Benzodiazepines

1. Benzodiazepines The truth shall set you free

3. Benzodiazepines • The first benzodiazepines were marketed in 1960 • Benzodiazepines are the most widely prescribed psychoactive drugs in the world and are frequently used to treat anxiety disorders, insomnia, seizure disorders, skeletal muscle spasticity, alcohol withdrawal, and as premedicants prior to surgical or diagnostic procedures. • Some are short-acting, which is used for sleep and panic, and some are long-acting, which is used for anxiety. • Considered Sedative-, Hypnotic-, or Anxiolytic.

4. Neurochemical impacts of benzodiazepines

5. Benzodiazepines • These drugs work by selectively affecting neurons that have receptors for the neurotransmitter gamma aminiobutyricacid (GABA) • When Benzodiazepines are introduced, the inhibiting effects of GABA are magnified • As a result, individuals who take these drugs experience altered mood, relaxed muscles and drowsiness

6. Women and benzodiazepines

7. Women and Benzodiazepines • Women are prescribed benzodiazepines more often than men and for a longer duration • Women are more likely to have been diagnosed with an anxiety disorder compared to men. Benzodiazepines are often the prescribed medical treatment • Women are also more likely than men to be prescribed benzodiazepines and sleeping pills for non-medical reasons such as coping with grief or stress. They are also prescribed these drugs to adjust to natural processes such as childbirth and menopause • Physical ailments experienced by high stress levels can be temporarily relieved by benzodiazepines

8. Benzodiazepine use in Pregnancy and Fetal Outcomes

9. Benzodiazepine use in Pregnancy and Fetal Outcomes • Some benzodiazepines have been associated with birth defects if used in the first trimester. • Babies exposed in utero should be watched carefully after birth for signs of abrupt discontinuation syndrome. • If benzodiazepines are used regularly close to the delivery date, the baby may be born drowsy or may have withdrawal symptoms. • Benzodiazepines may cause drowsiness in the babies of breastfeeding women • There have been no reports of long-term adverse effects on the intelligence quotient or neurodevelopment of children born to mothers who took benzodiazepines during pregnancy.

10. dependence • Dependence is based on both the dosage and time course. The quicker acting the benzodiazepine, the higher the dependence liability. The quicker it crosses the blood brain barrier, the increased dependence • Psychological Dependence comes with those that have a rapid onset of effects (Xanax, Ativan) • Physical Dependence is more likely with drugs that have a short duration of action.

11. Therapeutic dependence • have taking benzodiazepines in prescribed "therapeutic" (usually low) doses for months or years. • have gradually become to "need" benzodiazepines to carry out normal, day-to-day activities. • have continued to take benzodiazepines although the original indication for prescription has disappeared. • have difficulty in stopping the drug, or reducing dosage, because of withdrawal symptoms. • On short-acting benzodiazepines they develop anxiety symptoms between doses, or get craving for the next dose. • Contact their doctor regularly to obtain repeat prescriptions. • Become anxious if the next prescription is not readily available; they may carry their tablets around with them and may take an extra dose before an anticipated stressful event • May have increased the dosage since the original prescription. • May have anxiety symptoms, panics, agoraphobia, insomnia, depression and increasing physical symptoms despite continuing to take benzodiazepines.

12. Prescribed high dose dependence • Some patients who start on prescribed benzodiazepines begin to "require" larger and larger doses. • May persuade their doctors to escalate the size of prescriptions, and may contact several doctors or hospital departments to obtain further supplies • This group combines benzodiazepine misuse with excessive alcohol consumption. 30-90% of poly drug abusers also use benzos • Patients in this group tend to be highly anxious, depressed and may have personality difficulties. • They may have a history of other sedative or alcohol misuse. They do not typically use illicit drugs but may obtain "street" benzodiazepines if other sources fail. • Are used to increase the "kick" obtained from illicit drugs, (opiates,) and to alleviate the withdrawal symptoms of other drugs of abuse (opiates, barbiturates, cocaine, amphetamines and alcohol). People who have been given benzodiazepines during alcohol detoxification sometimes become dependent on benzodiazepines and may abuse illicitly obtained benzodiazepines as well as relapsing into alcohol use • Occasionally high doses of benzodiazepines are used alone to obtain a "high". Recreational use of diazepam, alprazolam, lorazepam, temazepam, triazolam, flunitrazepam and others has been reported. • The drugs are taken orally, often in doses much greater than those used therapeutically (e.g.100mg diazepam or equivalent daily) but some users inject benzodiazepines intravenously • These high dose users develop a high degree of tolerance to benzodiazepines and, although they may use the drugs intermittently, some become dependent. • Detoxification of these patients may present difficulties since withdrawal reactions can be severe and include convulsions.

13. Risk factors • Benzodiazepines are licit drugs and are generally prescribed to patients by a doctor. They are the most widely prescribed psychoactive drug in the world (CAMH website). • The main factor that would influence someone to use benzodiazepines is if they were experiencing anxiety and stress, or trouble sleeping, that could not be treated through other means (various exercises, talk therapy etc...). • Benzodiazepines are generally not addictive as long as they are taken for short periods of time, and are taken on low doses • Individuals that have abused other drugs are more susceptible to abusing benzodiazepines.

