De-escalate Benzodiazepine Use

Abstract

Over the past five decades, benzodiazepines have been routinely prescribed in the treatment of anxiety disorder due to their overall efficiency and quick action. Yet, drugs in this class are increasingly associated with a spike in misuse owing to its relatively high potential for abuse. Adult patients with anxiety disorders have particularly borne the brunt of this serious challenge, prompting renewed calls for the de-escalation of benzodiazepine use. The following is an in-depth evaluation of this contemporary debacle through an exhaustive appraisal of published literature on the subject when attempting to introduce an actionable solution to the problem.

Keywords: benzodiazepines, de-escalation, abuse, misuse

Introduction

            Today, benzodiazepines use is crucial in treating symptoms commonly associated within convulsive disorders and anxiety disorder. Librium (chlordiazepoxide) was the first drug in this class to be approved for use within the United States and its insular territories during the early 1960s (Tyrer, 2019). However, the drug’s relative efficiency and availability is increasingly being overshadowed by concerns about over-prescription and subsequent abuse and misuse. This is further exacerbated by the absence of a collective consensus among medical experts on the diagnostic criterion which should be satisfied to warrant a benzodiazepine prescription. The federal government, through the Department of Health and Human Services (HHS), has recently tried to address the concerns raised by attempting to regulate the production and sale of benzodiazepines, albeit with little success. Insufficient data on drug utilization behaviors and problems associated with recommending relatively high doses of benzodiazepines has also impeded efforts to appropriately conduct comparative drug consumption within the United States. Addressing this issue is therefore imperative when aspiring to avert the actual impact of abusing benzodiazepines today. According to Samardzic & Svob Strac (2016), benzodiazepine abuse is associated with physical effects such as poor coordination, loss of visuo-spatial ability, irritability, sleep disturbances, increased anxiety and continual drowsiness. Extreme cases of benzodiazepine abuse may also result in an emergency room (E.R) visit and even death. Addressing the current problem is crucial in concerted health promotion initiatives to promote the appropriate use of the medication, prevent harm from abuse, and improve patient outcomes.

Background & Significance

            The behavioral effect of benzodiazepines has been compared to the impact of high doses of barbiturates on the body.  Traditionally, benzodiazepines are renowned for a sedative-hypnotic effect, inducing muscle relaxation, and causing an overall reduction in levels of anxiety. However, it is worth noting that patients taking benzodiazepines are highly likely to experience thee “withdrawal rebound phenomenon” associated with the drug (Peppin et al., 2020). A pattern of physical dependence amongst patients is beginning to emerge as a consequence of prolonged and uninhibited use of the drug. The overall inability among anxiety patients to successfully address the withdrawal effects is among one of the primary reasons why attention is currently turning to the long effects of prescribing. Lab experiments with rats and dogs after prescribing doses of Temazepam and Camazepam has also recorded similar results, further raising their side effect profile (Balon & Starcevic, 2020, p. 978). It has, thus, been proved beyond any reasonable doubt that benzodiazepines create physical dependencies and with a significant impact on living organisms. Their reinforcing efficacy is, thus, higher in individuals who ultimately develop a physical dependence to the drug. Benzodiazepine abuse often starts with patient’s prescription drugs that later progress to taking more than the recommended doses before developing tolerance. Common withdrawal effects after stopping a benzodiazepine cessation include perceptual distortion, insomnia, coordination problems, and restlessness (Tyrer, 2019).These effects are particularly common among individuals blatantly abusing the drug or those on a restively high dose of the medication. Tolerance also fosters the need for higher doses for the drug to elicit an initial therapeutic effect.

