Assessment of benzodiazepine dependence in alcohol and drug dependent outpatients: a research report

Effects of ketogenic diet and ketone monoester supplement on acute alcohol withdrawal symptoms in male mice

RATIONALE

After alcohol ingestion, the brain partly switches from consumption of glucose to consumption of the alcohol metabolite acetate. In heavy drinkers, the switch persists after abrupt abstinence, leading to the hypothesis that the resting brain may be "starved" when acetate levels suddenly drop during abstinence, despite normal blood glucose, contributing to withdrawal symptoms. We hypothesized that ketone bodies, like acetate, could act as alternative fuels in the brain and alleviate withdrawal symptoms.

OBJECTIVES

We previously reported that a ketogenic diet during alcohol exposure reduced acute withdrawal symptoms in rats. Here, our goals were to test whether (1) we could reproduce our findings, in mice and with longer alcohol exposure; (2) ketone bodies alone are sufficient to reduce withdrawal symptoms (clarifying mechanism); (3) introduction of ketogenic diets at abstinence (a clinically more practical implementation) would also be effective.

METHODS

Male C57BL/6NTac mice had intermittent alcohol exposure for 3 weeks using liquid diet. Somatic alcohol withdrawal symptoms were measured as handling-induced convulsions; anxiety-like behavior was measured using the light-dark transition test. We tested a ketogenic diet, and a ketone monoester supplement with a regular carbohydrate-containing diet.

RESULTS

The regular diet with ketone monoester was sufficient to reduce handling-induced convulsions and anxiety-like behaviors in early withdrawal. Only the ketone monoester reduced handling-induced convulsions when given during abstinence, consistent with faster elevation of blood ketones, relative to ketogenic diet.

CONCLUSIONS

These findings support the potential utility of therapeutic ketosis as an adjunctive treatment in early detoxification in alcohol-dependent patients seeking to become abstinent.

TRIAL REGISTRATION

clinicaltrials.gov NCT03878225, NCT03255031.

Psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire - Portuguese Version (BENDEP-SRQ-PV)

Objective

To assess psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire – Portuguese Version (BENDEP-SRQ-PV) in a sample of Brazilian chronic hypnotic users.

Methods

One hundred and seventy-nine chronic hypnotic users (benzodiazepines and Z-drugs) were recruited, attended a psychiatric evaluation, and answered the BENDEP-SRQ-PV. Factor structure, reliability, and influence of covariates (dependence diagnosis and type of drug consumed) were assessed in a structural equation modelling environment. Discrimination was assessed with receiver operating characteristic (ROC) plots and stability with the test-retest method.

Results

Participants, mostly women (91.6%), aged 51 to 64 years old, had been using hypnotics for an average of 34.8 months, with a mean defined daily dose of 0.72. Psychometric analysis demonstrated construct and criterion validity, reliability, and response stability. The factor structure was maintained as originally proposed: problematic use (ω = 0.73), preoccupation (ω = 0.74), lack of compliance (ω = 0.74), and withdrawal (ω = 0.93).

Conclusion

The BENDEP-SRQ-PV is an adequate measure of hypnotic dependence in the Brazilian population of chronic users. Our results support using the scale for follow-up in clinical and research applications and in correlational studies.

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.

Benzodiazepine dependence in subjects with alcohol use disorders: what prevalence?

OBJECTIVE

To our knowledge, no studies have been conducted in France on benzodiazepine (BZD) dependence among outpatients with alcohol use disorders (AUD). Some international studies have been conducted on the consumption of BZD in this specific population, but the comparisons among them are difficult. We aimed to assess the current prevalence of probable benzodiazepine and BZD-like hypnotics (Z-drugs) dependence among outpatients seeking treatment for AUD.

METHODS

Participants were patients seeking treatment for AUD for the first time or repeating treatment after more than twelve months. Recruitment took place in seven addiction centres between January and December 2013 in the Nantes region (France). BZD/Z-drug dependence was assessed according to the DSM-IV diagnostic criteria for dependence. This information was gathered through a self-report questionnaire.

