Quality of life in a cohort of high-dose benzodiazepine dependent patients

Economic and clinical burdens and associated health disparities in HIV/AIDS management using big data: potentially inappropriate use and deprescribing of benzodiazepines

This study aimed to examine factors, healthcare utilization, and medical costs associated with potentially inappropriate use of benzodiazepines in persons living with HIV (PLWH). We used big data from Medicare claims in 2017. Potentially inappropriate use of benzodiazepines was defined as having any benzodiazepine claims in individuals 65+ years or having benzodiazepine claims for more than four weeks in individuals 18-64 years. Logistic regressions, zero-inflated negative binomial regressions, and generalized linear models were used. This study included 1,211 PLWH and 235 (19.41%) had potentially inappropriate use of benzodiazepines. PLWH who were 65+ years (OR: 0.56; 95% CI: 0.33, 0.96), non-Hispanic blacks (OR: 0.29; 95% CI: 0.20, 0.41), or Hispanics (OR: 0.55; 95% CI: 0.35, 0.88) were less likely to use benzodiazepines inappropriately. PLWH who had potentially inappropriate use of benzodiazepines had more inpatient (IRR: 1.46; 95% CI: 1.10, 1.94), outpatient (IRR: 1.14; 95% CI 1.02, 1.28), and emergency room (IRR: 1.32; 95% CI: 1.03, 1.68) visits. Potentially inappropriate use of benzodiazepines was associated with higher total (β: 0.16; 95% CI: 0.07, 0.25), Medicare (β: 0.18; 95% CI: 0.07, 0.28), and out-of-pocket (β: 0.21; 95% CI: 0.05, 0.36) costs. This study provides real-world evidence to support deprescribing benzodiazepines in PLWH.

Emerging and upcoming therapies in insomnia

Insomnia, commonly treated with benzodiazepine (BZD) receptor agonists, presents challenges due to associated serious side effects such as abuse and dependence. To address these concerns, many researches have been conducted to develop and advance both pharmacological and non-pharmacological interventions. Dual orexin receptor antagonists (DORAs), which include suvorexant, daridorexant and lemborexant, have recently been approved by United States Food and Drug Administration (US FDA) as a novel pharmacotherapeutic alternative. Unlike BZD receptor agonists that act as positive allosteric modulators of the gamma-aminobutyric acid type A subunit alpha 1 receptor, DORAs function by binding to both orexin receptor types 1 and 2, and inhibiting the action of the wake-promoting orexin neuropeptide. These drugs induce normal sleep without sleep stage change, do not impair attention and memory performance, and facilitate easier awakening. However, more real-world safety information is needed. Selective orexin-2 receptor antagonists (2-SORAs) is under clinical developments. This review provides an overview of the mechanism of action in relation to insomnia, pharmacokinetics, efficacy and safety information of DORAs and SORA. According to insomnia management guidelines, the first-line treatment for chronic insomnia is cognitive behavioral therapy for insomnia (CBT-I). Although it has proven effective in improving sleep-related quality of life, it has several restrictions limitations due to a face-to-face format. Recently, prescription digital therapy such as Somryst® was approved by US FDA. Somryst®, a smartphone app-based CBT-I, demonstrated meaningful responses in patients. However, digital limitations may impact scalability. Overall, these developments offer promising alternatives for insomnia treatment, emphasizing safety, efficacy, and accessibility.

Long-term use of benzodiazepines in chronic insomnia: a European perspective

Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.

Concordance in psychopharmacological treatment before and after first mental health consultation

PURPOSE

To analyse concordance between treatment prescribed before and after the first mental health consultation. We understand concordance in two different senses: first, as a similar amount of equivalent doses and drug type; second, as a similar treatment for each patient.

METHOD

This is an analytical, descriptive, retrospective study on psychopharmacological treatment before and after first mental health consultation of 1236 patients. Drugs were classified into four groups and the equivalent dose respect to reference medication was considered in each group in order to make a comparison between primary and mental health.

RESULTS

Moderate concordance was found in prescribed treatments before and after first mental health consultation (except antidepressants). The average number of benzodiazepines decreased, as did average doses prescribed at mental health consultation respect to previously prescribed treatment; average doses of antidepressants, however, increased. From the patient's perspective, dose increase was more frequent than decrease. Nevertheless, a high percentage of polymedicated patients were found, although this percentage decreased after the first mental health consultation.

CONCLUSION

There exists a moderate concordance between the pharmacological treatment prescribed before and after the first mental health consultation. However, the use of benzodiazepines diminished significantly after the first consultation, mainly due to a decrease in the percentage of polymedicated patients.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Study protocol-Evoked craving in high-dose benzodiazepine users

Benzodiazepine (BDZ) abuse, especially concerning high doses of BDZs, is an impairing substance use disorder (SUD) that is often difficult to treat. Craving and cue reactivity (CR) are two important phenomena that have a prominent role in maintaining addiction and triggering relapses in BDZ abuse; nevertheless, they have rarely been addressed in scientific literature. The present study aims to fill these gaps by implementing a highly innovative virtual reality (VR) design to assess the impact of substance-related environmental cues on BDZ craving, as well as their influence on patients' affective states. Therefore, on one hand, this research will contribute to the assessment of VR feasibility in the study of these phenomena, and, on the other, it will help disentangle the role that CR and craving have on mood and attention, which are equally important factors to consider when treating SUDs. We will recruit a healthy control group and a patient group comprising people seeking treatment for BDZ detoxification. The experimental design will consist of the presentation of three VR scenarios, one neutral, one BDZ-related but without BDZ cues, and another with BDZ cues. The craving will be measured through a virtual analog scale (VAS); the Profile of Mood States (POMS) and Alcohol Attention Scale (AAS) questionnaires in a modified version will also be administered. We will additionally control for VR-induced feelings of sickness by administering the Simulator Sickness Questionnaire (SSQ), and the Presence Questionnaire (PQ) will be used to investigate participants' sense of presence in virtual environments. We expect patients to exhibit higher levels of craving, and that the craving will be higher after exposure to a cue-related virtual environment as compared to a neutral scenario.

