anon schreef:
> BENZODIAZEPINES
>
> Quotations & Abstracts
Sigh.....OK, one more time.
Long term benzo use *does* indeed often cause some (reversible)
short-term memory loss, mostly more annoying than debilitating.
Impairment of cognitive function is highly debatable and mostluy occurs
in the elderly and as a result of unskilled prescribing.
I always admitted benzos cause *dependence* (not to be confused with
*addiction* with its hallmarks *tolerance* and *craving* which hardly
ever occur when medication is properly prescribed for the right
reasons). So do myriads of other prescription drugs including
antidepressants, insulin, digoxin, pain killers etc.etc.
When prescribing a benzo (or one of these many other meds) for
maintenance use the doctor should warn the patient that dependence will
occur and that they can run into problems trying to stop the meds which
should only be done by way of a slow taper. See the Ashton manual and
the Lexington-on-line site.
The second part of this (mis)information contains nothing that is
relevant for the discussion about the prescription of benzos for
anciet/panic. It's about street abuse, dependence in babies (no one
should take benzos while pregnant and the baby's dependence will be the
least of the probems this can cause such as severe birth defects) and
the fact that cognitive (if any) and memory problems are reversible
after stopping the drug which only proves my point.
We are posting here in a newsgroup for people with anxiety disorders.
I'm not in it to win an argument but to balance the information which I
regard as totally lopsided and biased.
I am now seriously leaving this thread and let everyone make up their
own minds on the basis of the presented evidence from both sides.
Philip
>
> Twenty-one patients with significant long-term therapeutic
benzodiazepine
> (BZ) use, who remained abstinent at 6 months follow-up after
successfully
> completing a standardized inpatient BZ withdrawal regime, and 21 normal
> controls matched for age and IQ but not for anxiety, were repeatedly
tested
> on a simple battery of routine psychometric tests of cognitive function,
> pre- and post- withdrawal and at 6 months follow-up. The results
> demonstrated significant impairment in patients in verbal learning and
> memory, psychomotor, visuo-motor and visuo-conceptual abilities,
compared
> with controls, at all three time points. Despite practice effects, no
> evidence of immediate recovery of cognitive function following BZ
withdrawal
> was found. Modest recovery of certain deficits emerged at 6 months
follow-up
> in the BZ group, but this remained significantly below the equivalent
> control performance. The implications of persisting cognitive deficits
after
> withdrawal from long-term BZ use are discussed. [SUMMARY p. 203]
>
> "The main cognitive functions *****sed in this study include working
memory,
> verbal learning and memory, visuo-motor and visuo-conceptual skills. The
> lack of evidence for clinically significant cognitive recovery raises
> concern about the severity and reversibility of any underlying
BZ-induced
> organic impairment." [p. 211]
>
> "The adverse effects of acute diazepam administration on memory and
arousal
> in man are well known (Lister & File, 1984; Lister, 1985), and have been
> linked to the high density of BZ receptors in the hippocampus and
reticular
> formation (Wolkowitz et al. 1987), although the neurochemical basis of
> chronic post-withdrawal deficits has yet to be demonstrated." [p. 212]
>
> "Persisting neuropsychological deficits affecting psychomotor function
and
> new verbal learning have occupational implications. Driving and safety
at
> work with machinery may both be impaired (Skegg et al. 1979, Roy-Byrne &
> Cowley, 1990).Patients' impairment, following withdrawal from long-term
BDZ
> use, is likely to be less than that due to acute drug ingestion or the
early
> withdrawal phase. Yet, one must be cautious in predicting either rapid
or
> comprehensive cognitive recovery for those patients contemplating or
> undergoing a withdrawal regime, or in estimating the cognitive effects
of
> mood dysfunction, which require further investigation." [p. 211] Lack of
> Cognitive Recovery Following Withdrawal from Long-Term Benzodiazepine
Use.
> Tata PR, Rollings J, Collins M, Pickering A, Jacobson RR, Psychological
> Medicine 1994; 24: 203-213.
>
> "...the use of benzodiazepines in patients with chronic pain would
> theoretically be ill-advised because they reduce the turnover of
s*****onin,
> thus interfering with natural sleep and lowering the tolerance to
chronic
> pain. However, the most significant problem that benzodiazepines create
> seems to be cognitive impairment with associated EEG changes (--).
