Benzodiazepines dependency

Despite the risks of benzodiazepine dependence and overdose among alcoholic patients beyond the period of acute withdrawal, there may be a role for the judicious use of benzodiazepines in treating these patients. To the degree that early relapse, which commonly disrupts alcoholism treatment, is a result of continued withdrawal-related symptoms (e.g., anxiety, depression, insomnia) that can be suppressed by low doses of benzodiazepines, retention in treatment could be enhanced by the use of benzodiazepines (Kissin 1977). Moreover, for some patients, benzodiazepine dependence, if it does occur, may be more benign than alcoholism. 

Ross J, Darke S The nature of benzodiazepine dependence among heroin users in Sydney, Australia. Addiction 95 1785-1793, 2000 Rounsaville BJ, Kleber HD Untreated opiate addicts. Arch Gen Psychiatry 42 1072— 1077, 1985b... 

Marks (1978) reviewed published reports of benzodia2epine dependence in the literature from 1961 to 1977 and estimated that benzodiazepine dependence occurred in one case per 50 million patient-months of use. His assessment of risk has been criticized, however, because published case reports tend to occur less frequently than the phenomenon they describe. Benzodiazepine dependence case reports peaked between 1969 and 1973, about 10 years after the introduction of the drugs (Petursson and Lader 1981a). 

Although many factots contribute to drug dependence and misuse, only the pharmacological origins of benzodiazepine dependence will be considered here. The capacity of a benzodiazepine to induce dependence is telated to its... 

Clinical situations in which detoxification is indicated can be grouped into three categories 1) for patients who have been taking a maintenance therapeutic dosage for moderate to long periods of time and for whom a trial without medication is warranted, 2) for patients taking supratherapeutic doses (usually in the context of benzodiazepine dependence), and 3) for patients who use benzodiazepines as part of mixed substance dependence. Detoxification should be approached differently in each category. 

Allison C, Pratt JA Neuroadaptive processes in GABAergic and glutamatergic systems in benzodiazepine dependence. Pharmacol Ther 98 171-195, 2003... 

Busto UE, Romach MK, Sellers EM Multiple drug use and psychiatric comorbidity in patients admitted to the hospital with severe benzodiazepine dependence. J Clin Psychopharmacol 16 51-57, 1996... 

Cantopher T, Olivieri S, Cleave N, et al Chronic benzodiazepine dependence a comparative smdy of abrupt withdrawal under propranolol cover versus gradual withdrawal. Br J Psychiatry 156 406-411, 1990 Caplan RD, Andrews FM, Conway TL, et al Social effects of diazepam use a longitudinal field study. Soc Sci Med 21 887—898, 1985 Charney DA, Paraherakis AM, Gill KJ The treatment of sedative-hypnotic dependence evaluating clinical predictors of outcome. J Clin Psychiatry 61 190—195, 2000... 

Petursson H, Lader MH Benzodiazepine dependence. BrJ Addict 76 133—143,1981a Petursson H, Lader MH Withdrawal from long-term benzodiazepine treatment. Br Med J (Clin Res Ed) 283 643—643, 1981b Pichard L, Gillet G, Bonfils C, et al Oxidative metabolism of zolpidem by human liver... 

Silberstein SD, McCrory DC Butalbital in the treatment of headache history, pharmacology, and efficacy. Headache 41 953-967, 2001 Smith DE, Wesson DR Benzodiazepine dependency syndromes. J Psychoactive Drugs 15 85-95, 1983... 

Vorma H, Naukkarinen H, Sarna S, et al Treatment of out-patients with complicated benzodiazepine dependence comparison of two approaches. Addiction 97 851-859, 2002... 

If withdrawal is from alcohol, administer the CIWA-Ar to determine withdrawal severity. A score of 8 to 10 denotes relatively mild withdrawal, and the patient can be treated as an outpatient with supportive care only. A score from 11 to 14 can be treated on either an outpatient or inpatient basis, with either supportive care or with benzodiazepines, depending on the presence of underlying medical problems and the prior history of... 

