Upload
jerome
View
224
Download
0
Embed Size (px)
Citation preview
7/30/2019 Benzodiazepines - GP Handbook
1/21
G
eneral
Practitioner
H
andb
ook
A handbook for
General Practitioners and
other health professionals
to assist in the
management of
benzodiazepine withdrawal
1995
Drug and Alcohol Services Council161 Greenhill Road Parkside SA 5063
ISBN 0 7308 0095 4
ISBN 0 7308 0629 4
B E N Z O D I A Z E P I N E S
7/30/2019 Benzodiazepines - GP Handbook
2/21
1
Introduction
Who needs help to stop?
Management of withdrawalTherapeutic relationship
Withdrawal regimens
Alternative pharmacotherapy
Withdrawal symptoms
Referral
Prevention of dependence
C O N T E N T S
4
9
9
11
16
17
18
20
7/30/2019 Benzodiazepines - GP Handbook
3/21
2
This handbook is designed to assist
doctors in the management of
patients ceasing benzodiazepine use,
and is to be read in conjunction with the two
accompanying patient booklets.
This material was written as a result of
our experience in the treatment of peoplewith problems of benzodiazepine dependence
and our interactions with doctors involved in
the front line of dealing with these patients.
We have attempted to distil information from
research carried out by ourselves and others
on benzodiazepine withdrawal and, in
particular, ways in which withdrawal can beminimised.
The accompanying booklets have two
broad functions. BENZODIAZEPINES 1:
Reasons to Stop will assist patients in
deciding whether they should, with your
assistance, cease their prescribed
benzodiazepines. BENZODIAZEPINES 2:
I N T R O D U C T I O N
7/30/2019 Benzodiazepines - GP Handbook
4/21
3
Stopping Use provides the patient with
assistance and strategies during the process
of drug cessation. We suggest that
BENZODIAZEPINES 1 be available in your
surgery or, alternatively, provided to your
patients during a consultation regarding
benzodiazepine use.BENZODIAZEPINES 2should be provided to patients during the
consultation where planned drug withdrawal
is discussed.
Dr Jason White
SENIOR LECTURER
DEPARTMENTOF CLINICAL
& EXPERIMENTAL
PHARMACOLOGY
UNIVERSITYOF ADELAIDE
Dr Robert Ali
DIRECTOR, CLINICAL SERVICES & POLICYCOORDINATION
DRUG & ALCOHOL SERVICES COUNCIL
Acknowledgments
Catherine McGregor for her valuable input and
trialling of the booklets with patients and medical
practitioners.
Danny Stevens for editing and production.
7/30/2019 Benzodiazepines - GP Handbook
5/21
4
easing benzodiazepine use can be
relatively easy for many people,
but very difficult for others.CVarious estimates suggest that 3040%
of those people who take prescribed
quantities for longer than one month
will experience significant withdrawalsymptoms upon abrupt cessation.
Common symptoms associated with
benzodiazepine withdrawal are listed
below. These symptoms do not
necessarily occur in all people. Nor will
they occur at the same time. Typically,
symptoms are constant in the earlystages, and then become intermittent.
Some patients will experience symptoms
for less than two weeks, while in general
the time period is around six to eight
weeks. A minority of patients will
experience symptoms intermittently
for months.
WHO NEEDS HELP TO STOP?