Acute,
> single dose administration of diazepam does seem to produce impairment
in
> learning, memory, and psychomotor functioning." [p. 828]
>
> "...the evaluating psychiatrist noted that a great deal of cognitive
> impairment seemed to occur more often in patients using benzodiazepines
than
> in patients using only narcotics." [p. 828]
>
> "...one could conclusively state that benzodiazepines were far more
likely
> to produce cognitive impairment, with concomitant EEG changes, than were
> narcotics."[p. 830] " While neither narcotics nor benzodiazepines should
be
> used on a long-term basis, cognitive impairment was far more apparent
with
> the latter class of drugs. The question of the reversibility of the
> benzodiazepine effect is the subject of current research, but at this
time
> one may only underscore a recent suggestion by the Food and Drug
> Administration that benzodiazepines be limited to short-term use." [p.
830]
> Comparison of Cognitive Impairment Due to Benzodiazepines and to
Narcotics.
> American Journal of Psychiatry 1980; 137: 828-830.
>
> "The committee further noted that there was little convincing evidence
that
> benzodiazepines were efficacious in the treatment of anxiety after four
> months' continuous treatment. It considered that an appropriate warning
> regarding long-term efficacy be included in the recommendations,
> particularly in view of the high pro****tion of patients receiving
repeated
> prescriptions for extended periods of time ... It further suggested that
> patients receiving benzodiazepine therapy be carefully selected and
> monitored and that prescriptions be limited to short-term use" Committee
on
> Review of Medicines, Systematic Review of the Benzodiazepines, Brit Med
J,
> 29 March 1980, 910-912.
>
> "Benzodiazepine dependence would be of minor clinical significance if it
> occurred only in those few individuals taking high doses of drugs; but
it
> would be very im****tant indeed if it supervened even to a minor degree
in
> patients on usual clinical doses. Our clinical impression is that many
> patients experience symptoms on reduction or withdrawal of their
> benzodiazepine medication, and that whilst these symptoms somewhat
resemble
> those of anxiety they differ qualitatively and are often more severe
than
> those for which the medication was originally given" C. Hallström, M.
Lader,
> Benzodiazepine withdrawal phenomena, Int. Pharmacopsychiat, 1981, 16,
> 235-244.
>
> "Dependence on the benzodiazepines does occur. Patients taking these
drugs,
> even at therapeutic doses, for two or more months, may develop a
physical
> withdrawal syndrome. The cardinal feature of the syndrome is anxiety,
which
> may be mistakenly interpreted as a recrudescence of the original anxiety
for
> which the drug was prescribed" N. Hockings, B.R. Ballinger, Hypnotics
and
> anxiolytics, in New Drugs, [London: British Medical Association, 1983,
> 149-155.
>
> "The medical profession took nearly 20 years from the introduction of
> benzodiazepines to recognise officially that these minor tranquillisers
and
> hypnotics were potentially addictive. The 'happiness pills', which had
been
> propping up a fair pro****tion of the adult population since the early
1960s,
> were found to have an unexpectedly bitter aftertaste: doctors and
patients
> alike were unprepared for the problems of dependence and withdrawal that
are
> now known to be common even with normal therapeutic doses" Editorial
(Anon),
> The benzodiazepine bind, The Lancet, 22 September 1984, 706.
>
> "The extent of pharmacological dependence with regular as opposed to
> intermittent dosage of benzodiazepines was not fully appreciated until
> recently. This was probably because prominent features of drug
dependence,
> such as tolerance and escalation of dosage, are uncommon among patients
> starting on normal doses. The chief manifestation is a withdrawal
syndrome
> on stopping the drug" Anon (A. Herxheimer, ed.), Some problems with
> benzodiazepines, Drug & Ther Bull, March 25 1985, 23 (6), 21-23.
>
> "In the UK, 11.2% of all adults take an anti-anxiety drug at some time
> during any one year. But over a quarter of these people (3.1% of all
adults)
> are chronic users, taking such medication every day. Even at a
conservative
> estimate, 20% of these will develop symptoms when they attempt to
withdraw.
