The damnation of benzodiazepines

Defining benzodiazepine dependence: the confusion persists

Little consensus exists on the risk of benzodiazepine (BZD) dependence. We investigated how often BZD dependence and related concepts have been defined in the literature on BZD effects in humans. In addition, the definitions of BZD dependence were compared in order to assess the similarity of contents. From a total of 250 papers (published between 1988 and 1991) 51 provided 126 dependence-related definitions. Six studies referred to the DSM definitions and one to the WHO definition. The obsolete concept of addiction was frequently defined (n=13), with little consensus about its meaning. Psychological and physical dependence were defined fairly often (n=29), also with low levels of consensus. We conclude that the discussion on the risk of BZD dependence would be well-served by attempting to improve consensus first. This may lead to more meaningful data on the incidence, prevalence and relevant co-factors of BZD dependence. An outline for criteria for benzodiazepine dependence is presented.

Why benzodiazepines are not going away

Benzodiazepines are still widely prescribed in psychiatry, mainly for the treatment of anxiety-related disorders. This is not because they are only taken by a hard core component of patients who are addicted and do not need them; it is because they remain the most effective and rapid acting of all drug treatments. Strategies for practitioners to use them more confidently are described.

Sevrage aux benzodiazépines des sujets dépendants aux opiacés en traitement de substitution

INTRODUCTION

Benzodiazepines are the most widely used psychotropic agents in the world. Abuse and dependence are reported in the general population and among drug misusers, including those dependent on heroine. Benzodiazepine use by heroine users increases their risk of overdose, not only from heroin but also substitution drugs such as methadone and more recently buprenorphine. Hence, detoxification from benzodiazepines is desirable.

OBJECTIVE

The objective of this paper was to review the literature and determine the best benzodiazepine detoxification procedure for opiate-dependent individuals receiving substitution treatment.

METHODS

Relevant studies were sought through systematic searches of Medline and Toxibase (a database focusing on substance abuse).

RESULTS

There were fewer controlled studies than expected about benzodiazepine detoxification, and all of them excluded subjects who misused opiates or were in opiate substitution treatment. The best evidence supports a procedure where the patient is switched to a long-lasting benzodiazepine and the dose then tapered by 25% of the initial dose each week. Diazepam is the drug most often used in the framework. In opiate users, diazepam may raise special problems of misuse, as suggested by clinical and epidemiologic studies. Nonetheless, diazepam is the only benzodiazepine found to be effective for this withdrawal in controlled studies and some studies indicate that unprescribed diazepam use in heroin users is sometimes motivated by the desire to alleviate withdrawal symptoms and discomfort.

CONCLUSION

Although diazepam appears to have potential for abuse, the available data does not rule out its therapeutic interest for benzodiazepine withdrawal in patients on opiate substitution treatment in an adequate treatment setting. Specific studies of this population are needed.

Use and misuse of benzodiazepines in Brazil: a review

Benzodiazepines are among the most prescribed and consumed medication groups in the world. Although benzodiazepines are used in the treatment of several psychiatric and non-psychiatric disorders, and are generally safe and well-tolerated, the potential for misuse and abuse is considerable. This makes the study and regulation of benzodiazepine prescription and consumption an item of concern in public health around the world. Most developed countries have consistent data of benzodiazepine sales and consumption; however, data from developing countries is scarce, making health policies on the use of benzodiazepines a much tougher issue in these countries. This article aims to review the epidemiology of benzodiazepine use in Brazil, as well as to analyze how legislation, physician misinformation and economic factors might contribute to making benzodiazepine abuse a problem in the country.

Changes in "withdrawal symptoms" following discontinuation of low-dose diazepam

The intensity of putative benzodiazepine withdrawal symptoms was evaluated as part of a double blind placebo-controlled study of benzodiazepines and behaviour therapy in the management of agoraphobia. During the first phase of that study, some subjects were switched from low dose diazepam to placebo, and others remained on diazepam. Symptoms were evaluated in long-term benzodiazepine users (n = 30) and non-users n = 32) when they first entered the study and 4 weeks later, after both groups had been randomized to either diazepam or placebo, using eight analog rating scales measuring commonly reported withdrawal symptoms. At baseline, both users and non-users reported a substantial number of symptoms, with higher levels in the more anxious patients, but no differences between groups. After the transition to either diazepam or placebo, the users switched to placebo reported significantly higher levels of symptoms than users switched to diazepam and non-users combined. Multiple regression analysis suggested that the increase in symptoms was associated with the increase in anxiety, which was higher in the withdrawing group than the other three groups. These results raise questions concerning the extent to which withdrawal symptoms uniquely characterize benzodiazepine withdrawal. They confirm the common assumption that an increase in symptoms often accompanies withdrawal from benzodiazepines, but suggest that such symptoms are not so intense as to make withdrawal excessively difficult, at least in low-dose users.