Case Report: High doses of Zolpidem and QT interval lengthening: Is there a relationship? A case series

Zolpidem is indicated in cases of severe insomnia in adults and, as for BDZs, its assumption should be limited to short periods under close medical supervision. Since several drugs cause corrected QT interval (QTc) elongation, the authors investigated whether high daily doses of Zolpidem could cause QTc elongation. The study was conducted in the Addiction Medicine Unit of the G.B. Rossi University Hospital in Verona. The data were collected from hospitalizations carried out between January 2015 and February 2020 and refer to a total of 74 patients, 38 males and 36 females, who were treated for detoxification from high doses of Zolpidem with the "Verona Detox Approach With Flumazenil." One patient out of 74 had QTc elongation (479 ms). The patient was male and took a daily dose of 50 mg of Zolpidem; he did not take concomitant therapies that could cause QTc lengthening. He had no electrolyte alterations, no contemporary or previous intake of barbiturates, heroin, cocaine, THC, alcohol, NMDA or nicotine which could cause an elongation of the QTc interval. The present study highlights the low risk of QTc elongation due to high dosages of Zolpidem; however, if, on one hand, we can affirm that Zolpidem is a safe drug, on the other, the widespread use of high dosages of this drug for prolonged periods of time is problematic and worrying.

Polysubstance Use Patterns Among High Dose Benzodiazepine Users: A Latent Class Analysis and Differences Between Male and Female Use

Benzodiazepines (BZDs) represent one of the most widely used groups of pharmaceuticals, but if used for long periods of time they are associated with dependence and an increased risk of harmful effects. High-dose (HD) BZD dependence is a specific substance use disorder associated with a poor quality of life. It is especially important to pinpoint differences in HD BZD addict subgroups in order to tailor treatment to the individual's specific needs, also considering possible comorbidities with other substance use disorders. We conducted a study to evaluate HD BZD dependence (converted doses to diazepam equivalents, mg) in an Italian sample of 1,354 participants. We also investigated if and to which extent participants co-used other substances (alcohol, tobacco, cannabis/cannabinoids, cocaine, and heroin). We then performed latent class analysis (LCA) to identify the use patterns of these substances, finding three classes: participants in Class 1 (4.3% of the sample) had the highest probability of also using cocaine and alcohol (Polysubstance BZD users); Class 2 comprised subjects with the highest probability of being former heroin, cocaine, THC, and alcohol users (Former polysubstance BZD users); Class 3 represented mono-dependence BZD users (78.5% of the sample) and was the most prevalent among women, while young men were most prevalent in Class 1. The present study underlines different characteristics in HD BZD users both concerning other addictions and sex, and also highlights the need for a stricter control of BZD use, ranging from prescriptions to sales.

Benzodiazepine high-doses: The need for an accurate definition

OBJECTIVES

A clear definition of what we understand of high-dose misuse or of a 'markedly increased dose' (as stated by the DSM-5) is important and past definitions may be inadequate. The aim of this review is to describe the different definitions used and to test these definitions for their accuracy.

METHODS

A narrative PubMed literature review was conducted based on articles published between 1 January 1990 and 31 December 2020 describing benzodiazepines (in MeSH Terms or MeSH Major Topic) and high-dose (or high-dosage). Specific definitions were applied to a population sample to show how definitions affect high-dose benzodiazepine prevalence.

RESULTS

Multiples of an equivalent-diazepam dose or of the World Health Organization 'defined daily dosage' were used more frequently than the overstep of the recommended maximum therapeutic dosage as a cut-off point.

CONCLUSION

High-dose use is rare but the prevalence in the general population varies among studies, mainly due to different definitions, making both clinical and epidemiological comparisons between studies difficult. Defining a high-dose user as a person who takes at least a higher dose than the maximum usual therapeutic dose over a defined period of time therefore appears to be clinically more consistent.

Substance use and symptoms of mental health disorders: a prospective cohort of patients with severe substance use disorders in Norway

BACKGROUND

There is high co-occurrence of substance use disorders (SUD) and mental health disorders. We aimed to assess impact of substance use patterns and sociodemographic factors on mental health distress using the ten-item Hopkins Symptom Checklist (SCL-10) over time.

METHODS

Nested prospective cohort study of 707 participants with severe SUD across nine opioid-agonist-therapy outpatient clinics and low-threshold municipality clinics in Norway, during 2017-2020. Descriptive statistics were derived at baseline and reported by means and standard deviation (SD). A linear mixed model analysis was used to assess the impact of substance use patterns and sociodemographic factors on SCL-10 sum score with beta coefficients with 95% confidence intervals (CI).

RESULTS

Mean (SD) SCL-10 score was 2.2 (0.8) at baseline with large variations across patients. We observed more symptoms of mental health disorders among people with frequent use of benzodiazepines (beta 3.6, CI:2.4;4.8), cannabis (1.3, CI:0.2;2.5), opioids (2.7, CI:1.1;4.2), and less symptoms among people using frequent stimulant use (- 2.7, CI:-4.1;-1.4) compared to no or less frequent use. Females (1.8, CI:0.7;3.0) and participants with debt worries (2.2, CI:1.1;3.3) and unstable living conditions (1.7, CI:0.0;3.3) had also higher burden of mental health symptoms. There were large individual variations in SCL-10 score from baseline to follow-up, but no consistent time trends indicating change over time for the whole group. 65% of the cohort had a mean score > 1.85, the standard reference score.

CONCLUSIONS

People with SUD have a considerable burden of mental health symptoms. We found no association between substance use patterns and change in mental health symptoms over time. This could suggest that the differences observed were indicating flattening of effects or self-medication to a larger degree than medication-related decline in mental health. This call for better individualized mental health assessment and patient care.