RESULTS

Among the 1005 patients included in this study, 413 were BZD/Z-drug users (41.1%). Among the 413 patients, 217 were probably dependent on at least one substance, which represents 21.6% of the total population and 52.5% of BZD/Z-drug users.

CONCLUSION

BZD/Z-drug dependence represents a public health concern. Prescribers should take the risks into account and keep treatment courses to a minimum.

Efficacy of vestipitant, a neurokinin-1 receptor antagonist, in primary insomnia

STUDY OBJECTIVES

Investigate the hypnotic effects of repeated doses of neurokinin-1 receptor antagonist, vestipitant, in primary insomnia.

DESIGN

Randomized, double-blind, placebo-controlled 28-day parallel-group study.

SETTING

Eleven sleep centers in Germany.

PATIENTS

One hundred sixty-one patients with primary insomnia.

INTERVENTIONS

Patients received vestipitant (15 mg) or placebo for 28 days; 2-night polysomnographic assessment occurred on nights 1/2 and 27/28.

MEASUREMENTS AND RESULTS

Wake after sleep onset (WASO) was improved on nights 1/2 and 27/28 (ratio, vestipitant versus placebo [95% confidence interval]: 0.76 [0.65, 0.90], P = 0.001 and 0.79 [0.65, 0.96], P = 0.02, respectively), demonstrating maintenance of the effect following repeated dosing. Latency to persistent sleep was shorter with vestipitant on nights 1/2 (P = 0.0006 versus placebo), but not on nights 27/28. Total sleep time (TST) improved with vestipitant (nights 1/2: P < 0.0001, nights 27/28: P = 0.02 versus placebo). Next-day cognitive function tests demonstrated no residual effects of vestipitant (P > 0.05 versus placebo). Adverse events (AEs) occurred in 25% of vestipitant patients versus 22% for placebo. Headache was the most common AE (8% of vestipitant patients versus 9% for placebo).

CONCLUSIONS

Vestipitant improved sleep maintenance in patients with primary insomnia, with no associated next-day cognitive impairment. The effects on wake after sleep onset and total sleep time were maintained following repeated dosing.

Medication dependence and anxiety

Anxiety disorders are common and costly psychiatric illnesses. Pharmacological treatment was enhanced with the introduction of benzodiazepines, which proved safer and more effective than older drugs. The risk of dependence, however, has made clinicians reluctant to use these medications. In fact, few patients appear to develop significant difficulties with these drugs, given how widely they are used. Careful planning for discontinuation of therapy is important. In addition, for some individuals, there appears to be a complex and as yet unelucidaied relationship between dependence on drugs or alcohol and anxiety. The newer antidepressants offer efficacy without abuse or dependence liability, but are expensive and have side effects that are intolerable for some patients. Pharmacological therapy for anxiety should be prescribed and managed so as to minimize any existing risk, while aiming to restore the patient to wellness in terms of symptoms and function.

Beyond classical benzodiazepines: novel therapeutic potential of GABAA receptor subtypes

GABA(A) (γ-aminobutyric acid, type A) receptors are a family of ligand-gated ion channels that are essential for the regulation of central nervous system function. Benzodiazepines - which non-selectively target GABA(A) receptors containing the α1, α2, α3 or α5 subunits - have been in clinical use for decades and are still among the most widely prescribed drugs for the treatment of insomnia and anxiety disorders. However, their use is limited by side effects and the risk of drug dependence. In the past decade, the identification of separable key functions of GABA(A) receptor subtypes suggests that receptor subtype-selective compounds could overcome the limitations of classical benzodiazepines; furthermore, they might be valuable for novel indications such as chronic pain, depression, schizophrenia, cognitive enhancement and stroke.

