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 back.

Patient Y • • • • 71 yr old female.

Taking diazepam for “nerves”, for decades.

Diazapam on repeats.

Attended for medication review.

Uses • • Act on inhibitory GABA receptors to depress CNS 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 effective) 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 intended 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 • • • Considerations 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 slow Psychological interventions

Psychological intervention • • • Counselling to CBT Key worker through drug and EtOH rehab services Self help-battle against tranquillizers ( www.bataid.org

), benzodiazipines co operation not confrontation ( www.bcnc.org.uk

), www.non benzodiazepines.org.uk

Those not wanting to stop taking benzodiazepines • • • Listen and address their concerns Discuss tolerance and adverse effects Encourage dose reduction, even if not stopping

Benzodiazipine misusers • • • • • Often associated with polysubstance abuse Medical prescriptions is primary source of supply Multiple false identities/temporary residents with a story of forgotten or lost medication GP may worry re confrontation but best not to prescribe If requesting detox, refer to specialist drug and EtOH service.

Possible Effect on children of misusers • • • • • 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 misuse/dependence 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 withdrawa l

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 rules

Summary • • • • • • • 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.