The Undertreatment of Anxiety: Overcoming the Confusion and Stigma

1. The patient, the nurse, and organizational variables all interact in a dynamic and complex manner, which all have an impact on decisions about intervention. 2. The numbers and variety of agents ordered as PRN indicate the responsibility for treatment placed by physicians on nurses and their reliance on appropriate and accurate nursing assessment. 3. Much of the stigma surrounding symptoms of anxiety and their treatment is based not only on the nature of the illness, but on the perceptions and beliefs concerning the use of anti-anxiety agents.

The behavioural and neuronal effects of the chronic administration of benzodiazepine anxiolytic and hypnotic drugs

Benzodiazepine anxiolytic and hypnotic drugs are some of the most widely prescribed drugs in the Western world. Despite this fact, the mechanisms that underlie the development of tolerance to, and dependence upon, benzodiazepines are poorly understood. The aim of this review is to summarize and critically evaluate the experimental evidence relating to the chronic behavioural and neuronal effects of benzodiazepines. Behavioural studies in animals generally indicate that tolerance gradually develops to the muscle relaxant, ataxic, locomotor and anticonvulsant effects of benzodiazepines. The evidence relating to the development of tolerance to the anxiolytic effects of benzodiazepines is less clear. The literature on the possible mechanisms of benzodiazepine tolerance and dependence is large, highly complex and difficult to interpret. The effect of chronic benzodiazepine treatment varies enormously as a function of the benzodiazepine used and the treatment schedule employed. Many studies have demonstrated a down-regulation of benzodiazepine binding sites, although affinity is usually unchanged. The evidence relating to the number and affinity of GABAA binding sites is unclear. Some studies suggest that chronic benzodiazepine administration results in a reduction in the number of Cl- channels associated with the GABAA receptor complex, although it is not clear that the efficacy of the GABA binding site in operating the Cl- channel necessarily changes. There is, however, substantial evidence to support the hypothesis that chronic benzodiazepine treatment results in a reduction in the coupling between the GABAA and benzodiazepine binding sites (the "functional uncoupling hypothesis"). Although some electrophysiological studies suggest that chronic benzodiazepine treatment results in a subsensitivity to GABA, this effect seems to be highly area-specific.

Guidelines for the rational use of benzodiazepines. When and what to use

The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic) confer a therapeutic value in a wide range of conditions. Rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines, as well as the requirements of individual patients. As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks. Temazepam, loprazolam and lormetazepam, which have a medium duration of action are suitable. Diazepam is also effective in single or intermittent dosage. Potent, short-acting benzodiazepines such as triazolam appear to carry greater risks of adverse effects. As anxiolytics, benzodiazepines should generally be used in conjunction with other measures (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action. Indications for benzodiazepines include acute stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as initial treatment for severe panic and agoraphobia. Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment. Alprazolam has been widely used, particularly in the US, but is not recommended in the UK, especially for long term use. Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses. The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection. Long term prescription is occasionally required for certain patients.

Fatal poisonings attributed to benzodiazepines in Britain during the 1980s

The fatal toxicity indices of benzodiazepines during the 1980s were calculated from national prescribing data and mortality statistics. The overall rate was 5.9 deaths per million prescriptions for benzodiazepines taken alone or with alcohol only, anxiolytics being less toxic than hypnotics. Diazepam appeared more toxic than average among anxiolytics (P < 0.05), and flurazepam and temazepam more toxic than average among hypnotics (both P < 0.001). It was shown that the finding for diazepam was probably explained by concurrent use of alcohol, which implies that other anxiolytics may be safer in cases where there is alcohol misuse; but the greater toxicity of flurazepam and temazepam remained unexplained. Benzodiazepines are indeed much less toxic than the barbiturates they superseded, but they are not innocuous and temazepam in particular requires further evaluation.

