Benzodiazepine
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Benzodiazepine: identification and management of dependence There is now abundant evidence that benzodiazepines in therapeutic dosage produce pharmacological dependence after long term therapy. The dependence is characterised by a withdrawal syndrome which includes major perceptual disturbances such as depersonalisation, hypersensitivity, abnormal perception of movement, weight loss, epileptic seizures, and psychotic symptoms such as paranoid delusions and visual hallucinations. Pharmacological dependence has been reported with several different benzodiazepines including diazepam, lorazepam, temazepam, triazolam and clobazam . There is evidence that withdrawal from lorazepam leads to more serious withdrawal symptoms than withdrawal from diazepam. A possible reason for this may be the short elimination half life (14 hours) of lorazepam resulting in a rapid fall of the drug levels in the brain after withdrawal. In general. the higher the dose of benzodiazepine the greater the likelihood of dependence and patients w/1O take benzodiazepines in intermittent flexible dosage are less likely to develop dependence than those who take the equivalent dose as a regular daily requirement. Pharmacological dependence on benzodiazepines is also affected by factors quite independent of pharmacokinetics, such as personality. Compared with those who had no withdrawal symptoms, patients who experienced withdrawal symptoms after gradual reduction of long term benzodiazepines had significantly greater lability, sensitivity, impulsiveness, irresponsibility and resourcelessness. The only satisfactory way of identifying benzodiazepine dependence is by recognising symptoms of the withdrawal syndrome which usually manifest within 2-3 days of stopping a short acting benzodiazepine and within 7 days of stopping long acting compounds. Symptoms at first consist of anxiety and its accompanying somatic symptoms such as insomnia and general unease. This is followed by the development of the full abstinence syndrome characterised by depersonalisation, unusual perceptual disturbance, hypersensitivity to light and sound, unsteadiness, paresis, numbness. a sense of depreSSion, dysphoria, and in rare cases paranoid symptoms, hallucinations and epileptic fits. This syndrome lasts for periods of 1-6 wee\<.s . None of the symptoms of withdrawal can be regarded as pathognomonic although the perceptual disturbances appear to be more important with benzodiazepine Withdrawal than other states of deoendence. The most effective immediate treatment is the replacement of the drug being withdrawn . This however. can give rise to problems with later withdrawal. Gradual reduction of benzodiazepines over a period of 6-8 weeks is less likely to lead to severe withdrawal symptoms than abrupt discontinuation of treatment. Cross tolerance occurs between members of the benzodiazepine group of drugs and it is inappropriate to benzodiazepine as specific treatment. to reduce the severity of withdrawal symptoms a short acting 0157-7271/ 84/ 0728-0003/ 0$01 .00/0 © ADIS Pr9ss benzodiazepine may be changed to a long acting one, as it is easier to withdraw from a long acting benzodiazepine in view of the gradual fall in plasma levels that accompanies reduction. This reduces the severity of the withdrawal symptoms. Major tranquillisers in low dosage may be used as treatment but most anti-anxiety drugs are also prone to dependence. Propranolol and other i3-blockers are known to attenuate many of the symptoms of withdrawal and have the advantage of not creating pharmacological dependence . There are no detailed studies of the effects of psychological treatment in the management of benzodiazepine dependence. In one small study, group therapy was of no benefit in helping patients to stop benzodiazepines after long term use. Tyrer. PJ and Seivewnght, N . Postgraduate Medical Journal 60 (Suppl 2) 41 (1984) R98ctions 28 Jul 1984 3
Transcript of Benzodiazepine
Benzodiazepine: identification and management of dependence
There is now abundant evidence that benzodiazepines in therapeutic dosage produce pharmacological dependence after long term therapy. The dependence is characterised by a withdrawal syndrome which includes major perceptual disturbances such as depersonalisation, hypersensitivity, abnormal perception of movement, weight loss, epileptic seizures, and psychotic symptoms such as paranoid delusions and visual hallucinations. Pharmacological dependence has been reported with several different benzodiazepines including diazepam, lorazepam, temazepam, triazolam and clobazam. There is evidence that withdrawal from lorazepam leads to more serious withdrawal symptoms than withdrawal from diazepam. A possible reason for this may be the short elimination half life (14 hours) of lorazepam resulting in a rapid fall of the drug levels in the brain after withdrawal. In general. the higher the dose of benzodiazepine the greater the likelihood of dependence and patients w/1O take benzodiazepines in intermittent flexible dosage are less likely to develop dependence than those who take the equivalent dose as a regular daily requirement. Pharmacological dependence on benzodiazepines is also affected by factors quite independent of pharmacokinetics, such as personality. Compared with those who had no withdrawal symptoms, patients who experienced withdrawal symptoms after gradual reduction of long term benzodiazepines had significantly greater lability, sensitivity, impulsiveness, irresponsibility and resourcelessness.
The only satisfactory way of identifying benzodiazepine dependence is by recognising symptoms of the withdrawal syndrome which usually manifest within 2-3 days of stopping a short acting benzodiazepine and within 7 days of stopping long acting compounds. Symptoms at first consist of anxiety and its accompanying somatic symptoms such as insomnia and general unease. This is followed by the development of the full abstinence syndrome characterised by depersonalisation, unusual perceptual disturbance, hypersensitivity to light and sound, unsteadiness, paresis, numbness. a sense of depreSSion, dysphoria, and in rare cases paranoid symptoms, hallucinations and epileptic fits. This syndrome lasts for periods of 1-6 wee\<.s . None of the symptoms of withdrawal can be regarded as pathognomonic although the perceptual disturbances appear to be more important with benzodiazepine Withdrawal than other states of deoendence.
The most effective immediate treatment is the replacement of the drug being withdrawn . This however. can give rise to problems with later withdrawal. Gradual reduction of benzodiazepines over a period of 6-8 weeks is less likely to lead to severe withdrawal symptoms than abrupt discontinuation of treatment. Cross tolerance occurs between members of the benzodiazepine group of drugs and it is inappropriate to give ·\~nother
benzodiazepine as specific treatment. to reduce the severity of withdrawal symptoms a short acting
0157-7271/ 84/ 0728-0003/ 0$01 .00/ 0 © ADIS Pr9ss
benzodiazepine may be changed to a long acting one, as it is easier to withdraw from a long acting benzodiazepine in view of the gradual fall in plasma levels that accompanies reduction . This reduces the severity of the withdrawal symptoms. Major tranquillisers in low dosage may be used as treatment but most anti-anxiety drugs are also prone to dependence. Propranolol and other i3-blockers are known to attenuate many of the symptoms of withdrawal and have the advantage of not creating pharmacological dependence . There are no detailed studies of the effects of psychological treatment in the management of benzodiazepine dependence. In one small study, group therapy was of no benefit in helping patients to stop benzodiazepines after long term use. Tyrer. PJ and Seivewnght, N . Postgraduate Medical Journal 60 (Suppl 2) 41 (1984)
R98ctions 28 Jul 1984 3
