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Treating BZD dependency |
by Paul McGeown & David Helliwell
Benzodiazepines are a useful class of drugs, widely used for their sedative, anxiolytic and anti epileptic properties. Since the first benzodiazepine (Librium) was marketed in 1960 they have become some of the most widely prescribed medications, and certainly have been the most prescribed class of psychotropic medication. The class effect of these drugs is to increase the inhibitory effect of GABA within the central nervous system, inducing relaxation, sedation and a reduction in anxiety.
The usefulness of this group of medications however is significantly limited by its potential for dependency – tolerance and misuse. For many people the resultant morbidity outweighs any clinical benefit.
In the halcyon days of benzodiazepine prescribing, assertive and persuasive marketing led to massive prescription of the drugs, which ultimately resulted in a general understanding that caution must be used when prescribing them. However it is exactly the efficaciousness of the medication that ensures it continues to be still used widely.
Benzodiazepines appear in a considerable proportion of presentations to Riverlands, either as a primary dependency or as a complicating factor in an existing addictive process. Patterns of use include years of stable prescribing by one GP to a client who has become deeply neuroadapted or doctor-shopping clients who visit a range of GPs for their regular prescriptions. Drug using clients may have access to street benzodiazepines and use them for binges or as part of a regular polydrug dependency.
Morbidity
Morbidity in benzodiazepine dependent clients includes depression, rebound anxiety and insomnia, black-outs often associated with crime – frequently shoplifting – “hindbrain crime” and significant withdrawal syndrome including seizures.
Uses
The range of conditions for which benzodiazepines are useful include insomnia, anxiety associated with depression, grief and trauma, poorly controlled epilepsy, alcohol withdrawal, back pain and other musculoskeletal conditions. These ailments can be difficult to treat in general practice, time consuming and complex. Benzodiazepines are effective in relieving the symptoms and provide quick relief to patients who often have a significantly positive experience with them.
Developing problems
Several factors assist in the development of problems associated with benzodiazepine prescribing. Firstly we can rarely be certain that a client is not seeing other doctors for supplementary prescriptions unless we specifically check with pharmacists or the HIC.
Tolerance to the drugs happens relatively quickly, within 1-2 months of use, resulting in withdrawal symptoms and rebound anxiety and insomnia. Clients may become inadvertently dependent unless the prescribing clinician remains conscious of the need to set defined limits around use and to give clear information to the client about the risks involved with the medication – dependency, sedation, potentiation by other sedatives, eg. alcohol, opiates and tricyclic anti depressants.
Prescribing
When prescribing this class of drugs, a plan for use including duration, parallel therapies and plan for cessation of the medication should be carefully noted and discussed with the patient. There is some potential for medico legal consequences if iatrogenic dependency occurs.
Current recommendations are that benzodiazepines should be used usually for short periods of time and should be accompanied by other supportive treatments aimed at correcting underlying problems – eg. depression, grief.
Clients who present claiming to be epileptic and request treatment with clonazepam really do need to be reviewed and assessed to ensure that the primary problem is not actually benzodiazepine dependency.
Types of BZD
Benzodiazepines vary in potency, duration and specificity with respect to sedation or anxiety reduction. Some have been marketed primarily as anxiolytics claiming less risk of dependency, eg. alprazolam (Kalma, Xanax). Certain benzodiazepine-like agents such as zopiclone (Imovane) and zolpidem (Stilnox) are marketed with emphasis on the reduced capacity for dependence, although experience and further research has shown that above the recommended dose range there exists the possibility of addiction and use as date rape agents, both having amnestic and sedative qualities.
Our experience at Riverlands has been that alprazolam (Xanax, Kalma) has become more widely used as an illicit street benzodiazepine since the rescheduling of flunitrazepam to S8 status. It has some street value and is popular amongst drug dependent people for its potency and ability to combine with other medications, or used by itself in greater quantities to produce sedation and disinhibition. The resulting state is dangerous because of its potential to raise the risk of drug overdose especially when combined with opiates, respiratory obstruction while sleeping, trauma while in a disinhibited state, impulsive behaviour, eg. shoplifting, unprotected sex.
Far from being a relatively harmless anxiolytic, this medication becomes a potent sedative with significant amnestic properties.
Managing withdrawal
Management of benzodiazepine withdrawal is a complex process, which is usually coloured by anxiety, insomnia, relapse and fear, even in motivated clients.
At Riverlands we think of the process as being a three phase procedure. An initial admission to the inpatient unit may be useful for clients who are taking multiple benzodiazepines, large quantities or uncertain quantities, or those with a history of seizures. During this phase we stabilise the client on diazepam and reduce them to a comfortable, stable daily dose, aiming for a BD regime. We can usually get clients down to 20 –30 mg diazepam per day regardless of how much they were taking at initial presentation.
The second phase involves a supportive GP who can continue to see the client on a regular basis, and a pharmacist who is willing to dispense the diazepam in a controlled fashion (eg. three times per week, or even daily in some cases). The aim of this phase is to reduce the client slowly but steadily off, perhaps as slow as 0.5 – 1 mg a week. It is useful to have a formal written plan with regular consultations to monitor progress and furnish prescriptions as required. The process should be flexible and should allow for periods where no reduction is possible or temporary increase in daily dose.
Other medications at this time that may prove useful include antidepressant medication with anxiolytic or sedative properties, beta blockers, low dose major tranquillisers, sedative antihistamine medication. Management of social and emotional factors is essential and encouragement to attend to issues of diet and exercise are also important. Management of insomnia is crucial and instructions on sleep hygiene will be invaluable. The involvement of a drug and alcohol counsellor or support group may be useful.
This phase of the process may be all that is needed, with a client able to reduce completely off at this steady rate. Some may benefit from a third stage, which involves admission to Riverlands once they have reduced to the lowest possible dose in the community that they can tolerate. An inpatient admission to Riverlands provides a supportive, safe, medically assisted way of finishing the withdrawal of medication.
Some clients, especially those who have been using benzodiazepines for years, may be so deeply neuroadapted that they cannot tolerate complete reduction and the focus of treatment needs to be on a sustainable, safe prescribing process using minimal quantities of diazepam and support in addressing other social and emotional issues and underlying anxiety.
BZD dependency is tricky and the VMOs at Riverlands will support the process and arrange inpatient management if required with assessment and recommendation of withdrawal regimes. They can be contacted via Lismore Base Hospital or directly on 6620 7600.
Paul McGeown & David Helliwell are GPs who specialise in D&A issues.
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