Epidemiology of benzodiazepine dependence

Dépendance aux benzodiazépines et syndrome de sevrage. Revue de la littérature

Ce travail rapporte les résultats d'une revue de la littérature mondiale (247 publications), concernant les syndromes de sevrage et la dépendance aux benzodiazépines, réalisant ainsi une mise à jour de l'tude eifectuée par Marks (1986) pour la période 1961-1984. Quatre-vingts cas publiés individuellement et 269 cas publiés par séries ont été recensés pour la période 1984-1988 (janvier), soit en ajoutant ces chiffres à ceux de Marks (1986): 928 cas individuels et 969 cas publiés par séries, soit encore au total: 1 897 cas publiés. L'analyse détaillée de ces cas, leur signification en termes de risque sont rapportées et discutées.

Au plan pratique, il apparaît que toutes les benzodiazépines peuvent être à l'origine de syndrome de sevrage, y compris celles à demi-vie courte. Le risque de dépendance est d'autant plus important que la durée de la prescription et les posologies employées sont élevées. Il est donc nécessaire de préconiser un sevragesystématiquementprogressif, quelles que soient la molécule et la durée de prescription, d'éviter l'administration aux sujets ayant des antécédents d'abus de toxiques ou de médicaments, de réserver l'usage à long terme aux pathologies anxieuses chroniques, en réévaluant régulièrement l'indication, de prescrire le moins longtemps possible et à la dose la plus faible possible dans tous les autres cas, en faisant varier la posologie selon l'évolution de l'intensité des symptômes.

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.

Delirium and Dementia

Approximately 35% to 37% of older emergency department (ED) patients will have delirium or dementia, which can negatively affect safe and appropriate clinical care. This article describes the epidemiology of delirium and dementia in the ED and how it affects clinical care and patient outcomes. Screening for delirium and dementia in the context of the busy ED environment, as well as their diagnostic evaluation and management, is discussed.

Benzodiazepines consumption: does dependence vary with age?

We have compared two groups of chronic benzodiazepines (or zolpidem/zopiclone) users: "Seniors," aged 65 years or more, and "Adults," aged less than 65 years. The study took place in the Pays de Loire region. The questionnaire assesses dependence based on items from the DSM-IV. The analysis was based on 176 Senior questionnaires and 212 Adult questionnaires. Whereas Senior patients take benzodiazepines routinely with little negative consequences, Adults suffer from underlying psychological trouble, mention a higher consumption than planned, which causes negative consequences. 35.2% of Seniors are dependent on benzodiazepines versus 49.8% of Adults.

Altered mental status in older patients in the emergency department

Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.

Epidemiology and risk factors for delirium across hospital settings

Delirium is one of the most common causes of acute end-organ dysfunction across hospital settings, occurring in as high as 80% of critically ill patients that require intensive care unit (ICU) care. The implications of this acute form of brain injury are profound. Across many hospital settings (emergency department, general medical ward, postoperative and ICU), a patient who experiences delirium is more likely to experience increased short- and long-term mortality, decreases in long-term cognitive function, increases in hospital length of stay and increased complications of hospital care. With the development of reliable setting-specific delirium-screening instruments, researchers have been able to highlight the predisposing and potentially modifiable risk factors that place patients at highest risk. Among the large number of risk factors discovered, administration of potent sedative medications, most notably benzodiazepines, is most consistently and strongly associated with an increased burden of delirium. Alternatively, in both the hospital and ICU, delirium can be prevented with the application of protocols that include early mobility/exercise. Future studies must work to understand the epidemiology across settings and focus upon modifiable risk factors that can be integrated into existing delirium prevention and treatment protocols.

Factors associated with benzodiazepine dependence among community-dwelling seniors

BACKGROUND

Benzodiazepine (BZD) dependence among seniors is an understudied problem.

OBJECTIVE

Identify the factors associated with BZD dependence.

METHOD

Face-to-face computer-assisted interviews were conducted in the homes of 2,785 persons aged 65 years or older, randomly selected.

RESULTS

Nine-and-a-half percent of BZD users met DSM-IV-TR criteria for BZD dependence. Factors associated with BZD dependence are being a woman, and having cognitive impairment, panic disorders, suicidal ideations, and a degree of embarrassment in obtaining help for emotional problem.

DISCUSSION

Nurses should be better positioned to identify those elderly users of BZDs who are more likely to be dependent and to address the problem through BZD withdrawal program.

