Benzodiazepine dependence in primary care

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					Benzodiazepine dependence in
        primary care
         Aisha Bhaiyat
         13 April 2010
                  Patient X
• 25 yr old male.
• Previous hx of opiate misuse.
• Now working as a manager.
• Needs to fly to attend a meeting in Dublin, for
  one day.
• Is afraid of flying.
• Requesting diazepam for the flight there and
                    Patient Y
•   71 yr old female.
•   Taking diazepam for “nerves”, for decades.
•   Diazapam on repeats.
•   Attended for medication review.
• Act on inhibitory GABA receptors to depress
• Anxiolytic, sedative, anticonvulsant, muscle
  relaxant, EtOH/stimulant drug withdrawal,
  premed anaesthesia
             Adverse effects
• Inevitable tolerance, reduces effectiveness.
  Results in dosage escalation
• Little tolerance to cognitive
  impairment/amnesia. Risks accidence/falls.
• Dependence-continuing treatment then only
  serves to prevent withdrawal of symptoms
  which resemble initial complaint
• Drug interactions- synergism with EtOH and
  drugs. Risk of overdose.
     Tolerance and dependence
• Hypnotic effect-within a few days-weeks (after
  2/52 of regular use, B become ineffective as
  sleeping tabs)
• Anxiolytic-within 4-6 months (half of those
  taking for 1 yr or more do so due to
  dependence rather than B being medically
• Anticonvulsant-few weeks
• Cognitive impairment/amnesia –very little (so
  despite effect of BZ decreasing CI/A continue)
   DSM IV criteria for dependence
3 or more of following
• Tolerance –Increasing amount required for desired
   effect/reduced effect with same amount
• Withdrawal
• Taken in larger amounts or longer periods than was
• Persistant desire/unsuccessful effort to cut down
• A great deal of time is spent to obtain/use/recover from a
   substances effect
• Social/occupation/recreational effects due to substance use
• Substance use is continued despite persistent/recurrent
   physical/psychological problems due to substance use
         Withdrawal syndrome
• Time lag corresponds to half life
• Severity correlates with time used, dose and
  with short acting and potency of drug
• Symptoms of withdrawal resemble the
  original complaint resulting in a temptation to
  continuing usage.
  Patients wanting to stop taking
• Is the patient ready?
• Where? By GP or specialist centre?
• Advice patients information about undergoing
  withdrawal and that they will be in control
      Management of expected
       withdrawal symptoms
• Anxiety-consider slowing withdrawal, non-
  drug treatment, adjunct treatments (not
  established practice but may help)
• Insomnia-not likely to occur if withdrawal is
• Psychological interventions
      Psychological intervention
• Counselling to CBT
• Key worker through drug and EtOH rehab
• Self help-battle against tranquillizers
  (, benzodiazipines co-
  operation not confrontation
  (, www.non-
  Those not wanting to stop taking
• Listen and address their concerns
• Discuss tolerance and adverse effects
• Encourage dose reduction, even if not
        Benzodiazipine misusers
• Often associated with polysubstance abuse
• Medical prescriptions is primary source of
• Multiple false identities/temporary residents
  with a story of forgotten or lost medication
• GP may worry re confrontation but best not to
• If requesting detox, refer to specialist drug and
  EtOH service.
      Possible Effect on children of
•   Neglect, physical and emotional abuse
•   Accidents
•   Poverty
•   Frequent changes in residence
•   Presence and availability of toxic substance to
    the child
Tips if prescribing benzodiazipine 1
• Avoid in those with hx of drug
• Prescribe lowest dose and maximum 2 wks
• Do not add to repeats
• Consider alternatives eg relaxation techniques
• Advise patients re adverse effects
Tips if prescribing benzodiazipine 2
Advice patients of the following
• Advise of risk cognitive impairment eg
  accidents, effect on driving
• Advise of risk of tolerance
• Advise of risk of dependence and withdrawal
                 Legal stuff
• Class C
• Driving- non-prescribed/supratherapuetic
  dose constitutes dependency/misuse, must
  inform DVLA
• Travel - if more than 3/12 supply then
  personal import/export licence from UK and
  letter from prescribing doctor. Patient to
  contact consulate of country being visited re
• Distinguish between BZ symptom treatment
  and chronic dependence
• Holistic care
• Withdraw gradually
• Non drug strategies-patient education, CBT
• Adjunct drug therapy-not firmly established
  (but may be helpful)
• Regular follow up of symptoms and dose
• Remember legal stuff –driving and travel.

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