Abstract:Benzodiazepines (BZDs), have been found to be addictive and abused, thus medical professionals prescribing them should reduce orders or replace with alternative treatment plans for mental health problems. several studies to substantiate the safety risks associated with BZDs prescribed to those with anxiety, depression, family mental health disorders and substance abuse. Studies have found significance in BZDs abuse potential, prescriptions are continually handed out to those with reported substance abuse. Medical professionals need broader educational aspects, patient history and cross-pharmacy checks prior to prescribing BZDs, to reduce harm in patients and others resulting from BZDs abuse. This research has summarized the findings, with a current understanding about the safety of BZDs prescribed for patients with substance abuse and the need for change in methods currently used to prescribe them.
Reduction of harm will not occur without acute coordination of patient care. Due to the fatal risks of BZDs use with patients with substance abuse, alternative treatment methods are available and should be exhausted prior to consideration of prescribing BZDs. BZDs use is not safe in patients with substance abuse.
Since BZDs’ have been introduced in the treatment field for mental health disorders, controversy as to their safety to be prescribed to patients with substance abuse has been studied and debated. With any medication, risks and benefits must be weighed for treatment consideration.
Posternak and Mueller found much ambiguity over the definitions of BZDs abuse and dependence, to include those with a history of substance abuse being a major risk factor to abuse and dependency on BZDs (2001). This study is contradictory for support of BZDs treatment for those patients with reported substance abuse as found with Ciraulo and Nace, hence the abuse comes from the obtaining from non-medical sources, use in higher than prescribed amounts and use for poorly defined conditions (2000).
BZDs are prescribed without review of the patient’s medical, drug use/abuse and family history of which studies have found a correlation between mental health disorders and their potential of BZDs abuse increases risk of harm. Fløvig, Vaaler and Morken’s study methods found that the use of substances is usually by subjective reporting, thus inclusion of the frequency and quantity with which the substance is necessary (2009). For example, it is not uncommon to request the quantity and frequency of other chemical substances such as cigarettes and alcohol during a specified period. These answers are significant to potential BZDs abuse. . Patients abusing BZDs can be detoxed from them safely without suffering, thus discovering and obtaining alternative treatment for their symptoms of which they were initially prescribed. BZDs abuse slows the recovery process from other substance abuse addictions such as opiates of which is a continuing substance abuse risk.
This author found that the standard prescribed use to prevent dependency is 2 – 4 weeks; however BZDs are prescribed for longer periods. It is baffling as to the contradiction of studies that indicate the efficacy and use of BZDs in patients with psychological disorders are well tolerated, but lack potential harm with those with dual diagnosis to include substance abuse addiction. This author had not found substantiated reports to support continued BZDs use with patients with dual diagnosis that included substance addiction. Elliott, Glenday, Freeman, Ajeda, Johnston, Christie, et al, study from a census from Australia and the United Kingdom, found that BZDs included in polydrug abuse is a contributing factor in overdose among opiate users (2005). Why is it that some methadone treatment modalities will not treat persons prescribed BZDs and others allow it? Research studies need to continue to validate findings to the safety concerns with patients with dual diagnosis, hence chemical substance addiction and mental health disorder, such as anxiety, depression and insomnia. In addition, Ashworth, Gerada and Dallmeyer found that larger doses of methadone is associated with better treatment outcomes and that methadone should remain unchanged during BZDs detox (2002).
Consideration to potential addiction coordination of care is necessary to limit BZD use (Salzman, 1998). Addiction to BZDs is highly associated with personal and familial antisocial personality disorder, of which includes trouble with the law and family members that were antisocial (Van Valkenburg and Akiskal, 1999). If there is any report of this type of history, further records need to be obtained. The patient may be anxious and frustrated with delay of treatment; however their safety is at the forefront, where it belongs.
Consideration of family mental health disorders is part of prevention. Van Valkenburg and Akiskal study did find that “Anxious patients with-out antisocial relative and who maintain stable longstanding personal relationships are at very low risk of sedative abuse” (1999, p. 5). Prevention of abuse is preferable, however with the current BZDs dependency and abuse, reduction of BZDs should be considered with a tapering process. Prevention of abuse is preferable, however with the current BZDs dependency and abuse, reduction of BZDs should be considered with a tapering process. Several studies, that included meta-analyses that involved treatment strategies for BZD-dependent patients, found focus on alternative approaches that would achieve abstinence that included complete BZD withdrawal. The parent compound contained in Diazepam has a very rapid onset of euphoric effect. This euphoric effect is effective for the anxiety symptoms that will be evident during a detox. Again, a slow taper to abstinence is the goal. BZDs tapers successful withpatients in methadone maintenance treatment (Weizman, Gelkopf, Melamed, Adelson and Bleich, 2003; Ciraulo and Nace, 2000).
