Use and abuse of the benzodiazepines

Prevalence and concentrations of sedative-hypnotic drugs in blood of drivers involved in road traffic crashes in the Padova region of Italy - not so easy to interpret

BACKGROUND & OBJECTIVES

This study reports the prevalence and concentrations of sedative-hypnotic drugs as exemplified by benzodiazepines (BZD) and zolpidem (Z-hypnotic) in blood samples from drivers involved in road traffic accidents (RTA) in the Padova region of Italy. Another aim of the study was to estimate the prevalence of these drugs with concentrations in blood above the therapeutic intervals and above specific per se limits.

METHODS

A total of 4066 blood samples collected from drivers involved in RTA were analysed for the presence of alcohol, drugs of abuse and medicinal drugs with sedative-hypnotic properties. Prevalence of drivers positive for BZDs and zolpidem were reported according to the reporting limit of our laboratory (1 ng/mL) in a sort of zero tolerance approach and compared with the prevalence according to analytical cut-offs used in the "European Union's research project on Driving Under the Influence of Drugs, Alcohol and Medicines" (DRUID). The impairment-based, per se limits adopted in Norway and in England and Wales and the values used to define "therapeutic ranges" in blood and in plasma/serum were also applied to the case study.

RESULTS

175 blood samples were positive for sedative-hypnotics above 1 ng/mL, with the following prevalence: diazepam 44%, nordazepam 41.8%, lorazepam 32.6%, zolpidem 28%, oxazepam 25.6%, alprazolam 16%, delorazepam 11,6%, lormetazepam 11,6%, temazepam 11.6%, clonazepam 11.6%, triazolam 6.9%, N-desalkylflurazepam 4.6%, bromazepam 2.3%. When applying DRUID analytical cut-offs, the prevalence of BZDs and zolpidem sharply decreases. Applying the impairing cut-offs used in Norway, 56% of positive samples were above the limits equivalent to a BAC of 0.2 g/L, 39% above the limits corresponding to 0.5 g/L, and 23% above the cut-off corresponding to 1.2 g/L. Only 1% of the drivers had drug concentrations above the per se concentration limits adopted in England and Wales [26]. When comparing blood levels with therapeutic ranges in plasma, bromazepam, lormetazepam and delorazepam were often found above the highest limits. The adjustment of the concentrations with the plasma-to-blood ratios causes a significant increase of cases above the therapeutic ranges in plasma.

CONCLUSIONS

Sedative-hypnotic drugs are medicinal substances frequently identified in drivers involved in RTA, commonly in concentrations associated with driving impairment. Besides the concentrations of drugs in blood, several factors have to be considered to conclude that a driver was impaired. The frequent association with alcohol, cocaine and other BZDs, confirms the abuse potential of these medications.

The Pharmacological Assessment of GABAA Receptor Activation in Experimental Febrile Seizures in Mice

Hyperthermia-induced febrile seizures (FSs) are the most common seizures during childhood, and prolonged complex FSs can result in the development of epilepsy. Currently, GABA_A receptor modulators such as benzodiazepines and barbiturates are used as medications for FSs with the aim of enhancing GABA-mediated inhibition of neuronal activity. However, it is still up for debate whether these enhancers of GABAergic neurotransmission could depolarize immature neurons with relatively higher levels of the intracellular Cl⁻ in the developing brain during FSs. Here, we performed simultaneous video-local field potential monitoring to determine whether benzodiazepines and barbiturates affect the phenotypes of FSs in postnatal day (P)11 and P14 mice. We found that low-dose administration of diazepam decreased the incidence of clonic seizures at P11. We also found that high-dose administration of diazepam and pentobarbital exacerbated the behavioral and electrophysiological phenotypes of the induction phase of experimental FSs at P11 but not at P14. We further found that the deteriorated phenotypes at P11 were suppressed when Na⁺K⁺2Cl⁻ cotransporter isoform 1 (NKCC1), which mediates Cl⁻ influx, was blocked by treatment with the diuretic bumetanide. Though our findings do not exclude the involvement of sedation effect of high-dose GABA_A receptor modulators in worsening experimental FSs at P11, pharmacological enhancement of GABAergic signaling could aggravate seizure activity in the early phase of FSs.

Effects of alprazolam and haloperidol on thyroglobulin, antithyroglobulin, anti thyroid peroxidase and TSH in Rat

Background:

A large number of psychotropic drugs can interfere with the thyroid physiology, function and autoimmunity.

Objective:

The aim of the present study was to investigate the effects of alprazolam and haloperidol on thyroglobulin, antithyroglobulin (aTg), antithyroid peroxidase, and thyroid stimulating hormone levels on rats.

Materials and Methods:

First group of adult male Wistar rats was the control, second group received 0.5 mg kg

Results:

We have investigated a decrease in aTg amounts of control group (5.461±0.718) compared with drug treated rats with alprazolam (1.433±0.225) and haloperidol (1.21±0.228). (P

Conclusion:

We found that these two drugs may interfere with the thyroid physiology and metabolism.

Sedative-hypnotics are widely abused by drivers apprehended for driving under the influence of drugs

BACKGROUND

Sedative-hypnotics are commonly encountered in drivers apprehended for driving under the influence of drugs (DUID). Previous research has mainly concentrated on the residual effects of the drugs.

METHODS

In this study, the extent of sleep medication use and abuse among drivers apprehended on suspicion of DUID was assessed. Additionally, the prevalence and concentrations of the drugs, concomitant use of other drugs of abuse, and the age and sex of the drivers positive for the most commonly prescribed sedative-hypnotics (temazepam, midazolam, nitrazepam, zopiclone, and zolpidem) in DUID cases in Finland in 2009 to 2011 were examined.

RESULTS

Sedative-hypnotics were found in 3155 samples of the 13,248 that were analyzed. Temazepam was present in over half of the cases (57.9%), along with other benzodiazepines such as midazolam (13.1%) and nitrazepam (7.0%) and the non-benzodiazepine hypnotics zopiclone (12.2%) and zolpidem (9.8%). The mean age of the drivers using the studied sedative-hypnotics was 33.5 years. Many of the drivers were polydrug users; concomitant stimulant use was found in nearly half of the cases. Cannabis and alcohol were also very common co-findings. In nearly 20% of the cases, the driver had taken more than 1 of the studied sedative-hypnotics; only 2.5% had no findings other than a single sedative-hypnotic in their blood. The drug use pattern of those positive for zopiclone and zolpidem was somewhat different from that of users of benzodiazepine sedative-hypnotics; their age was higher and the concomitant use of illegal stimulants was markedly less prevalent than among the users of temazepam, midazolam, and nitrazepam.