7/30/2019 Benzodiazepines - GP Handbook
6/21
5
General
These symptoms tend to occur with any
central nervous system depressant-type
drug withdrawal (including alcohol).
anxiety, panic attacks, depression
and agoraphobia sleep disturbances
irritability, difficulty in
concentrating and remembering
tremor and general shakiness
sweating
nausea, loss of appetite, loss of
weight flu-like illness
seizures (if taking greater than
50 mg equivalent diazepam per day)
7/30/2019 Benzodiazepines - GP Handbook
7/21
6
Specific to Benzodiazepine
Withdrawal
metallic taste
distorted hearing sounds appear
unduly loud or strange
feelings of depersonalisation andunreality
distorted vision patient may feel
they are seeing things through
a veil
sense of smell and touch
heightened and distorted
pain, stiffness and muscularspasms, particularly in the
face and scalp, which can result in
headaches and muscle twitching
paranoid thoughts and feelings
7/30/2019 Benzodiazepines - GP Handbook
8/21
7
Benzodiazepine use can be a problem in
four main groups of patients:
Firstly, some people find that they are
unable to stop taking their medication as
a result of their inability to cope with the
withdrawal symptoms.
Secondly, some individuals experiencetolerance to the pharmacological effects.
This may manifest itself through either
breakthrough withdrawal symptoms or the
patient self-reporting a need to increase the
dosage to maintain control. You will need to
discuss the implications of this with your
patient as any increase in dose and/orduration of use may enhance dependence.
It is now generally agreed that to minimise
the likelihood of withdrawal symptoms
patients should not be prescribed
benzodiazepines for periods longer than two
to four weeks and even these patients
should reduce the dose of medication
gradually.
7/30/2019 Benzodiazepines - GP Handbook
9/21
8
Thirdly, side effects of prolonged
benzodiazepine use may prove to be
debilitating in particular at risk
populations. Common problems to
emerge are depression and impairments
of psychomotor, cognitive and memory
functions. These may manifest in theelderly as pseudodementia or trauma
due to falls.
Finally, we should mention the group
that take large doses of benzodiazepines,
well in excess of the prescribed
quantities, to enjoy the intoxication.
These people are typically in their lateteens to early twenties and often are
misusing other drugs. People in this
group generally do better if referred to a
specialist drug and alcohol agency.
7/30/2019 Benzodiazepines - GP Handbook
10/21
9
Therapeutic Relationship
Patients seeking repeat prescriptions
or those for whom you feel benzodiazepines
are no longer appropriate may be offered
BENZODIAZEPINES 1: Reasons to Stop.
This booklet will assist them in making
an informed decision as to continueduse. When the patient has made the
decision to stop or reduce their
medication,BENZODIAZEPINES 2:
Stopping Use can be provided to
reinforce your advice and instruction.
When the patient seeks assistance in
withdrawing from benzodiazepines you
should assist them in estimating the
risk/benefit ratio. There is evidence that
those who have a clear commitment and
support from significant others have a
better prognosis and are less likely to
relapse. Providing open and honest
information and continuing support are
MANAGEMENT OF WITHDRAWAL
7/30/2019 Benzodiazepines - GP Handbook
11/21
10
important elements of a successful
withdrawal program.
Most patients are best managed in
the community setting at a time when
there are no unusual stressors in their
life. It is important to emphasise to your
patient that withdrawal is not a raceand you are more concerned with long
term outcomes. Weekly meetings to
discuss the prior weeks symptoms and
reach a conjoint decision about further
reduction is ideal. The opportunity can
also be taken to talk through the
strategies set out in the patient booklets.
7/30/2019 Benzodiazepines - GP Handbook
12/21
11
Withdrawal regimens
Most patients who have been on
benzodiazepines for two months or
longer can be weaned off over a period of
46 weeks. However, the rate of
withdrawal should be titrated against
the severity of withdrawal symptoms.Weekly reductions of 5% of the previous
weeks dose are usually tolerated.
However, where withdrawal is severe,
you may need to hold the patient at a
particular dose level until withdrawal
symptoms subside. For patients who
have been prescribed multiple dailydoses, the daily benzodiazepine dose
should now be taken in four divided
doses at fixed times. Removing the night
time component last helps reduce the
severity of rebound insomnia.
7/30/2019 Benzodiazepines - GP Handbook
13/21
12
2 hours
8 hours
10 hours
12 hours
12 hours
14 hours
15 hours
18 hours
25 hours
28 hours
32 hours
60 hours
70 hours
Short half-life benzodiazepines
appear to be associated with more
intense withdrawal symptoms due to
their rapid elimination (see following
table).
