Carefully analyze benzodiazepine dependence.
Sir William Osier stated, "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has." Among the factors that professionals should initially evaluate are physiological variants including genetic predispositions; childhood traumas; onset of drug, alcohol, or benzo use; amount of drug use and years of use; anxiety, panic and sleep disorders; other comorbidities; and psychiatric disorders that have initiated or dictated continued use of benzos.
Complicated patients are best treated in an inpatient setting. Patients benefit from treatment in stages. Modify your treatment approach based on the severity of the combined disorders. Some patients will need extensive and extended treatment.
In treating patients with chronic opioid and benzo dependencies in an inpatient setting, initiate stabilization of the opioids by using medication in a controlled fashion to stabilize the patient's physiology. Address the benzodiazepine first by stabilizing the dosage (this is the first line of treatment), and then individualizing a tapering protocol. One can then address the opioids without causing respiratory depression. Proceed with tapering the opioids in a step down fashion, or transitioning to buprenorphine and/or oxymorphone to taper to avoid respiratory depression or sleep apnea. Following opioid stabilization, formulate a strategy and proceed with the final benzo taper.
In tapering benzodiazepines, conventional recommendations are to utilize a stable drug such as Librium or phenobarbital. Those patients who have comorbid conditions, hepatic impairment or aging physiology might not metabolize these drugs well. In these instances, shorter-acting, easily metabolized drugs such as loraz-epam or oxazepam can be used, at least initially until a low enough dosage can be comfortably achieved. Then, when the patient is metabolically stable a taper could include phenobarbital or a longer-acting benzodiazepine.
Symptoms of benzodiazepine discontinuation include the appear-ance of recurrence or relapse symptoms, rebound symptoms, addiction, or true withdrawal. Prolonged/protracted withdrawal from benzos is an issue in complicated patients. In medically compromised patients (patients with heart disease, Crohn's disease, or rheumatologic, diabetic and neurological disorders), stabilize the person's medical condition prior to detoxing him/her off benzos.
When dealing with prolonged withdrawal syndrome, there is limited evidence in terms of the chronic neuroplastic changes that occur with benzo dependency regarding recovery of receptors and biochemistry homeostasis. Drug-induced neuroplastic changes might never fully correct. Withdrawal symptoms might therefore represent a return of symptoms from neuroplastic imbalance and chronic changes, as well as unresolved psychiatric symptoms. These patients could benefit from additional pharmacologic maintenance.
Adjunctive medications such as carbamazepine, valproate, propranolol, clonidine, buspirone and trazodone are used in these cases. New medications, including doxepin (Silenor) 3 to 6 mg, Lunesta in tapering doses 3-2-1 mg, Rozerem 8 mg, and Saphris (for anxiety stabilization and sleep effect), are quite useful in stabilizing individuals. Protracted use of phenobarbital if necessary is an option if abuse of benzos remains.
Benzo abuse and overdose
Benzodiazepine abuse and overdose as a single agent rarely lead to death. Polypharmacy amplifies the risk of treating patients in an outpatient setting. Patients detoxing in an outpatient setting have the potential for self-medicating and abuse.
In uncomplicated benzo patients, prescribe a small amount of a safe benzo for five to seven days. See them frequently until they reach stability. Be careful if patients are on multiple drugs, particularly during the detox phase, because the risk is highest for self-abuse and overdose at this time.
One might prefer short-acting drugs such as lorazepam or oxazepam for safety because they are quickly metabolized. These may be safer when the hepatic microsmal enzyme oxidase system is impaired. Switch to Librium (chlor-diazepoxide) or phenobarbital in an outpatient setting at a time when patients are physiologically improved.
Observe patients until the benzos have cleared. The final phase of clearance could take several days after the last dose. Individuals are prone to have recurrent symptoms and sleep disruption from rebounding off the benzos on their own. Inpatient treatments use benzos, and following discharge patients may go through withdrawal or have return of symptoms. Relapse occurs when symptoms of benzo withdrawal are intolerable. It is a human condition to relapse on drugs when one perceives the symptoms to be intolerable.
Regarding co-occurring psychiatric disorders, most studies find a correlation between the degree of psychopathology and the degree of withdrawal symptoms off benzodiazepines. This correlates with the difficulty in completing benzo tapering, and the length of time to successfully complete the process. In effect, increased psychiatric symptoms correlate with increased and protracted withdrawal symptoms. Use benzos that have a simpler metabolism and quicker clearance, with less potential for accumulation.
During initial treatment, one might use a chlordiazepoxide or phenobarbital taper and use lorazepam for breakthrough anxiety and/or panic until symptoms are stable. Different treatment settings and different patient populations required different approaches.
The elderly are frequently on multiple medications (medical polypharmacy), and have metabolic issues of aging that can delay excretion of benzodiazepines by two to five times. Even younger patients with significant comorbidities demonstrate physiological aging. Short-acting benzos such as Ativan (lorazepam) and Serax (oxazepam) have a greater margin of safety in these individuals. The elderly benefit a great deal from benzo withdrawal, decreasing the risk of falls and cognitive impairment.
Finally, sleep medicine evaluation and sleep hygiene programs are invaluable, as is treating sleep as a separate specialty. In these comor-bid patients there are significant sleep disorders. Unfortunately, clinical research suggests neuroplasticity and chronicity with sleep disorders. Future research might reveal that sleep disorders predispose individuals to self-medication with benzos.
Jerry Rand, MD, is Executive Medical Director of Bay Recovery Centers in San Diego. He has been a physician for more than 37 years, with specialties in areas including dual diagnosis and pain. His e-mail address is firstname.lastname@example.org.
by Jerry Rand, MD