> That means a quarter of a million people in the UK. The sooner the
medical
> profession faces up to its responsibilities towards these iatrogenic
> addicts, the sooner it will regain the confidence of the anxious members
of
> our community" M.H. Lader, A.C. Higgitt, Management of benzodiazepine
> dependence - Update 1986, Brit J Addiction, 1986, 81, 7-10.
>
> "There is now little doubt that regular use of benzodiazepines can lead
to
> drug dependence in patients who are not drug abusers. Such patients come
to
> rely on the drugs for psychological comfort and suffer withdrawal
symptoms
> if the drug is stopped or the dosage reduced. It is estimated that
one-third
> of patients taking benzodiazepines for six months become dependent...
> Present estimates suggest that perhaps 500,000 people in the UK... are
now
> dependent on benzodiazepines" H. Ashton, Dangers and medico-legal
aspects of
> benzodiazepines, J. Med Defence Union, Summer 1987, 6-8.
>
> "It seems likely that many popular beliefs about benzodiazepine
'addiction'
> are related to the clear cut and increasingly do***ented phenomenon of
> withdrawal reactions following the use of these drugs and to the
resulting
> difficulty anxious patients sometimes have stopping drug treatment
because
> of such reactions. This phenomenon (ie inability to discontinue the drug
> because of withdrawal symptoms) is termed 'dependence' and by itself is
> enough to qualify patients for the new DSM-III-R. Diagnostic and
Statistical
> Manual of Mental Disorders, 3rd ed., revised) diagnosis of 'psychoactive
> substance dependence" (P.R. Roy-Byrne, D. Homer, Benzodiazepine
withdrawal:
> overview and implications for the treatment of anxiety, Am J Med, June
1988,
> 84, 1041 - 1052.
>
> "It has been estimated that one in three patients prescribed
benzodiazepines
> in normal therapeutic doses for six weeks would experience withdrawal
> symptoms if treatment were withdrawn abruptly. Even with gradual
withdrawal,
> patients would request further prescriptions. Thus, there is a
considerable
> risk of dependence even in comparatively short-term use" M.A. Cormack,
R.G.
> Owens, M.E. Dewey, The effect of minimal interventions by general
> practitioners on long-term benzodiazepines use, J Roy Coll Gen
> Practitioners, October 1989, 39, 408-411.
>
> "The presence of a predictable abstinence syndrome following abrupt
> discontinuance of benzodiazepines is evidence of the development of
> physiological dependence... "Historically, long-term, high-dose,
> physiological dependence has been called addiction, a term that implies
> recreational use. In recent years, however, it has become apparent that
> physiological adaptation develops and discontinuance symptoms can appear
> after regular daily therapeutic dose administration ... in some cases
after
> a few days or weeks of administration. Since therapeutic prescribing is
> clearly not recreational abuse, the term dependence is preferred to
> addiction, and the abstinence syndrome is called a discontinuance
syndrome"
> American Psychiatric Association Task Force on Benzodiazepine
Dependency.
> Benzodiazepine Dependence, Toxicity, and Abuse. Wa****ngton DC: APA,
1990.
>
> "I don't think anyone really knows what long-term effects the
> benzodiazepines are likely to have on the brain tissue ... [they] may
damage
> your brain cells and produce real physical damage to your thinking
processes
> and there is also the risk that the benzodiazepines will cause
psychological
> damage." Dr Vernon Coleman, Life Without Tranquillisers, 1985, p55.
>
> Drug companies making these products constantly warn doctors not to
allow
> patients to take them for more than a week or two. They advise doctors
not
> to make these drugs available on 'repeat prescription'. Evidence showing
> that these drugs are addictive and potentially dangerous has been
> ac***ulating rapidly since the early 1970s. Numerous research papers
have
> been published showing that products in this group can cause problems
such
> as memory loss as well as anxiety, depression and sleeplessness.
