Additional Treatment Considerations - Disorders of Sedative–Hypnotics

Additional Treatment Considerations

Psychiatric Comorbidity

Most patients who are being prescribed long-term benzodiazepine therapy have underlying major depressive disorder, panic disorder or GAD. The clinical dilemma is deciding which patients are receiving appropriate maintenance therapy for a chronic psy-chiatric condition. Physical dependence on benzodiazepines may be acceptable if the patient’s disabling anxiety symptoms are ameliorated. The reason for the patient’s request for benzo-diazepine withdrawal from long-term, stable dosing should be carefully explored. Valid reasons to discontinue benzodiazepine treatment include: 1) breakthrough of symptoms that were previously well controlled; 2) impairment of memory or other neurocognitive functions; and 3) abuse of alcohol, cocaine, or other medications.

Patients with severe underlying psychiatric disorders may have unrealistic hopes of becoming medication-free. Often the origin of request for benzodiazepine withdrawal comes from concerned friends or relatives.

Abuse Potential of Benzodiazepines

Most people do not like the subjective effects of benzodiazepines, especially in high doses. Even among drug addicts, the benzodi-azepines alone are not common intoxicants. They are, however, widely used by drug addicts to self-medicate opiate withdrawal and to alleviate the side effects of cocaine and amphetamines. Patients receiving methadone maintenance use benzodiazepines to boost (enhance) the effects of methadone. Some alcoholic patients use benzodiazepines either in combination with alcohol or as a second-choice intoxicant, if alcohol is unavailable. Fat-soluble benzodiazepines that enter the CNS quickly are usually the benzodiazepines preferred by addicts.

Addicts whose urine is being monitored for benzodi-azepines prefer benzodiazepines with high milligram potency, such as alprazolam or clonazepam. These benzodiazepines are excreted in urine in such small amounts that they are of-ten not detected in drug screens, particularly with thin-layer chromatography.

Treatment of High-dose Benzodiazepine Dependence

For high-dose benzodiazepine dependence, the pharmacologi-cal treatment strategy is the same as that for barbiturates. The phenobarbital conversion equivalents are shown in Table 44.3. The dose conversions computed using Table 44.3 prevent the emergence of severe withdrawal of the classic sedative–hypnotic types. Some patients who take high doses of benzodiazepines, or even therapeutic doses for months to years, may have prolonged withdrawal symptoms.

Low-dose Benzodiazepine Withdrawal Syndromes

Many people who have taken benzodiazepines in therapeutic doses for months to years can abruptly discontinue the drug with-out developing withdrawal symptoms. But other patients, taking similar amounts of a benzodiazepine develop symptoms ranging from mild to severe when the benzodiapine is stopped or when the dosage is substantially reduced. Characteristically, patients toler-ate a gradual tapering of the benzodiazepine until they are at 10 to 20% of their peak dose. Further reductions in benzodiazepine dose then cause patients to become increasingly symptomatic. In addition medicine literature, the low-dose withdrawal may be called therapeutic-dose withdrawal, normal-dose withdrawal, or benzodiazepine discontinuation syndrome. The symptoms can ultimately be categorized as symptom reemergence, symptom rebound, or a prolonged withdrawal syndrome.

Many patients experience a transient increase in symptoms for 1 to 2 weeks after benzodiazepine withdrawal. The symptoms are an intensified return of the symptoms for which the benzodiazepine was prescribed. This transient form of symptoms intensification is called symptom rebound. The term comes from sleep research in which rebound insomnia is commonly observed after sedative–hypnotic use. Symptom rebound lasts a few days to weeks after discontinuation Symptom rebound is the most common withdrawal consequence of prolonged benzodiazepine use.

The symptoms for which the benzodiazepine has been taken may return to the same level as before benzodiazepine therapy. This is called symptom reemergence (or recrudescence). In other words, the patient’s symptoms, such as anxiety, insom-nia, or muscle tension, that had abated during benzodiazepine treatment return.

The reason for making a distinction between symptom re-bound and symptom reemergence is that symptom reemergence suggests that the original symptoms are still present and must be treated. Symptom rebound is a transient withdrawal syndrome that will disappear over time.

A few patients experience a severe, protracted withdrawal syndrome that includes symptoms (e.g., paresthesia and psycho-sis) that were not present before. This withdrawal syndrome has generated much of the concern about the long-term safety of the benzodiazepine