Continuous Infusion of Flumazenil in the Management of Benzodiazepines Detoxification

An effective approach in the treatment of benzodiazepine (BZD) overdosing and detoxification is flumazenil (FLU). Studies in chronic users who discontinued BZD in a clinical setting suggested that multiple slow bolus infusions of FLU reduce BZD withdrawal symptoms. The aim of this study was to confirm FLU efficacy for reducing BZD withdrawal syndrome by means of continuous elastomeric infusion, correlated to drugs plasma level and patients' compliance. Methods: Seven-day FLU 1 mg/day subcutaneously injected through an elastomeric pump and BZDs lormetazepam, clonazepam, and lorazepam were assessed by HPLC-MS/MS in serum of patients before and after 4 and 7 days of FLU continuous infusion treatment. Changes in withdrawal severity were assessed by using the BZD Withdrawal Scale (BWS). Results: Fourteen patients (mean age ± SD 42.5 ± 8.0 years, 5 male and 9 female), admitted to the hospital for high-dose BZD detoxification, were enrolled in the study. Serum FLU concentrations significantly decreased from 0.54 ± 0.33 ng/ml (mean ± SD) after 4 days of treatment to 0.1 ± 0.2 ng/ml at the end of infusion. Lormetazepam concentrations were 502.5 ± 610.0 ng/ml at hospital admission, 26.2 ± 26.8 ng/ml after 4 days, and 0 at the end of treatment. BWS values decreased during FLU treatment temporal period. FLU was well-tolerated by patients. Conclusions: Elastomeric FLU infusion for BZD detoxification is a feasible administration device to maintain adequate, constant, and tolerated FLU concentrations for reducing BZD withdrawal symptoms.

Impact of clinical and sociodemographic factors on fatigue among patients with substance use disorder: a cohort study from Norway for the period 2016-2020

Background

The impact of clinical and sociodemographic factors on fatigue remains unknown among patients with substance use disorders (SUD). This study aims to evaluate fatigue among patients with SUD using a nine-item fatigue severity scale (FSS-9) and identify the impact that clinical and sociodemographic factors – such as injecting substance use, chronic infectious diseases, liver fibrosis, opioid agonist therapy (OAT), debt difficulties, and housing situation – have on fatigue.

Methods

We used data from a cohort of patients with SUD in Norway with annual health assessments surveying FSS-9 and some clinical and sociodemographic factors. A total of 915 FSS-9 measurements were collected from 654 patients during the period 2016–2020. We defined baseline as the first annual health assessment when the health assessments were listed chronologically. Time was defined as years from baseline. We used a linear mixed model to analyse whether the clinical and sociodemographic factors affected the FSS-9 sum score, presented with beta coefficients (β) with 95% confidence intervals (CI).

Results

The mean sum score of the FSS-9 was 43 (standard deviation: 16) at baseline. Females compared with males (adjusted mean difference of FSS-9 sum score: 4.1, 95% CI: 1.3–7.0), having debt difficulties compared with having no debt difficulties (2.9;0.4–5.3), and frequent use of benzodiazepines (5.7;3.0–8.4) or amphetamines (-5.0;-8.0– -2.0) compared to less frequent or no use of these substances changed the FSS-9 baseline sum score. The other clinical and sociodemographic factors did not predict any clinically relevant change in the FSS-9 sum score from baseline to the following health assessments.

Conclusion

Patients with SUD suffer from high levels of fatigue. Female patients, patients with debt difficulties, and those with extensive use of benzodiazepines are at particular risk of being fatigued. This should be taken into consideration when planning health services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-020-00334-x.

Potentially Inappropriate Medications and Polypharmacy: A Study of Older People with Mild Cognitive Impairment and Mild Dementia

BACKGROUND

With multimorbidity increasing among older people, polypharmacy and the use of potentially inappropriate medications (PIMs) are assuming a prominent role in the life of the geriatric population.

OBJECTIVE

To investigate the association of polypharmacy and PIM use with a wide range of factors in older people with mild cognitive impairment (MCI) to mild dementia.

METHODS

The study population comprised 160 outpatients with a Clinical Dementia Rating of 0.5-1 and a Mini-Mental State Examination score of 20-30. Patients were classified as receiving polypharmacy when they took ≥5 different medications at the same time. PIMs were identified using the STOPP-J criteria. Cognitive, neuropsychological, nutritional, and physical function tests were performed and body measurements taken. Quality of life (QOL) was assessed using both components of the EQ-5D scale, the index score and the visual analogue scale (QOL VAS). A comorbidity index was calculated for all participants.

RESULTS

PIM use was significantly associated with lower scores on the verbal fluency (initial letters) test and QOL index. Participants receiving polypharmacy showed an increased likelihood of worse frailty status and lower QOL VAS score. The number of medications was significantly associated with a worse frailty status.

CONCLUSION

In a geriatric population with MCI to mild dementia, PIM use was associated with lower verbal fluency (initial letters) score and lower QOL, while the presence of polypharmacy was correlated with a worse frailty status and lower QOL. The number of medicines, instead, was correlated with a worse frailty status only.

Detoxification Improves Multidomain Cognitive Dysfunction in High-Dose Benzodiazepine Abusers

Purpose

High-dose benzodiazepines (BZDs) abuse has been documented to cause multidomain cognitive dysfunction. We explored whether cognitive abnormalities to high-dose BZD abuse might be reversed by detoxification with slow subcutaneous infusion of flumazenil.

Methods

We recruited 96 patients consecutively admitted to the Department of Internal Medicine, Addiction Medicine Unit, Verona University Hospital, Italy for detoxification from high-dose BZD dependence. After selection for inclusion and exclusion criteria, 50 patients (23 men, 27 women; age 42.7 ± 10.3 years) were included. They underwent a comprehensive neuropsychological battery to explore verbal memory, visuospatial memory, working memory, attention, and executive functions 28–30 days prior to admission for detoxification (T0) and at the end of detoxification, i.e., 7 days after admission (T1). A group of 50 healthy adults (24 men, 26 women; mean age 44.5 ± 12.8 years) matched for age, sex, and education served as controls.