CONCLUSIONS

There were very few cases in our study population where the positive sedative-hypnotic finding could have been due to appropriate medical use. The extremely prevalent concomitant use of other psychoactive drugs and the high median serum concentrations of the studied sedative-hypnotics suggest their widespread abuse among apprehended drivers.

Superparamagnetic Fe3 O4 @SiO2 core-shell composite nanoparticles for the mixed hemimicelle solid-phase extraction of benzodiazepines from hair and wastewater samples before high-performance liquid chromatography analysis

Magnetic Fe3 O4 /SiO2 composite core-shell nanoparticles were synthesized, characterized, and applied for the surfactant-assisted solid-phase extraction of five benzodiazepines diazepam, oxazepam, clonazepam, alprazolam, and midazolam, from human hair and wastewater samples before high-performance liquid chromatography with diode array detection. The nanocomposite was synthesized in two steps. First, Fe3 O4 nanoparticles were prepared by the chemical co-precipitation method of Fe(III) and Fe(II) as reaction substrates and NH3 /H2 O as precipitant. Second, the surface of Fe3 O4 nanoparticles was modified with shell silica by Stober method using tetraethylorthosilicate. The Fe3 O4 /SiO2 composite were characterized by X-ray diffraction, scanning electron microscopy, Fourier transform infrared spectroscopy, and vibrating sample magnetometry. To enhance their adsorptive tendency toward benzodiazepines, cetyltrimethylammonium bromide was added, which was adsorbed on the surface of the Fe3 O4 /SiO2 nanoparticles and formed mixed hemimicelles. The main parameters affecting the efficiency of the method were thoroughly investigated. Under optimum conditions, the calibration curves were linear in the range of 0.10-15 μgmL(-1) . The relative standard deviations ranged from 2.73 to 7.07%. The correlation coefficients varied from 0.9930 to 0.9996.

Do Benzodiazepines Still Deserve a Major Role in The Treatment of Psychiatric Disorders? A Critical Reappraisal

Discovered in the late 1950s by Leo Sternbach, the first benzodiazepine (BZD) chlordiazepoxide was followed by several congeners, which rapidly constituted one of the largest and most widely prescribed classes of psychotropic compounds. After 50 years, BZDs are still routinely utilized not only in psychiatry but, more generally, in the whole of medicine. Despite their high therapeutic index which makes BZDs safer than other compounds like barbiturates, as well as their rapidity of onset, psychiatrists and family physicians are well aware about the controversy that surrounds the wide use – often not adequately based on scientific evidence – of BZDs in many psychiatric disorders. In this overview of international treatment guidelines, systematic reviews and randomized clinical trials, the aim was to provide a critical appraisal of the current use and role of BZDs in psychiatric disorders and their disadvantages, with specific emphasis on anxiety and affective disorders, sleep disorders, alcohol withdrawal, violent and aggressive behaviours in psychoses, and neuroleptic-induced disorders. In addition, specific emphasis has been given to the extent of usage of BZDs and its appropriateness through the assessment of available international surveys. Finally, the entire spectrum of BZD-related adverse effects including psychomotor effects, use in the elderly, paradoxical reactions, tolerance and rebound, teratologic risk, dependence, withdrawal and abuse issues was examined in detail.

Anxiolytic-like effect of linezolid in experimental mouse models of anxiety

Linezolid, an oxazolidinone class antibiotic is a reversible and nonselective inhibitor of monoamine oxidase (MAO) enzyme, mainly for MAO-A subtype. Its antidepressant-like effect has been previously demonstrated in the rodent models of depression. MAO-A enzyme has been shown to play a role in the pathophysiology of anxiety disorders and inhibition of MAO-A in the brain could be used to treat anxiety disorders. Thus, the objective of this study was to investigate the putative anxiolytic effects of linezolid in rodent models of anxiety. Mice were acutely injected with linezolid (5-40 mg/kg, i.p.), diazepam (2 mg/kg, i.p.) and moclobemide (10 mg/kg., i.p.). Linezolid (20 and 40 mg/kg), diazepam and moclobemide significantly (p<0.05) increased the percentage of time spent and entries into open arms in the elevated plus maze (EPM) test without altering the closed arm entries. Linezolid (10-40 mg/kg) significantly (p<0.05) increased the latency time to leave the light compartment, linezolid (20 and 40 mg/kg) significantly (p<0.05) increased total time spent in light compartment and linezolid (40 mg/kg) significantly (p<0.05) increased the number of transition between compartments in the light/dark (L/D) aversion test. Moreover, diazepam and moclobemide also showed significant (p<0.05) effects on all parameters in the (L/D) test. In addition, linezolid (20 and 40 mg/kg), diazepam and moclobemide significantly (p<0.05) increased the number of and time spent in head dipping, whereas significantly (p<0.05) decreased the head dipping latency in hole board (HB) test. In the present study linezolid at higher doses (20 and 40 mg/kg), diazepam and moclobemide showed more pronounced anxiolytic effects as compared to lower doses of linezolid (5 and 10 mg/kg). Whereas, the effects of linezolid at higher doses, diazepam and moclobemide on mice behavior in anxiety models was found quite similar. In conclusion, these results verified, for the first time, the anxiolytic properties of linezolid and suggest that linezolid may be considered an alternative approach for the management of anxiety disorders.

Assessment of pharmacotherapeutic safety of medical prescriptions for elderly residents in a long-term care facility

The present study aimed to estimate the prevalence of elderly using potentially inappropriate medications (PIM) and with occurrence of potentially hazardous drug interactions (PHDI); to identify the risk factors for the prescription of PIM and to evaluate the impact of pharmaceutical intervention (PI) for the prescription of safer therapeutic alternatives. Therefore, a cross-sectional study was performed in a long-term care facility in São Paulo State, between December/2010 and January/2011. The medical records of the patients >60 years old who took any drugs were consulted to assess the pharmacotherapeutic safety of the medical prescriptions, in order to identify PIM and PHDI, according to the Beers (2003) and World Health Organization criteria, respectively. PI consisted of a guidance letter to the physician responsible for the institution, with the suggestions of safer equivalent therapeutics. Approximately 88% of the elderly took at least one drug, and for 30% of them the PIM had been prescribed. Most of the PIM identified (53.4%) act on the central nervous system. Among the 13 different DI detected, 6 are considered PHDI. Polypharmacy was detected as a risk factor for PIM prescription. After the PI there was no change in medical prescriptions of patients who had been prescribed PIM or PHDI. The data suggests that PI performed by letter, as the only interventional, method was ineffective. To contribute it a wide dissemination of PIM and PHDI among prescriber professionals is necessary for the selection of safer treatment for elderly. Additionally, a pharmacist should be part of the health care team in order to help promote rational use of medicines.

