a control group and to assess the impact of RMG dispensation receipt on a collaboratively determined set of primary and secondary outcomes.

ETHICS AND DISSEMINATION

Study activities were developed to adhere to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, recommended COVID-19 research practices, and guided by the Truth and Reconciliation Commission's Calls to Action for public health, data governance and research ethics related to Indigenous people. Results will be disseminated incrementally, on an ongoing basis, through the consortium established for this study, then published in peer-reviewed journals.

Evaluation of Clinical Decision Support to Reduce Sedative-Hypnotic Prescribing in Older Adults

OBJECTIVE

We sought to characterize the performance of inpatient and outpatient computerized clinical decision support (CDS) alerts aimed at reducing inappropriate benzodiazepine and nonbenzodiazepine sedative medication prescribing in older adults 18 months after implementation.

METHODS

We reviewed the performance of two CDS alerts in the outpatient and inpatient settings in 2019. To examine the alerts' effectiveness, we analyzed metrics including overall alert adherence, provider-level adherence, and reasons for alert trigger and override.

RESULTS

In 2019, we identified a total of 14,534 and 4,834 alerts triggered in the outpatient and inpatient settings, respectively. Providers followed only 1% of outpatient and 3% of inpatient alerts. Most alerts were ignored (68% outpatient and 60% inpatient), while providers selected to override the remaining alerts. In each setting, the top 2% of clinicians were responsible for approximately 25% of all ignored or overridden alerts. However, a small proportion of clinicians (2% outpatient and 4% inpatient) followed the alert at least half of the time and accounted for a disproportionally large fraction of the total followed alerts. Our analysis of the free-text comments revealed that many alerts were to continue outpatient prescriptions or for situational anxiety.

CONCLUSION

Our findings highlight the importance of evaluation of CDS performance after implementation. We found large variation in response to the inpatient and outpatient alerts, both with respect to follow and ignore rates. Reevaluating the alert design by providing decision support by indication may be more helpful and may reduce alert fatigue.

Delirium in your house: a survey during General Practitioner-programmed home visits

OBJECTIVES

To assess the prevalence of delirium (DEL) among older patients living at home and periodically visited by their General Practitioners (GPs).

DESIGN

Observational study.

SETTING

In Italy, programmed home visits by the GPs are regularly scheduled for their vulnerable and frail patients who are often on poly-drug regimens and suffering from dementia.

PARTICIPANTS

N = 102 patients among those receiving programmed home visits by n = 6 GP based in the Brianza area (Lombardy).

MEASUREMENTS

Patients were screened for delirium with the Italian version of the 4AT, with a score ≥ 4 considered as a positive indicator for DEL. The Charlson Comorbidity Index (CCI), the Short Physical Performance Battery (SPPB), the presence of dementia, and benzodiazepine (BZD) use were recorded.

RESULTS

DEL+ was detected in almost half of the recruited sample (44.1%), and it was clearly associated with increased comorbidity and decreased motor abilities. Pre-existing dementia was documented in most of DEL+ patients (71.1%), while this was the case for only a minority of DEL- (5.2%, p < 0.00001). Analogously, BZD use was over-represented in the DEL+ group with respect to the DEL- one (73.3% vs. 22.8%, p < 0.00001).

CONCLUSIONS

DEL prevalence as detected by GP during programmed home visits is surprisingly high, and related to motor impairment, comorbidities (among which dementia), and BZD use. DEL prompt recognition should be one of the goals of GP-programmed home visits, since this treatable and preventable condition is associated to an elevated burden of frailty and risk of death.

