Benzodiazepines are psychotropic drugs – drugs that affect the mind and are mood altering. They are a central nervous system depressant and slow the whole system down. They enhance the effect of the brain’s naturally occurring ‘calming’ neurotransmitter (chemical messenger). GABA or gamma amino butyric acid. They are commonly known as ‘minor’ tranquillisers and are prescribed mainly for anxiety and sleeping problems. The term minor tranquilliser is to differentiation from ‘major’ tranquillisers example such as drugs used for schizophrenia. If you have had a pre med you probably had benzodiazepine, it’s the relaxant most commonly used prior to Anaesthetic If you have an epidural they often give you an benzodiazepine (operations) Benzo’s are used in a very few cases for people who have epilepsy who are unable to tolerate epilepsy medication.
All benzo’s are tranquillisers the names are based on what the pharmaceutical companies have called them. Short acting benzos are used for sleeping pills, longer acting for anxiety. The most common ones are Temazepam , Xanax and Valium They are effective drugs; when used correctly. HOWEVER Benzodiazepines do not treat the underlying cause of insomnia or treat anxiety. They relieve the symptoms Sleeping pills are only affective for 4 – 6 nights and tranquillisers are only affective for 2 – 3 months Although they help people sleep they affect the sleep architecture so people wake more often during the night, don’t have the really deep sleep and have less REM sleep (dreamtime) Half life = the benzo acts on the brain and then returns to the liver where active metabolites are again released into the bloodstream and go back to the brain. The drug is in the system but does not affect the person
Benzo’s suppress emotional processing They affect the frontol lobe of the brain – reducing inhibitions Depression is a side affect (?) During alcohol withdrawal benzo’s are administered to avoid seizures unfortunately huge proportion became addicted to benzo’s when they came alcohol
NATIONAL HEALTH & MEDICAL RESEARCH COUNCIL this is Australia’s peak body for health and medical research, health advice; and for ethics in health care and health and medical research. Care should be taken when prescribing because of; risk of tolerance, dependence and withdrawal syndromes When driving of operating machinery (impaired performance) When combined with other central nervous symptom sedatives including alcohol as common side effects can be addict In the elderly as they are more sensitive to the sedative effects and the duration of action may be prolonged Benzodiazepines can be addictive after 7 days but most don’t have withdrawal symptoms till after 4 weeks. In the early days it may mean insomnia for 2 nights (rebound insomnia)
On average people have been on benzo’s for over 6 years before they come to reconnexion Severity of withdrawal varies greatly. Can take 2 years to come off if on high doses for long time People experience breakthrough withdrawal and think this means their anxiety (or insomnia is getting worse) Body becomes tolerant = increased anxiety or insomnia There is no way of predicting who will become dependant 11% will have seizures if withdrawing from normal doses 70 – 80% will seizure if they are on high doses of benzo’s Benzodiazepines act by enhancing the effect of the neurotransmitter GABA and the brain responds by closing down the number of GABA receptors. When the benzodiazepines are removed there is not only the chemical reduction there are less receptors. Change in brain chemistry causes the withdrawal symptoms.
Frontal lobe = logic reasoning structure is impaired. Do things on benzo’s they normally wouldn’t do – like shoplifting disinhibiting
Diazepam is the standard against which these are compared Perception with Alprazolam Xanax that people are not on a high dose. A common dose is 4 mg of xanax which is 4 times the dosage of valium 3 tables = 12 tablets of valium (training programs for GPs they have been horrified to find that out!) It is easy to get repeats on xanax but not on valium so commonly xanax is the hardest to get off Xanax one of the newest benzodiazepines (but has been on the market for around 15 years) Seen as the new dawn of benzo’s not dependent etc Xanax is quick acting and then drops sharply off so people believe it’s very affective in panic attacks. But it still takes around 10 minutes to work and most panic attacks last around 10 minutes, stays in the system for a lot longer and of course withdrawal symptoms are anxiety!!!
Xanax peaks at 4- 5 days Long term use – cognitive memory will be affected. 4 – 5 days withdrawal will be okay Peaks about 18 days, do don’t attibute to their withdawal think its their symptoms coming back. 20% will have contracted withdrawal
There is significant improvement when they come off benzos
Skin sensitive, light sensitive Pins and needles Bloating Diarrhoea Suicide much higher than average Hallucinatory – visual – spiders etc can be misdiagnosed as psychosis. Don’t have normal coping strategies Disassociation, depersonalisation significant affect amongst 50% of people Rekindles the thing that they have suppressed – Maori women who baby died – cot death, after 17 years on withdrawing all the emotions of grief came back plus guilt because she has never been totally ‘there’ for her other children.
Older people = over 65 Benzo’s copy so benzo’s bind better with the receptors- homeostatis Shuts down some of the receptors, messages isn’t getting through even though receptors are full After 6 mths or so Benzo’s reduce or stop production of GABA Benzo’s and cannabis are only 3 – 9 moth affect nervous system our natural balance our calming chemical Gabba on chemical Balancing No difference only marketing Xanax and temazepam most alike
Falls risk increased by 4 = death Makes job harder 3 xanax cut out a quarter – standard practice to transfer to longer acting like valium 10 mg=2 mr tabs does equivalent far to high – feel different on valium Shouldn’t be used with drug withdrawal increases risk of suicide. At detox no benzo’s unless alcohol Middle aged women greatest suicide rate - middle of the day released without follow up 8,500 in Melbourne alone in 2007 No cold turkey – very dangerous 10% reduction per week or fortnight fastest reaction 5% reduction every 2 weeks.