Concentrations of diazepam and nordiazepam in 1,000 blood samples from apprehended drivers--therapeutic use or abuse of anxiolytics?

Using an in-house forensic toxicology database, we selected 1000 cases of driving under the influence of drugs (DUIDs) over a 12-month period if diazepam (D) and nordiazepam (ND) were both present in the blood samples. Quantitative analysis of D and ND in blood was done by solvent extraction (butyl acetate) and capillary column gas chromatography (GC) with a nitrogen-phosphorous (N-P) detector. The limits of quantitation of this analytical method for D and ND in blood were 0.05 mg/L. The correlation between D and ND concentrations in blood was statistically significant (r = .58, P < .001), as expected for a parent drug and its primary metabolite. However, the frequency distributions were markedly skewed to the right with mean (median) and highest concentrations of 0.37 (0.20) and 6.1 mg/L for D and 0.39 (0.20) and 5.6 mg/L for ND. The mean (median) total concentration (D + ND) was 0.76 mg/L (0.50 mg/L), and the concentration ratios D/ND and ND/D were 1.29 (median 0.95) and 1.41 (median 1.06), respectively. In 90 cases (9%), the concentration of D in blood exceeded 0.83 mg/L, which corresponds to an upper therapeutic limit in plasma (∼1.5 mg/L), assuming a plasma/blood distribution ratio of 1.8:1.

What non-alcohol drugs are used by drinking drivers in Sweden? Toxicological results from ten years of forensic blood samples

INTRODUCTION AND METHOD

Using a forensic toxicology database (TOXBASE), the toxicological results from 10 years of forensic blood samples from people arrested for driving under the influence of alcohol and/or other drugs were reviewed.

RESULTS

Alcohol was the only drug identified in blood in N=35,704 cases at a median blood-alcohol concentration (BAC) of 1.63 mg/g. The mean age (±SD) of these offenders was 40±15years and 89% were male. The median BAC was lower (1.30 mg/g) in drivers who had consumed alcohol and used a prescription drug before driving (N=1,251). The mean age of this group of traffic offenders was 38±13years and 85% were male. Both the median BAC (0.97 mg/g) and the mean age were lowest (36±11years, 92% male) in N=3,153 drivers who had consumed alcohol and used illicit drugs before driving. Cannabis, amphetamine, cocaine and morphine (metabolite of heroin) were the commonest illicit drugs identified in blood samples. Sedative-hypnotics (benzodiazepines) were the major prescription drugs co-ingested with alcohol. Poly-drug use was a common finding in these traffic delinquents, although individuals who only drank alcohol had a higher median BAC and were also several years older than drinking drivers combining alcohol with other drugs before driving.

IMPACT ON INDUSTRY

Zero-tolerance legislation did not deter hard-core offenders. In future there should be more focus on treatment for alcohol and substance abuse disorder rather than conventional punishments for this type of traffic crime.

The medicalization of sleeplessness: a public health concern

Sleeplessness, a universal condition with diverse causes, may be increasingly diagnosed and treated (or medicalized) as insomnia. We examined the trend in sleeplessness complaints, diagnoses, and prescriptions of sedative hypnotics in physician office visits from 1993 to 2007. Consistent with the medicalization hypothesis, sleeplessness complaints and insomnia diagnoses increased over time and were far outpaced by prescriptions for sedative hypnotics. Insomnia may be a public health concern, but potential overtreatment with marginally effective, expensive medications with nontrivial side effects raises definite population health concerns.

Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated. GAD is chronic, disabling, and associated with other health problems. Treatment response is often unsatisfactory, but the clinical evidence base for new treatments has expanded substantially in the past decade and suggests a growing range of options for reducing the burden of GAD. The objective of this article was to review current literature on GAD and its management to provide an overview of the clinical importance of GAD in primary care and available treatments.

DATA SOURCES

Recent studies (ie, over the past decade) on the epidemiology and treatment of GAD were identified by searching Medline using the term generalized anxiety disorder only and in combination with the terms epidemiology and treatment and for each drug class (benzodiazepines, azapirones, antidepressants, antihistamines, alpha-2-delta ligands, and antipsychotics) and for named drugs (buspirone, venlafaxine, duloxetine, fluoxetine, escitalopram, olanzapine, paroxetine, pregabalin, quetiapine, and risperidone in addition to psychological therapies and cognitive-behavioral therapy. The literature search was conducted in August 2008 for the period 1987-2009.

STUDY SELECTION

Studies were included if judged to be relevant to a review of the epidemiology and management of GAD. Articles were excluded if they were not written in English or were published more than 10 years before the literature search was conducted. A few older studies were included for which more recent research evidence was not available. Recent national and international guidelines for the management of GAD were also reviewed.

DATA EXTRACTION/SYNTHESIS

Most currently available interventions have similar overall efficacy, and treatment choices should reflect the situation of individual patients. Important unmet needs exist for treatments (1) that work rapidly, with (2) broad spectrum benefits, (3) that can improve rates of remission and well-being, (4) are devoid of risk for withdrawal symptoms, and (5) have few if any adverse interactions with other drugs. Additional needs include (6) safer drugs for the elderly, (7) safe and effective drugs for children with GAD, (8) further evaluation of psychotherapy, and (9) understanding the appropriate circumstances for, and optimal choices of, drug combination.

CONCLUSION

While the development of novel treatments evolves, current management approaches can focus on improving identification and defining optimal use of available therapies for GAD.

Gender differences in the use of anxiolytics and antidepressants: a population based study

PURPOSE

In the majority of studies on determinants of use of anxiolytics and antidepressants a substantially higher consumption is observed among women than among men. We investigated gender differences in the association between the use of anxiolytics and antidepressants and mental health and explored if there are indications of gender differences in inappropriate use of these medicines.

METHODS

Data were from the 2004 Belgian Health Interview Survey, a nationally representative sample of the Belgian population. The analysis was restricted to the population of 15 years and older (n = 11,220). The probability of use of anxiolytics and antidepressants was assessed through logistic regression models by gender and through models including the interaction between gender and mental health.

