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Benzodiazepines Tranquilisers and their risk Benzodiazepines are also referred to as tranquillisers and are drugs mainly prescribed for anxiety and insomnia. They are occasionally prescribed for epilepsy, as muscle relaxants, and as a detox from alcohol. They should only be prescribed short term as they can have serious side effects, withdrawal symptoms and addiction problems if overused. They should only be used short for the likes of anxiety until the effects of longer term treatment options (eg. counselling, antidepressants, mood stabiliser medication) starts working. Benzodiazepines have been prescribed in Ireland for over 50 years and there has been a long history of overprescribing. When they first came out, the likes of “valium” were seen as wonder drugs, their potential problems and side effects were not realised initially and “mother’s little helpers” were overprescribed by family doctors. Only in the last few years have efforts been made to reduce over and inappropriate prescribing. How they work? Benzodiazepines work by increasing the efficiency of a natural brain chemical called GABA. GABA works by reducing the excitability of transmitters (neurons) in the brain. This slows the communication between neurons giving a calming effect to many functions of the brain. Benzodiazepines main effect is to reduce anxiety and agitation, while it does this quickly (within half an hour); this effect is short lived (a few hours only). They are quite effective in reducing anxiety and have few side effects if only used short term at the lowest possible dose. Side effects can include drowsiness and slowing of mental and bodily movements. These effects are more pronounced in the elderly so extreme care must be taken if they must be prescribed for older people. Benzodiazepines cause sedation so benzodiazepines can be dangerous if combined with other sedative drugs or alcohol and can affect driving or operating machinery. Benzodiazepines may cause confusion, slurred speech, coordination problems, impairment of judgement and memory loss in some people, especially at higher doses. Paradoxically they can cause mood swings in some people (perhaps this is more when the dose wears off). With long term use, tolerance can occur; this involves needing higher doses to produce the same effects. Dependence can also occur with longer term use (more than a week); symptoms can include feeling a constant need for the drug with the feeling of not being able to function right without it and developing withdrawal symptoms if the drug is stopped. A person’s tolerance to the effects of a benzodiazepine can develop quickly, even within a couple of weeks. Withdrawal symptoms can be debilitating and can include nausea, vomiting, sweats, low mood, and paranoia and panic attacks. The anxiety that occurs with detox (withdrawal) from benzodiazepines is often worse than the original anxiety they were originally prescribed for; leading to the vicious circle of the person needing to continue and then constantly need higher doses if not monitored closely (as the person becomes tolerant to the drug if used long term). Benzodiazepines combined with alcohol or other medication (even some common over the counter medicines such as pain-killers and anti-histamines) can cause loss of consciousness and respiratory failure. Side effects are rare if doses are kept low and courses are short (ideally 4 weeks maximum). Paradoxical reactions (unexpected increases in agitated or aggressive behaviour) can occur but are rare. Page Types of benzodiazepine There are three main groups of benzodiazepine and they are categorised by how quickly they work and are eliminated from the body. Short-acting benzodiazepines include midazolam (Hypnovel®), and 1 Benzodiazepines are recommended for use for a maximum of 4 weeks; prescribing more than 4 weeks supply is not licenced (meaning it is not authorised or recommended by health authorities or the manufacturers of these drugs). Prescribing for longer than 4 weeks is limited to consultants who are familiar with all the alternatives and feel there is no other options despite the risks (eg) severe cases of anxiety triazolam (Halcion®). Intermediate acting benzodiazepines include alprazolam (Xanax®), clonazepam (Rivotril®), lorazepam (Ativan®), nitrazepam (Mogadon®) and temazepam (Nortem®). Long-acting benzodiazepines include diazepam (Valium®, Anxicalm®), flurazepam (Dalmane®, Dalmapam®) and chlordiazepoxide (Librium ®). Some have a very sedative effect so are only used as sleeping tablets; these include triazolam (Halcion®), nitrazepam (Mogadon®), temazepam (Nortem) and flurazepam (Dalmane). They should only be used short term as sedatives due to the reasons like tolerance, dependence and withdrawal symptoms described earlier. Generally shorter acting compounds are better for the elderly as the longer acting compounds can build up over time as elderly patients’ are less able to metabolise them. However short acting benzodiazepines are more likely to become habit forming or create dependency so should only be