Particular attention to Fenton, Keyes, Martins and Hasin, findings that anxiety medications have clinical utility, thus greaterclinical attention should be given to the potential for theirabuse among patients with history or current substance abuse (2010). The purpose of the BZD script is one of which is to partner with the fixing of the clinical diagnosis and not issuing an indefinite Band Aid. This approach is treating the thoughts associated with diagnosis, in addition to addictive behaviors. Behaviors need to change of which BZDs are not the magical fix.
There is a considerable overlap between drug and alcohol dependence and psychiatric disorders that include BZDs abuse, therefore should medical care professionals increase managed care responsibilities with those involved in treatment of substance use disorders (SUDs) prior to prescribing BZDs? Those seeking treatment to recover from opiate addictions need managed care with dual-diagnosis in addiction and mental health disorders (Weizman, Gelkopf, Melamed, Adelson and Bleich, 2003). Detox is possible from BZDs addiction with those in methadone maintenance treatment programs. It does not make sense to continue BZDs for a mental health treatment method, as the safety risks increases with BZDs use and those substance abuse patients in methadone treatment. Results from several studies warrant the necessary close monitoring of patients’ history prior to prescribing BZDS for anxiety, depression, insomnia and other mental health disorders. Other treatment methods must be exhausted, with documentation to substantiate progress or failed attempts.
BZDs Patients Substance Abuse2010 Zuschlag M
Benzodiazepines Use is Not Safe in Patients with Substance Abuse<br />Mara Zuschlag<br />December 12, 2010<br />Argosy University<br />
Benzodiazepines (BZDs)<br />Addictive and abuse risk for individuals with polysubstance addictions, anxiety and history of family mental health disorders.<br />BZDs abuse is a risk for individuals with polysubstance addictions, anxiety and history of family mental health disorders<br />BZDs are commonly prescribed for anxiety, insomnia and clinical depression.<br />BZDs are popular with drug users.<br />Coordination of care between mental health providers, medical professionals and substance abuse modalities is crucial for effective recovery.<br />
History<br /><ul><li>BZDs were first introduced the physical dependence potential was unknown
Common mental health illnesses and treatment with BZDs are panic disorders, anxiety, post-traumatic stress disorders, schizophrenia and personality disorders (Ashworth, Gerada and Dallmeyer, 2002).
BZDs prescribed were common practice as part of the management of primary care mental health problems.</li></li></ul><li>Ambiguity in BZD Dependence and Abuse<br />Studies of Posternak and Mueller, BZDs have been effective of efficacy in treatment of those with anxiety, panic disorders, agoraphobia, social phobia and alcohol-induced anxiety disorders. <br />BZDs prescribed for these patients, are well tolerated, however their studies have found their potential for abuse and harm (Posternak and Mueller ,2001).<br />This study is contradictory for support of BZDs treatment for those patients with reported substance abuse as found with Ciraulo and Nace, hence the abuse comes from the obtaining from non-medical sources, use in higher than prescribed amounts and use for poorly defined conditions (2000).<br />Ambiguity is not an adequate argument to prescribe BZDs, of which includes fatal results<br />
Acute Medical, Family and Substance Use History Evaluated<br />Without a patient’s history review, <br /><ul><li>prescription is ordered
risks are increased if other substances are abuse
compromising medical conditions that could lead to death.</li></ul>Studies have found anxiety in the family history increases the risk of BZDs abuse (Van Valkenburg and Akiskal, 1999). <br />Antisocial behavior reported by the patient or by a family member increases risk of BZDs abuse.<br />BZDs prescriptions need to be replaced with alternatives to treat anxiety and depression during treatment of opiate addiction.<br />
Harm and Safety Risks<br />Harm and safety risk of benzodiazepine abuse increases for individuals with severe dependence, polysubstance dependence, and antisocial personality disorder, of which is in general consensus with other studies (Ciraulo and Nace, 2000). <br />Increased risk of safety with BZDs use and polydrug abuse<br />BZDs use attributed to memory loss, and injection use constitutes a major clinical and public health problem (Darke and Ross, 1994). <br />BZDs included in polydrug abuse is a contributing factor in overdose among opiate users<br />Cardiovascular, respiratory failures<br />Overdoses<br />If current studies have validated harm reduction in negating use of BZDs when substance abuse is prevalent, then medical professionals need to increase their responsibility to restrict their use. <br />
