Abuse, addiction, tolerance, and dependence to benzodiazepines in medical and nonmedical populations

Outcomes of patients treated with low-dose flumazenil for benzodiazepine detoxification: A description of 26 participants

INTRODUCTION

Benzodiazepines are commonly prescribed for a variety of indications and can be employed in the short- and long-term. While they are efficacious, issues arise from long-term use with the emergence of dependence and tolerance to doses within the therapeutic range and beyond. Discontinuation from benzodiazepines can be problematic for patients and may result in a withdrawal syndrome, which can be protracted and last months to years.

METHODS

26 participants received low-dose subcutaneous flumazenil infusions (4 mg/24 h for approximately eight days) as part of a randomised control crossover trial. Return to benzodiazepine use was assessed monthly for three months based on the benzodiazepine use in the previous week. Where data was not available, the treating psychiatrist examined patient files and clinical documents to determine benzodiazepine use. Withdrawal and craving scores were also measured.

RESULTS

Abstinence rates from benzodiazepines at one-, two-, and three-month follow ups were 65.4 %, 50.0 %, and 46.2 % respectively. When considering patient files and clinical documents for those lost to follow-up, abstinence rates were higher at 73.1 %, 65.4 % and 61.5 % at the one-, two-, and three-month follow ups respectively. Withdrawal and craving scores were higher in those that had returned to any benzodiazepine use.

CONCLUSION

Self-reported rates of abstinence from benzodiazepines at three months was between 46.2 % and 61.5 %. Flumazenil may yield greater success than benzodiazepine tapering from high dose benzodiazepine use (≥30 mg diazepam equivalent). Further research should compare abstinence rates after treatment with flumazenil compared to benzodiazepine tapering in high dose benzodiazepine users.

Benzodiazepine tapering: a prospective study

BACKGROUND

Benzodiazepines (BZD) are the most widely used sedative-hypnotics, and evidence is rapidly accumulating suggesting potential BZD dependence, association of chronic use with adverse effects and a definite abstinence syndrome produced by withdrawal.

AIMS

The present investigation followed prospectively long-term BZD users over 1 year following graded BZD withdrawal in terms of clinical and withdrawal symptoms.

METHODS

Clinical symptoms were measured by the Comprehensive Psychopathological Rating Scale (CPRS) and by the Newcastle Anxiety and Depression Diagnostic Index (NADDI) in a sample of BZD users over a 50-week period following graded BZD withdrawal.

RESULTS

The results showed that the frequency and severity of clinical symptomatology measured by both scales significantly decreased over time. A detailed analysis of possible patterns of symptoms on both scales revealed four patterns: 1) a gradual decrease over the 50-week time period; 2) an increase in the severity of symptoms at the onset of tapering and a decrease in severity post-tapering; 3) an increase in the severity of symptoms 4 weeks after the cessation of BZD tapering; and 4) no change over the 50-week time period. Rate of BZD withdrawal was associated with CPRS ratings of global illness at admission and at end of treatment, but was not associated with duration or dosage of BZDs, type of BZD, prescriptive and/or non-prescriptive drug use prior to admission, marital status, sex or age.

CONCLUSIONS

The results of the present study provide a detailed picture of the pattern of symptoms, their time course and multidimensional determinants of the BZD withdrawal symptoms.

Alprazolam prescribing in Tasmania: a two-fold intervention designed to reduce inappropriate prescribing and concomitant opiate prescription

OBJECTIVE

The population rate of alprazolam prescribing in Tasmania has been more than double that of national rates. Serious adverse events have been observed through co-administration of opioid medications with alprazolam. A two-fold intervention, comprising GP education coupled with changes to prescribing regulations, was designed with the intention to decrease inappropriate prescribing of alprazolam and thereby reduce adverse outcomes. The aim of this study was to assess the impact of the intervention on prescribing rates.

METHOD

We measured the number of alprazolam prescriptions for the years prior to and the year following the intervention. Health Insurance Commission data were utilized to enable comparison of subsidized prescription rates for alprazolam in Tasmania, and compared with national data. Participants were registered medical practitioners in Tasmania who were potential prescribers of alprazolam. The interventions were three GP Education Meetings during June 2007, one in each of the major regions of Tasmania, regarding evidence-based interventions for panic disorder. Changes to regulatory procedures to minimize co-prescription of alprazolam with opioids was implemented in September 2007.

RESULTS

A reduction in alprazolam prescribing in Tasmania occurred after the interventions.

CONCLUSION

Education can be an effective strategy to influence prescribing behaviour of doctors. It is likely that this effect can be augmented by adoption of more stringent regulatory requirements.

Benzodiazepine use among opiate-dependent subjects in buprenorphine maintenance treatment: correlates of use, abuse and dependence

BACKGROUND

Previous studies from North America, Europe and Australia have reported high levels of benzodiazepine use among opiate-dependent patients in opiate maintenance treatment. However, to date, there are no available data on patterns of abuse and dependence on benzodiazepines according to DSM criteria among these patients.

AIMS

To describe the independent correlates of use, abuse and dependence on benzodiazepines among buprenorphine patients selected from standard treatment settings.

