Benzodiazepines: The Silent Partner Exploring practical considerations of working with polydrug user

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Benzodiazepines The Silent PartnerExploring
practical considerations of working with polydrug
users

• Laura Freeman, Ph.D.
• Glasgow Addiction Services
• Training Psychologist

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Illuminating hidden corners.

• A great deal of information about the practical
  considerations of benzo use, but the information
  is found in
• McClelland (1990). The Forensic Implications of
  Benzodiazepine Use. Benzodiazepines Current
  Concepts.
• Bond (1998). Drug-Induced Behavioural
  Disinhibition. CNS Drugs.
• Nelson Chouinard (1999). Guidelines for the
  clinical use of benzodiazepines. Can J Clin
  Pharmacology.

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Illumination continued.

• Griffiths Weerts (1997). Benzodiazepine
  self-administration in humans and laboratory
  animals implications for problems of long-term
  use and abuse. Psychopharmacology.
• Blair Curran (1999). Selective impairment in
  the recognition of anger induced by diazepam.
  Psychopharmacology.
• Goulla Anger (2004). Drug-Facilitated Robbery
  or Sexual Assault Problems Associated with
  Amnesia. Therapeutic Drug Monitoring.

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Illumination continued.

• Paraherakis et al. (2001). Neuropsychological
  Functioning in Substance-Dependent Patients.
• Darke et al (2000). Cognitive impairment among
  methadone maintenance patients.
• Lader et al (1999). Limitations on the use of
  benzodiazepines in anxiety and insomnia are
  they justified. European Neuropsychopharmacoloty

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Information on the potential impact of the
benzos is there, we just have not translated it
to front-line work (or even found all of it!)
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Working with Benzo UseParadoxical Effects

• BNF states clearly that some people have a
  paradoxical effect to benzos
• A paradoxical increase in hostility and
  aggression may be reported by patients taking
  benzodiazepines. The effects range from
  talkativeness and excitement, to aggressive and
  antisocial acts. Adjustment of the dose (up or
  down) usually attenuates the impulses. Increased
  anxiety and perceptual disorders are other
  paradoxical effects. Increased hostility and
  aggression after barbiturates and alcohol usually
  indicates intoxication. (p. 173). March, 2006.

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Working with Benzo UseParadoxical Effects

• No way to know if or if not.
• Suggestions of about 5.
• However, those at higher risk are said to be
  those with pre-existing impulse control.
• Alcohol is consistently pointed out as increasing
  the risk.

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Working with Benzo UseParadoxical Effects

• Direct impact on much of the work we do in the
  addiction field.
• Anger management
• Coping with triggers
• Social skills training
• Even recognition and naming of emotions

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Working with Benzo UseAnterograde Amnesia

• Window of 90 to 2 hours after diazepam is taken,
  at risk for anterograde amnesia.
• Issue of consolidating new memory
• Verbal memory automatic activities
• Dose dependent, and depends on type
• Occurs even with chronic use
• Still functioning others and the individual may
  not be aware

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Working with Benzo UseAnterograde Amnesia

• Timing of the use of benzos
• Relationship of timing to therapeutic work
• Use of strategies other than verbal
• Reminders to take home
• Use of repetition
• Use of strategies to make input unique

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Consider the combination of Paradoxical Effects
and Anterograde Amnesia
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Major Challenge

• If people experience paradoxical effects, but
  then dont remember them.they will continue to
  believe that the drug is working.
• Insomnia as one example

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Working with Benzo UseImpact on Expectations

• People use for insomnia, anxiety distress,
• Lader (1999) says short-term efficacy for
  insomnia anxiety long-term controversial
• Again, the BNF
• Chronic insomnia is rarely benefited by
  hypnotics
• BZ are indicated for the short-term relief (2-4
  weeks only) of anxiety p.174

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Working with Benzo UseImpact on Expectations

• So, as services we need make sure clearly
  communicate the limitations of any prescribing
• If prescribing, clearly communicate the reasons
  for prescribing
• And actively help individuals become more aware
  of side effects and potential coping strategies.

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Now, in a polysubstance cocktail culture.
Overdose risk

• Cocaine, alcohol and methadone are the leading
  cause of overdose death in the US.
• What happens when we add in the benzos?
• Sleep apnea risk needs to be considered with both
  alcohol and benzo use how about methadone in the
  mix?

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Now, in a polysubstance cocktail culture. Drug
Interactions and Euphoria

• Pattern of binge drinking on an empty stomach is
  common pattern.
• Diazepam has a fast onset,
• Add to this methadone, and
• Cocaine, and thus
• Coca-ethylene
• And you have a potent cocktail!

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Now, in a polysubstance cocktail culture.
Cognitive Impairment

• Cognitive impairment among those stable on
  methadone maintenance in Australiarelated to
• Number of overdoses
• Extent of alcohol use
• Short and long term verbal learning most severely
  impacted.
• Do the benzos complicate this picture?

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Suggestions for Practical Considerations

• Timing of the use of benzos and therapeutic work
• Use of strategies other than verbal
• Reminders to take home
• Use of repetition
• Use of unique strategies
• Educate and find ways to illustrate

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Suggestions for Practical Considerations

• Educate about the cocktail overdose riskAnd
  the impact of cocaine.
• Find ways to increase awareness of side effects
  and ways to cope.
• Explicitly address expectations and
  responsibility for making change.
• Assess for sleep apnea.

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What are the other techniques?

• Rethinking Subtance Abuse (2006)
• Carroll said 3 basic research based principles to
  consider in helping people make and maintain
  change.
• Enhancing motivation
• Developing control over impulsive behaviour
• Reinforcement management

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Questions to explore in research

• Overdose risk both behavioural drug related
• Sleep apnea
• Cognitive impairment
• Memory when where which benzos and
  strategies for coping
• How to help people develop more control over
  impulsive behaviour
• How do we reinforce changes in behaviour?
• What about brief interventions?
• How do we make changes to reduce the market?