Results

At T0, patients scored significantly worse than healthy controls in all the neuropsychological tests. Depression and anxiety scores were associated with impaired verbal memory at T0 in patients. T1–T0 comparison showed improved performances in all neuropsychological tests after the end of detoxification in patients.

Conclusion

We confirmed that all neuropsychological domains were significantly and profoundly impaired by high-dose BZD abuse and documented that cognitive abnormalities improved after detoxification with slow subcutaneous infusion of flumazenil.

Role of nurses in supporting proactive deprescribing

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

Social dysfunction in mood disorders and schizophrenia: Clinical modulators in four independent samples

INTRODUCTION

Social dysfunction is a common symptom of several neuropsychiatric disorders. However, only in the last few years research began to systematically investigate clinical aspects of this relevant outcome. Interestingly, its distribution and link with other clinical variables is still unclear. This study investigated social dysfunction in 4 different cohorts of patients affected by mood disorders and schizophrenia to evaluate 1) the degree of social dysfunction in these populations; 2) the associations among social dysfunction and socio-demographic and psychopathological features.

METHODS

Data from 4 independent studies (CATIE, GSRD ES1, ES2 and ES3, STAR*D, STEP-BD) were investigated. Behavioural and affective indicators of social dysfunction were derived and operationalized from scales or questionnaire items related to the interaction with relatives, friends and significant people in patients affected by schizophrenia (N = 765) and mood disorders (N = 2278 + 1954 + 1829). In particular the social dysfunction indicator was derived from Sheehan Disability Scale (SDS) for GSRD sample, from the Work and Social Adjustment Scale (WSAS) for STAR*D sample, from the Life-Range of Impaired Functioning Tool (LRIFT) for STEP-BD sample, and from the Quality of Life Scale (QOLS) for CATIE sample. The distribution of social dysfunction was described and association with socio-demographic and psychopathological characteristics were analysed.

RESULTS

Social dysfunction indicators showed a broad distribution in all samples investigated. Consistently across studies, social dysfunction was associated with higher psychopathological severity (all samples except CATIE) and suicide risk (GSRD ES1 and ES2, STAR*D, and STEP-BD) that explain up to 47% of the variance, but also to lower education level (GSRD ES2, STAR*D, CATIE, and STEP-BD), poorer professional/work status (GSRD ES2 and ES3, STAR*D, CATIE, and STEP-BD), marital status (STAR*D and CATIE), age (younger age in GSRD ES1 and STAR*D, older age in CATIE), higher BMI (GSRD ES2 and ES3, and STEP-BD), and smoking (GSRD ES2 and ES3).

CONCLUSION

Our results demonstrated that a significant percentage of patients affected by both mood disorders and schizophrenia shows relevant social dysfunction. Social dysfunction is related, but not completely explained by psychopathological severity. In several patients, it tends to persist also during remission state. Socio-demographic and lifestyle factors were also found to play a role and should therefore be taken into consideration in further studies investigating social dysfunction.

Adult Attention-Deficit/Hyperactivity Disorder and Quality of Life in High-Dose Benzodiazepine and Related Z-Drug Users

BACKGROUND

Problematic high-dose benzodiazepine (BZD) and related Z-drug use for a long period is a substance use disorder previously found to be associated with adult attention-deficit/hyperactivity disorder (ADHD) and worse quality of life (QoL). Whether adult ADHD impacts QoL in high-dose BZD/Z-drug users has not been explored.

AIM

The aim of the study was to explore the impact of adult ADHD on QoL in high-dose BZD and related Z-drug users.

METHODS

We recruited 393 patients (205 men and 188 women) consecutively admitted to the Department of Medicine, Addiction Medicine Unit, Verona University Hospital, Italy, from July 2016 to July 2019 for detoxification from high-dose BZD or Z-drug dependence. Demographic and clinical variables and QoL measures were recorded. The World Health Organization ADHD Self-Report Scale version 1.1 Symptom Checklist Part A was used to detect adult ADHD.

RESULTS

In our sample, 39.4% of patients were positive to adult ADHD testing (ADHD+), with some clinical features differing in comparison to patients negative to ADHD testing (ADHD-). QoL was worse in high-dose BZD/Z-drug users than the general population. The ADHD+ group showed significantly worse QoL measures than the ADHD- group. Multivariate analysis, including potential covariates showed adult ADHD and age to have the most robust and consistent positive effect for age (i.e., higher QoL) and negative effect for ADHD (i.e., lower QoL) on QoL measures.

CONCLUSIONS

Adult ADHD is associated with worse QoL measures in high-dose BZD/Z-drug users. Future studies should explore whether appropriate BZD/Z-drug detoxification might improve QoL measures and whether the most appropriate detoxification protocol differs in ADHD+ versus ADHD- populations.

Beyond Prescriptions Monitoring Programs: The Importance of Having the Conversation about Benzodiazepine Use

: Internationally there is an escalation of prescription-related overdose deaths, particularly related to benzodiazepine use. As a result, many countries have implemented prescription monitoring programs (PMPs) to increase the regulation of benzodiazepine medications. PMPs centralize prescription data for prescribers and pharmacists and generate alerts to high-doses, risky combinations, or multiple prescribers with the aim to reduce inappropriate prescribing and subsequently the potential of patient harm. However, it has become clear that prescribers have been provided with minimal guidance and insufficient training to effectively integrate PMP information into their decision making around prescribing these medications. Accordingly, this paper discusses how PMPs have given rise to a range of unintended consequences in those who have been prescribed benzodiazepines (BDZs). Given that a gradual taper is generally required to mitigate withdrawal from BDZs, there are concerns that alerts from PMPs have resulted in BDZs being ceased abruptly, resulting in a range of unintended harms to patients. It is argued that best practice guidelines based upon a patient-centered framework of decision-making, need to be developed and implemented, in order to curtail the unintended consequences of PMPs. This paper outlines some key considerations when starting the conversation with patients about their BDZ use.