14. Risk factors in women • Risk factors for women specifically: • Illicit drug use more common among men while licit and prescribed drug use more common among women; benzo's are licit! (Counselling women, lecture 1) • Women who are survivors of violence/trauma are at higher risk of substance abuse (counselling women, lecture 1) • The stigma is greater for women abusing substances compared to men (counselling women, lecture 1), this could lead to women choosing substances that are more socially acceptable (licit), or substances that are more subtle • Studies have shown that elderly women are at the highest risk for abusing low-dosage benzo's for long periods of time. • Benzo'shave been linked to weight loss • Alcohol abuse can lead to benzo abuse. Alcohol abuse builds up a tolerance for benzo's, and thus requires more benzo's to do theirjob. This could lead to benzo addiction

15. Why choose benzos over other drugs • Benzo's are chosen over other drugs, because they are generally prescribed by doctors, and because they are the most widely prescribed psychoactive drug in the world • Benzo'sare also chosen over other drugs becomes they are easily addictive when they are abused (taken for too long, or take the wrong dose). • Individuals that take benzo'sshould stay away from other drugs. Depressants will intensify the feelings of the benzo's and stimulants will counteract the effects of the benzo's, and often bring about symptoms that the individual is trying to get rid of (anxiety etc..).

16. Some Facts about Benzo Withdrawal • The Committee on the Review of medicines (1980) found little benefit of using a benzodiazepine after 4 months of continuous use. It was suggested that it was merely preventing withdrawal symptoms from occurring. After which time the patient could experience the withdrawal effects even though they are still taking the medication, referred to as the ‘problem phase’ or tolerance withdrawal. (withdrawal symptoms such as sleep disturbance, anxiety with panic disorders time for next dose and agoraphobia • Once you start the withdrawal process, the symptoms mirror the reason you had started the benzodiazepines in the first place and often you return to using to feel “normal” (often a higher dose). These withdrawal symptoms is the body trying to detoxify from the drugs and the symptoms are referred to as “discontinuation syndrome”. Withdrawal symptoms can resemble psychiatric symptoms which doctors interpret for the need of benzodiazepines which leads to withdrawal failure and reinstatement of benzodiazepines (often higher doses). • Never come off a psychiatric drug cold turkey, as long term use chemically alters the pathology of your brain chemistry. Immediate withdrawal will cause the brain to rectify the situation and have serious withdrawal affects. Can cause anxiety, irritability, insomnia and sensory disturbances. Some people can be severe and resemble psychiatric and medical conditions such as schizophrenia or seizure disorders. More serious side effects include suicide • Benzowithdrawal is similar to alcohol withdrawal syndrome and severe cases can cause seizures. Severe and life threatening symptoms stem from abrupt or over rapid dosage reduction from high doses • Generally the higher the dose and the longer the use and the more rapidly discontinued, the more likely severe symptoms can occur.

17. Withdrawal • Perceptual distortions Paresthesia • Difficulty walking Feelings of unreality • Visual disturbances Depression • Paranoid thoughts and feelings of persecution Anxiety • Gastrointestinal symptoms Tension • Increased sensitivity to light, noise, taste and smell Agitation • Sleep disturbance Dysphoria • Impaired perception of movement Muscle pain • Headache Confused states • Psychosis Suicide • * insomnia was the most commonly experienced withdrawal symptom (57.5%)

18. Withdrawal the ashton manual • The Ashton Manual is a guide written by Heather Ashton whose clinical expertise is in psychopharmacology and psychiatry and she ran a clinic for 12 years. She believes that with “ sufficient motivation and the proper approach almost all patients can successfully withdraw from benzodiazepines”. • Withdrawal from low dose dependence takes 6-12 months, and the client can fluctuate from good days and bad days so need at least 6 months before any re- evaluation. • Withdrawal from reducing dose from long half life benzos can be delayed by 3 weeks, where short acting benzo withdrawal occurs within 24-48 hrs. • Severity and length of withdrawal syndrome is likely determined by various factors, rate of tapering, length of use of benzos, dose size and genetic factors • Long term use of benzos can cause cognitive, neurological, and intellectual impairment (after 1 year of abstinence had returned to normal) • The success rate of a slow withdrawal schedule is approximately 65%, however, some studies have found higher success rates of between 88 - 100 percent.

19. Withdrawal using the ashton manual • Before starting benzodiazepine withdrawalConsult your doctor and pharmacistMake sure you have adequate psychological supportGet into the right frame of mindBe confidentBe patientChoose your own wayThe withdrawalDosage taperingSwitching to a long-acting benzodiazepineDesigning and following the withdrawal scheduleWithdrawal in older people

20. Interesting facts • the first benzo to hit the market was Valium in 1960. They replaced barbituates, and were considered much safer. Benzodiazepines are also used to treat seizures • About 2 per cent of the adult population of the US (around 4 million people) appear to have used prescribed benzodiazepine hypnotics or tranquillisers regularly for 5 to 10 years or more. • Rebound insomnia and anxiety can occur after 7 days use • After 7 nights use, withdrawal related to insomnia rebounds worse than the baseline • Rebound daytime anxiety and tension can occur after 7 days of short acting benzohypnotics • Intermittent use of benzos can cause insomnia • 10 nights of triazolam can cause anxiety, distress, weight loss, panics, depression, derealisation (alteration of perception so the world seems strange or unreal), and develop paranoia • Benzos and alcohol can cause serious complications during withdrawal and are more hazardous than withdrawing from opiates.