Decrease your anxiety managing sedative-hypnotic use disorders! By the end of this episode, you will have practical tips on how to discuss benzodiazepine use, plan a taper, and support your patient throughout the process. We’re joined by Dr. Ximena Levander @XimenaLevander (OHSU).
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It’s important to know where patients are getting their benzodiazepines. Ask the following questions on their benzodiazepine source.
Pressed pills from the street can contain fentanyl (Green, 2016). Thus, educate patients on this and provide naloxone and overdose prevention when appropriate. It is also important to discuss other benzodiazepine harm reduction tools, including the risks of mixing benzodiazepines with other medications that cause respiratory depression and the importance of starting low and going slow.
Other Sedatives and hypnotics
Ask your patients if they use non-benzodiazepine sedatives, such as gabapentinoids (e.g., gabapentin, pregabalin), barbiturates, muscle relaxants, and z-drugs such as zolpidem as there may be an increased risk of adverse events for a patient taking multiple of these substances.
When prescribing benzodiazepines or trying to determine what patients are taking from other sources, urine drug screens can be a helpful tool but require thoughtful interpretation. Particularly for benzodiazepines, urine drug screens (immunoassays) have significant limitations as they are designed to detect specific benzodiazepine metabolites (Kale, 2019). It is important to understand what metabolite the immunoassay is designed to detect (Craven, 2014). For example, benzodiazepine immunoassay screens are often negative for clonazepam and alprazolam as well as novel benzodiazepines that are not tested for on routine screening urine drug screens.
Confirmation testing with gas chromatography can be helpful to detect specific types of benzodiazepines. Importantly, all testing should be discussed with patients ahead of time as a way to gather information and facilitate a conversation rather than used for punitive purposes.
Benzodiazepines are indicated for treatment of generalized anxiety, panic attacks, insomnia, and alcohol withdrawal. Typically, these indications are intended for short-term use, generally not chronic use.
Adverse effects of benzodiazepines include physiological dependence that can develop in as little a few weeks of regular use (Peng, 2022), excessive sedation, falls, motor vehicle accidents especially in older patients (benzodiazepines are on the BEERS list), rebound anxiety, insomnia symptoms with any dose reduction, and many medication interactions (Soyka, 2017).
Benzodiazepine withdrawal symptoms may include irritability, GI symptoms, rebound anxiety, insomnia, difficulty concentrating, delirium, seizures, and death (Peng, 2022). The evidence for effective treatment of benzodiazepine withdrawal is limited. In Dr. Levander’s expert opinion, she will use the CIWA-Ar (a validated scale for alcohol withdrawal) to monitor benzodiazepine withdrawal symptoms while someone is in the hospital. The CIWA-B has been used in research studies to assess benzodiazepine withdrawal but does not have clinical correlation data for medication management (e.g., does not give us cutoffs on when to administer medication).
Benzodiazepine withdrawal can be protracted and lead to post-acute withdrawal syndrome (PAWS) that can last weeks (Ashton, 1991).
Many patients do not have a sedative-hypnotic use disorder and are not experiencing harm from the medication. In that case, clinicians should discuss the risks and benefits of continuing benzodiazepines with their patients and monitor for any signs and symptoms of impairment/adverse effects.
For patients who meet DSM-5 criteria for sedative-hypnotic use disorder and those who don’t meet diagnostic criteria but are experiencing harm from the medication, the general approach is to taper someone off the benzodiazepines. A taper plan should be crafted and discussed with your patient before starting. When considering a benzodiazepine taper, we must ask: who are we treating? Are we trying to make ourselves feel better, our clinic system feel better, or our patients feel better? Center the discussion around patient preferences and safety.
When developing a benzodiazepine taper, in Dr. Levander’s expert opinion, she recommends converting to a long-acting benzodiazepine, such as diazepam. Benzodiazepine equivalency charts (GlobalRPH, Ashton manual) can be used as a starting point to guide conversion. These charts have limitations due to individual variability in benzodiazepine metabolism, so be prepared to adjust the dose based on your patient’s symptoms.
In general, slower outpatient tapers (over weeks to months) are recommended (Soyka, 2017). Rapid tapers (over 3-7 days) are more difficult to tolerate and generally require a supervised environment, such as a medically supervised detoxification facility or hospital.
Rapid tapers may be indicated if there are significant concerns about safety with the
continuation of benzodiazepines which may include the following:
Rapid tapers are typically done over 3-7 days in a monitored setting. Medically supervised benzodiazepine withdrawal treatment protocols usually involve a fixed taper (20-30% dose reduction/day) with a long-acting benzodiazepine. Non-benzodiazepine adjunctive medications may be offered and continued on discharge since some symptoms of benzodiazepine withdrawal can continue for weeks or even months after taper completion.
Many clinicians use the CIWA-Ar scoring system in the hospital setting to monitor symptoms. While the CIWA-Ar was not developed for benzodiazepine withdrawal, it is often the most readily available tool to monitor symptom severity. As previously mentioned, the CIWA-B has been validated to assess benzodiazepine withdrawal (Busto, 1989). Still, its use is more common for research purposes and less common in clinical settings where nurses and other healthcare professionals lack training on how to use it.
Prolonged outpatient tapers are typically planned over weeks to months. If a patient uses a short-acting benzodiazepine, transition them to a dose-equivalent long-acting benzodiazepine over approximately two weeks. Additional first-line treatment for underlying anxiety disorders and insomnia can be initiated before or during this transition.
Once fully converted to a long-acting benzodiazepine, per Dr. Levander’s expert opinion, aim for ~10% dose reduction per week. The initial transition period and the end of the taper are times when it is most important to see patients frequently. Clinicians should ensure close follow-up with weekly or at least every two-week visit during the taper.
The end of the taper tends to be the most challenging for patients. Sometimes it’s necessary to slow the taper down. If a patients continues to be challenges with tapering the medication or do not want to taper further, and have no immediate or significant risks, you should consider continuing them on a lower benzodiazepine dose and periodically revisit risks and benefits with them as appropriate.
A full taper off the medication may be challenging if patients have been taking benzodiazepines for many years. Data suggests that sustained cessation of use is difficult – approximately ⅓ of tapered patients will return to use (Voshaar, 2006).
Recently, a new clinical concept has been proposed – complex persistent benzodiazepine dependence which you can read more about in Peng, 2022,
Consider adjunctive medications, such as gabapentin, carbamazepine, or valproic acid, to help with withdrawal symptoms (Baandrup, 2018). If patients have underlying anxiety, offer treatment (SSRI, buspirone). If they have insomnia, offer CBT-i (CBT for insomnia). Remember to review their other medications (e.g., stimulants), which could contribute to anxiety or insomnia, and lower those dosages as needed. Additionally, behavioral support can be helpful for patients (Darker, 2015). In addition to behavioral health resources in person, many phone apps may be helpful with rebound symptoms of anxiety and insomnia (Breath2Relax, VA CBTi). For patients with co-occurring OUD, it is essential to treat OUD with first-line medications while balancing risks and benefits.
Josie and the Pussycats (film)
Listeners will develop a framework to approach the evaluation and management of sedative-hypnotic use disorders.
After listening to this episode listeners will…
Dr. Levander reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Morford, K, Levander, X. Huxley-Reicher, Z, Stahl N, Chan, CA. #6 Get Hip to Sedative-Hypnotic Use Disorders. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/episode-list August 11, 2022
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