High-dose lormetazepam dependence: strange case of Dr. Jekyll and Mr. Hyde

High-dose benzodiazepine (BZD) abuse is emerging as a substance use disorder (SUD). The aim of the study is to explore the impact of high-dose lormetazepam (LMZ) abuse and the characteristics of patients affected by this SUD in a tertiary referral addiction unit. We have retrospectively evaluated 1112 patients admitted to the Addiction Medicine Unit, Verona University Hospital, Italy for detoxification from high-dose BZD dependence. LMZ was the most common BZD, with an increasing prevalence from January 2003 to June 2018. Socio-demographic (more women; higher age and education) and clinical features (higher daily diazepam dosage equivalent, BZD abuse duration, age of first BZD intake; BZD prescribed more frequently for sleep disorders; less frequent history of other SUDs, previous/active alcohol, previous opioids abuse; more frequent overall major psychiatric diseases and major depression; less-frequent bipolar disorders and other psychoses, personality disorders, and more than one psychiatric disease) of LMZ vs. other BZD abusers significantly differed. 96.7% LMZ abusers took oral solution, while two-thirds of other BZD abusers took tablets. Oral solution, BZD abuse duration and prescription of BZD for sleep disorders increased, while history of other SUDs, previous/active alcohol and active cannabinoids SUD reduced the risk of high-dose LMZ vs. other BZDs abuse. The large prevalence of high-dose LMZ abusers in Italy may be strongly related to the availability and characteristics of oral formulation that may transform the innocuous Dr. Jekyll tablets into an evil Mr. Hyde. Restriction to the market of LMZ oral formulation might reduce the risk of high-dose abuse.

Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort

OBJECTIVES

To examine the association between effort-reward imbalance and incident long-term benzodiazepine use (LTBU).

METHODS

We included 31 077 employed participants enrolled in the French population-based CONSTANCES cohort between 2012 and 2014 who had not undergone LTBU in the 2 years before enrolment. LTBU was examined using drug reimbursement administrative databases. The effort-reward imbalance was calculated in quartiles. We computed ORs (95% CIs) for LTBU according to effort-reward imbalance over a 2-year follow-up period. We adjusted for age, gender, education, occupational grade, income, marital status, tobacco smoking, risk of alcohol use disorder, depressive symptoms and self-rated health.

RESULTS

Over the 2-year follow-up, 294 (0.9%) participants experienced incident LTBU. In the univariable analysis, effort-reward imbalance was associated with subsequent LTBU with ORs of 1.79 (95% CI 1.23 to 2.62) and 2.73 (95% CI 1.89 to 3.95) for the third and fourth quartiles, respectively, compared with the first quartile. There was no interaction between effort-reward imbalance and any of the considered variables other than tobacco smoking (p=0.033). The association remained significant in both smokers and non-smokers, with higher odds for smokers (p=0.031). In the fully adjusted model, the association remained significant for the third and fourth quartiles, with ORs of 1.74 (95% CI 1.17 to 2.57) and 2.18 (95% CI 1.50 to 3.16), respectively. These associations were dose dependent (p for trend <0.001).

CONCLUSIONS

Effort-reward imbalance was linked with incident LTBU over a 2-year follow-up period after adjustment for sociodemographic and health-related factors. Thus, screening and prevention of the risk of LTBU should be systematised among individuals experiencing effort-reward imbalance, with special attention paid to smokers.

The epidemiology of benzodiazepine misuse: A systematic review

BACKGROUND

Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research.

METHODS

PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

RESULTS

The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment.

CONCLUSIONS

Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.

Prevalence of prescribed benzodiazepine long-term use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort

Background

Data are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population.

Methods

Data came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender.

Results

Weighted prevalence of BLTU were 2.8%(95% CI:2.3–3.4) and 3.8%(95% CI: 3.3–4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02–1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU.

Conclusions

BLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6933-8) contains supplementary material, which is available to authorized users.

Factors associated with health-related quality of life in a large national sample of patients receiving opioid substitution treatment in Germany: A cross-sectional study

BACKGROUND

Knowledge of health-related quality of life (HRQOL) of patients receiving opioid substitution treatment (OST) is limited and fragmented. The present study examines the HRQOL of a large national sample of OST patients in Germany and sociodemographic and clinical correlates.

METHODS

Cross-sectional data on the HRQOL of 2176 OST patients was compared with German general population norms. Patients were recruited from 63 OST practices across Germany. To identify correlates of HRQOL, as measured with the SF-12, we performed bi- and multivariate analyses with sociodemographic and clinical variables, including patient- and clinician-reported outcomes on physical and mental health.

RESULTS

Patients' HRQOL was significantly poorer than in the general population, especially their mental HRQOL. Factors associated with lower physical HRQOL were older age, longer duration of opioid dependence, hepatitis C virus infection, and HIV infection. Benzodiazepine use was associated with lower mental HRQOL, and amphetamine use with higher physical HRQOL, compared to non-use of these substances. For both mental and physical HRQOL, the factor with the strongest positive association was employment and the factors with the strongest negative associations were physical and mental health symptom severity, psychiatric diagnosis, and psychopharmacological medication.

CONCLUSIONS

Compared to the general population, we found substantially lower HRQOL in OST patients, especially in their mental HRQOL. OST programs can benefit from further improvement, particularly with regard to mental health services, in order to better serve their patients' needs. Clinicians may consider the use of patient-reported outcome measures to identify patients' subjective physical and psychological needs. Further research is needed to determine if employment is a cause or consequence of improved HRQOL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02395198 , retrospectively registered 16/03/2015.