used in limited cases. Uses for benzodiazepines Benzodiazepines are never recommended as a standalone treatment (eg for anxiety), but should be used in conjunction with other treatments for any underlying condition. They should be avoided in people with a tendency or history to misuse drugs or alcohol as they have more potential to develop dependence on benzodiazepines and overdose due mixing with other substances. Withdrawal from alcohol Unlike other conditions, benzodiazepines are still used the treatment of choice for alcohol withdrawal. Chlordiazepoxide (Librium ®) is the benzodiazepine of choice for alcohol withdrawal. The dose is started high and tapered off and discontinued within one week. Addiction to alcohol increases the likelihood of addiction to benzodiazepines due to their addictive nature so benzodiazepines should only be used short term. The anticonvulsant properties of benzodiazepines also mean they can prevent seizures which can occur in some people withdrawing from long term alcohol abuse. Detox from alcohol is only the first step in staying dry from alcohol and the person will need long term support such as counselling and other treatments to stay dry. Anxiety Disorders The main reason benzodiazepines are prescribed is for the short-term treatment (max of 4 weeks but the shorter the period the better) of anxiety disorders or panic disorder. Benzodiazepines should only be used for treatment resistant cases and should never be the first treatment option. They should be used with care in post-traumatic stress disorder (PTSD) as studies indicate they can sometimes make symptoms worse. Benzodiazepines should not be used for people experiencing bereavement as they can inhibit psychological adjustment and reduce the normal mourning process. Benzodiazepines should not be used as first treatment options of anxiety disorder but only as temporary treatment during initial treatment while waiting for definitive therapy with longer term medications (eg. antidepressants) and psychotherapy (eg. counselling) to take effect. Taking benzodiazepines for more than four weeks mainly results in effects described earlier such as loss of effectiveness, tolerance to their effects, dependence, potential withdrawal syndromes, side effects, and reduced effectiveness of the long term treatment plan (eg) antidepressants, counselling. Benzodiazepines taken for more than 2 weeks continuously should be reduced slowly instead of discontinuing suddenly to prevent withdrawal symptoms. Page Insomnia Benzodiazepines may be used as a short term treatment for insomnia. Non benzodiazepines (Z) Hypnotics (such as zopiclone and zolpidem) may be associated with fewer side effects. The recommendation is that all hypnotics are only prescribed for two to four weeks. Sleeping tablets should only be considered if insomnia is severe and causing extreme distress. For severe insomnia, only the short-acting benzodiazepines should be prescribed for the shortest possible time period such 2 Benzodiazepines should be reserved for the treatment of patients who have not improved with treatment by at least two therapies (eg. SSRI (selective serotonin reuptake inhibitor) and a psychological treatment like counselling). However these concerns should not prevent their use in those with persistent, severe, distressing and impeding anxiety symptoms. There are a small minority (who do not develop a tolerance) who benefit from long term use of benzodiazepines as attempts to reduce benzodiazepines causes a relapse. as temazepam (Nortem®, Insomniger®), lormetazepam (Noctamid®), flurazepam (Dalmane®), and triazolam (Halcion®). The newer non benzodiazepine sleeping tablets such as zopiclone (Zimovane®, Zimoclone®) and zolpidem (Stilnoct®, Zolnod®) may cause less side effects and are less addictive than older varieties but it is still easy to become dependent on them. They tend to give a metallic taste in the mouth. There is not much difference in effectiveness between the non-benzodiazepines and older benzodiazepines. Sleeping tablets are best avoided in the elderly if possible as they cause confusion and increase the likelihood of falls. Acute Mania Mania is the “high” phase that people suffering from bipolar disorder (also known as “manicdepression”) can experience; it is usually followed by period of deep depression. Benzodiazepines are used in treating Acute Mania (the high phase) or Hypomania (low depressive mood stage), on a short term basis until the longer acting medications such as antipsychotics (eg. quetiapine, olanzapine) or mood stabilising medication (eg. lithium) kick in. Use in Psychosis Benzodiazepines are used in the treatment of psychosis (a short term psychotic state where a person loses touch with reality; psychosis is often caused by other conditions like schizophrenia or bipolar disorder). If a person with psychosis is very distressed and needs to be calmed quickly, then a benzodiazepine may be required for what is referred to as Rapid Tranquillisation, either alone, or in combination with an antipsychotic (a mood stabiliser medication). In some rarer cases, patients