Drugs used for psychiatric disorders

Psychiatric disorders are common in the elderly. Antidepressants are probably underprescribed. In recurrent depression, lifelong prophylaxis may be required. Benzodiazepines can aggravate cognitive impairment and cause falls; they should not be used for chronic insomnia. Antipsychotic drugs are useful for the treatment of delusions and hallucinations but are less effective for disturbed behaviour in dementia sufferers. There are no satisfactory drugs for treating dementia at present, but promising palliative treatments for Alzheimer's disease are under trial.

Alprazolam in panic disorder: a retrospective analysis

1. The charts of 78 panic disorder outpatients treated with alprazolam (mean dose 4.30 mg/day, mean duration 31.9 months) were reviewed for demographics, past history (including substance abuse and major depression), and evidence of alprazolam abuse. In addition, the patients were evaluated by Clinical Global Index for improvement at last contact. 2. Moderate to significant recovery was found in 77% of patients. Major depression was seen in 41%. Depressed patients were more likely to have coexisting agoraphobia and a past history of alcohol abuse than non-depressives. 3. There was no DSM-III-R anxiolytic abuse, but 12% showed unauthorized use of the alprazolam. These subjects were three times more likely to have a history of drug abuse than non-misusers. 4. These results indicate that alprazolam is effective in the long-term treatment of panic disorder, but that prolonged management may be required. Further, the data raise concerns about use in panic patients with substance abuse histories.

Benzodiazepine use and anxiolytic abuse and dependence in treated alcoholics

The prevalence and correlates of benzodiazepine use and anxiolytic abuse and dependence are examined in a sample of 427 patients in Toronto, Canada, who met lifetime DSM-III criteria for alcohol abuse or dependence. The patients were evaluated with the NIMH-DIS and other standard psychiatric and substance abuse rating scales. Forty per cent were recent users of benzodiazepines and 20% had abused or been dependent upon anxiolytics, including benzodiazepines, during their lifetime. Patients with antisocial personality disorder (ASPD) were at higher risk for an anxiolytic disorder as were women and the unemployed. Recent users of benzodiazepines showed more current psychological distress, depressive symptomatology and more severe substance abuse problems than other patients and were more likely to have a lifetime DSM-III anxiety disorder. Patients with anxiolytic disorders, even if ASPD was controlled for, showed more psychiatric impairment and drug abuse problems than the remaining patients. Of those with a positive urine screen, 46% did not report using benzodiazepines in the previous week. Nineteen per cent of the patients who did not report benzodiazepine use in the previous week had a positive urine screen and were more likely to be found in the detoxification unit.

A rapid screening method for the assessment of benzodiazepine receptor-related physical dependence in mice. Evaluation of benzodiazepine-related agonists and partial agonists

We have developed a model of benzodiazepine-type physical dependence in which mice were injected subcutaneously with the test compound on a fixed schedule (0800 and 1600 for 3 days, the PM dose = AM dose x 2). If tolerated, then a starting dose of 150 mg/kg/day was generally used initially and the dose was lowered to 15 and 1.5 mg/kg/day in subsequent assays if the higher doses were active in the test. Twenty-four hours after the last dose, the mice received an intravenous injection of flumazenil (2.5 mg/kg), and 5 min later they were tested for electroshock seizure thresholds by an up-down titration method. Flumazenil-precipitated withdrawal was manifested by a lowering of the mA seizure threshold. We have found that compounds with benzodiazepine agonist properties significantly lower these thresholds in a dose-related fashion. For example, the following compounds (lowest effective mg/kg/day dose) were active in this regard, chlordiazepoxide (150), diazepam (15), flurazepam (15), alprazolam (15), triazolam (15), midazolam (15), zopiclone (150), Ro 16-6028 (150), and Ro 17-1812 (150). In contrast, zolpidem (150), tracazolate (15), and CL 218872 (15) did not cause physical dependence by this criterion. This rapid and simple screening test may be readily used to predict the physical-dependence-inducing properties of compounds that act at the benzodiazepine receptor.

Psychopharmacology of anxiety

This overview deals first with the actual views on the neurobiology of anxiety, focusing on the limbic system and epileptiform neuronal activities. No single neurotransmitter system is likely to be involved exclusively in prevention or generation of anxiety and, hence, to be a target for drugs affecting anxiety specifically. Next, animal tests currently used to identify drugs effective in the treatment of anxiety, in particular specific forms of anxiety, are discussed. Drugs currently used in the treatment of anxiety as well as anxiogenic agents and their mechanisms of action are compared. The future development in the field of anxiety-reducing drugs is seen in partial agonists of benzodiazepine receptors. Specific ligands of the various 5-HT receptors may replace benzodiazepine receptor ligands in specific forms of anxiety disorders, but do not seem to represent general alternatives, in particular, when an immediate attenuation of anxiety is required.