Diagnosis and treatment of acute alcohol intoxication and alcohol withdrawal syndrome: position paper of the Italian Society on Alcohol

The chronic use of alcohol can lead to the onset of an alcohol use disorder (AUD). About 50% of subjects with an AUD may develop alcohol withdrawal syndrome (AWS) when they reduce or discontinue their alcohol consumption and, in 3-5% of them, convulsions and delirium tremens (DTs), representing life-threatening complications, may occur. Unfortunately, few physicians are adequately trained in identifying and treating AWS. The Italian Society on Alcohol has, therefore, implemented a task force of specialists to draw up recommendations for the treatment of AWS with the following main results: (1) while mild AWS may not require treatment, moderate and severe AWS need to be pharmacologically treated; (2) out-patient treatment is appropriate in patients with mild or moderate AWS, while patients with severe AWS need to be treated as in-patients; (3) benzodiazepines, BDZs are the "gold standard" for the treatment of AWS and DTs; (4) alpha-2-agonists, beta-blockers, and neuroleptics may be used in association when BDZs do not completely resolve specific persisting symptoms of AWS; (5) in the case of a refractory form of DTs, the use of anaesthetic drugs (propofol and phenobarbital) in an intensive care unit is appropriate; (6) alternatively to BDZs, sodium oxybate, clomethiazole, and tiapride approved in some European Countries for the treatment of AWS may be employed for the treatment of moderate AWS; (7) anti-convulsants are not sufficient to suppress AWS, and they may be used only in association with BDZs for the treatment of refractory forms of convulsions in the course of AWS.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α₂δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H₁ antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Work-Related Stressors and Increased Risk of Benzodiazepine Long-Term Use: Findings From the CONSTANCES Population-Based Cohort

Objectives. To examine whether stressful job exposure to the public could be associated with having long-term benzodiazepine use.Methods. From the participants included between 2012 and 2016 in the French population-based CONSTANCES cohort, 13 934 men and 19 261 women declared a daily job exposure to the public and rated the frequency of stressful exposure. We examined benzodiazepine long-term use by using drug reimbursement administrative registries. Logistic regressions provided odds ratios (ORs) of benzodiazepine long-term use, with stratification for gender and adjustment for age, education, and area deprivation index. Occupational grade, job strain, depression, self-rated health, and alcohol use disorder were additional stratification variables.Results. Benzodiazepine long-term use was positively associated with stressful exposure to the public ("often or always" vs "rarely or never") in men (OR = 2.2; 95% confidence interval [CI] = 1.8, 2.8) and women (OR = 1.6; 95% CI = 1.4, 1.9), with dose-dependent relationships (P trends < .001). Adjustments and analyses in subgroups without other individual or environmental vulnerability factors led to similar results.Conclusions. Stressful job exposure to the public increases the risk of benzodiazepine long-term use. Prevention programs aiming at reducing the burden of benzodiazepine long-term use would benefit in targeting this specific population.

Potentially inappropriate use of benzodiazepines and z-drugs in the older population-analysis of associations between long-term use and patient-related factors

Introduction

The long-term use of benzodiazepines (BZD) and z-drugs in older populations is associated with a variety of sociodemographic and health-related factors. Recent studies reported that long-term BZD and z-drugs use is associated with increased age, female sex, and severe negative psychological (e.g., depression) and somatic (e.g., chronic disease) factors. The current study explores the sociodemographic and health-related factors associated with long-term BZD and z-drugs use in the elderly.

Methods

We conducted a cross-sectional survey among randomly selected patients of one health insurance plan (“AOK North-West”) with BZD and z-drugs prescriptions in the past 12 months. The sample was stratified by appropriate German prescription guidelines (yes vs. no) and age (50–65 vs. >65 years). To examine the association of selected sociodemographic and psychological variables (e.g., sex, employment status, quality of life, depression) with long-term use, a binary logistic regression analysis was conducted.

Results

In total, data from 340 patients were analyzed. The mean age was 72.1 (SD = 14.5) years, and the most commonly used substances were zopiclon (38.1%), oxazepam (18.1%), and lorazepam (13.8%). The mean defined daily dose (DDD) was 0.73 (SD = 0.47). Insomnia was the main reason for prescribing BZD and z-drugs. The long-term use of BZD and z-drugs was significantly associated with unemployment (OR = 2.9, 95% CI [1.2–7.1]) and generally problematic medication use (OR = 0.5, 95% CI [0.2–1.0]).

Discussion

Unemployment status and problematic medication use had a significant association with the patient-reported, long-term use of BZD and z-drugs. Divergent prescription patterns might suggest problematic patterns of BZD and z-drugs use. The causal connection between the identified factors and problematic BZD and z-drugs prescription is not discussed in this paper. Nevertheless, employment status and possible evidence of general problematic drug use may be a warning signal to the prescribers of BZD and z-drugs.

Association between severity of illicit drug dependence and quality of life in a psychosocial care center in BRAZIL: cross-sectional study

Background

Quality of life must be one of the main purposes for the treatment of drug users, requiring a better understanding of the association between the quality of life and the severity of dependency. This study aimed to investigate the correlation between severity of substance use in various areas of human functioning and quality of life of illicit drug users in a psychosocial care center for alcohol and drugs.

Methods

This cross-sectional study included 60 participants – illicit drug users – treated at a psychosocial care center for alcohol and drugs. Participants were evaluated with the short version of World Health Organization Quality of Life (WHOQOL-Bref) instrument to measure the quality of life, the 6th version of Addiction Severity Index (ASI-6) to assess the severity of dependence in several areas and the Mini International Neuropsychiatric Interview (MINI) to identify the presence of psychiatric disorders. Pearson and Spearman correlation tests and linear regression were applied to verify the association between the severity of dependence and the quality of life, and Student’s t-test to compare the mean quality of life between individuals with and without psychiatric comorbidities.