Avaliação multidimensional do usuário de drogas e a Escala de Gravidade de Dependência

INTRODUÇÃO: Antes de iniciar um tratamento para abuso de substâncias psicoativas (SPA), é primordial avaliar os prejuízos que estas acarretam na vida dos usuários. Considerando a complexidade dessa avaliação, o instrumento atualmente mais utilizado no mundo para a abordagem multidimensional de problemas relacionados ao abuso de SPA é a Escala de Gravidade de Dependência (Addiction Severity Index, ASI). OBJETIVO: Através da revisão da literatura sobre o tema, da apresentação de um caso clínico, de aspectos da ASI e da discussão de tópicos contemplados na avaliação de usuários de drogas, este trabalho tem como finalidade auxiliar o profissional de saúde a sistematizar a avaliação desses pacientes. MÉTODO: A revisão da literatura foi realizada nas bases de dados MEDLINE, LILACS e PsycINFO, utilizando os descritores assessment e evaluation, cruzados com o termo substance-related disorders dos Medical Subject Headings e subexpressões nele incluídas. RESULTADOS E CONCLUSÃO: Na literatura, há uma carência de artigos sobre o tema, e, no Brasil, ainda não existem instrumentos que se proponham a avaliar os usuários de drogas de forma tão ampla como a ASI. A utilização de uma escala com essas características pode ser útil para o sistema de saúde brasileiro, favorecendo a identificação precoce de problemas e propiciando melhora na qualidade da assistência prestada.

Risk drinking behavior among psychotropic drug users in an aging Finnish population: the FinDrink study

Psychotropic drug use and alcohol consumption is increasing among aging Finns. Alcohol use is not recommended with benzodiazepines and some other psychotropic medicines. Concomitant use may lead to accidents and other serious consequences. The aim of this study was to analyze the drinking behavior of psychotropic drug users in an aging Finnish population. This study is part of the ongoing epidemiologic FinDrink study. Self-reported data on alcohol consumption and psychotropic drug use were collected from the Kuopio Ischaemic Heart Disease Risk Factor Study examinations conducted in 1998-2001. Overall, 854 men and 920 women participated in the study. A total of 204 (11.5%) individuals used psychotropic drugs regularly (14.2% of women and 8.5% of men; P<.001). Three quarters of the study population had used alcohol weekly during the preceding year (68.9% of women and 87.5% of men; P<.001). Men who use anxiolytics and sedatives were more likely to drink alcohol at least twice a week (odds ratio=2.42; 95% confidence interval=1.30-4.51), to be binge drinkers (odds ratio=1.86; 95% confidence interval=1.01-3.43) and to be heavy alcohol consumers (odds ratio=2.22; 95% confidence interval= 1.13-4.39) than men not using psychotropics. In women, alcohol consumption and drinking patterns were same between the groups. Our results indicate the potential for alcohol-related health risks among aging Finnish men and women using psychotropic drugs.

Determination of the main risk factors for benzodiazepine dependence using a multivariate and multidimensional approach

The aim of this study was to identify risk factors for benzodiazepine (BZD) dependence, such as sociodemographic variables, characteristics of BZD use, and psychiatric parameters, which to date have been found to relate inconsistently to indicators of BZD dependence such as chronic BZD use and BZD withdrawal symptoms. The Benzodiazepine Dependence Self-Report Questionnaire (Bendep-SRQ), Schedules for Clinical Assessment in Neuropsychiatry (SCAN), and Symptom Checklist-90 (SCL-90) were administered to 599 outpatients using BZDs. Regression analyses were conducted using BZD dependence diagnoses and severity scales as dependent variables. BZD dependence diagnoses were only predicted by being a self-help patient and long BZD elimination half-life (for only the DSM-III-R). The main predictors of BZD dependence severity, as measured by the ICD-10, DSM-III-R scales, and Bendep-SRQ Rasch scales, were in decreasing order: (1) being a self-help patient; (2) higher BZD dose, longer duration of BZD use, younger age; and (3) non-native cultural origin, lower level of education, being in outpatient treatment for alcohol and/or drug dependence, and the interaction of BZD dose with duration of BZD use. We conclude that a limited number of recognizable risk factors appear to predict the severity of BZD dependence. Additional administration of a specific BZD dependence instrument is recommended to confirm suspected BZD dependence and guide further clinical decision-making.