Benzodiazepine dependence in
primary care
Aisha Bhaiyat
13 April 2010
Patient X
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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
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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, nondrug 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 cooperation not confrontation
(www.bcnc.org.uk), www.nonbenzodiazepines.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
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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 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
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.