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Carefully analyze benzodiazepine dependence

November 17, 2011
by Jerry Rand, MD
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Benzodiazepines are prescribed for a variety of illnesses, including anxiety disorders but also used in cases of schizophrenia, depression, polysubstance abuse, alcohol withdrawal and other disorders. The selection of treatment strategies for benzodiazepine dependence should be dictated by considering the comorbid underlying illnesses present. The reason for the patient's initial use and dosage of benzodiazepines may no longer apply, so as in the case with opioids, reducing or discontinuing the drug should always be considered.

Sir William Osler stated, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” Among the factors that professionals should initially evaluate are physiological variants including genetic predispositions; childhood traumas; onset of drug, alcohol, or benzo use; amount of drug use and years of use; anxiety, panic and sleep disorders; other comorbidities; and psychiatric disorders that have initiated or dictated continued use of benzos.

Safety issues

Complicated patients are best treated in an inpatient setting. Patients benefit from treatment in stages. Modify your treatment approach based on the severity of the combined disorders. Some patients will need extensive and extended treatment.

In treating patients with chronic opioid and benzo dependencies in an inpatient setting, initiate stabilization of the opioids by using medication in a controlled fashion to stabilize the patient's physiology. Address the benzodiazepine first by stabilizing the dosage (this is the first line of treatment), and then individualizing a tapering protocol. One can then address the opioids without causing respiratory depression. Proceed with tapering the opioids in a step down fashion, or transitioning to buprenorphine and/or oxymorphone to taper to avoid respiratory depression or sleep apnea. Following opioid stabilization, formulate a strategy and proceed with the final benzo taper.

In tapering benzodiazepines, conventional recommendations are to utilize a stable drug such as Librium or phenobarbital. Those patients who have comorbid conditions, hepatic impairment or aging physiology might not metabolize these drugs well. In these instances, shorter-acting, easily metabolized drugs such as lorazepam or oxazepam can be used, at least initially until a low enough dosage can be comfortably achieved. Then, when the patient is metabolically stable a taper could include phenobarbital or a longer-acting benzodiazepine.

Symptoms of benzodiazepine discontinuation include the appearance of recurrence or relapse symptoms, rebound symptoms, pseudo-addiction, or true withdrawal. Prolonged/protracted withdrawal from benzos is an issue in complicated patients. In medically compromised patients (patients with heart disease, Crohn's disease, or rheumatologic, diabetic and neurological disorders), stabilize the person's medical condition prior to detoxing him/her off benzos.

When dealing with prolonged withdrawal syndrome, there is limited evidence in terms of the chronic neuroplastic changes that occur with benzo dependency regarding recovery of receptors and biochemistry homeostasis. Drug-induced neuroplastic changes might never fully correct. Withdrawal symptoms might therefore represent a return of symptoms from neuroplastic imbalance and chronic changes, as well as unresolved psychiatric symptoms. These patients could benefit from additional pharmacologic maintenance.

Adjunctive medications such as carbamazepine, valproate, propranolol, clonidine, buspirone and trazodone are used in these cases. New medications, including doxepin (Silenor) 3 to 6 mg, Lunesta in tapering doses 3-2-1 mg, Rozerem 8 mg, and Saphris (for anxiety stabilization and sleep effect), are quite useful in stabilizing individuals. Protracted use of phenobarbital if necessary is an option if abuse of benzos remains.

Benzo abuse and overdose

Benzodiazepine abuse and overdose as a single agent rarely lead to death. Polypharmacy amplifies the risk of treating patients in an outpatient setting. Patients detoxing in an outpatient setting have the potential for self-medicating and abuse.

In uncomplicated benzo patients, prescribe a small amount of a safe benzo for five to seven days. See them frequently until they reach stability. Be careful if patients are on multiple drugs, particularly during the detox phase, because the risk is highest for self-abuse and overdose at this time.

Jerry Rand, MD
Jerry Rand, MD

One might prefer short-acting drugs such as lorazepam or oxazepam for safety because they are quickly metabolized. These may be safer when the hepatic microsmal enzyme oxidase system is impaired. Switch to Librium (chlordiazepoxide) or phenobarbital in an outpatient setting at a time when patients are physiologically improved.

Observe patients until the benzos have cleared. The final phase of clearance could take several days after the last dose. Individuals are prone to have recurrent symptoms and sleep disruption from rebounding off the benzos on their own. Inpatient treatments use benzos, and following discharge patients may go through withdrawal or have return of symptoms. Relapse occurs when symptoms of benzo withdrawal are intolerable. It is a human condition to relapse on drugs when one perceives the symptoms to be intolerable.