Benzodiazepines: abuse and new use

Both abuse and new uses for benzodiazepines are reviewed. The pharmacology of benzodiazepines is summarized and statistics regarding their general use are given. The question of benzodiazepine abuse is reviewed in some detail and the question of rebound, recurrence of symptoms and physiological withdrawal is differentiated. Benzodiazepines are regarded as a very safe class of drugs and the abuse potential is felt to be negligible provided that they are prescribed for appropriate conditions and monitored carefully. The dangers of alternatives to benzodiazepines such as alcohol or barbiturates is emphasized. New uses for benzodiazepines are reviewed including the use of benzodiazepines in panic disorder, as well as an adjunct in the therapy of mania and some psychotic states. Rational prescribing of benzodiazepines is encouraged and the attitude that these are dangerous and addictive drugs is discouraged and put into perspective.

Benzodiazepines, putative anxiolytics and animal models of anxiety

Anxiety is a complex state that includes a broad range of classified symptoms. Anxiolytic treatment has been dominated by the use of benzodiazepine drugs (BZs), which is often prolonged. However, the multiplicity of anxiety states and the lack of BZ specificity preclude the potent targeting of the drugs to different states, and point to the problem of drug dependence. Furthermore, animal models of anxiety give different results when challenged with apparently similar drugs. The search for alternative drugs with a higher specificity has led to 5-HT receptor subtypes. In this review, Simon Green describes how recent research might have dual benefits: in improving drug therapy of anxiety in humans, and in analysing and categorizing more clearly the concept of anxiety itself.

Antidepressant drug prescribing in general practice: a 6-year study

We analysed antidepressant drugs (AD) prescription ratios of the GPs working in Verona, Italy, over a 6-year period (1983-1988). The data, provided by a local drug information system (SIF-USL), were calculated as Defined Daily Dose (DDD), which is the unit of drug consumption recommended by WHO. We found that DDD/1000 patients/day increased over the period, mainly because of an increase in the use of 'second-generation' antidepressants and other non-tricyclic antidepressants. An increase in the levels of prescription of AD was observed over the 6 years. This increase was statistically significant when comparing the first (1983) with the other years. Low correlations were found between DDD/patient/year ratios and GPs' age, sex and list size. Harmonic analysis of the seasonal variations in prescriptions of AD revealed a substantial pattern of seasonality, in which the first four harmonics accounted for the greater part (95.5%) of the seasonality. AD prescribing may be linked more closely to seasonal holiday patterns than to seasonality in the onset of depressive disorders.

Psychopathology and treatment of 30,344 twins in Sweden. I. The appropriateness of psychoactive drug treatment

We studied whether regular treatment with tranquilizing and hypnotic drugs among 30,344 twins in Sweden 15-47 years old was associated with robust indicators of poor health. Longitudinal psychiatric diagnoses and subsequent suicides were analyzed with data from cross-sectional health questionnaires. Women were almost twice as likely to report medication, even those with psychiatric inpatient diagnoses. Within each of mental, somatic, and lifestyle domains, medication was more frequent among those with multiple problems. The partial odds for medication for those with a diagnosis of psychosis were 11.81, affective disorder 10.94, neurotic or personality disorder 11.09, alcoholism 5.00, and drug addiction 13.92. We conclude that reported regular treatment with tranquilizing and hypnotic drugs in young Swedish adults was significantly associated with diagnosed and subjective somatic and mental health problems, and thus largely in agreement with current peer guidelines. The reasons why women were more often treated than men requires further study.

Diazepam (Valium): its dependency liability

Reports of the withdrawal syndrome following discontinuation of diazepam and drug dependence fears have contributed to diazepam's displacement as the most popular anxiolytic agent. Reports of the withdrawal syndrome, the factors involved in withdrawal, and the remedies proposed for diazepam withdrawal symptoms are reviewed.

Prejudice and AIDS: the views and experiences of people with HIV infection

Discrimination against people on the basis of physical or mental infirmity is common and creates a considerable burden for sufferers. There has been considerable debate about the prejudice against people with disease resulting from human immunodeficiency virus (HIV) infection. This study reports on the views and experiences of stigmatization by 192 outpatients with HIV infection interviewed at two London teaching hospitals. Despite reticence about discussing their infection, one quarter of patients had received negative reactions from confidants. The implications for health and social policies are discussed.