>
> Ironically, these are the three symptoms for which they are most
commonly
> prescribed. The Committee on Safety of Medicines has received re****ts
> showing that these drugs are well known to cause well over 100 different
> side effects. Earlier this month the DHSS and the Home Office publicly
> admitted that the size of Britain's tranquilliser addiction problem is
> worrying them by bringing these drugs under the Misuse of Drugs Act 1971
-
> the same legislation that controls drugs such as heroin. And yet
thousands
> of doctors don't seem to take any notice. It may be true that many still
> don't know what else to do for patients who are suffering from anxiety
or
> stress-related diseases. The only conclusion I can draw is that several
> thousand British doctors do not read articles in the medical journals
nor do
> they study literature which is published by the drug companies.
>
> These painfully ignorant doctors have between them created the biggest
drug
> addiction problem this country has ever known. It's their addiction to
> prescribing these terrible drugs that has given us a nation of junkies.
The
> nightmare pills: How millions are caught in the tranquilliser trap,
Today,
> 07 May, 1986, Dr Vernon Coleman.
>
> "Anxiolytic treatment should be limited to short periods... because of
the
> danger of insidious development of dependence and subsequent difficulty
in
> withdrawing the drug... Withdrawal of the drug following either high
dosage
> or long-term administration should be gradual as abrupt withdrawal may
> produce confusion, toxic psychosis, convulsions or a condition
resembling
> delirium tremens. In milder cases symptoms may be similar to the
original
> complaint and encourage further prescribing." 1981 British National
> Formulary.
>
> Anxiolytic treatment should be limited to the lowest possible dose for
the
> shortest possible time... Prescribing of these drugs is widespread but
> dependence (both physical and psychological) and tolerance occurs. This
may
> lead to difficulty in withdrawing the drug after the patient has been
taking
> it regularly for more than a few weeks. Hypnotics and anxiolytics should
> therefore be reserved for short courses to alleviate acute conditions.
> British National Formulary, March 1998 edition.
>
> Benzodiazepines are indicated for the short-term relief (two to four
weeks
> only) of anxiety that is severe, disabling or subjecting the individual
to
> unacceptable distress, occurring alone or in association with insomnia
or
> short-term psychosomatic, organic or psychotic illness. The use of
> benzodiazepines to treat short-term 'mild' anxiety is inappropriate and
> unsuitable. Benzodiazepines should be used to treat insomnia only when
it is
> severe, disabling, or subjecting the individual to extreme distress. The
> Committee on Safety of Medicines, January 1988.
>
> "Prolonged or excessive use of benzodiazepines may occasionally result
in
> the development of psychological dependence with withdrawal symptoms on
> sudden discontinuation. This is more likely in patients with a history
of
> alcoholism, drug abuse or patients with marked personality disorders.
> Treatment in all patients should be withdrawn gradually. Careful
monitoring
> of all patients is essential." 1983 John Wyeth Data Sheet.
>
> "It is more difficult to withdraw people from BDZs than it is heroin, it
> just seems that the dependency is so ingrained and the withdrawal
symptoms
> you get are so intolerable that people have a great deal of problem
coming
> off. The other aspect is that with heroin, usually the withdrawal is
over
> within a week or so, with BDZs, a pro****tion of patients go on to long
term
> withdrawal & they have very unpleasant symptoms for month after month, &
I
> get letters from people saying you can go on for two years or more. Some
of
> the tranquilliser groups can do***ent people who still have symptoms ten
> years after stopping." Professor Malcolm H Lader, Royal Maudesley
Hospital,
> "You & Yours" - BBC Radio 4, 1999.
>
> The benzodiazepines are still extensively used in psychiatry, neurology
and
> medicine in general. Anxiety disorder and severe insomnia are im****tant
> syndromal indications, but these drugs are widely prescribed at the
> symptomatic level, resulting in potential overuse. The official data
sheets
> recommend short durations of usage and conservative dosage. Although
> short-term efficacy is established, long-term efficacy remains
> controversial, as relevant data are scanty and relapse, rebound and
> dependence on withdrawal not clearly distinguished. The risks of the
> benzodiazepines are well-do***ented and comprise psychological and
physical
> effects. Among the former are subjective sedation, paradoxical release
of
> anxiety and/or hostility, psychomotor impairment, memory disruption, and
> risks of accidents. Physical effects include vertigo, dysarthria, ataxia
> with falls, especially in the elderly. Dependence can supervene on
long-term
> use, occasionally with dose escalation. The benzodiazepines are now
> recognised as major drugs of abuse and addiction. Other drug and
non-drug
> therapies are available and have a superior risk benefit ratio in
long-term
> use. It is concluded that benzodiazepines should be reserved for
short-term
> use - up to 4 weeks - and in conservative dosage. Professor Malcolm H
Lader,
> Institute of Psychiatry, University of London, UK. Limitations on the
use of
> benzodiazepines in anxiety and insomnia: are they justified? In: Eur
> Neuropsychopharmacol 1999 Dec;9 Suppl 6:S399-405.
