Benzodiazepine dependence in primary care Aisha Bhaiyat 13 April 2010.
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Transcript of Benzodiazepine dependence in primary care Aisha Bhaiyat 13 April 2010.
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Benzodiazepine dependence in primary care
Aisha Bhaiyat13 April 2010
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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.
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Patient Y
• 71 yr old female.• Taking diazepam for “nerves”, for decades.• Diazapam on repeats.• Attended for medication review.
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Uses
• Act on inhibitory GABA receptors to depress CNS
• Anxiolytic, sedative, anticonvulsant, muscle relaxant, EtOH/stimulant drug withdrawal, premed anaesthesia
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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.
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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)
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DSM IV criteria for dependence3 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
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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.
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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
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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
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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
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Those not wanting to stop taking benzodiazepines
• Listen and address their concerns• Discuss tolerance and adverse effects• Encourage dose reduction, even if not
stopping
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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.
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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
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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
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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
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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
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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.