Results

Negative correlation was found between the severity of dependence on the drugs dimensions: alcohol, psychiatric, medical, legal, family/social support and family/social problems of ASI-6, and the quality of life domains measured by the WHOQOL-Bref. The evidence was strongest in the psychiatric and medical dimensions. There was a significant difference in the quality of life mean among participants presenting or not presenting psychiatric comorbidities, for the psychological domain in anxiety disorders, and for the physical and psychological domains in mood disorders.

Conclusion

The quality of life decreased as the severity of dependence increased, with different results in the various areas of the participant’s life. This result emphasizes the need for training the professional team which works in the substance use disorders area for more comprehensive diagnostic evaluations and more appropriate therapeutic interventions for each area. The associations were more evident in the medical and psychiatric fields, indicating the need for greater attention to be paid in relation to medical and psychiatric comorbidities.

Electronic supplementary material

The online version of this article (10.1186/s12955-017-0795-5) contains supplementary material, which is available to authorized users.

Low risk of seizures with slow flumazenil infusion and routine anticonvulsant prophylaxis for high-dose benzodiazepine dependence

High-dose benzodiazepine (BZD) dependence represents an emerging and under-reported addiction phenomenon and is associated with reduced quality of life. To date there are no guidelines for the treatment of high-dose BZD withdrawal. Low-dose slow flumazenil infusion was reported to be effective for high-dose BZD detoxification, but there is concern about the risk of convulsions during this treatment. We evaluated the occurrence of seizures in 450 consecutive high-dose BZD dependence patients admitted to our unit from April 2012 to April 2016 for detoxification with low-dose slow subcutaneous infusion of flumazenil associated with routine anticonvulsant prophylaxis. In our sample, 22 patients (4.9%) reported history of convulsions when previously attempting BZD withdrawal. Only four patients (0.9%) had seizures during ( n = 2) or immediately after ( n = 2) flumazenil infusion. The two patients with seizures during flumazenil infusion were poly-drug misusers. The most common antiepileptic drugs (AEDs) used for anticonvulsant prophylaxis were either valproate 1000 mg or levetiracetam 1000 mg. Our data indicate that, when routinely associated with AEDs prophylaxis, low-dose slow subcutaneous flumazenil infusion represents a safe procedure, with low risk of seizure occurrence.

The role of dual diagnosis in health-related quality of life among treatment-seeking patients in Spain

PURPOSE

The comorbidity of any substance use disorder and another mental disorder is defined as dual diagnosis. Dual diagnosis is very common and clinical and therapeutic consequences have been described. This cross-sectional study aimed to analyse health-related quality of life (HRQoL) according to clinical characteristics and psychiatric comorbidities in patients with substance dependence.

METHODS

A total of 1276 substance-dependent patients seeking treatment were recruited. HRQoL was evaluated by the Short-Form 36 (SF-36) questionnaire. The SCID-I, SCID-II and Conners' adult ADHD diagnostic interview were used to evaluate dual diagnosis. A visual analogue scale was used to measure craving. Bivariate and multivariate analyses were performed, and correction for multiple tests was conducted.

RESULTS

Substance-dependent patients had impaired quality of life, especially in the mental component. SF-36 physical and mental component scores were 47.7 ± 10.9 and 36.1 ± 14.1, respectively. Furthermore, 65% of the patients had dual diagnosis, 51% had an Axis I DSM-IV-TR mental disorder and 35% had some personality disorder. Impaired physical quality of life was independently associated with medical condition, age, being female, depressive disorder and anxiety disorder. Depression disorder, any personality disorder, active consumption last month, Attention deficit hyperactivity disorder, anxiety disorder, suicide attempt were independently associated with worse mental quality of life.

CONCLUSION

These findings emphasize the significance of dual diagnosis in the impairment of HRQoL in substance-dependent patients, particularly with regard to mental component. In addicted patients with low scores on SF-36, psychiatric comorbidity should be evaluated and treated in an integrated approach.

Diazepam filled hard capsules intended for detoxification of patients addicted to benzodiazepines and Z-drugs

Objectives

The abuse of benzodiazepines and Z-drugs reduces the quality of life of millions of addicted people worldwide. They cannot be discontinued abruptly due to harmful withdrawal symptoms. Detoxification is usually based on replacement of short/middle acting benzodiazepines or Z-drugs by diazepam and tapering the dose over time. In order to enhance patient adherence to an individual withdrawal plan, suitable diazepam dosage forms have to be available. Hard capsules containing an exact and uniform dose could be used for the relief of symptoms caused by altering the plasma level and overcoming psychogenic stress from the dose reduction.

Methods

This work demonstrates that capsules with a content of diazepam ranging from 2.125mg to 0.492 mg (dose decreasing always by 15%) cannot be easily prepared by standard mortar technology in a pharmacy. To meet mass and content uniformity European Pharmacopoeia criteria, capsules were prepared by improved technology based on the preparation of binary blends of calcium phosphate anhydrous and diazepam in descending concentrations in a high-speed mixer (time 30 s) and densification of about 10% during filling of the capsules.

Results

All batches (n=20) prepared by improved technology met the requirement for content uniformity compared with only nine batches prepared by standard mortar blender technology. Based on the process capability index, none of the samples prepared by standard technology fitted pharmacopeia limits at the statistically acceptable level. On the other hand, all batches prepared by improved technology exhibited acceptable process capability index.

Conclusions

We have shown that at least 99.73% of batches prepared by our improved technology would meet the pharmacopoeia limits for content uniformity and are suitable for treatment of this type of addiction.