>
> The concepts of dependence, addiction and abuse comprise overlapping
> clinical phenomena. The earlier anxiolytic drugs, in particular the
> barbiturates, were prone to abuse, i.e., non-medical use, and to
high-dose
> misuse. Their modern counterparts, the benzodiazepines, are abused in a
> patchy way and are sometimes taken in regularly high doses. However, the
> main problem is physical dependence as manifested by a withdrawal
syndrome
> on discontinuation of the drug. The withdrawal syndrome has been
carefully
> described and comprises physical and psychological features. In
particular,
> perceptual symptoms such as photophobia, hyperacusis and feelings of
> unsteadiness may predominate. The syndrome may come on during dosage
> reduction but generally starts 2-10 days after cessation of the
> benzodiazepine, depending on its elimination half-life. About a third of
> long-term users suffer a recognisable syndrome even after a tapered
> withdrawal, its duration usually being only a few weeks. A few patients
go
> on to a prolonged withdrawal syndrome, often characterised by muscular
> spasm. The treatment of the withdrawal syndrome is sup****tive and
> non-specific. A few patients started on benzodiazepine therapy escalate
the
> dose. They tend to show the characteristic 'passive-dependent'
personality
> features and may previously have misused other CNS depressants such as
the
> barbiturates and alcohol. Abuse of benzodiazepines occurs in a rather
varied
> way from country to country. Worldwide, flunitrazepam has caused concern
> but, in the UK, the main problem has been the intravenous use of
temazepam.
> The molecular pharmacology of the benzodiazepine receptor has been
> extensively studied and is undoubtedly complex. Professor Malcolm H
Lader,
> Department of Clinical Psychopharmacology, Institute of Psychiatry,
London,
> UK. Anxiolytic drugs: dependence, addiction and abuse. Eur
> Neuropsychopharmacol 1994 Jun;4(2):85-91.
>
> Withdrawal of benzodiazepines is currently advised for long-term
> benzodiazepine users because of doubts about continued efficacy, risks
of
> adverse effects, including dependence and neuropsychological impairment
and
> socio-economic costs. About half a million people in the UK may need
advice
> on withdrawal. Successful withdrawal strategies should combine gradual
> dosage reduction and psychological sup****t. The benzodiazepine dosage
should
> be tapered at an individually titrated rate which should usually be
under
> the patient's control. The whole process may take weeks or months.
> Withdrawal from diazepam is convenient because of available dosage
> strengths, but can be carried out directly from other benzodiazepine.
> Adjuvant medication may occasionally be required (antidepressants,
> propranolol) but no drugs have been proved to be of general utility in
> alleviating withdrawal-related symptoms. Psychological sup****t should be
> available both during dosage reduction and for some months after
cessation
> of drug use. Such sup****t should include the provision of information
about
> benzodiazepines, general encouragement, and measures to reduce anxiety
and
> promote the learning of non-pharmacological ways of coping with stress.
For
> many patients the degree of sup****t required is minimal; a minority may
need
> counselling or formal psychological therapy. Unwilling patients should
not
> be forced to withdraw. With these methods, success rates of withdrawal
are
> high and are unaffected by duration of usage, dosage or type of
> benzodiazepine, rate of withdrawal, symptom severity, psychiatric
history or
> personality disorder. Longer-term outcome is less clear; a considerable
> pro****tion of patients may tem****arily take benzodiazepines again and
some
> need other psychotropic medication. However, the outcome may be improved
by
> careful pharmacological and psychological handling of withdrawal and
> post-withdrawal phases. Ashton CH, Department of Pharmacological
Sciences,
> University of Newcastle upon Tyne, UK. The treatment of benzodiazepine
> dependence, Addiction 1994 Nov;89(11):1535-41.
