Substance Misuse and Benzodiazepines

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Substance Misuse and Benzodiazepines
Dr. N. F. Wright, Lead Clinician, CCDAS
E-mail
neville.wright_at_cumbria.nhs.uk
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Pattern of Use

• Primary intoxicant
• Adjunctive intoxicant - opiates
• - alcohol
• Stimulant facilitation - Amphetamine S.E.
  control
• - Cocaine
  - chill, come down
• Self medication - hypnotic
• - anxiolytic
• - detoxification

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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
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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!
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Consequences of Misuse

• Intoxication - Falls/RTAs, other accidents
• - Criminality
  invisibility
• - Aggression rare
  paradoxical reactions
• - Amnesia
• Acute overdose - alone surprisingly safe
• - combination with
  opiates/alcohol
• DANGEROUS D.R.Ds

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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 !

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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
• -
  RTAs, 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

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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.

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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?