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Substance Misuse and Benzodiazepines

Substance Misuse and Benzodiazepines. Dr. N. F. Wright, Lead Clinician, CCDAS E-mail neville.wright@cumbria.nhs.uk. Pattern of Use. Primary intoxicant Adjunctive intoxicant - opiates - alcohol Stimulant facilitation - Amphetamine – S.E. control

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Substance Misuse and Benzodiazepines

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  1. Substance Misuse and Benzodiazepines Dr. N. F. Wright, Lead Clinician, CCDAS E-mail neville.wright@cumbria.nhs.uk

  2. Pattern of Use • Primary intoxicant • Adjunctive intoxicant -opiates - alcohol • Stimulant facilitation -Amphetamine – S.E. control - Cocaine - ‘chill’, ‘come down’ • Self medication -hypnotic - anxiolytic -detoxification

  3. Type & Route • Diazepam (Valium), almost exclusively oral • Temazepam – oral or i/v • Lorazepam – oral • Clonazepam – oral ‘Benzo like’ substances • Zopiclone – oral/i/v • Chlormethiazole – oral • Meprobamate/Baclofen - oral Frequency

  4. SOURCES • Diazepam – Asia, former Soviet block, Southern Europe, local prescription • Temazepam – Former Soviet block, Southern Ireland, vetinary • Lorazepam/Clonazepam – Locally prescribed/Southern Europe ‘Benzo like’ – Locally prescribed/Southern Europe I N T E R N E T!

  5. Consequences of Misuse • Intoxication- Falls/RTA’s, other accidents - Criminality – ‘invisibility’ - Aggression – rare paradoxical reactions - Amnesia • Acute overdose - alone surprisingly safe - combination with opiates/alcohol DANGEROUS D.R.D’s

  6. Consequences of Misuse (cont) • Chronic Heavy Use- Very little general medical - Decreased cognitive function?? Permanent - Physical & psychological DEPENDENCE • Withdrawal- Fits, muscle twitches - Anxiety, perceptual changes, mood disorder - Psychosis (transient) • Reduces efficacy of S.M. treatments Nothing like as bad as alcohol !

  7. APPROPRIATE USES Why not ban them? Most effective and safest acute anxiolytics • Psychiatric emergencies- rapid tranquillisation - short term adjunct to antidepressants/antipsychotics/mood stabilisers • Acute stress reactions- Bereavement - RTA’s, etc - Flying & other phobias • Short term hypnotics • Treat for anxiety disorders– Third line (B.A.P. 2005) especially treatment resistant G.A.D. • Detoxification– Alcohol/mainstay - Chlordiazepoxide (Librium) - Lesser role in other substances • Medical procedures- Endoscopy, etc.

  8. Detoxification • Convert to Diazepam equivalents - tablet choice - daily pickup facility • Gentle withdrawal, duration proportional to length of misuse 6 weeks to 6 months! • Firm but sympathetic approach, some role for alternative therapies. • Prophylactic antidepressants sometimes indicated.

  9. Solutions • No maintenance prescribing for addiction issues (2007 orange guidelines) • Better control of repeat prescriptions • Drug user education, not just harmless medical drug • Better provision of specialist treatment for anxiety disorders – psychological and pharmacological • Better access for drug misusers to above! • Interval prescribing facility for Librium?

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