The prevalence and clinical course of sedative-hypnotic abuse and dependence in a large cohort

Relatively little is known about the prevalence and clinical characteristics of dependence on sedative-hypnotics, and almost nothing has been published regarding abuse. This report relates information on Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IIIR) sedative-hypnotic use disorders among subjects from the Collaborative Study on the Genetics of Alcoholism (COGA). A standardized interview was used to generate data on 407 men and women in Group 1 with sedative-hypnotic dependence (4.4% of the COGA sample), 34 in Group 2 with abuse (0.4%), and 3,426 comparison subjects in Group 3 with alcohol dependence in the absence of a sedative-hypnotic use disorder (36.7%). The remaining COGA subjects (48.5%) were not included as they had neither alcohol nor sedative-hypnotic dependence or abuse. Those with sedative-hypnotic abuse or dependence were more likely to be Caucasian individuals with abuse or dependence on marijuana, cocaine, amphetamines, or opioids. Subjects in Groups 1 and 2 were also more likely to have histories of independent major depressive and panic disorders, as well as substance-induced mood disorders. Those with dependence, compared to abuse, were likely to be women, reported staying intoxicated for a day or more, but noted less abuse of opioids or amphetamines, although Group 2 members also had high rates of difficulties with sedative-hypnotics. These results highlight notable rates of sedative-hypnotic dependence in the COGA families, and indicate that while sedative-hypnotic abuse does occur, and while the clinical course can involve relatively serious problems, it is less common than dependence.

Anxiolytic and hypnotic use in 376 psychiatric inpatients. GERMED Neuropsychotropics Group

This objectives of this study were three-fold: retrospectively evaluate anxiolytic/hypnotic consumption by psychiatric inpatients, identify the risk factors of prolonged intakes, and prospectively measure the impact of hospitalisation on the use of those drugs. Three hundred and seventy-six patients hospitalised in 11 psychiatric departments in the Paris region were studied using a structured interview for the anxiolytic/hypnotic treatments, DSM-III-R criteria, GHQ-12, HAD, Spiegel's questionnaire, COVI's anxiety scale and the CGI. Eighty-five per cent of the patients had taken one anxiolytic/hypnotic or more in the 3 months preceding hospitalisation. Hospitalisation induced little change in anxiolytic/hypnotic use: dosage frequency increased from 77% to 84% between the week preceding hospitalisation and that preceding discharge; 26% of consumers were taking at least two anxiolytics or two hypnotics in the first period vs. 23% in the second. The absence of withdrawal during hospitalisation was related to the high age and a diagnosis of depression rather than schizophrenia, to the existence of continuous intake over the 3 months preceding hospitalisation and to higher drug doses during the 7 days preceding hospitalisation. Prescription of treatment at the end of hospitalisation in previously non-user subjects was related to a higher HAD anxiety score at discharge.

High prevalence of benzodiazepine dependence in out-patient users, based on the DSM-III-R and ICD-10 criteria

Despite the fact that there have been many reports on benzodiazepine (BZD) dependence, consensus about its definition has not been reached. Reliable prevalence data to estimate the dependence liability of BZDs are therefore lacking. This study is the first to assess the prevalence of BZD dependence in out-patient BZD users (115-general practice (GP) patients, 124 psychiatric out-patients and 33 self-help patients) on the basis of the DSM-III-R and ICD-10 substance dependence criteria. Past year and lifetime diagnoses of BZD dependence were made by means of the Schedules for Clinical Assessments in Neuropsychiatry (SCAN). High prevalence figures were found, ranging from 40% in the GP patients (DSM-III-R past year) to 97% in the self-help patients (ICD-10 lifetime), indicating that BZD users run a high risk of developing BZD dependence. The clinical management of BZD use could benefit from further development of diagnostic instruments such as a self-report questionnaire which reflects the severity of BZD dependence.

Management of the prescription-drug-dependent adult: case of meprobamate abuse and its treatment

Misuse of prescription drugs in the elderly can be a serious problem that is difficult to manage. Prescriptions for non-narcotic central nervous system (CNS) depressants (e.g., anxiolytics and sedative-hypnotics) are commonly written, and their use is associated with severe intoxication and withdrawal effects. The presence of comorbid psychiatric conditions (e.g., depression or panic disorder), for which these agents are prescribed frequently, complicates the clinical picture. This paper, using case examples of meprobamate abuse, describes how physicians can recognize, manage, and treat a patient who is abusing a non-narcotic CNS depressant.

