Bzd 2012[1]

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Bzd 2012[1]

  1. 1. Originally Presented by Dr. Marissa Capette Dr Jeku Jacob and CNC Lisa-Jayne Ferguson Drug & Alcohol Service St Vincent’s Hospital Benzodiazepines Effects, Withdrawal & Treatment Options
  2. 2. BZD’s - Introduction  The most widely used of all psychotropic drugs  Treatment of  Anxiety states  Muscle spasm/ tension  Seizures  Insomnia  Safer than barbiturates (less chance of OD)  However dependence can develop (3 weeks) – tolerance and withdrawal
  3. 3. BZD’S ARE USED BY 2 MAIN GROUPS  Elderly & women (low dose)  Young, polysubstance users (high dose)
  4. 4. WHY PEOPLE USE BZD? Enhance & prolong the 'high‘ of other drugs Alleviate withdrawal effects Users of stimulants take benzodiazepines as 'downers' The mixture of alcohol and benzodiazepines produces a hedonic effect
  5. 5. BZD Intoxication  Decreased anxiety  Sleepiness  Sedation  Anti-convulsant effects  Blurred vision  Poor memory recall  Dizziness/vertigo  Confusion  Slurred speech  Ataxia, poor motor co- ordination  Stupor  Paradoxical violence and disinhibited behaviour
  6. 6. BZD INTOXICATION  Dose dependant  Sedation Stupor Respiratory depression  Death can result if taken with other drugs
  7. 7. Health & social hazards of BZD misuse General Complications of IV use Fatalities due to overdose (particularly in combination with opioids) Thrombophlebitis Blackouts and memory loss Deep and superficial abscesses Paranoia Deep vein thrombosis Violence and criminal behaviour Pulmonary microembolism Risk-taking sexual behaviour Rhabdomyolysis, tissue necrosis Foetal and neonatal risks if taken in pregnancy Gangrene, requiring amputation (usually due to inadvertent intra-arterial injection) Dependence Hepatitis B and C Withdrawal seizures HIV infection
  8. 8. Comparison Table Trade names Time to peak Half life Diazepam Valium, Ducene, Antenex 30-90 mins 20-48 hrs Temazepam Temaze, Normison 30-60 mins 5-15hrs Oxazepam Serepax, Murelax 2-3 hrs 4-15 hrs Alprazolam Xanax, Kalma 1 hr 6-25 hrs Lorazepam Ativan 2 hrs 12-16 hrs Clonazepam Ritrovivl, Paxam 2-3 hrs 22-54 hrs
  9. 9. Benzodiazepine Equivalence 5 mg Diazepam equal to – – Alprazolam 0.5-1 mg – Temazepam 10-20 mg – Clonazepam 0.5 mg – Oxazepam 15 mg – Lorazepam 1 mg
  10. 10. Adapted from Frank L, Pead J. New concepts in drug withdrawal: a resource handbook © 1995 State of Victoria. Withdrawal Profile
  11. 11. Withdrawal Symptoms  Rebound anxiety (particularly with short acting)  Insomnia  Poor concentration and memory  Muscle aches, stiffness and spasms  Tremor, sweats  Racing thoughts, agitation  Confusion  Depression  Increased sensory perception → hallucinations  Delirium  Seizures
  12. 12. Signs of Withdrawal  Withdrawals featuring a delirium can mimic amphetamine intoxication or psychotic episode 2nd to underlying Mental Health issues  Pupils dilated and fine tremor may indicate Benzodiazepine withdrawal
  13. 13. Assessment Duration Amount Street or GP (phone) Regularity of use, binge etc... Does the pt wish to change intake?
  14. 14. In-Pt Withdrawal Treatment  Convert short acting regular BZD dose to long acting BZD (Diazepam)  Patient stabilised at a dose of 40% of their regular intake (or 80 mg/day whichever is lower) in 3 - 4 divided doses  Day 5 onwards – Reduce by 10% every 2-4/7’s, depending on pt’s response
  15. 15. Community Withdrawal Treatment  Reduce by 10 mg / week until 40 mg  Then by 5mg / week  This will take about 12 weeks  Supportive GP  Pick up from pharmacy  Pt can sign Dr Shopping form
  16. 16. Withdrawal Symptoms Withdrawal symptoms do not decrease steadily from a peak, but follow a fluctuating course with good & bad periods Eventually the good periods will last longer & become more frequent Abrupt or over-rapid withdrawal, especially from high dosage, can give rise to severe symptoms (convulsions, psychotic reactions, acute anxiety states) New South Wales Drug and Alcohol Withdrawal Clinical Practice Guidelines (2007)
  17. 17. Treatment Options  Detox / Rehabilitation (Limited facilities)  Self Management & Recovery Training (SMART)  Narcotics Anonymous/ 12 Step programme  Individual Counselling  Alcohol & Drug Information Service - 93618000 or local area A&D service
  18. 18. Benzodiazepine Overdose: Treatment  Monitor vitals & O2 sats  Charcoal/Osmotic Purgative if recent ingestion  Flumazenil – Benzodiazepine antagonist (0.2 mg/min IV initially, repeat up to 3 mg maximum)  Caution in patients where Benzodiazepine dependence is suspected: risk of Benzodiazepine withdrawal seizure
  19. 19. Case Study  58 year old female admitted to hospital after chest pain  On day 4, patient suffered two grand mal seizures.  Pt known to be alcohol dependant  Pt suspected of abusing benzodiazepenes  Refused to admit to more than 10 mg/ night.

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