RESULTS

The association between the use of antidepressants and mental health did not vary substantially between men and women. Among men the use of anxiolytics showed a strong association with sleeping problems, but not with depressive disorders. Among women the use of anxiolytics was significantly associated with the three mental health conditions that were investigated: depressive disorder, anxiety, and sleeping problems.

CONCLUSIONS

The link between mental health and use of anxiolytics differs by gender. Some indications exist for gender differences in inappropriate use of anxiolytics, whereas this does not hold true for the use of antidepressants. Further efforts are needed to increase the awareness of prescribers, policy makers, and the general public on the appropriate use of anxiolytics, especially among women and in the older population.

Estresse e qualidade do sono entre enfermeiros que utilizam medicamentos para dormir

OBJETIVOS: Identificar os níveis de estresse, analisar a utilização de medicamentos para dormir e correlacionar níveis de estresse, qualidade do sono e uso de medicamentos. MÉTODOS: Estudo quantitativo, transversal, descritivo e comparativo, realizado com 203 enfermeiros de uma instituição hospitalar da cidade de Campinas, São Paulo, Brasil. Foi utilizado um questionário de identificação, Escala Bianchi de Stress modificada (EBSm) e o Índice de Qualidade do Sono de Pittsburgh. RESULTADOS: Dentre 203 enfermeiros, 17,7% utilizavam medicamentos para dormir. Dos enfermeiros que utilizaram medicamentos para dormir 48,6% demonstraram estado de alerta e alto nível de estresse (p = 0, 016) e apresentaram na sua totalidade (n=36) uma qualidade de sono ruim. CONCLUSÃO: Os enfermeiros que utilizaram medicamentos para dormir apresentaram níveis de estresse mais elevados e prejuízos que comprometem a qualidade do sono.

The detection of various opiates and benzodiazepines by comprehensive two-dimensional gas chromatography/time-of-flight mass spectrometry

A technique using comprehensive two-dimensional gas chromatography/time-of-flight mass spectrometry (GC x GC/TOFMS) is applied to qualitative and quantitative drug testing. Human serum was 'spiked' with known quantities of benzodiazepines and a 'street heroin' mixture including some of the major metabolites and impurities. The sample components were extracted from the matrix by solid-phase extraction (SPE). Constituents containing polar hydroxyl and/or secondary amine groups were derivatised with N-methyl-N-(tert-butyldimethyl)trifluoroacetamide (MTBSTFA) to improve the chromatographic performance. An orthogonal separation of the matrix constituents was achieved by coupling a DB-5ms (5% phenyl) to a BPX50 (50% phenyl) GC column. The eluant was focused onto the second column by a twin-stage cryo-modulator. Rapid 6 s modulation times were achieved by transfer from a 30 m x 0.25 mm (length x internal diameter) to a 2 m x 0.1 mm column. TOFMS with rapid spectral acquisition (< or =500 spectra/s) was employed in the mass range m/z 40-650. A clean mass spectrum was obtained for each analyte using mass spectral deconvolution software. The sensitivity and repeatability of the method were evaluated by the preparation of calibration standards for two benzodiazepines, flunitrazepam and its major metabolite 7-aminoflunitrazepam (7-amino-FN), in the concentration range 5-1000 ng/mL. The limits of detection (LODs) and limits of quantitation (LOQs), calculated by repeat injections (x10) of the lowest standard, were 1.6 and 5.4 ng/mL (flunitrazepam); 2.5 and 8.5 ng/mL (7-amino-FN), respectively. There is scope to extend this protocol to screen a large number of drugs and metabolites stored in a library database.

Effects of common medications used for sleep disorders

Sleep disorders are common and their diagnosis is becoming more widespread with improved awareness among clinicians and patients. The armamentarium for the pharmacologic treatment of sleep disorders is rapidly growing, demanding that clinicians be aware of their indications, adverse effects, and interactions. As disorders, such as narcolepsy, shift-work sleep disorder, and RLS are more readily identified, pharmacologic treatments for these conditions will also become more common.

The influence of co-morbidities on prescribing pharmacotherapy for insomnia: evidence from US national outpatient data 1995-2004

OBJECTIVE

Patients with insomnia are likely to have other co-morbidities that could affect pharmacotherapeutic choices. This study examined the prevalence and impact of co-morbidities on the pharmacological treatment of insomnia.

STUDY DESIGN

A retrospective data analysis of the National Ambulatory Medical Care Survey from 1995 to 2004, comprising patients with a diagnosis of insomnia, was conducted. Multivariate logistic regression models were used to predict the impact of co-morbidities on pharmacotherapy for insomnia.

RESULTS

A total of 5,487 unweighted patient visits with insomnia were identified, representing 161.4 million patients in the US. Approximately 38% of these patients had at least one co-morbid condition. Patients with mental co-morbidities, especially anxiety, had decreased likelihood of receiving pharmacotherapy for insomnia.

CONCLUSIONS

Mental co-morbidities such as episodic mood disorder, anxiety and depression are prevalent in patients with insomnia. However, many co-morbid patients do not receive pharmacological therapy specific for insomnia.

Concentrations of scheduled prescription drugs in blood of impaired drivers: considerations for interpreting the results

We report the concentrations of scheduled prescription drugs in blood samples from people arrested in Sweden for driving under the influence of drugs (DUID). The investigation covered a 2 year period 2004 (N = 7052 cases) and 2005 (N = 7759 cases) and was prompted by recent legislation stipulating zero-concentration limits in blood for controlled substances. However, prescription drugs are exempt from the zero-limit law provided that the medication was being used in accordance with a doctor's prescription. The blood concentrations of various psychoactive substances were compared with the limits of quantitation of the analytic method used and the so-called therapeutic concentration range according to various reference books and tabulations. Diazepam [N = 1950 (26%)] and nordazepam [N = 2168 (28%)] were the therapeutic agents most frequently identified in these forensic blood samples along with other benzodiazepines such as alprazolam [N = 430 (5.6%)], flunitrazepam [N = 308 (4.0%)], and nitrazepam [N = 222 (2.9%)]. The newer hypnotics, exemplified by zolpidem [N = 148 (1.9%)] and zopiclone [N = 111 (1.5%)], were also high on the list of psychoactive substances identified. Interpreting the concentration of a prescription drug in blood in relation to whether the person had taken an overdose or was abusing the substance in question is not always easy. The age, gender, degree of obesity, and ethnicity of the person concerned; the pharmacokinetic profile of the drug; polymorphism of drug-metabolizing enzymes as well as liver and kidney function and blood hematocrit need to be considered. Among preanalytic factors, stability of the drug in blood after sampling, the type of tubes and preservatives used, the dosage form and route of administration deserve consideration. When therapeutic drug monitoring concentrations are compared with forensic toxicology results, then the plasma-to-whole blood distribution ratio of the drug also needs to be considered. In blood samples from DUID suspects, the concentrations of many commonly used sedatives and hypnotics exceeded the accepted therapeutic limits, which gives an indication of the abuse potential of these types of medications.