A critical residue in the α1M2-M3 linker regulating mammalian GABAA receptor pore gating by diazepam

Benzodiazepines (BZDs) are a class of widely prescribed psychotropic drugs that modulate activity of GABA_A receptors (GABA_ARs), neurotransmitter-gated ion channels critical for synaptic transmission. However, the physical basis of this modulation is poorly understood. We explore the role of an important gating domain, the α₁M2–M3 linker, in linkage between the BZD site and pore gate. To probe energetics of this coupling without complication from bound agonist, we use a gain of function mutant (α₁L9'Tβ₂γ_2L) directly activated by BZDs. We identify a specific residue whose mutation (α₁V279A) more than doubles the energetic contribution of the BZD positive modulator diazepam (DZ) to pore opening and also enhances DZ potentiation of GABA-evoked currents in a wild-type background. In contrast, other linker mutations have little effect on DZ efficiency, but generally impair unliganded pore opening. Our observations reveal an important residue regulating BZD-pore linkage, thereby shedding new light on the molecular mechanism of these drugs.

Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring

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.

Atypical benzodiazepine misuse and withdrawal in patient with epilepsy: a case report

Background

Benzodiazepines (BDZ) are a class of psychoactive drugs that have been widely used for the treatment of many medical conditions. In this paper, a case of an atypical pattern of diazepam dependence in a patient with epilepsy is presented. The article may be an interesting proposition for rational management in the treatment of benzodiazepine dependence in a patient with non-withdrawal and withdrawal seizures. Detoxification is used then to optimize neurological treatment.

Case presentation

A 52-year-old Caucasian male, diagnosed with epilepsy with partial complex, and rarely tonic-clonic seizures and benzodiazepine (diazepam) misuse, was admitted to a detoxification unit specialized to treat substance dependence. This patient presented an atypical schedule of substance misuse with a weekly dose of 40 to 45 mg of diazepam, taken once a week, every Saturday. The patient reported having a group of symptoms that usually preceded generalized seizures that were described as the “aura” manifesting as confusion, derealisation, anxiety, and difficulties in speaking. First Saturday after admission to the hospital, the first aura experience was reported, while diazepam level in serum was higher than usual, which was supporting also strong psychological background for withdrawal. On weekend days, 3 weeks after admission, when the patient was receiving 3 mg of diazepam daily, he developed a severe “aura.” The EEG showed no seizure activity. Two weeks later (again Friday to Saturday), the patient reported the occurrence of aura, the EEG recording showed paroxysmal discharges, generalized multiple spikes associated with slow waves, lasting about 30 s, accompanied by eyelid myoclonia and disturbed consciousness. A week later another aura developed that resolved spontaneously without a seizure. Twelve days later, diazepam was completely removed; the elimination of serum benzodiazepines took place. The patient did not report aura until the end of the stay and he was dismissed 5 weeks later.

Conclusions

The differential diagnosis of an aura can be challenging. Carefully proceed serum monitored elimination of benzodiazepines in epileptic patients may serve in safety benefits and helps to achieve detoxification goals. Hence, it is important to prevent, recognize, and treat benzodiazepine dependence in every patient and may improve epilepsy treatment outcome.

Kava as a Clinical Nutrient: Promises and Challenges

Kava beverages are typically prepared from the root of Piper methysticum. They have been consumed among Pacific Islanders for centuries. Kava extract preparations were once used as herbal drugs to treat anxiety in Europe. Kava is also marketed as a dietary supplement in the U.S. and is gaining popularity as a recreational drink in Western countries. Recent studies suggest that kava and its key phytochemicals have anti-inflammatory and anticancer effects, in addition to the well-documented neurological benefits. While its beneficial effects are widely recognized, rare hepatotoxicity had been associated with use of certain kava preparations, but there are no validations nor consistent mechanisms. Major challenges lie in the diversity of kava products and the lack of standardization, which has produced an unmet need for quality initiatives. This review aims to provide the scientific community and consumers, as well as regulatory agencies, with a broad overview on kava use and its related research. We first provide a historical background for its different uses and then discuss the current state of the research, including its chemical composition, possible mechanisms of action, and its therapeutic potential in treating inflammatory and neurological conditions, as well as cancer. We then discuss the challenges associated with kava use and research, focusing on the need for the detailed characterization of kava components and associated risks such as its reported hepatotoxicity. Lastly, given its growing popularity in clinical and recreational use, we emphasize the urgent need for quality control and quality assurance of kava products, pharmacokinetics, absorption, distribution, metabolism, excretion, and foundational pharmacology. These are essential in order to inform research into the molecular targets, cellular mechanisms, and creative use of early stage human clinical trials for designer kava modalities to inform and guide the design and execution of future randomized placebo controlled trials to maximize kava's clinical efficacy and to minimize its risks.

