Transcript Document

Benzodiazepines: The ‘Silent’
Partner
Exploring practical considerations
of working with polydrug users…
Laura Freeman, Ph.D.
Glasgow Addiction Services
Training Psychologist
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.
Illumination continued….
Griffiths & Weerts (1997). Benzodiazepine selfadministration in humans and laboratory
animals – implications for problems of longterm 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.
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
Information on the potential
impact of the benzo’s is
there, we just have not
translated it to front-line
work (or even found all of
it!)…
Working with Benzo Use:
Paradoxical Effects
BNF states clearly that some people have a
paradoxical effect to benzo’s:
“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.
Working with Benzo Use:
Paradoxical 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.
Working with Benzo Use:
Paradoxical 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
Working with Benzo Use:
Anterograde 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
Working with Benzo Use:
Anterograde Amnesia
Timing of the use of benzo’s
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”
Consider the combination
of Paradoxical Effects and
Anterograde Amnesia
Major Challenge
If people experience paradoxical effects,
but then don’t remember them….they
will continue to believe that the drug is
working….
Insomnia as one example
Working with Benzo Use:
Impact 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
Working with Benzo Use:
Impact 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.
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
benzo’s?
Sleep apnea risk needs to be considered
with both alcohol and benzo use; how
about methadone in the mix?
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!
Now, in a polysubstance cocktail
culture…. Cognitive Impairment
Cognitive impairment among those
stable on methadone maintenance in
Australia…related to:
Number of overdoses
Extent of alcohol use
Short and long term verbal learning most
severely impacted.
Do the benzo’s complicate this picture?
“Suggestions” for Practical
Considerations
Timing of the use of benzo’s 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
“Suggestions” for Practical
Considerations
Educate about the cocktail + overdose
risk…And 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.
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
Questions to explore in research…
Overdose risk – both behavioural + drug related
Sleep apnea
Cognitive impairment
Memory – when + where + which benzo’s 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?