with a psychotic illness may fail to respond sufficiently to antipsychotics, and can mean that benzodiazepines may need to be prescribed longer term. Catatonia Benzodiazepines are the medication of choice in catatonia (also known as “neurogenic motor immobility” which is a phenomenon characterised by muscle rigidity and a mental stupor). Benzodiazepines are effective for catatonic symptoms because they have muscle relaxant properties and are fast acting and easily administered. Special populations: Pregnancy Benzodiazepines should be avoided during pregnancy if possible as they can cause problems like hypothermia, reduced movement and respiratory depression in the unborn child. Ideally benzodiazepines should be discontinued before a planned pregnancy. If a woman becomes pregnant while taking benzodiazepines, they should be gradually withdrawn as soon as possible. However a risk benefit analysis should be undertaken by a mental health professional, and if other treatments such as avoidance of stress, relaxation, anxiety management, counselling and Cognitive Behaviour Therapy (CBT) do not give sufficient relief, then benzodiazepines are justified. Severe and persistent anxiety for a pregnant woman can be a risk to the unborn baby’s health so specialist advice is required in this situation. Page 3 Older people In older people, benzodiazepines are associated with more severe side effects including marked sedation and psychomotor impairment (slowdown of mental and physical activity), higher risk of fractures (especially hip fractures) and driving accidents, and a quicker development of tolerance, dependence and withdrawal symptoms (when compared to younger patients). Our bodies’ clear drugs slower as we get older which is a major factor for the increased susceptibility to side effects from drugs such as benzodiazepines. Side effects may be less is shorter acting benzodiazepines are prescribed (eg) alprazolam instead of diazepam. Anxiety is often associated with depression in older people and can be treated with anti-depressants and psychological therapies (eg. counselling, CBT) instead of benzodiazepines. In general, older people have better quality of lives if not prescribed benzodiazepines and benefits associated with successful reduction in rates of benzodiazepine use include increased alertness, mobility, reduced incontinence and improved well-being. People with an Intellectual Disability Benzodiazepines cause sedation and hence an increased risk of falls. They also reduce the person’s ability to engage with activities during the day so can reduce their quality of life. Children Benzodiazepines are rarely used for children but there are certain occasions where they play an important in managing children with similar presentations seen in adults, eg. Manic symptoms, acute agitation associated with psychosis, short term treatment of acute and debilitating anxiety, and part of treatment for Post-Traumatic Stress Disorder. Children and adolescents may also present with severe agitation or aggressive behaviour in situations like a learning difficulty, developmental disorders (such as Autism and Asperger’s) or severe psychological reactions due to stressful events such as abuse and trauma. Such rapid tranquilisation may be required for the safety of child or adolescent and those around them. Benzodiazepine use for children and adolescents must be of the shortest duration possible and must be reviewed regularly. Informed parental consent is preferable whenever possible, unless one needs to act under common law due to the urgency of the situation. All psychotropic medication (medication for mental health conditions) prescribed for children must be by a specialist in Child Mental Health. People with substance misuse problems Benzodiazepines are abused as recreational drugs and there is a black market for them. Patients with substance misuse problems often abuse multiple substances with benzodiazepines being one of the most commonly abused, often in combination with other drugs in order to enhance their effects, to experience euphoric effects and an altered state of consciousness. They are also used to ease withdrawal symptoms associated with other drugs including alcohol, cocaine and heroin. Other reasons substance misusers take benzodiazepines that are not prescribed (i.e. buy them on the street) include underlying symptoms of anxiety, panic attacks, phobic disorders, depression, posttraumatic stress disorder, and psychotic symptoms due to the likes of schizophrenia or bipolar disorder. Prescribing of benzodiazepines to substance misusers is best provided by specialist treatment services. Withdrawal from benzodiazepines for people suffering from substance misuse should be done extremely slowly and the dose should be reduced gradually every 2 to 4 weeks; this can take up to a year in some cases to ensure adequate withdrawal. Disclaimer: Please ensure you consult with your healthcare professional before making any changes recommended Page 4 For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591. You can also e-mail queries to [email protected].