2. What are benzodiazepines? <ul><li>Minor tranquillisers and sleeping pills </li></ul><ul><li>Properties: </li></ul><ul><li>Relieve anxiety </li></ul><ul><li>Sedative </li></ul><ul><li>Anti-convulsant </li></ul><ul><li>Muscle relaxant </li></ul>
3. List of benzodiazepines Normison, Temaze, Euhypnos, Temtabs, Nocturne Temazepam 5-10 Serepax, Murelax, Alepam Oxazepam 6-10 Mogadon, Alodorm Nitrazepam 15-38 Rohypnol, Hypnodorm Flunitrazepam 25-30 Valium, Antenax, Ducene Diazepam 20-48 Rivotril, Paxam Clonazepam 22-54 Xanax, Kalma Alprazolam 10-14 Brand names Generic name Half life (hrs)
4. Indications for valid prescribing of benzodiazepines <ul><li>Anxiety disorders </li></ul><ul><li>Sleep </li></ul><ul><li>Muscle Relaxant </li></ul><ul><li>Medical procedures </li></ul><ul><li>Alcohol withdrawal </li></ul><ul><li>They are not validly prescribed for: </li></ul><ul><li>Grief, anger, depression, drug withdrawal. </li></ul>
5. RACGP Guidelines <ul><li>Should be prescribed for the shortest possible time, lowest possible dose </li></ul><ul><li>Ideally no more than 7 days </li></ul><ul><li>Maximum 2-4 weeks </li></ul><ul><li>“limited to patients whose symptoms are disabling or who are subjected to unacceptable distress” </li></ul><ul><li>Only when other treatments have failed </li></ul>
6. Benzodiazepine Dependency <ul><li>Estimated 50-80% of people using benzodiazepines continuously to 6-12 months will become dependent. </li></ul><ul><li>Those who become dependent will experience withdrawal, although severity will vary. </li></ul><ul><li>For long term users, withdrawal symptoms may be present while on the regular dose (“Breakthrough withdrawal”) </li></ul>
7. Benzodiazepine binding sites <ul><li>Most commonly found in areas of the brain controlling our consciousness, coordination, emotions, memory, muscle tone and thinking. </li></ul>
8. Benzodiazepines are prescribed for; <ul><li>Most often women </li></ul><ul><li>Older people </li></ul><ul><li>Migrant population </li></ul>
9. Benzodiazepine withdrawal <ul><li>Wide range of distressing symptoms </li></ul><ul><li>Anxiety and insomnia are common withdrawal symptoms –often the presenting problem </li></ul><ul><li>Can be protracted – weeks or months </li></ul>
10. Benzodiazepine Withdrawal <ul><li>Onset: 2-3 days for short-acting </li></ul><ul><li>5-7 days for long-acting </li></ul><ul><li>Symptoms typically last 2-4 weeks, up to a few months </li></ul><ul><li>Symptoms can be more intense at the beginning and end of reduction </li></ul><ul><li>Symptoms typically fluctuate </li></ul><ul><li>Symptoms vary from mild to severe </li></ul>
11. Common withdrawal symptoms <ul><li>Anxiety & panic attacks </li></ul><ul><li>Insomnia </li></ul><ul><li>Heightened sensitivity of the senses </li></ul><ul><li>Muscle twitching and spasm </li></ul><ul><li>Pins and needles </li></ul><ul><li>Nausea </li></ul><ul><li>Dizziness </li></ul><ul><li>Depression </li></ul><ul><li>Loss of memory </li></ul><ul><li>Loss of appetite </li></ul><ul><li>Hallucinations </li></ul>
12. Specific Risks for Polydrug Users <ul><li>Greatly increased risk of overdose </li></ul><ul><li>Increased risk taking behaviour – sharing needles, sexual promiscuity, unsafe sex </li></ul><ul><li>Disinhibition – more aggressive, socially inappropriate, increased risk of sexual assault </li></ul><ul><li>Increased offending (with memory loss) </li></ul><ul><li>Specific harms from IV use of benzos </li></ul>
13. Overdose statistics (Victorian Institute of Forensic Medicine 2005) <ul><li>In all deaths involving heroin 2001-2005, benzodiazepines were found in 60% of cases ( Cf 31% alcohol, 20% heroin alone) </li></ul>
14. IV use of benzodiazepines <ul><li>Many of the benzodiazepines are an irritant, essentially burning the vein lining. </li></ul><ul><li>Veins narrow and block, reducing blood flow </li></ul><ul><li>May cause severe infection of skin and bone. </li></ul><ul><li>Particles in the tablets/capsules do not break down small enough to inject </li></ul><ul><li>If the vein is missed, tissue surrounding the injection site may become infected, causing swelling, infection, abscesses or ulcers. </li></ul><ul><li>Can cause blood clots in the lungs </li></ul>
15. Older people and medication <ul><li>Older people </li></ul><ul><li>37% sleeping tablets </li></ul><ul><li>15% antidepressants </li></ul><ul><li>Adult population </li></ul><ul><li>4% sleeping tablets </li></ul><ul><li>5% antidepressants </li></ul>
16. Effects of benzodiazepines for older people <ul><li>Over sedation </li></ul><ul><li>Falls and hip fractures </li></ul><ul><li>Impaired blood pressure regulation </li></ul><ul><li>Cognitive impairment & memory loss </li></ul><ul><li>Nocturnal urinary incontinence </li></ul><ul><li>Emotional changes- worsening depression </li></ul><ul><li>Worsening sleep </li></ul><ul><li>Respiratory problems </li></ul>