Benzodiazepines withdrawal

Benzodiazepine withdrawal may occur when use of the antianxiety drugs is abruptly discontinued after 3 to 4 months of therapy. Occasionally, withdrawal symptoms may occur after as little as 4 to 6 weeks of therapy. Symptoms of benzodiazepine withdrawal include increased anxiety, concentration difficultiesi, tremor, and sensory disturbances, such as paresthesias photophobia, hypersomnia, and metallic taste. To help prevent withdrawal symptoms, the nurse must make sure the dosage of the benzodiazepine is gradually decreased over a period of time, usually 4 to 6 weeks... 

Although rare, benzodiazepine toxicity may occur from an overdose of the drug. Benzodiazepine toxicity causes sedation, respiratory depression, and coma. Flumazenil (Romazicon) is an antidote (antagonist) for benzodiazepine toxicity and acts to reverse die sedation, respiratory depression, and coma within 6 to 10 minutes after intravenous administration. The dosage is individualized based on the patient s response, widi most patients responding to doses of 0.6 to 1 mg. However, die drug s action is short, and additional doses may be needed. Adverse reactions of flumazenil include agitation, confusion, seizures, and in some cases, symptoms of benzodiazepine withdrawal. Adverse reactions of flumazenil related to the symptoms of benzodiazepine withdrawal are relieved by die administration of die benzodiazepine. 

Table 3-2. Adjunctive medications used in the treatment of benzodiazepine withdrawal ...

The use of divalproex in benzodiazepine withdrawal has also become a common clinical strategy. It is usually started in doses of 500—1,000 mg in two or three divided doses daily and increased to achieve serum levels of 50—120 pg/mL. Some protocols recommend a loading dose of 20 mg/kg. 

Ashton H Benzodiazepine withdrawal an unfinished story. Br Med J (Clin Res Ed)... 

Goodman WK, Charney DS, Price LH, et al Ineffectiveness of clonidine in the treatment of the benzodiazepine withdrawal syndrome report of three cases. Am J Psychiatry 143 900—903, 1986... 

Saxon L, Hjemdahl P, Hiltunen AJ, et al Effects of flumazentl in the treatment of benzodiazepine withdrawal—a double-hlind pilot study. Psychopharmacology (Bed) 131 153-160, 1997... 

Sellers EM Alcohol, barbiturate and benzodiazepine withdrawal syndromes clinical management. CMAJ 139 113—120, 1988... 

Tyrer P, Rutherford D, Huggett T Benzodiazepine withdrawal symptoms and propranolol. Lancet 1 520—522, 1981... 

Vorma H, Naukkarinen H, Sarna S, et al Long-term outcome after benzodiazepine withdrawal treatment in subjects with complicated dependence. Drug Alcohol Depend 70 309-314, 2003... 

The use of benzodiazepines should be avoided. There are other safer pharmacological alternatives. Benzodiazepine withdrawal may play a role in the occurrence of delirium in the elderly. Other withdrawal symptoms include tremor, agitation, insomnia and seizures (Turnheim 2003). Thus, when there is long-term use of benzodiazepines abrupt discontinuation might be difficult. Discontinuation should however not be withheld but done slowly and step-wise. If benzodiazepines are used in the elderly, short-acting benzodiazepines such as oxazepam are preferred, because they do not accumulate in the elderly to the same extent (Kompoliti and Goetz 1998). If short-acting benzodiazepines are used they should be prescribed with caution, at low doses, and for short periods. As with all pharmacotherapy the effects should be evaluated. Benzodiazepines are sometimes used as a behavioural control. One should always ask if this use is for the benefit of staff or the benefit of the patient. The presence of staff may be sufficient for behavioural control. 

Because GAD is a chronic illness, benzodiazepines are often used in long-term maintenance therapy, leading to physical dependence over the course of several weeks. Consequently, abrupt discontinuation of a benzodiazepine can result not only in rebound anxiety and a rapid relapse but an acute benzodiazepine withdrawal... 

Although many physicians routinely use benzodiazepines to treat combative, delirious patients, this is not recommended. First, benzodiazepines can cloud consciousness and actually worsen the confusion of delirium. Second, benzodiazepines can worsen the breathing problems of patients with pneumonia or emphysema, two common causes of delirium. The lone exception is a delirium that is caused by alcohol or benzodiazepine withdrawal. A benzodiazepine MUST be used for alcohol... 