Multiple drug use and psychiatric comorbidity in patients admitted to the hospital with severe benzodiazepine dependence

This study aimed to evaluate the concurrent and lifetime psychiatric comorbidity and drug use patterns in patients admitted to the hospital for detoxification from benzodiazepines. Psychiatric assessments using the Structured Clinical Interview for DSM-III-R with a psychosis screening module (SCID-P and II) were conducted in 30 inpatients admitted to the medical unit treatment unit of the Clinical Research and Treatment Institute of the Addiction Research Foundation for the treatment of severe benzodiazepine dependence. Patients (mean age, 36 years; range, 22-58; number of DSM-III-R criteria met for benzodiazepine substance dependence, > or = 7 out of 9 [73%], all 9 criteria [40%]) used benzodiazepines and other drugs over prolonged periods of time at high doses, and their daily functioning was substantially impaired (Mean Global Assessment of Functioning Score, 48; range, 31-60). The most common lifetime psychiatric diagnoses were major depression (33%), other psychoactive drug dependence (100%) (opioids, 77%; alcohol, 53%), and panic disorder (30%). Current psychiatric diagnoses in addition to benzodiazepine dependence included other psychoactive substance use disorders (83%) (opioids, 67%; cocaine, 13%; multiple concurrent substance use, 17%), panic disorder (13%), and generalized anxiety disorder, (20%). Personality disorders included antisocial (42%), avoidant (25%), and borderline (17%). These findings demonstrate that in patients severely dependent on benzodiazepines, additional psychoactive substance use and mental disorders are prominent. The pattern of drug use and psychiatric comorbidity differentiates these patients from therapeutic-dose benzodiazepine users.

Types of benzodiazepines abused by chemically dependent inpatients

Records of inpatients (N = 1,483) over a three-year period at an addiction treatment center were evaluated for the presence of benzodiazepine (BZ) dependence (N = 136). The preferred BZ for 43% of the subjects was diazepam, and alprazolam for 14% of subjects. Chlordiazepoxide, lorazepam, and clorazepate were each the preferred BZ for 4% of patients. Cocaine and opioid abusers were six times more likely to abuse diazepam than any other BZ. Alprazolam patients required a significantly longer period of detoxification than diazepam patients. Four percent of BZ-dependent patients (N = 6) abused BZs only and had no other substance abuse history.

Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers

A sample of 171 benzodiazepine (bzd) users was investigated in the pharmacy where the patients filled in their prescriptions. Of the sample, 29.8% were males and 70.2% were females. About 60% of the patients had their current prescription from a general practitioner, the rest from different specialists. 70.8% stated to take bzds on more than 3 days of the week. The mean duration of intake of the entire sample was 4.5 years. The most frequent reasons for bzd intake were sleep disturbance followed by nervousness and somatic diseases. A total of 74.9% of the patients turned out to be well informed about the potential dependence hazards of bzd long term intake, but less than half of them had been informed by the prescribing physician. In a second step it could be demonstrated by means of multiple stepwise logistic regression analysis that certain characteristic parameters differentiate long-term users and persons with signs of potential abuse and dependence from other bzd users.

But what if a patient gets hooked? Fallacies about long-term use of benzodiazepines

Is a person who needs a certain drug to function normally and has a relapse of symptoms when it is withdrawn addicted? Dr Talley says no. Patients with a chronic anxiety disorder depend on benzodiazepines to enable them to live among the stresses of the real world, much like ulcer patients need ongoing drug therapy to subdue their problem. The fact that symptoms recur on withdrawal of the drug proves the continuing efficacy of the drug in controlling symptoms. Dr Talley gives advice on prescribing benzodiazepines for the long term that will help physicians and patients to avoid trouble.

Appropriately treating insomnia with triazolam

Insomnia is a problem that extends beyond the nighttime. People who experience sleep disturbances complain that they stay awake for a long time before they fall asleep. They may wake up several times during the night and cannot return to sleep and/or they wake up early in the morning. As a result, they feel sleepy during the day and are less alert. Various forms of insomnia are described that require--as much as possible--an individualized treatment approach. Besides sleeping hygiene, benzodiazepines certainly occupy a place in the treatment of insomnia. Triazolam, a triazolobenzodiazepine, closely approaches the characteristics of an ideal hypnotic: pharmacological activity at the level of the receptors, moderate absorption, short-acting, and rapid elimination. It is effective and safe if prescribed correctly and at the appropriate dosage.

Does routine screening for benzodiazepines help to diagnose dependence in psychiatric inpatients?