The effect of chronic lorazepam administration in aging mice

To assess benzodiazepine tolerance in aged animals, lorazepam or vehicle was administered chronically to male Crl: CD-1(ICR)BR mice. Pharmacodynamic and neurochemical endpoints were examined on days 1 and 14 of drug administration. There was no age-related significant difference in plasma lorazepam levels. Young and middle-aged animals demonstrated behavioral tolerance to lorazepam, while the aged animals showed a similar trend which failed to reach significance. In addition, aged animals also showed a trend toward tolerance to the anticonvulsant effects of lorazepam. There were no changes in alpha1 mRNA levels in cortex or hippocampus following administration of lorazepam when compared to vehicle-treated animals in any age group. Aged animals, however, had an initial increase in alpha1 mRNA expression in cortex and hippocampus on day 1 of vehicle treatment followed by decreased expression on day 14. These age-related changes were abolished by lorazepam administration. In summary, age-related sensitivity to the effects of lorazepam was not demonstrated in the present study. However, comparison of these data to other studies indicates that the effect of chronic benzodiazepine treatment may be specific to the benzodiazepine administered, the technique used to quantify mRNA expression changes, the subunits of the GABA(A) receptor investigated and the brain region analyzed. The phenomenon of benzodiazepine sensitivity in the elderly is an area of research which remains controversial and may well be compound specific. Determining benzodiazepines that do not produce pharmacodynamic sensitivity, such as lorazepam, may allow more careful prescribing and dosing of these drugs, and perhaps even the development of specific agents which could avoid this sensitivity.

Fast gas chromatography-negative-ion chemical ionization mass spectrometry with microscale volume sample preparation for the determination of benzodiazepines and alpha-hydroxy metabolites, zaleplon and zopiclone in whole blood

Fast gas chromatography/negative-ion chemical ionization mass spectrometric (GC/NICI-MS) assay combined with rapid and nonlaborious sample preparation is presented for the simultaneous determination of benzodiazepines and alpha-hydroxy metabolites, zaleplon and zopiclone in whole blood. The compounds were extracted from 100 microl of whole blood by simultaneous multitube, microscale liquid-liquid extraction (LLE) and derivatized by N-methyl-N-(tert-butyldimethylsilyl)trifluoroacetamide (MTBSTFA), without the need for the time-consuming concentration stage. In the analytical separation, various parameters of fast GC/NICI-MS were applied, e.g. the use of hydrogen as a GC carrier gas, a high carrier gas velocity, a small film thickness of the analytical column, fast MS data acquisition, fast temperature ramping, and high initial and final temperatures of GC column. Sensitive identification, screening and quantitation of 18 compounds of interest were achieved in chromatographic separation in only 4.40 min. Accurate and reproducible results were obtained by using five different and carefully selected deuterated analogues on the basis of the chemical properties of the target analytes. Nevertheless, for alpha-OH-midazolam, and for bromazepam and flunitrazepam at low concentrations, the results can be considered only semiquantitative on the basis of the validation data. The extraction efficiencies ranged from 74.3 to 105.7% and the limits of quantitation (LOQ) from 1 to 100 ng ml(-1). Rapid sample preparation and fast chromatographic separation allowed cost-efficient, reliable and high sample-throughput analyses with a low amount of manual work. The method was fully validated and accredited according to EN ISO/IEC 17025 standards and is applicable for sensitive, reliable and quantitative determination of benzodiazepines, zaleplon and zopiclone, e.g. in clinical and forensic toxicology.

Physician and patient factors associated with the prescribing of medications for sleep difficulties that are associated with high abuse potential or are expensive: an analysis of data from the National Ambulatory Medical Care Survey for 1996-2001

OBJECTIVE

This study evaluated the association between various socioeconomic and clinical factors relating to patients and physicians and the prescribing of medications that have a high abuse potential or are expensive for the treatment of sleep difficulties in a nationally representative sample of outpatient physician visits in the United States.

METHODS

This cross-sectional study used data from the National Ambulatory Medical Care Survey from 1996-2001. Patients aged > or =18 years who received treatment for sleep difficulties in US outpatient settings over this period were included in the study sample. Office visits were considered related to insomnia/sleep difficulties if relevant International Classification of Diseases, Ninth Revision, diagnosis codes were recorded and if insomnia was reported as the reason for the visit or any medication with a primary indication for insomnia was prescribed. Medications associated with dependence and withdrawal symptoms were categorized as having a high abuse potential. Medications were considered expensive if the average wholesale price of 100 tablets was > or =$150 (ie, the 75th percentile of the total cost of all medications prescribed for sleep disorders only). The data were subjected to multivariate logistic regression analysis.

RESULTS

From 1996 through 2001, 2966 unweighted patient visits for insomnia/sleep difficulty were identified, representing approximately 94.6 million weighted observations in the overall US population; pharmacotherapy only was prescribed at 48% (45 million) of these visits. Medications with abuse potential were prescribed at 53% (24 million) of visits. Among visits at which pharmacotherapy was prescribed, visits by male patients were 39% less likely than visits by female patients to result in a prescription for a medication with abuse potential (odds ratio [OR] = 0.61; 95% CI, 0.45-0.81). Visits by patients with psychiatric comorbidities were 80% more likely to be associated with receipt of a prescription for a medication with abuse potential than were visits by patients with no such comorbidities (OR = 1.80; 95% CI, 1.31-2.47). Expensive medications were prescribed at 25% (15 million) of visits involving some pharmacotherapy. Patients aged > or =65 years were 44% less likely to receive a prescription for an expensive medication than was the reference group, patients aged 18 to 34 years (OR = 0.56; 95% CI, 0.35-0.90). Hispanic patients were 56% less likely to receive a prescription for an expensive medication than were non-Hispanic patients (OR = 0.44; 95% CI, 0.22-0.88).