Flumazenil s one problematic side effect is that it can trigger benzodiazepine withdrawal including increased pulse, increased blood pressure, shakiness, anxiety, and seizures. Because it is only used in the hospital, supportive medical care is, by definition, available if this occurs. 

Q68 Benzodiazepines with a short elimination half-life present a less severe withdrawal after drug discontinuation than drugs with a long elimination half-life. Symptoms of benzodiazepine withdrawal syndrome include anxiety, depression, insomnia and headache. 

Tolerance to benzodiazepines Flumazenil may cause benzodiazepine withdrawal symptoms in individuals who have been taking benzodiazepines long enough to have some degree of tolerance. Slower titration rates of 0.1 mg/min and lower total doses may help reduce the frequency of emergent confusion and agitation. 

Auditory unformed tinnitns, whistles formed voices, often insulting or accusatory - benzodiazepine withdrawal - cocaine, amphetamine, alcoholic hallucinosis, drug induced deliria and psychotic states... 

Tactile formication, feeling of insects etc. - cocaine, amphetamines, alcohol and benzodiazepine withdrawal... 

Hypnagogic, hypnopompic onset and offset of sleep (often associated with nightmares) - beta-blockers, benzodiazepine withdrawal... 

Other drugs related to amphetamines or cocaine may cause similar symptoms (Table 2), and formication is not uncommon in alcohol and benzodiazepine withdrawal (Sims, 1988 Ashton, 1997), both of which are associated with increased catecholamine activity. 

A benzodiazepine withdrawal syndrome has been described in some patients discontinuing therapy (Table 2). Although potentially serious, it is generally mild and self-limiting (up to 6 weeks), but may accompany or provoke a recurrence of anxiety symptoms and cause great concern to the patient. As with any other treatment, the risks and benefits of benzodiazepine therapy should be carefully assessed and discussed with the patient. Monotherapy will not be first-line treatment for the majority of patients, but benzodiazepines offer a valuable option that should not be discounted. 

Buspirone is as effective as the benzodiazepines in the treatment of general anxiety. However, the full anxiolytic effect of buspirone takes several weeks to develop, whereas the anxiolytic effect of the benzodiazepines is maximal after a few days of therapy. In therapeutic doses, buspirone has little or no sedative effect and lacks the muscle relaxant and anticonvulsant properties of the benzodiazepines. In addition, buspirone does not potentiate the central nervous system depression caused by sedative-hypnotic drugs or by alcohol, and it does not prevent the symptoms associated with benzodiazepine withdrawal. 

Will not prevent benzodiazepine withdrawal Patient/Family Education... 

Unlike benzodiazepines, buspirone is not associated with sedative or abuse problems, but some clinicians have observed that bus-pirone s anxiolytic properties do not appear to be as potent as those of benzodiazepines, particularly in patients who have previously received a benzodiazepine. Because buspirone is not sedating and has no psychomotor effects, it has a distinct advantage over benzodiazepines when optimal alertness and motor performance are necessary. Response to buspirone occurs in approximately 2-4 weeks. Buspirone does not show cross-tolerance with benzodiazepines and other sedative or hypnotic drugs such as alcohol, barbiturates, and chloral hydrate. Therefore, buspirone does not suppress benzodiazepine withdrawal symptoms. In anxious patients who are taking a benzodiazepine and who require a switch to buspirone, the benzodiazepine must be tapered gradually to avoid withdrawal symptoms, despite the fact that the patient is receiving buspirone. 

Marks, J. Techniques of benzodiazepine withdrawal in clinical practice. Med. Toxicol. 3, 324-333. 1988. 

Fatseas M, Lavie E, Denis C, Franques RP Tignol J (2006). Benzodiazepine withdrawal in subjects on opiate substitution treatment. Presse Medicate, 35, 599-606... 

Scott R (1990). The prevention of convulsions during benzodiazepine withdrawals. British Journal of General Practice, 40, 261 Seifert J, Metzner C, Paetzold W, Borsutzky M, Ohlmeier M, Passie T, Hauser U, Becker H, Wiese B, Emrich HM Schneider U (2005). Mood and affect during detoxification of opiate addicts a comparison of buprenorphine versus methadone. Addiction Biology, 10, 157-64... 

Ashton H. Benzodiazepine withdrawal outcome in 50 patients. BrJ Addict 1987 82 665-671. 

Schweitzer E, Rickels K. Failure of buspirone to manage benzodiazepine withdrawal. Am J Psychiatry 1986 258 204-205. 

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