            The significance of this study is, therefore, promoting efforts to stem benzodiazepine dependence while promoting the recovery of former addicts. Benzodiazepines have a far-reaching effect on the human body and may have gar-reaching effects on their sobriety. Medical practitioners are currently aware of its far-reaching impacts and supported medical detox and tapering off the medication to prevent addiction while addressing the prevailing excess. Recovery programs for benzodiazepines include medication such as Nacronon, recommended in the management of withdrawal effects and maintaining robust sobriety plans dig recovery. This is further influenced by effort to avert cognitive effects associated with drug. According to Lader (2019), benzodiazepine abuse is likely to slow the processing of thoughts and verbal abilities, which are particularly common in persons recovering from the drugs. This reality has prompted medical practitioners to campaign against the long-term impact, Furthermore; the prevention of drug dependence goes a long way in managing substance abuse which impacts a considerable cross-section of individuals on prescription medication. Dependence on benzodiazepines is associated with poly-drug abuse and likely to be fatal in the event it is not managed within an appropriate timeline (Jones, 2016). Continued use of benzodiazepines is likely to serve as a gateway drug to heroin, methadone, and alcohol use among high-dose benzodiazepine abuse. The street value of benzodiazepines has further promoted addiction to the drug. .  These effects are particularly common among individuals blatantly abusing the drug or those on a restively high dose of the medication. Tolerance also fosters the need for higher doses of the drug to elicit an initial therapeutic effect. Individuals with anxiety disorder represent an at-risk population due to their propensity to misuse prescribed benzodiazepines. The drug’s rapid onset of action and mind-altering properties further increases the frequency of cases involving addiction. As a consequence, healthcare practitioners and the sector in general are now confronted with an emerging public health crisis which threatens to introduce a new retrogressive epoch in healthcare. Furthermore, the community will also be contending with a new wave of addiction to prescription drugs similar to the opioid crisis and with far reaching consequences for society in general.

Review & Synthesis of Literature

  • PICOT question: “Among adult patients with anxiety disorders what is the best strategy in de-escalating benzodiazepine use to prevent its abuse and/or misuse?”

As mentioned earlier, adult patients with anxiety disorder abuse or misuses prescribed medications for their respective condition. Bandelow et al. (2017) were among a select few who conducted an assessment of the pre-post effect in relation to changes in size prior and after commencing treatment with medications and psychotherapies. A total of 35,000 patients aged between 7 years and 65 years were included as an ideal sample population for the psychotherapy studies. The result would later indicate that individuals within this particular grouped exhibited less damaging effect within an outpatient setting. Additionally, major variables: IV1 was Tx, no Tx for IV2, other Tx for IV, and level of anxiety as an indicator for DVI. The Hamilton Anxiety Rating Scale (HAM-A) was also utilized as an ideal diagnostic measure and analysis based on frequency and relative risk. The findings recorded indicated a significant drop in anxiety levels after the implementation of a drug treatment regimen and CBT. In relation to the synthesis of this scholarly work, the evidence was robust and supported the treatment of GAD, PDA, and SAD. It would, therefore, go a long way in contributing to the application of tools and large data in the diagnosis and rating of patients with anxiety and on benzodiazepines.

Similarly, Bandelow et al. (2015) conducted a meta-analysis and a systematic review ion comparing the relative efficacy of pharmacological intervention as opposed to a combined treatment for Generalized Anxiety Disorder (GAD), Panic Disorder (PD). A total of 37,333 participants took part in the study which also included randomized trials with adults receiving pharmacological treatment for GAD. The IV1 was BZD, IV2 no Tx, an SSRI for IV3 and the level of anxiety as the primary DV1. Similarly, the Hamilton Anxiety Rating Scale (HAM-A) was applied in this particular case data analysis conducted based on frequency and relative risk. The preliminary findings recorded in this study indicated a lower level of anxiety after the implementation of a treatment plan with a selective serotonin reuptake inhibitor (SSRI). The study’s transparent design, analysis approach based on the HAM-A scale and the presence of a predefined question, later answered appropriately, were some of the major strengths noted during the initial appraisal. However, the researchers’ overreliance on a single viewer framework in the evaluation of published literature and the presence of mixed treatment meta-analyses were among some of the major weaknesses noted. This was further compounded by insufficient data when conducting respective statistical analyses.