Ensuring Patient Protections When Tapering Opioids: Consensus Panel Recommendations

Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with long-term use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.

Update on Pharmacotherapy in Psychodermatological Disorders

Psychodermatological (PD) conditions encountered in dermatologic practice include primary psychiatric conditions such as delusions of parasitosis or secondary psychiatric conditions such as anxiety and depression due to dermatologic disease. The psychotropics include antipsychotic agents, anti-anxiety agents, antidepressants, and miscellaneous drugs such as anti convulsants. Anti psychotics are further divided into first-generation and second-generation drugs. Currently, second-generation drugs e.g., risperidone are preferred over first-generation drugs e.g., pimozide in delusional infestation owing to the side effect profile of the latter. Anti-anxiety agents include benzodiazepines used in acute anxiety and buspirone in chronic anxiety disorders. They are frequently prescribed along with antidepressants. Although dependence and necessity of tapering is a problem with benzodiazepines, delayed onset of action is a feature of buspirone. The commonly used antidepressants in dermatology include selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline), selective serotonin norepinephrine reuptake inhibitors (venlafaxine, desvenlefaxine, and duloxetine), norepinephrine dopamine reuptake inhibitors (bupropion), tricyclic antidepressants (doxepin, amitriptyline, imipramine, and clomipramine), and tetracyclic antidepressants (mirtazapine). Miscellaneous drugs include anticonvulsants such as gabapentin and pregabalin, naltrexone, and N-acetyl cysteine. The principles of PD treatment are first establish the psychiatric diagnosis, followed by initiating drug treatment. The choice of drugs is dependent on multiple factors such as side-effect profile, drug interactions, and co-morbid conditions. Usually, drugs are started at a low dose and gradually increased. A literature search was done in Pubmed, Google Scholar, and Medline databases, and articles on treatment were analyzed.

Risks of Benzodiazepines in Chronic Obstructive Pulmonary Disease with Comorbid Posttraumatic Stress Disorder

RATIONALE

Benzodiazepines are associated with mortality and poor outcomes among patients with chronic obstructive pulmonary disease (COPD), but use of benzodiazepines for dyspnea among patients with end-stage disease may confound this relationship.

OBJECTIVES

Assess the mortality risks of long-term benzodiazepine exposure among patients with COPD and comorbid post-traumatic stress disorder (PTSD), patients with chronic nonrespiratory indications for benzodiazepines.

METHODS

We identified all patients with COPD and PTSD within the Veteran's Health Administration between 2010 and 2012. We calculated propensity scores for benzodiazepine use and compared overall and cause-specific mortality of patients with long-term (≥90 d) benzodiazepine use relative to matched patients without use. Secondary analyses assessed propensity-adjusted survival by characteristics of benzodiazepine exposure.

RESULTS

Among 44,555 eligible patients with COPD and PTSD, 23.6% received benzodiazepines long term. In the matched sample of 19,552 patients, we observed no mortality difference (hazard ratio [HR] for long-term use, 1.06; 95% confidence interval [CI], 0.95-1.18) but greater risk of death by suicide among those with long-term use (HR, 2.33; 95% CI, 1.14-4.79). Among matched and unmatched patients, short-term benzodiazepine use, but not long-term use, was associated with increased mortality (short-term: HR, 1.16; 95% CI, 1.05-1.28; long-term: HR, 1.03; 95% CI, 0.94-1.13).

CONCLUSIONS

Risks for respiratory compromise related to long-term benzodiazepine use in COPD may be less than previously estimated, but short-term use of benzodiazepines could still pose a mortality risk. Suicide associated with benzodiazepine use in this population warrants further investigation.

