Benzodiazepine abuse discontinuation

Benzodiazepines have a low abuse potential when they are properly prescribed and their use is supervised (American Psychiatric Association 1990). However, physical dependence often occurs when benzodiazepines are taken at higher-than-usual doses or for prolonged periods. If benzodiazepines are discontinued precipitously, withdrawal effects (including hyperpyrexia, seizures, psychosis, and even death) may occur. Signs and symptoms of withdrawal may include tachycardia, increased blood pressure, muscle cramps, anxiety, insomnia, panic attacks, impairment of memory and concentration, perceptual disturbances, and delirium. In addition, withdrawal-related derealization, hallucinations, and other psychotic symptoms have been reported. These withdrawal symptoms may begin as early as the day after discontinuation of the benzodiazepine, and they may continue for weeks to months. Evidence indicates that withdrawal reactions associated with shorter-half-life benzodiazepines peak more rapidly and more intensely. 

When benzodiazepines are used or abused chronically, they may cause adaptive changes in benzodiazepine receptors such that their power to modulate GABA-A receptors in response to a benzodiazepine decreases with time (Fig. 13—32). These patients may become irritable or anxious or even experience panic attacks if they suddenly stop taking the drugs (Fig. 13—33). This shift in benzodiazepine abusers to a desensitized receptor (Fig. 13—32) may manifest itself as the need to take higher doses of benzodiazepines to get high. This receptor desensitization is most likely to be uncovered once chronic abusive benzodiazepine administration is discontinued, particularly if discontinuation is sudden (Fig. 13-33). This desensitized receptor worsens the impact of benzodiazepine discontinuation because the brain, which is... 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

Zolpidem, chemically unrelated to benzodiazepines or barbiturates, acts selectively at the y-aminobutyric acidA (GABAA)-receptor and has minimal anxiolytic and no muscle relaxant or anticonvulsant effects. It is comparable in effectiveness to benzodiazepine hypnotics, and it has little effect on sleep stages. Its duration is approximately 6 to 8 hours, and it is metabolized to inactive metabolites. Common side effects are drowsiness, amnesia, dizziness, headache, and GI complaints. Rebound effects when discontinued and tolerance with prolonged use are minimal, but theoretical concerns about abuse exist. It appears to have minimal effects on next-day psychomotor performance. The usual dose is 10 mg (5 mg in the elderly or those with liver impairment), which can be increased up to 20 mg nightly. Cases of psychotic reactions and sleep-eating have been reported. 

Drug abuse and dependence Withdrawal symptoms following abrupt discontinuation of benzodiazepines have occurred in patients receiving excessive doses over extended periods of time. Gradual withdrawal is preferred. 

Alprazolam has been researched more extensively than any other benzodiazepine in panic disorder, and is very effective. Because of its short duration of action, it generally must be administered in three to five daily doses. Clonazepam, which has a longer duration of action than alprazolam, has also been investigated in panic disorder. It can generally be administered twice a day. Clonazepam is reported to have less abuse potential than alprazolam and to be easier to taper during discontinuation owing to its longer half-life. 

Benzodiazepines are rarely abused and are not known to create dependence or to produce withdrawal when discontinued. True or False. 

As well as unwanted effects related to direct drug effects, hypnotics, like many other medications, are associated with offset effects, namely withdrawal reactions after discontinuation, abrupt or gradual [4], Numerous terms are used in this context, and include those relating to non-medical use, i.e., abuse and addiction. The purpose of this chapter is to review briefly the clinical problems that can be encountered when discontinuing hypnotic dmgs within the normal therapeutic context. For a review on the abuse and dependence potential of the non-benzodiazepine hypnotics, zolpidem and zopiclone, reference should be made to the paper by Hajak et al. [5],... 

Minor tranquilizers and sedative-hypnotics are widely used in general medical practice and psychiatry. Although the benzodiazepines as a class are much safer than earlier medications (there is less risk of dependency and abuse, and withdrawal symptoms are generally much less dangerous than with barbiturates), problems do exist when patients begin to reduce doses, especially if they discontinue rapidly or "cold turkey." Benzodiazepine withdrawal sjmdromes are encoimtered frequently. They cause considerable patient distress, can be dangerous at times, and are almost always avoidable if the clinician follows the discontinuation guidelines carefully. 

Benzodiazepines are prescribed commonly for SAD. Clonazepam is the most extensively studied benzodiazepine for the treatment of generalized SAD. " Clonazepam improved fear and phobic avoidance, interpersonal sensitivity, fears of negative evaluation, and disability measures. " Adverse effects included sexual dysfunction, unsteadiness, dizziness, and poor concentration. " Clonazepam is often prescribed in conjunction with an antidepressant, psychotherapy, or both for initial symptom relief. Comorbid alcohol or substance abuse are contraindications to the use of benzodiazepines. Other limitations of clonazepam therapy include lack of efficacy in depression and difficulty with discontinuation. Because of the risk of dependency, benzodiazepines should be reserved for patients at a low risk of substance abuse, those who require rapid relief of symptoms, or those who have not responded to other therapies. 

The abuse of meprobamate has continued despite a substantial decrease in the clinical use of the drug. Carisoprodol (soma), a skeletal muscle relaxant whose active metabolite is meprobamate, also has abuse potential and has become a popular street drug. Meprobamate is preferred to the benzodiazepines by subjects with a history of drug abuse. After long-term medication, abrupt discontinuation evokes a withdrawal syndrome usually characterized by anxiety, insomnia, tremors, and, frequently, hallucinations generalized seizures occur in about 10% of cases. The intensity of symptoms depends on the dosage ingested. 

None of the widely quoted statistics embrace all those individuals dependent on drugs and medicaments, but always only those who attract attention because of crime, their lifestyle, or their social environment. In the case of benzodiazepines, appetite-suppressants and combinations of analgesics with caffeine, the low-dose dependence of the patient is often associated with social conditions, so that the problem is often seen in the context of the particular decade in which the abuse occurs. The same is true of the experimental drug-taker who discontinues his or her consumption after a short time and is not noticed. For this reason, exact national statistics on consumption behavior are difficult to obtain. Moreover, it is possible to detect trends, e.g. the appearance of new dependence phenomena, patterns of abuse, drug combinations or methods of application, and the analyst must arrange his work accordingly. 

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