Determinants of Quality of Life in High-Dose Benzodiazepine Misusers

Benzodiazepines (BZDs) are among the most widely prescribed drugs in developed countries, but they have a high potential for tolerance, dependence and misuse. High-dose BZD misuse represents an emerging addiction phenomenon, but data on quality of life (QoL) in high-dose BZD misusers are scant. This study aimed to explore QoL in high-dose BZD misuse. We recruited 267 high-dose BZD misusers, compared the QoL scores in those who took BZD only to poly-drug misusers, and explored the role of demographic and clinical covariates through multivariable analysis. Our data confirmed worse QoL in high-dose BZD misusers and showed that (a) QoL scores were not negatively influenced by the misuse of alcohol or other drugs, or by coexisting psychiatric disorders; (b) demographic variables turned out to be the most significant predictors of QoL scores; (c) BZD intake significantly and negatively influenced QoL. Physical and psychological dimensions of QoL are significantly lower in high-dose BZD misusers with no significant effect of comorbidities. Our data suggest that the main reason for poor QoL in these patients is high-dose BZD intake per se. QoL should be considered among outcome measures in these patients.

High prevalence of constipation and reduced quality of life in opioid-dependent patients treated with opioid substitution treatments

Objectives To evaluate prevalence and severity of constipation and quality of life (QoL) in a cohort of opioid-addicted patients treated with opioid substitution treatments (OST).

METHODS

A total of 1057 heroin-dependent patients treated with methadone or buprenorphine were enrolled in a multicenter observational study. Constipation was assessed by Wexner Constipation Scoring System (Wexner CSS), QoL by General Health Questionnaire (GHQ-12).

RESULTS

38.5% patients reported mild constipation, 33.3% reported moderate constipation, 14.8% severe constipation and 5.1% very severe constipation. Mean Wexner CSS score was 6.6 ± 4.8. 44.9% patients showed a GHQ-12 score ≥14; of these 18.3% patients showed a GHQ-12 score ≥20. Mean GHQ score was 13.8 ± 6.5. Mean Wexner CSS score was significantly higher in methadone patients (p = 0.004), in those taking psychoactive drugs (p = 0.0001) and in female (p < 0.0001) with respect to counterparts. Similarly, GHQ-12 mean scores were higher methadone group (p = 0.003), in those taking psychoactive drugs (p < 0.0001), and in female (p = 0.039) with respect to counterparts. ANOVA and ANCOVA showed a significant influence of methadone and female gender on Wexner CSS score while psychoactive drugs significantly influenced both tests.

CONCLUSIONS

The present study shows that patients affected by opioid-dependence in OST with methadone and buprenorphine have a high prevalence of constipation and reduced QoL.

Quality of Life in Patients with Substance Use Disorders Admitted to Detoxification Compared with Those Admitted to Hospitals for Medical Disorders: Follow-Up Results

Quality of life (QoL) in patients admitted to a general hospital was compared with those admitted to a detoxification unit for the treatment of substance use disorder (SUD). This study combines data from two separate data collections: a cross-sectional study in a general hospital unit (somatic sample, N = 519) and a follow-up study in a detoxification unit (SUD sample, N = 140). A total of 659 patients recruited during 2008-2013 were included in this study. All patients completed a generic QoL questionnaire at inclusion, and the SUD sample also completed it at the six-month follow-up. SUD patients experienced comparably low physical QoL and had significantly lower psychological, social, and existential QoL domain scores when compared with the somatic sample. Mental distress and having a SUD were the major factors explaining variations in QoL, with both influencing QoL negatively. In the SUD sample, QoL improved moderately at the six-month follow-up with less improvement for the domain relationship to a partner. To facilitate the recovery of SUD patients, clinicians must view their patients' situation holistically and invest efforts into the different life domains affected by poor QoL.

Perceived quality of life, 6 months after detoxification: Is abstinence a modifying factor?

Purpose

Patients with a substance use disorder (SUD), admitted for detoxification, often suffer from a poor quality of life (QoL). We set out to monitor QoL, together with substance use, in a departure from the usual norm of measuring substance use alone as a treatment outcome. Literature searches revealed scant knowledge of how QoL is influenced. With this in mind, we aimed to investigate whether total abstinence, prior to follow-up, could influence QoL.

Methods

We studied a prospective cohort of 140 patients admitted for inpatient detoxification treatment at Sørlandet Hospital (Norway), from September 2008 to August 2010. QoL was measured by a generic five-item questionnaire, the QoL-5. The extremes of this scale ranged from the worst possible rating of 0.1 to 0.9, as the best. A norm for the general population was benchmarked at 0.69. Change in QoL was calculated by subtracting baseline QoL from that achieved at the 6-month follow-up interview; linear regression modeling was used to study the influence of individual QoL predictors.

Results

The mean QoL at baseline was 0.46, 39 % below that of the general reference population. By applying the clinical interpretation of the scale, we found a modest overall mean improvement in QoL at follow-up (0.11 points); the greatest increases were seen for patients with the lowest baseline QoL scores. Abstinence prior to follow-up correlated with improved QoL, while living alone and psychological distress were negative influences.

Conclusions

For patients with a SUD, clinicians should emphasize that abstinence may help to improve their QoL.

Identification and management of alcohol withdrawal syndrome

Symptoms of alcohol withdrawal syndrome (AWS) may develop within 6-24 h after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens. The gold-standard treatment for AWS is with benzodiazepines (BZDs). Among the BZDs, different agents (i.e., long-acting or short-acting) and different regimens (front-loading, fixed-dose or symptom-triggered) may be chosen on the basis of patient characteristics. Severe withdrawal could require ICU admission and the use of barbiturates or propofol. Other drugs, such as α2-agonists (clonidine and dexmetedomidine) and β-blockers can be used as adjunctive treatments to control neuroautonomic hyperactivity. Furthermore, neuroleptic agents can help control hallucinations. Finally, other medications for the treatment for AWS have been investigated with promising results. These include carbamazepine, valproate, sodium oxybate, baclofen, gabapentin and topiramate. The usefulness of these agents are discussed.