After admission, 899 inpatients of a psychiatric university hospital were routinely screened for benzodiazepines (BDZ) in the urine. BDZ were detected in 134 (15%) patients with various primary diagnoses. Criteria for BDZ abuse or dependence were found in 36 patients. In 35 cases, either intake of BDZ had not been reported in the first psychiatric interview, or such a report had not been documented in the patient's charts. None of these 35 patients was found to have BDZ abuse or dependence. Psychiatric inpatients with BDZ abuse or dependence seem to report their intake of BDZ. These findings suggest that a routine screening for BDZ can hardly help to diagnose dependence within a university hospital setting. Nevertheless, an objective test for intake of BDZ may be useful in special cases.

Prevalence of benzodiazepine abuse and dependence in psychiatric in-patients with different nosology. An assessment of hospital-based drug surveillance data

Frequencies of abuse and dependence assessed continuously within a drug surveillance system were analysed as a contribution to risk-benefit evaluations of benzodiazepines (BZDs). In 4.7% of 15,296 patients admitted to psychiatric hospitals between 1980 and 1985, BZDs had been involved in some kind of abuse or dependence. Primary BZD dependence, defined as physical dependence on BZDs in patients who had not been dependent before, was observed in about 1% of admitted patients. Linking these data with psychiatric diagnoses revealed a high risk of primary BZD dependence for in-patients (11.8%) with anxiety neurosis (ICD-9, 300.0), and a lower risk for neurotic (300.4) and for endogenous depressives (296.1) (risk 3.7% and 2.7% respectively). Older age was also related to primary BZD dependence. For depressive in-patients, the risk was twice as high in females as in males. Anecdotal observations advocate more systematic investigation of the emotional effects of long-term therapy with BZDs.

Female alcoholics. I. Alcohol dependence and problems associated with prescribed psychotropic drug use

A case note study of 518 alcohol-dependent (DSM-III) inpatients examined their reported past history of prescribed psychotropic drug use patterns between 1973-1985. The subjects were cross-matched for gender, age and admission date and stratified into 3 time periods. The characteristics of psychotropic medication recipients were compared with those patients who reported no use of licit medications. Statistical analysis by logistic regression indicated that there was a significant relationship between the past use of psychotropic drugs with a parental history of excessive alcohol intake, the higher levels of MAST scores and the occurrence of past parasuicide events. Patients in their middle years (35-54) tended to have received significantly less psychotropic drugs than the younger or older age groups. The female (70%) to male (48%) ratio of past psychotropic use was 1.4:1. Gender differences were also noted in the use of antidepressants and illicit substances.

Benzodiazepine use in a rural general practice population

This study investigates the prevalence and pattern of benzodiazepine use in an isolated Australian rural general practice setting. Some clinical features of psychological dependence were also examined. Data were obtained from 771 patients attending each of two general practices over a five-day period. The results indicated that 11.3% of the sample had used a benzodiazepine in the preceding four weeks and that 82% of these had been regular users for over six months. Prevalence increased with age and 36.5% of patients over the age of 70 were using benzodiazepines. Features suggesting some degree of psychological dependence were found in over 50% of users. The findings illustrate the extensive and prolonged use of benzodiazepines and raise questions about overuse and dependence, particularly in the elderly.

Benzodiazepine withdrawal: overview and implications for the treatment of anxiety

The authors critically review 20 reports (studies and large case series) detailing the nature, severity, and variability of benzodiazepine withdrawal syndromes. Factors affecting the frequency and intensity of withdrawal are identified, and methodologic problems limiting the generalizability of certain findings are pointed out. Treatment approaches for minimizing withdrawal are reviewed, and implications for the problem of long-term benzodiazepine use and dependence are discussed.

Benzodiazepine dependence

Benzodiazepines (BDPs) are widely used drugs that are effective in controlling the symptoms of anxiety. Tolerance develops rapidly to some of the effects but not to anxiolytic effect in most patients. Dependence occurs at usual therapeutic doses and in a small proportion of patients is accompanied by an enormous increase in the dose taken. The majority of subjects using very high doses are dependent on other substances concurrently. On discontinuing BDPs patients may suffer from relapse of the original condition, rebound in the severity of the symptoms of the original condition or the onset of new symptoms in an abstinence syndrome. If BDPs are discontinued abruptly there may be severe consequences such as seizures. With tapering of the dose, even if this is rapid and from high dose, high potency BDP, the subject will probably experience considerable discomfort but rarely life-threatening effects. Whilst there is concern that BDPs are used too freely, the conditions treated are accompanied by significant morbidity and mortality. The prevalence of pure BDP dependence is low and it is still a matter of debate as to how often BDPs should be prescribed, for which conditions and for what length of time.