A p p r o x im a t e
h a l f - l i f eB e n z o d i a z e p i n e
* The half-life is that of the more important
active metabolite.
triazolam
oxazepam
temazepam
bromazepam
lorazepam
alprazolam
chlordiazepoxide
clobazam
flunitrazepam
nitrazepam
diazepam
clorazepate*
flurazepam *
7/30/2019 Benzodiazepines - GP Handbook
14/21
13
In patients who have previously had
severe withdrawal, it may be necessary
to substitute a long-acting
benzodiazepine such as diazepam.
The following table gives approximate
equivalent doses of diazepam. Note that
due to differences in metabolism theexact equivalent will vary from patient to
patient. The figures in the table should
be treated as a general guide only.
7/30/2019 Benzodiazepines - GP Handbook
15/21
7/30/2019 Benzodiazepines - GP Handbook
16/21
7/30/2019 Benzodiazepines - GP Handbook
17/21
16
Alternative pharmacotherapy
There is often a temptation to manage
withdrawal symptoms pharmacologically.
This has not proven to be particularly
rewarding. blockers and 2
agonists
have been tried for somatic symptoms
without much effect.Antidepressants and major
tranquillisers have been used for night
time sedation. Both agents have
potential risks: cardiotoxicity as a result
of an overdose from antidepressants and
tardive dyskinesia following prolonged
use of major tranquillisers. Recentconcerns over the safety of tryptophan
have reduced enthusiasm to use it as a
hypnosedative.
7/30/2019 Benzodiazepines - GP Handbook
18/21
17
Withdrawal symptoms
These usually commence 12 days
after reduction in dose of a short-acting
benzodiazepine or 57 days for a long-
acting benzodiazepine. The severity and
duration is variable as is the
constellation of symptoms. Typically thesymptoms will resolve 46 weeks after
completing the detoxification program.
However, symptoms may persist for up to
twelve months. For patients on low doses
of benzodiazepines, the duration and
intensity of withdrawal symptoms is not
clearly related to the prescribed dose.Individuals who take more than the
equivalent of 50 mg diazepam per day
are at risk of withdrawal seizures and/or
hallucinations.
7/30/2019 Benzodiazepines - GP Handbook
19/21
18
n addition to patients who use high
doses of benzodiazepines, you may also
seek to refer patients who are unableIto negotiate withdrawal under your
direction. Inpatient detoxification is best
undertaken by a specialist unit. Patients
who have one or more of the followingcharacteristics should be referred for
inpatient detoxification.
R E F E R R A L
7/30/2019 Benzodiazepines - GP Handbook
20/21
19
Patients best suited for inpatient
detoxification:
benzodiazepine daily dose greater than
the equivalent of 50 mg diazepam
per day
antisocial personality disorder past history of withdrawal seizures
failed previous outpatient detoxification
strong patient preference following
informed consent
patients with a current alcohol or other
drug dependence
Assistance and advice can be given by
the Drug & Alcohol Services Council
through the Alcohol & Drug Information
Service (ADIS), telephone 13 1340.
7/30/2019 Benzodiazepines - GP Handbook
21/21
20
Guidelines for prescribing
benzodiazepines
where possible use non-pharmacological
alternatives (eg counselling)
use only for appropriate indications
explain the use of the medication and
the context of its use use lowest dose necessary
assess efficacy at one week
one benzodiazepine if possible
regular review
limit prescription to 24 weeks
discontinue gradually
warn of possibility of dependency when
use is prolonged (informed consent)
contraindicated in patients known to besubstance abusers
in chronic conditions intermittent brief
use may be appropriate
roblems of dependence will be
minimised if the following
guidelines are followed.P
PREVENTION OF DEPENDENCE