>
> This paper presents the results of a survey carried out to investigate
the
> benzodiazepine (BZD) prescribing patterns of the general practitioners
(GP)
> in the catchment area of a Drug Dependence Unit located in a general
> hospital in Mataro (Barcelona, Spain). The aims of the survey were: (i)
to
> obtain descriptive information on the knowledge of the GPs about BZD and
its
> potential for dependence; (ii) to study the frequency of their
prescribing;
> and (iii) to examine different factors linked to their prescribing. The
> study was carried out using a combination of a personal interview and a
> self-administered questionnaire. A total of 68 doctors (88.3%) completed
the
> questionnaire. The results show that the GPs have, in general, correct
> knowledge about the therapeutic indications for BZD prescribing, but are
far
> less aware of their potential to induce dependence and how to manage
> withdrawal. The rate of prescribing seems to be high. Furthermore, the
> results of the external check of validity point out that doctors tend to
> underestimate the number of prescriptions. The majority of GPs express
the
> need for alternative resources to BZD prescribing. No significant
> associations have been found between doctor's characteristics, such as
> postgraduate training and type of practice, and their knowledge about
BZD
> and frequency of their prescribing. In our view, a more accurate
knowledge
> about BZD and alternatives to its use, both factors closely linked to
> training, together with the availability of non-pharmacological
resources,
> are likely to improve the quality of doctors prescribing habits, thus
> preventing risks such as dependence of BZD. Benzodiazepines in primary
> health care: a survey of general practitioners prescribing patterns,
Boixet
> M, Batlle E, Bolibar I, Unitat Assistencial de Drogodependencias, Servei
de
> Psiquiatria, Barcelona, Spain.
>
> Benzodiazepines are medications that are addicting - both in combination
> with other drugs and alone. The scope of the problem is thought to be
wide,
> but it has not been well do***ented for unclear reasons. Pharmacologic
> dependence has been do***ented in virtually all long-term users. Adverse
> effects occur secondary to their use and these effects are often subtle,
but
> significant. Various benzodiazepines present differences in
reinforcement,
> withdrawal, and adverse effects. Diagnostic issues, withdrawal, and
> treatment issues are discussed. Benzodiazepines and addiction. Psychiatr
> Clin North Am 1993 Mar;16(1):75-86. Juergens SM Virginia Mason
Outpatient
> Chemical Dependency Program, Virginia Mason Clinic.
>
>
>
--------------------------------------------------------------------------------
>
> Some Highlights from The Beat the Benzos Conference, Croydon, November
2000:
>
> Dr Nicholas Seivewright
> Dr Seivewright is a psychiatrist working in the area of drug misusers.
At
> the end of his talk he mentioned that he felt that his profession had no
> problem with reclassifying benzodiazepines (BDZs). He said that this
would
> solve the immediate problem of street abuse of the drugs, although there
may
> be problems with other aspects of reclassification.
>
> Dr James Robertson
> Paediatrician at Arrowe Park Hospital, The Wirral. Dr Robertson said he
> categorised BDZs as more dangerous than opiates or methadone to the
newborn
> and that "babies affected can go on suffering for months and months" and
> "that the parenting 'benzo babies' receive will be poor, not through any
> fault of the parent, but the fault of the drug plus the parent".
>
> Professor Stefan Borg
> Head of Addiction Medicine, Karolinska Institute, Sweden. Professor Borg
has
> been researching the biochemical changes induced by long term BDZ use.
He
> said extensive research in this area showed that cognitive /
> psycho-neurological impairment was measurable during long term BDZ use,
> increased during acute withdrawal and very slowly reverses over months
or
> years after cessation of the drugs. A most significant finding was that
> flumazenil, a BDZ antagonist ("antidote") when given to people, who had
been
> off the drugs for some time but continued with unpleasant symptoms,
improved
> or were completely relieved of these symptoms. Flumazenil is a Roche
product
> licensed for use in reversing the action of BDZs after anaesthesia and
> overdose.
>
>
|