CONCLUSIONS

This study found an increased probability of female patients with sleep difficulties receiving a medication with high abuse potential in outpatient settings in the United States from 1996 through 2001. In addition, there was a possible association between the age and ethnicity of patients with insomnia/sleep difficulties and the prescribing of expensive medications for sleep difficulties.

Sevrage aux benzodiazépines des sujets dépendants aux opiacés en traitement de substitution

INTRODUCTION

Benzodiazepines are the most widely used psychotropic agents in the world. Abuse and dependence are reported in the general population and among drug misusers, including those dependent on heroine. Benzodiazepine use by heroine users increases their risk of overdose, not only from heroin but also substitution drugs such as methadone and more recently buprenorphine. Hence, detoxification from benzodiazepines is desirable.

OBJECTIVE

The objective of this paper was to review the literature and determine the best benzodiazepine detoxification procedure for opiate-dependent individuals receiving substitution treatment.

METHODS

Relevant studies were sought through systematic searches of Medline and Toxibase (a database focusing on substance abuse).

RESULTS

There were fewer controlled studies than expected about benzodiazepine detoxification, and all of them excluded subjects who misused opiates or were in opiate substitution treatment. The best evidence supports a procedure where the patient is switched to a long-lasting benzodiazepine and the dose then tapered by 25% of the initial dose each week. Diazepam is the drug most often used in the framework. In opiate users, diazepam may raise special problems of misuse, as suggested by clinical and epidemiologic studies. Nonetheless, diazepam is the only benzodiazepine found to be effective for this withdrawal in controlled studies and some studies indicate that unprescribed diazepam use in heroin users is sometimes motivated by the desire to alleviate withdrawal symptoms and discomfort.

CONCLUSION

Although diazepam appears to have potential for abuse, the available data does not rule out its therapeutic interest for benzodiazepine withdrawal in patients on opiate substitution treatment in an adequate treatment setting. Specific studies of this population are needed.

Diazepam-induced changes of optokinetic nystagmus fast phase

Since specific benzodiazepine (Bz) binding sites have been found in the vision and oculomotor control areas of the central nervous system (CNS), the fast phases of optokinetic nystagmus (OKN) should be affected by Bz administration. In this study, we examine the effects of Bzs on OKN fast phases under closed- and open-loop experimental conditions. Six normal subjects participated in the experiments. The eye movements were measured by the magnetic field, search coil technique, 90 min after diazepam or placebo administration. The study was performed in a randomized, double-blind fashion. After diazepam, the mean amplitude (MAmp) and mean peak velocity (MVel) of OKN fast phases decreased significantly under both experimental conditions. The percentage decreases in MAmp and MVel under the open-loop condition were significantly larger than those under the closed-loop condition. The results indicate that the fast phases of OKN could sensitively reflect the pharmacodynamic effects of Bzs on the CNS.

Uso indevido de benzodiazepínicos: um estudo com informantes-chave no município de São Paulo

Este estudo teve por objetivo compreender a prática de prescrição, dispensação e uso prolongado de benzodiazepínicos, a partir da visão de profissionais de saúde e de usuários crônicos dessas substâncias. A amostra foi composta por técnica de bola de neve, totalizando19 informantes-chave. As entrevistas semi-estruturadas foram gravadas e transcritas para análise. A maioria dos entrevistados relatou ser freqüente a obtenção de prescrição de benzodiazepínicos por solicitações junto aos médicos, sem necessidade de consulta formal. Os usuários relataram histórico de uso prolongado (entre 2 e 8 anos) com finalidades outras que não apenas a terapêutica. Enfatizaram também a facilidade em adquirir a medicação e a falta de orientação médica sobre os cuidados necessários durante o tratamento. O estudo sugere que a ocorrência de uso indevido envolve não apenas o sistema de controle da dispensação, mas uma série de outros fatores, entre os quais as atitudes dos profissionais de saúde.

Sleep laboratory study on single and repeated dose effects of paroxetine, alprazolam and their combination in healthy young volunteers

AIMS

To evaluate the potential interaction of 20 mg paroxetine and 1 mg alprazolam (early morning once-daily administration) on polysomnographic (PSG) sleep and subjective sleep and awakening quality, both after a single intake and after reaching a steady-state concentration.

METHODS

Twenty-two (11 for the PSG) healthy young volunteers of both sexes with no history of sleep disturbances (Pittsburgh Sleep Quality Index <5) participated in a double-blind, double-dummy, placebo-controlled, repeated-dose, 4-period, cross-over study. All volunteers received all 4 treatment sequences: paroxetine-alprazolam placebo (PAP); paroxetine placebo-alprazolam (PPA); paroxetine-alprazolam (PA), and paroxetine placebo-alprazolam placebo (PLA), in a randomized order. Each treatment was administered over 15 consecutive days, with a treatment-free interval of 7 days prior to the subsequent study period. In each experimental period, one PSG sleep study was performed on the 1st night (single-dose effects) and another study was performed on the 15th night (repeated-dose effects). Additionally, two other PSG studies were assessed: an adaptation recording, and a control night recording. All-night PSG recordings were obtained following standard procedures. Each 30-second period was scored according to the criteria of Rechtschaffen and Kales by means of an automatic sleep analysis system: Somnolyzer 24x7. A self-rating scale for sleep and awakening quality and early morning behavior was completed no later than 15 min after awakening over the 15 days of each experimental intervention. General lineal models (treatment/time) were applied separately to each variable.

RESULTS

(1) No significant effects were observed in any sleep variables when control nights were compared with the 1st night with PLA. (2) Sleep continuity: After PAP a clear awakening effect was seen both in the first and second evaluations, mainly in wake time, movement time, number of awakenings and stage-1 duration. After PPA an evident hypnotic effect was observed on night 1. This effect was mainly observed in maintenance variables and slightly in sleep initiation variables; it had decreased by night 15. After PA an intermediate behavior in the variables related to sleep continuity was seen, highlighting the absence of the tolerance phenomenon observed when PPA was administered alone. (3) Sleep architecture: The most important effects in REM sleep were observed after PAP; an increase in REM latency and decreases in REM sleep. PAP also induced decreases in the number of non-REM and REM periods and increases in the average duration of non-REM periods and sleep cycles. PA presented a similar pattern to PAP, and PPA similar to PLA. In relation to non-REM sleep, PA showed more stage-2 and less slow-wave sleep (SWS). (4) Subjective perception: No significant differences were observed between treatments while they were being taken, but impairments in subjective sleep quality, awaking quality, latency and efficiency were seen, mainly after PA but also after PPA discontinuations.