          Brett & Murnion (2015) also conducted an elaborate Cochrane review with the primary aim of highlighting benzodiazepine dependence as a major public health concern. The initial review involved a grand total of 27 studies approved for the initial appraisal. Furthermore, IV1 was Benzo Tx, IV2 no Tx, IV3 other TX and DV1 based on the actual level of anxiety. The measures applied relied upon the Severity Dependence Scale and an appraisal of the impact of treatment with benzodiazepines and subsequent discontinuation. Results obtained from this review suggested that slowly tapering off prescribed medications within the benzodiazepine family and further amalgamating this approach with psychological treatment was superior to approaches centered only on reduction.  The analysis was based primarily on frequency and relative risk. Ultimately, it was determined that the de-escalation of prescribed benzodiazepines should be based an appropriate evaluation and identification of patients with anxiety disorder to gauge the actual risk of harm. Also noteworthy is the fact that prescribed benzodiazepines can be withdrawn at any given moment without requiring the application of additional treatment programs, but only applying pharmacotherapy to lower anxiety. A major strength of this particular study was the suggestion that incorporating cognitive behavioral therapy (CBT) during dose-reduction was quite effective compared to a single reduction routine. Yet, the primary weakness was insufficient data to gauge the actual efficiency of interview monitoring.

Evans (2015) conducted a systematic review with the main aim of presenting anxiety treatment to women across the board and records their overall satisfaction with a specified intervention in addressing symptoms of anxiety during treatment. Subjects were pregnant women from a diverse pool and across the three trimesters of pregnancy. Individuals less than 18 years of age and those incapable of providing informed consent. IV1 was Tx, IV2 registered no Tx, IV3 other Tx, and anxiety level for DVI.  Tools utilized in this study include the Becky Anxiety Inventory (BAI), Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder–2 items (GAD-2), and the Prenatal Distress Questionnaire (PDQ). Analysis was based primarily on frequency and relative risk. The decision on the most appropriate treatment option was based solely available barriers and motives, acceptability of proposed interventions, and overall satisfaction level. A major strength of the study was its exclusive focus on women when probing the most ideal option when probing the efficacy of a proposed intervention. However, weaknesses include the limited reporting of the questionnaire design and its administration.

          Roy-Byrne (2015) conducted a meta-analysis to investigate the best approach in the treatment of refractory anxiety. IV1 was Tx, IV2 recorded no Tx, IV3 other Tx, and the prevailing level of anxiety for DV1. The Coordinated Anxiety Learning and Management (CALM) tool was ideal for this study, especially in relation to identifying the most appropriate treatment options for individuals with anxiety. The analysis was based on the actual frequency of using benzodiazepines, its relative risk, and other available options. The strength of the evidence provided was on its focus on multiple treatment options and the amalgamation of CBT

          A routine meta-analysis by Platt (2016) sought to ascertain the impact of using benzodiazepines versus alternative treatment options. A total of 12 studies were appraised, in addition to the participation of 1338 adult patients with anxiety over a six-month period. BZDs Tx represented IV1, no Tx for IV2, other Tx for IV3 and level of anxiety for DV1. The GAD, PDSS, and SPIN were ideal tools for this study. The analysis was based on the actual frequency of using benzodiazepines. The findings indicated that natural non-chemical anxiolytic treatments are available and can be safely recommended for patients. The strength of this study was in its use of empirical data while its weakness which went a long way in painting an elaborate picture of benzodiazepine addiction as a major public health issue.              

Shinfuku (2019) conducted a randomized control study to investigate the short-and long-term effects of benzodiazepines. A total of 1228 participants took part in the study over a 13-week period. IV1 Tx, no Tx recorded for IV2, other Tx for IV3, and the level of anxiety for DV1. The HAM-A tool was implemented to gauge the efficacy of treatment option and an accompanying analysis based on relative risk and frequency of use.  After the first 8 weeks, it was discovered that no significant differences existed between prescribing benzodiazepines and antidepressants. The study was well designed, with accurate findings which supported the proposition. However, the limited amount of studies used meant that further investigation on the role and safety of benzodiazepines.

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