Limitation and Reduction of BZD Use<br />Standard prescribed use to prevent dependency is 2 – 4 weeks<br />Coordination of care is necessary to limit BZD use (Salzman, 1998). <br />Prior to prescribing BZDs, close review of family history is imperative to reduce risk of addiction. <br />Reduction in potential abuse of BZDs results:<br />Close patient monitoring<br />Adherence to recommended 2-4 week dosing guidelines <br />Single source dispensing, periodic drug tapering<br />Practice of consistent urine toxicology screenings<br />
Prevention of Abuse<br />Prevention begins with accurate review and assessment of patient medical, family and drug use history prior to prescribing<br />Diazepam has been found to be the BZD to replace other prescribed BZDs for an effective detox process for illicit drug users (Elliott, Glenday, Freeman, Ajeda, Johnston, Christie, et al., 2005).<br />Only 2- 4 week prescriptions<br />Cross prescription checks<br />Discontinue benzodiazepine use in pharmacotherapy <br />Cognitive behavioral therapy<br />
Alternative Treatment Methods<br />Initial low dose of BZD, together with cognitive-behavioral therapy (CBT). <br />Posternak and Mueller’s studies found evidence that BZDs may inhibit gains made from CBT, thus lower the dose to gain effective treatment, to include a tapering to abstinence (2001). <br />Herbal solutions to treat anxiety symptoms are available, such St. John’s Wort. <br />Relaxation techniques<br />meditation<br />Yoga<br />spiritual environments <br />
Conclusion<br />Prevention begins with accurate review and assessment of patient medical, family and drug use history prior to prescribing<br />Safety concerns exist with the physical aspects such as cardiovascular and respiratory failures with the abuse of BZDs, to include severe physical and mental impairments with polydrug use (Ciraulo and Nace, 2000; Ashworth, Gerada and Dallmeyer, 2002; Elliott, Glenday, Freeman, Ajeda, Johnston, Christie, et al., 2005).<br />Medical professionals must review all history of a patient, prior to prescribing BZDs to minimize risk of abuse.<br />Ciraulo and Nace’s studies found increase risk of BZDs abuse for individuals with severe dependence, polysubstance dependence, and antisocial personality disorder (2000).<br />Supportive studies found by Posternak and Mueller that BZDs should be avoided in anxiety disorder patients with a history of substance abuse or dependence (2001). <br /> Several valid and reliable studies have found that BZDs use is not safe in patients with substance abuse, increased thorough assessments must be done, to include cross pharmacy checks for duplication of BZDs prescriptions. <br />
References<br />Ashworth, M., Gerada, C., & Dallmeyer, R. (2002). Benzodiazepines: addiction and abuse. Drugs: Education, Prevention & Policy, 9(4), 389-397. doi:10.1080/09687630110099344.<br />Ciraulo, D., & Nace, E. (2000). Benzodiazepine Treatment of Anxiety or Insomnia in Substance Abuse Patients. American Journal on Addictions, 9(4), 276-284. doi:10.1080/105504900750047346.<br />Darke, S., & Ross, J. (1994). The use of benzodiazepines among regular amphetamine users. Addiction, 89(12), 1683-1690. Retrieved from Psychology and Behavioral Sciences Collection database.<br />Elliott, L., Glenday, J., Freeman, L., Ajeda, D., Johnston, B., Christie, M., et al. (2005). Reducing diazepam prescribing for illicit drug users: A randomised control study. Drug & Alcohol Review, 24(1), 25-31. doi:10.1080/09595230500125138.<br /> Fenton, M., Keyes, K., Martins, S., & Hasin, D. (2010). The Role of a Prescription in Anxiety Medication Use, Abuse, and Dependence. The American Journal of Psychiatry, 167(10), 1247-53. Retrieved from Research Library. (Document ID: 2162719931).<br />Fløvig, J., Vaaler, A., & Morken, G. (2009). Substance use at admission to an acute psychiatric department. Nordic Journal of Psychiatry, 63(2), 113-119. doi:10.1080/08039480802294787. <br />Posternak, M., & Mueller, T. (2001). Assessing the Risks and Benefits of Benzodiazepines for Anxiety Disorders in Patients with a History of Substance Abuse or Dependence. American Journal on Addictions, 10(1), 48-68. doi:10.1080/105504901750160484.<br />Salzman, C. (1998). Addiction to Benzodiazepines. Psychiatric Quarterly, 69(4), 251. Retrieved from Psychology and Behavioral Sciences Collection database.<br />The Substance Abuse and Mental Health Services Administration (2010). Office of Applied Studies. Non-Medical Use and Abuse: Prescription-type and Over-the-Counter Drugs. SAMSHA. Retrieved from http://www.samhsa.gov/<br />Van Valkenburg, C., & Akiskal, H. (1999). Which patients presenting with clinical anxiety will abuse benzodiazepines?. Human Psychopharmacology: Clinical & Experimental, 14S45-S51. Retrieved from Psychology and Behavioral Sciences Collection database.<br />Weizman, T., Gelkopf, M., Melamed, Y., Adelson, M., & Bleich, A. (2003). Treatment of benzodiazepine dependence in methadone maintenance treatment patients: a comparison of two therapeutic modalities and the role of psychiatric comorbidity. Australian & New Zealand Journal of Psychiatry, 37(4), 458-463. doi:10.1046/j.1440-1614.2003.01211.x.<br /> <br />