Originally Presented by Dr. Marissa Capette

Dr Jeku Jacob and CNC Lisa-Jayne FergusonDrug & Alcohol Service

St Vincent’s Hospital

Benzodiazepines

Effects, Withdrawal &

Treatment Options

BZD’s - Introduction The most widely used of all psychotropic drugs

Treatment of Anxiety states Muscle spasm/ tension Seizures Insomnia

Safer than barbiturates (less chance of OD)

However dependence can develop (3 weeks) – tolerance and withdrawal

BZD’S ARE USED BY 2 MAIN GROUPS

Elderly & women (low dose)

Young, polysubstance users (high dose)

WHY PEOPLE USE BZD?

Enhance & prolong the 'high‘ of other drugs

Alleviate withdrawal effects

Users of stimulants take benzodiazepines as 'downers'

The mixture of alcohol and benzodiazepines produces a hedonic effect

BZD Intoxication

Decreased anxiety Sleepiness Sedation Anti-convulsant effects

Blurred vision Poor memory recall Dizziness/vertigo Confusion Slurred speech Ataxia, poor motor co-

ordination Stupor Paradoxical violence and

disinhibited behaviour

BZD INTOXICATION

Dose dependant

Sedation StuporRespiratory depression

Death can result if taken with other drugs

Health & social hazards of BZD misuse

General Complicationsof IV use

Fatalities due to overdose (particularly in combination with opioids) Thrombophlebitis

Blackouts and memory loss Deep and superficial abscesses

Paranoia Deep vein thrombosis

Violence and criminal behaviour Pulmonary microembolism

Risk-taking sexual behaviour Rhabdomyolysis, tissue necrosis

Foetal and neonatal risks if taken in pregnancyGangrene, requiring amputation (usually

due to inadvertent intra-arterial injection)

Dependence Hepatitis B and C

Withdrawal seizures HIV infection

Comparison TableTrade names Time to peak Half life

Diazepam Valium, Ducene, Antenex

30-90 mins 20-48 hrs

Temazepam Temaze, Normison

30-60 mins 5-15hrs

Oxazepam Serepax, Murelax 2-3 hrs 4-15 hrs

Alprazolam Xanax, Kalma 1 hr 6-25 hrs

Lorazepam Ativan 2 hrs 12-16 hrs

Clonazepam Ritrovivl, Paxam 2-3 hrs 22-54 hrs

Benzodiazepine Equivalence

5 mg Diazepam equal to –– Alprazolam 0.5-1 mg– Temazepam 10-20 mg – Clonazepam 0.5 mg– Oxazepam 15 mg – Lorazepam 1 mg

Adapted from Frank L, Pead J. New concepts in drug withdrawal: a resource handbook © 1995 State of Victoria.

Withdrawal Profile

Withdrawal Symptoms

Rebound anxiety (particularly with short acting) Insomnia Poor concentration and memory Muscle aches, stiffness and spasms Tremor, sweats Racing thoughts, agitation Confusion Depression Increased sensory perception → hallucinations Delirium Seizures

Signs of Withdrawal

Withdrawals featuring a delirium can mimic amphetamine intoxication or psychotic episode 2nd to underlying Mental Health issues

Pupils dilated and fine tremor may indicate

Benzodiazepine withdrawal

Assessment

Duration

Amount

Street or GP (phone)

Regularity of use, binge etc...

Does the pt wish to change intake?

In-Pt Withdrawal Treatment Convert short acting regular BZD dose to long acting

BZD (Diazepam)

Patient stabilised at a dose of 40% of their regular intake (or 80 mg/day whichever is lower) in 3 - 4 divided doses

Day 5 onwards – Reduce by 10% every 2-4/7’s, depending on pt’s response

Community Withdrawal Treatment

Reduce by 10 mg / week until 40 mg Then by 5mg / week This will take about 12 weeks Supportive GP Pick up from pharmacy Pt can sign Dr Shopping form

Withdrawal SymptomsWithdrawal symptoms do not decrease steadily

from a peak, but follow a fluctuating course with good & bad periods

Eventually the good periods will last longer & become more frequent

Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states)

New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007)

Treatment Options Detox / Rehabilitation (Limited facilities)

Self Management & Recovery Training (SMART)

Narcotics Anonymous/ 12 Step programme

Individual Counselling

Alcohol & Drug Information Service - 93618000 or local area A&D service

Benzodiazepine Overdose: Treatment

Monitor vitals & O2 sats Charcoal/Osmotic Purgative if recent ingestion

Flumazenil – Benzodiazepine antagonist (0.2 mg/min IV initially, repeat up to 3 mg maximum)

Caution in patients where Benzodiazepine dependence is suspected: risk of Benzodiazepine withdrawal seizure

Case Study

58 year old female admitted to hospital after chest pain

On day 4, patient suffered two grand mal seizures.

Pt known to be alcohol dependant

Pt suspected of abusing benzodiazepenes

Refused to admit to more than 10 mg/ night.