CONCLUSION

The combination of PAP and PPA presented an intermediate pattern in relation to sleep continuity, with less awaking effect than PAP alone and less hypnotic effect than PPA alone, and without developing tolerance. The PAP and PPA combination also showed a similar effect to PAP on REM sleep and was the treatment with the longest stage 2 and shortest SWS. No subjective sleep and awakening effects were seen during drug intake but subjective withdrawal reports were seen after abrupt interruption. The high agreement rate for the epoch-by-epoch comparison between automatic and human scoring confirms the validity of the Somnolyzer 24x7 and thus facilitates sleep studies in neuropsychopharmacological research.

Effects of diazepam on the latency of saccades for luminance and binocular disparity defined stimuli

Saccadic latency is composed of separate sensory and motor processing delays. Therefore, any alteration in the sensory processing should effect the saccadic latency. Because the highest density of benzodiazepine (Bz) binding sites is located in cerebral cortex, sensory processing of stimuli in this cortical area is expected to be substantially effected by administration of Bzs. It is well known that sensory processing of binocular disparity occurs in the cerebral cortical areas and therefore the latency of saccades to stimuli defined by binocular disparity should be substantially affected by Bz intake. In this study, we tested this prediction by comparing the latency of saccadic eye movements for binocular disparity defined stimuli (stereo stimuli) with those for luminance contrast defined stimuli (luminance stimuli), after diazepam or placebo. Eye movements were mainly recorded by use of the magnetic search coil technique, and the study was performed in a randomized, double-blind way. Although diazepam prolonged the latency of saccades for stereo and luminance stimuli, the percentage increases in saccadic latency for the stereo stimuli were significantly larger than those for the luminance stimuli. Saccadic peak velocity, and saccadic amplitude, also significantly decreased after diazepam under conditions of stereo and luminance stimuli. However, there was no significant difference for either saccadic peak velocity or amplitude between the two types of target. The results suggest that the latency of saccades to binocular disparity defined random-dot stimuli could more sensitively reflect the pharmacodynamic effects of Bzs on the cerebral cortex.

Development and validation of a liquid chromatographic/electrospray ionization mass spectrometric method for the quantitation of prazepam and its main metabolites in human plasma

A method was developed and fully validated for the quantitation of prazepam and its major metabolites, oxazepam and nordiazepam, in human plasma. Sample pretreatment was achieved by solid-phase extraction using Oasis HLB cartridges. The extracts were analysed by high-performance liquid chromatography (HPLC) coupled with single-quadrupole mass spectrometry (MS) with an electrospray ionization interface. The MS system was operated in the selected ion monitoring mode. HPLC was performed isocratically on a reversed-phase XTerra MS C18 analytical column (150 x 3.0 mm i.d., particle size 5 microm). Diazepam was used as the internal standard for quantitation. The assay was linear over a concentration range of 5.0-1000 ng ml(-1) for all compounds analyzed. The limit of quantitation was 5 ng ml(-1) for all compounds. Quality control samples (5, 10, 300 and 1000 ng ml(-1)) in five replicates from three different runs of analysis demonstrated an intra-assay precision (CV) of < or = 9.1%, an inter-assay precision of < or = 6.0% and an overall accuracy (relative error) of < 4.6%. The method can be used to quantify prazepam and its metabolites in human plasma covering a variety of pharmacokinetic or bioequivalence studies.

Análisis de la correlación entre la calidad de la prescripción de antipsicóticos y el estado clínico en pacientes con esquizofrenia

OBJECTIVE

The aim of this study is to describe the psychopharmacological aspects of psychiatric practice in a group of schizophrenic patients and to evaluate whether or not practice agrees with treatment guidelines. The study also intends to objectively measure the psychopathological state of patients in order to establish correlation between different pharmacological aspects of treatment and their clinical outcomes.

METHOD

We have elaborated six recommendations concerning the pharmacological treatment of schizophrenia, taken from several guides, which are based on evidence. The psychopathological state of patients has been evaluated with the Brief Psychiatric Rating Scale (BPRS) and real prescription practice has been analysed. BPRS rates are compared depending on compliance with guidelines.

RESULTS

More than 60% of patients do not comply with at least 4 of 6 evidence-based recommendations; compliance with recommendations being associated with a minor BPRS punctuation. Differences in BPRS punctuation between compliant and not compliant groups for 3 recommendations (maintenance antipsychotic dosage, antipsychotic association and drugs with a negative effect on cognitive functions), are statistically significant(p < 0,05; bilateral).

DISCUSSION

Medical practice which closely follows treatment guidelines results in satisfactory clinical outcomes.

Lack of pharmacologic interaction between paroxetine and alprazolam at steady state in healthy volunteers

This investigation aimed to provide evidence on the lack of pharmacokinetic interaction of paroxetine (20 mg/d) and alprazolam (1 mg/d) in combined therapy. In addition, the central effects of both drugs when administered alone and in combination were assessed to rule out any relevant synergistic depressant central effect. Twenty-five healthy young adult volunteers participated in a double-blind, double-dummy, placebo-controlled, repeated dose (15 days), 4-period crossover study. Each subject received each of 4 treatment sequences (ie, paroxetine-alprazolam placebo, alprazolam-paroxetine placebo, paroxetine-alprazolam, and paroxetine placebo-alprazolam placebo) in randomized order. The ratios for area under the curve within a dosing interval and maximum plasma concentration of the paroxetine plus alprazolam sequence to single agent paroxetine were 1.07 (90% confidence interval = 0.99 to 1.16) and 1.05 (90% confidence interval = 0.97 to 1.13), respectively, with no statistically significant differences between the 2 treatments. Similarly, for alprazolam, ratios for the combined to the single treatment sequence were 0.99 (90% confidence interval = 0.93 to 1.05) and 1.00 (90% confidence interval = 0.94 to 1.07) for area under the curve within a dosing interval and maximum plasma concentration, respectively, showing no evidence for interaction. Comparative pharmacodynamics on the combination was assessed using 6 Psychomotor Performance Tests and 5 Visual Analogue Scales focused on mood variables. Alprazolam and paroxetine plus alprazolam induced similar and significant performance impairment and sedation after both single and repeated dose administration, being less evident on day 15. After dosing, paroxetine plus alprazolam showed a lower recovery pattern than alprazolam alone, especially on day 15. No treatment sequence showed cumulative effects after repeated dose administration. Psychomotor Performance Tests and Visual Analogue Scales data suggested lack of pharmacodynamic interactions. Accordingly, study results showed no evidence for pharmacologic interactions between paroxetine and alprazolam at steady state. The most commonly reported adverse event was drowsiness, with a higher incidence under both single and combined alprazolam treatments.