Although benzodiazepines are well tolerated, the possibility of personality changes (nonchalance, paradoxical excitement) and the risk of physical dependence with chronic use must not be overlooked. Conceivably, benzodiazepine dependence results from a kind of habituation, the functional counterparts of which become manifest during abstinence as restlessness and anxiety even seizures may occur. These symptoms reinforce chronic ingestion of benzodiazepines. 

Intensive Care Unit (ICU) Use with caution in the ICU because of the increased risk of unrecognized benzodiazepine dependence in such settings. 

Strang, J. et aJ. (1993). In C. Hallstrom (Ed.), Benzodiazepine dependence (12S-142). Oxford Oxford University Press. 

Because depression is often accompanied by anxiety, and antidepressant drags often increase the anxiety, it is common to co-prescribe benzodiazepines at the beginning of antidepressant treatment. This has also the reputation of decreasing the early risk of suicide. This adjunct therapy usually does not need to be pursued more than 4-8 weeks, with careful tapering to avoid withdrawal symptoms that are a cause for benzodiazepine dependence or unjustified continued use. 

The speciflc clinical use of the numerous available benzodiazepines depends on their individual pharmacokinetic and pharmacodynamic properties. Drugs with a high affinity for the GABAa receptor (alprazolam, clonazepam, lorazepam) have high anxiolytic efficacy drugs with a short duration of action (temazepam) are used as hypnotics to minimise daytime sedative effects. Diazepam has a long half-life and duration of action and may be favoured for long-term use or when there is a history of withdrawal problems oxazepam has a slow onset of action and may be less susceptible to abuse. 

Task Force Report of the American Psychiatric Association (1990) Benzodiazepine dependence, toxicity and abuse. American Psychiatric Press, Washington... 

Rickels, K., Case, W.G., Schweizer, E., Garcia-Espana, E, and Fridman, R. (1990) Benzodiazepine dependence management of discontinuation. Psychopharmacol Bull 26 63-68. 

Salzman, C. (1990) Benzodiazepine dependency summary of the APA task force on benzodiazepines. Psychopharmacol Bull 26 61-62. 

Patients with drug or alcohol problems and those with chronic pain disorders or severe personality disorders almost certainly should not take benzodiazepines because of the high potential for developing benzodiazepine dependence. 

American Psychiatric Association Benzodiazepine Dependence, Toxicity, and Abuse A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1990 Cohn JB, Wilcox CS Low-sedation potential of buspirone compared with alprazolam and lorazepam in the treatment of anxious patients a double-blind study. J Clin Psychiatry 47 409 12, 1986 Dolovich LR, Addis A, Vaillancourt JM, et al Benzodiazepine use in pregnancy and major malformations or oral cleft meta-analysis of cohort and case-control studies. BMJ 317 839-843, 1998 Goldberg HL, Finnerty RJ The comparative efficacy of buspirone and diazepam in the treatment of anxiety. Am J Psychiatry 136 1184—1187, 1979 Kupfer DJ, Reynolds CF 111 Management of insomnia. N Engl J Med 336 341-346, 1997... 

Many regimens intended to prevent the appearance of benzodiazepine dependency or to make the unavoidable withdrawal symptoms more tolerable have been devised and published (Marks, 1988 Sartorv and Maurer, 1991). Controlled trials have also been performed to compare abrupt and gradual withdrawal regimens and to assess the appearance of withdrawal symptoms after discontinuing benzodiazepines with long and short half-lives (Busto et ah, 1986 Rickels et ah, 1990 Schweizer et ah, 1990). The results of these trials can be summarized as follows ... 

Owen, R.T., Tyrer, P. Benzodiazepine dependence a review of the evidence. Drugs 25, 385-398, 1983... 

Finally, it should be stressed again that certainly not all benzodiazepine prescribing to opioid maintenance patients need be long term. McDuff et al. (1993) reported on detoxification from alprazolam, the benzodiazepine most commonly used by their methadone subjects. With methadone dosage usually remaining the same, patients were offered a set reducing course of alprazolam over 11 weeks. Of 22 patients, four refused the treatment and 12 out of 18 subsequently completed detoxification, although timescales in practice proved variable. In a comparative study by Weizman et al. (2003) just over a quarter of benzodiazepine-dependent methadone maintenance patients remained free of benzodiazepines... 

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