METHODS

Cross-sectional study in France between June 2001 and June 2004. Buprenorphine patients treated for over 3 months were recruited via physicians prescribing buprenorphine. Patients answered a self-administered questionnaire, the DSM-IV criteria for benzodiazepine abuse and dependence, the Beck Anxiety and Depression Inventories (BAI, BDI) and the Nottingham Health Profile (NHP). Main outcome was modalities of benzodiazepine use: no use vs. simple use vs. problematic use (abuse or dependence according to DSM-IV).

RESULTS

170 patients were recruited. 54% did not use benzodiazepines during the previous month, 15% were simple users and 31% were problematic users. Benzodiazepine use (all modalities) was associated with poly-use of psychotropics. Simple users of benzodiazepines were not statistically different from non-users for the other factors explored. Problematic users of benzodiazepines had higher depression and anxiety levels, correlated with quality of life impairment and precariousness. They used higher dosages of benzodiazepines than simple users.

CONCLUSIONS

Characteristics of simple benzodiazepine users were distinct from problematic users but not from non-users in this sample of buprenorphine patients. This should be taken into account in the clinical management of benzodiazepine use among buprenorphine patients.

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.

The prevalence and clinical course of sedative-hypnotic abuse and dependence in a large cohort

Relatively little is known about the prevalence and clinical characteristics of dependence on sedative-hypnotics, and almost nothing has been published regarding abuse. This report relates information on Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IIIR) sedative-hypnotic use disorders among subjects from the Collaborative Study on the Genetics of Alcoholism (COGA). A standardized interview was used to generate data on 407 men and women in Group 1 with sedative-hypnotic dependence (4.4% of the COGA sample), 34 in Group 2 with abuse (0.4%), and 3,426 comparison subjects in Group 3 with alcohol dependence in the absence of a sedative-hypnotic use disorder (36.7%). The remaining COGA subjects (48.5%) were not included as they had neither alcohol nor sedative-hypnotic dependence or abuse. Those with sedative-hypnotic abuse or dependence were more likely to be Caucasian individuals with abuse or dependence on marijuana, cocaine, amphetamines, or opioids. Subjects in Groups 1 and 2 were also more likely to have histories of independent major depressive and panic disorders, as well as substance-induced mood disorders. Those with dependence, compared to abuse, were likely to be women, reported staying intoxicated for a day or more, but noted less abuse of opioids or amphetamines, although Group 2 members also had high rates of difficulties with sedative-hypnotics. These results highlight notable rates of sedative-hypnotic dependence in the COGA families, and indicate that while sedative-hypnotic abuse does occur, and while the clinical course can involve relatively serious problems, it is less common than dependence.

Drug use and associated factors among rural adolescents in Costa Rica

The objectives of this study, carried out in 1995, were to assess both licit and illicit substance use among rural male and female Costa Rican adolescents, and associated health, psychological, and psychosocial problems. A sample of 304 students from rural schools was randomly selected. The mean age for females was 14.7 years (S.D. = 1.71), and for males was 14.4 years (S.D. = 1.62). The data were collected using the Latin-American version of Drug Use Screening Inventory (DUSI). Results showed a high prevalence of past-year alcohol use for both males and females (56.6% and 47.4%, respectively), and a lower prevalence of past-year tobacco use (44.0% and 7.7%). There results also showed a low level of use of solvent inhalants and benzodiazepines. In terms of illicit drugs, males preferred cocaine and marijuana, while females only reported amphetamine use. An analysis of adolescent functioning showed differences among alcohol users and nonusers in behavior patterns and peer relationships. However, no significant differences were found regarding rebellion, depression, and social isolation. The implications of these results are discussed, along with the importance of enhancing prevention, as well as early detection and intervention.

Polypharmacy in psychiatric treatment. Patterns of psychotropic drug use in Austrian psychiatric clinics

There are great variations in the way psychotropic drugs are prescribed. Most experts are in favour of psychopharmacological monotherapy, but little is known about the extent to which it is actually practised. A survey of the psychopharmacological medication of all patients under treatment was carried out in three Austrian psychiatric clinics of various types on two separate days. A psychiatric university clinic, the psychiatric department of a general hospital and a regional mental hospital were selected for the survey. It was established that only 8% to 22% of the patients underwent psycho-pharmacological monotherapy and that the patients received 2.2 to 3.3 psychotropics on average. Five to 22% of the patients received five or more psychotropic agents. The results are presented in more detail in relation to the diagnoses of schizophrenia and depression. The rare occurence of monotherapy might be due to unsound treatment regimens in some instances, but much more to a general trend in psychiatry fostering polydrug use.

Sedation in Neonatal and Pediatric Intensive Care

Despite the widespread use of potent sedative and analgesic agents in adult patients, it is remarkable that systemic analgesia and sedation have not been administered routinely to neonates and children until very recently. Adequate sedation and analgesia have historically been withheld from these patients because of the mistaken beliefs that pain perception was not fully developed and that these patients were much more prone to adverse effects of the most commonly used agents. There is now overwhelming evidence that pain perception and physiologic responses to stress are present in neonates of all gestational ages and a variety of effective sedative/analgesic agents have recently been added to the therapeutic armamentarium. We will outline the classes of agents currently available, briefly describe mechanisms of action and the relevant pharmacokinetic—pharmacodynamic parameters, summarize the short-term and long-term side effects following prolonged administration of these agents, and highlight practical considerations for the most commonly used sedative-analgesic medications.