Oral triazolam sedation in implant dentistry

Triazolam can be helpful for sedating dental implant patients when administered orally or sublingually in low dosages of 0.125 or 0.25 mg, but not exceeding 0.5 mg. It is a fast- but short-acting benzodiazepine with few side effects, and it has a long record of successful use. Its effects can be reversed with incremental intravenous flumazenil, although there is a risk of seizure. Triazolam has not been shown to be carcinogenic, and it has a low potential for abuse and addiction. It is contraindicated in patients who are pregnant, breast-feeding, and those concomitantly taking ethanol, macrolid antibiotics, some protease inhibitors, psychotropic medications, ketoconazole, itraconazole, nefaxodone, or other medications that impair oxidative metabolism mediated by cytochrome P450 3A (CYP 3A). Triazolam should be used with caution in patients taking grapefruit juice, cyclosporine, and other drugs such as calcium channel blockers including nifedipine, verapamil, and diltiazem. The lowest effective dose should be used.

Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: a review of case reports and epidemiological data

AIMS

The non-benzodiazepine hypnotics zolpidem and zopiclone, which are indicated for short-term treatment of insomnia, were considered originally by physicians as almost devoid of abuse and dependence potential. Several recent publications, however, have suggested that both agents carry a significant risk of abuse. To substantiate and re-evaluate this situation, the world literature was reviewed for cases of dependence of both agents; these cases were analysed in order to identify certain underlying patterns, if evident.

METHODS

A systematic review based on a Medline literature search was conducted including the years 1966-2002 to assemble all available clinical case reports that were analysed for typical features of abuse and dependence according to prespecified criteria. Only case reports were of interest, and clinical studies were excluded. No limitations as to language or publication year were applied. The terms 'zolpidem', 'zopiclone' and 'abuse', 'dependence', 'addiction', 'withdrawal' and 'intoxication' were used to identify relevant publications. Potentially relevant citations were retrieved and assessed for inclusion independently by two authors.

RESULTS

A total of 36 cases for zolpidem were identified, most of them reported in recent years, and 22 cases for zopiclone. Both sexes were involved to a similar extent; and cases were reported in all age groups. In extreme cases, dose increases reached a factor of 30-120 above the recommended doses. The majority of patients had a history of former drug or alcohol abuse and/or other psychiatric conditions.

CONCLUSION

On the basis of world-wide prescription numbers, which are approximately twofold higher for zolpidem (1,338,774,000 tablets from June 2001 to June 2002 in Europe, Japan and United States) than for zopiclone (664,897,000 tablets during the same period in Europe and Japan), the relative incidence of reported dependence similar for both drugs and remarkably lower than that of benzodiazepines used for the treatment of disturbed sleep. The findings offer the conclusion that zolpidem and zopiclone are relatively safe drugs. However, as both drugs are psychotropic drugs, patients with a history of abuse or dependence and those with psychiatric diseases seem to be at increased risk of abuse of these agents.

Therapeutic potential of kava in the treatment of anxiety disorders

Anxiety disorders are among the most common psychiatric disorders that affect all age groups of the general population. Currently, the preferred treatment is with pharmacological drugs that have antidepressant or anti-anxiety properties. However, these agents have numerous and often serious adverse effects, including sedation, impaired cognition, ataxia, aggression, sexual dysfunction, tolerance and dependence. Withdrawal reactions on termination after long-term administration are also a major limiting factor in the use of these agents. Herbal remedies, including kava (Piper methysticum), have been shown to be effective as alternative treatments, at least in mild to moderate cases of anxiety. Kava is a social and ceremonial herb from the South Pacific. It is available in the west as an over-the-counter preparation. Its biological effects, due to a mixture of compounds called kavalactones, are reported to include sedative, anxiolytic, antistress, analgesic, local anaesthetic, anticonvulsant and neuroprotective properties. The pharmacological properties of kava are postulated to include blockade of voltage-gated sodium ion channels, enhanced ligand binding to gamma-aminobutyric acid (GABA) type A receptors, diminished excitatory neurotransmitter release due to calcium ion channel blockade, reduced neuronal reuptake of noradrenaline (norepinephrine), reversible inhibition of monoamine oxidase B and suppression of the synthesis of the eicosanoid thromboxane A(2), which antagonises GABA(A) receptor function. Clinical studies have shown that kava and kavalactones are effective in the treatment of anxiety at subclinical and clinical levels, anxiety associated with menopause and anxiety due to various medical conditions. Until recently, the adverse effects attributed to kava use were considered mild or negligible, except for the occurrence of a skin lesion. This disorder, called kava dermopathy, occurs only with prolonged use of large amounts of kava and is reversible on reduced intake or cessation. Rare cases of interactions have occurred with pharmaceutical drugs that share one or more mechanisms of action with the kavalactones. In the past few years, about 35 cases of severe liver toxicity associated with kava intake have been reported in Europe and the US. However, a direct causal relationship with kava use has been difficult to establish in the majority of the cases, and there is insufficient evidence to implicate kava as the responsible agent. Nevertheless, until further research clarifies any causality, kava should be used with caution.

Psychotropic drug use, falls and hip fracture in the elderly

The use of benzodiazepines (BZD) or other psychotropic agents is an established risk factor for falls and hip fractures. The evidence supporting this association has been based solely on history and/or prescription data. In a case-control study we monitored the intake of BZD, tricyclic antidepressants (TCA) and barbiturates in patients with hip fracture by serum analysis, and compared this measurement with drug history and prescription records. The serum was BZD positive in 41% of 82 community-dwelling patients; an equivalent by history and/or prescription records, however, was detected in only 18% (p < 0.0001). In contrast, in 82 age- and gender-matched community-dwelling control patients, there was only a minor discrepancy (3%) in BZD use between anamnestic (N = 19) and analytical (N = 21) data. In 23 patients admitted from nursing homes, a similar trend was visible (39% serum positive for BZD vs 26% by drug history). Barbiturate use (N = 2) could be neglected, and TCA intake was minor (N = 7); in each case both assessments were in accordance. In conclusion, in patients with hip fracture, BZD use is substantially more frequent than reported and previously assumed, pointing to an underestimated risk factor for this injury.