Discontinuing psychotropic drug treatment

Interruption of ongoing treatment with benzodiazepines, antidepressants, antipsychotics and mood stabilisers including lithium can be followed by clinically significant withdrawal reactions within hours or days, as well as later increases in relapses or recurrences of the illness being treated. Such observations support the view that stopping treatment is not equivalent to being untreated. With lithium, antipsychotics and antidepressants, there is consistent evidence that abrupt or rapid discontinuation is followed by earlier clinical worsening than with more gradual removal of treatment. Moreover, treatment discontinuation can complicate interpretation of responses to changes in treatment, including in clinical practice and in experimental treatment trials. Notably, terminating preceding treatments can lead to both discontinuation and carry-over effects that can have an impact on the interpretation of observed outcomes.

A tailored e-learning gives long-term changes in determinants of GPs' benzodiazepines prescribing: a pretest-posttest study with self-report assessments

Objective: Despite guidelines and campaigns, general practitioners (GPs) continue to overprescribe benzodiazepines (BZDs). New approaches to improve prescribing are needed. Using behavior change techniques and tailoring interventions to user characteristics are vital to promote behavior change. This study evaluated the impact of a tailored e-learning module on factors known to determine BZD prescribing within GPs.Design: A pretest-posttest study design with three self-report assessments concerning determinants of BZD prescribing: at baseline, immediately after the module (short term) and six months after completion (long term).Setting: Flanders (Belgium)Intervention: A tailored e-module that focuses on avoiding initial BZD prescriptions and using psychological interventions as an alternative.Subjects: 244 GPsMain outcome measures: Assessed determinants include GPs' attitudes concerning treatment options, perceptions of the patient and self-efficacy beliefs. Readiness to adhere to prescribing guidelines was evaluated through assessing motivation, self-efficacy and implementability of non-pharmacological interventions.Results: A significant and durable impact on determinants of BZD prescribing was observed. GPs underwent desirable changes in attitudes, perceptions and self-efficacy beliefs and these changes remained significant six months later.Conclusion: Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs. Significant and lasting changes were observed in determinants of prescribing BZDs.Key PointsA tailored e-intervention resulted in significant and long term changes in previously identified determinants of prescribing BZDs. The e-module resulted in a positive impact on GPs' readiness to adhere to BZD prescribing guidance and the way they experience psychosocial consultations. Tailoring an e-intervention to target group characteristics appears to be successful in promoting behavioral change in experienced GPs.

Metabolic profile of pitaya (Hylocereus polyrhizus (F.A.C. Weber) Britton & Rose) by UPLC-QTOF-MSE and assessment of its toxicity and anxiolytic-like effect in adult zebrafish

Pitaya is a Cactacea with potential for economic exploitation, due to its high commercial value and its functional components - such betalains, oligosaccharides and phenolic compounds. Although the biological activities of pitaya have been studied using in vivo and in vitro models (anti-inflammatory and antiproliferative activities, as example), its anxiolytic-like effect is still unexplored. Therefore, the aim of this work was to perform a characterization of pulp and peel of pitaya (Hylocereus polyrhizus (F.A.C. Weber) Britton & Rose) using UPLC-QTOF-MS^E, and to assess its toxicity and anxiolytic-like effect in adult zebrafish (Danio rerio). The results showed 16 and 15 compounds (in pulp and peel, respectively), including maltotriose, quercetin-3-O-hexoside, and betalains, putatively identified by UPLC-QTOF-MS^E. Thus, pitaya pulp and peel showed no toxicity in both models tested (Vero cell lines and zebrafish model, LC₅₀ ˃ 1 mg/mL); and a significant anxiolytic activity, since the treated fish reduced the permanence in the clear zone (Light & Dark Test) compared to that in the control, exhibiting anxiolytic-simile effect of diazepam. However, these effects were reduced by pre-treatment with the flumazenil suggesting that the pulp and peel of pitaya are anxiolytics agents mediated via the GABAergic system. These findings suggested that H. polyrizhus has the potential of developing an alternative plant-derived anxiolytic therapy. In addition, pitaya peel (which is a waste in the food industry) should be regarded as a valuable product, which has the potential as an economic value-added ingredient for anxiety disorders.