are you asking for the management for what psychiatric disorder?

Maybe there is a reason that they use these drugs. Perhaps it helps them to deal with specific issues that they face and have found that alternatives promoted by the establishment do more harm than the illegal or unprescribed alternatives that they have found to work.

I would ask the patient why they use it, and not be judgmental, be supportive in trying to understand what value this provides to them, then try to find whether they might be willing to consider alternatives (but don't force them to or try to manipulate them into thinking that you have all the keys, for example, or they will never trust you).

As an addiction medicine specialist patient's that need treatment for anxiety the only medication recommended is klonopin.

I think a benzodiazepine addicted patient requires always a long inpatient-treatment in an addiction-specialised psychiatric unit including ICU. Long means for weeks: the half-life-time of chlordiazepoxide is 36 up to 200h, Diazepam up to 100h! So it takes a long time to detox.

Try to substitute all benzos with oxazepam and take bloodtests (chromatographic, quantitative!!! Urine tests and antibody-tests, i.e. immunoassays are worthless until the patient is clean!) to document the reduction of all the other benzos. Be aware of a benzodiazepine induced delirium (in that case, the patient needs ICU!).

After achivement of abstinence it will need more weeks of psychiatric control and diagnosis to differ between addiction induced craving and for example an axiety-dissorder. In any case the patient will need a lot of care.

Best regards

Chaim jellinek

I agree with both Drs. Imbert and Jellinek.  This isn't really poly-substance abuse, but rather benzodiazepine use disorder - all of these medications have essentially the same mechanism of action, which is that they act as repuptake inhibitors for GABA, thereby increasing GABA levels (primarily in the amygdala).  Problem: tolerance develops rapidly.  Risk: respiratory depression death, esp. if pt. mixes with alcohol, opioids, or other respiratory depressants.  

I agree that benzos have long-half lives and thus taper must be slow and gradual, but some of this can be done outpatient - they don't necessarily have to spend 90 days in detox, or whatever the half-life calculations would imply.  The real challenge is to keep the pt from going back to using benzos once they stop.  There is a real school of thought (esp. here in the US) amongst psychiatrists that it's almost impossible to stay free of benzos after long-term dependence has been established, and the idea is basically to wean the pt down to a "reasonable" dose of a safe long-half life (30 hr) med like clonzepam (as Dr. Bradley notes).

You should also investigate PREGABALIN - marketed by Pfizer as Lyrica - which has been used quite successfully as an anti-anxiety medication and as a substitute for benzos.  While it has some misuse potential (Schedule V in the US, meaning it's controlled substance but has little potential for misuse) I believe there are some studies showing that it is superior to benzos (as an alternative anxiety med) and also a good med to use for detox/transition.  I'm not an expert here, but many of the academic hospitals are starting to use it for anxiety instead of benzos, because benzos are highly addictive.  Another benefit to pregabalin is that it is -- anecdotally -- not nearly as difficult to discontinue as benzos.  So the Tx strategy for a multi-bento-dependent patient might be to gradually switch to pregabalin, and then gradually discontinue pregablin.  Still, the odds that the pt will ever be able to stay free of any GABA-upregulating meds are slim, as far as I know.  

I agree with Nathan about our need to understand what is the value for the patient of this behavior of use (or abuse). This is a very relevant issue because some consumption behaviours do not seem related to the pharmacological characteristics of the drug. Then, we must try to agree whether they might be willing to consider alternatives. However, it is a difficult issue in clinical practice which combines medical, social, and legal aspects.

I am also concerned about the implications of the diversion of drugs on the black market , or the implications of driving or working under the influence of high doses of benzodiazepines.

II would recommend first  a prolonged detox program in an inpatient setting with the initial substitution of all BDZ with a long half-life as delorazepam and than a tapering off  of 15% of the dosage every two weeks. 

The problem with PREGABALIN: it just works in benzo.-addictetd people for some weeks, then the running for daily higher dossages starts. Its well known in IVDU, the actual price on the street is as high as diazepam itself!

the price on the street is a good marker for the importance of a special drug in "self- treatment" of IVDUs. Also Doxepine is an often used drug while psychiatrists still believe it a good substance in treating addicts.

outpatient-treatment of benzo.-dependend patients works good with low-dose monovalent benzo.-users, but its nearly hopeless in cases of multidrug-high-dose benzo.-patients

thinks

Chaim

It's difficult for me understand the reason of assuming a so terrible "cocktail".What psychiatric pathology requires it? I don't know. "Self-medication" is a remote possibilty. How to manage the abuser patient? It depends on the underlying disorder. 

Hello,

Reading your question, I'm not sure if you're asking about a patient using these four drugs, or whether to prescribe one of these drugs to someone with poly-substance dependence. I am answering for the latter, but if this is not what you meant I can comment on the former.

Assuming the drugs in parentheses are the drugs the patient is using, this patient would not be considered a poly-drug user. All four drugs you mention are benzodiazepines so pharmacologically they have almost identical mechanisms of action. You can conceptualize them as one drug.

That said benzodiazepine misuse can be extremely problematic. Even though the risk for overdose is low (as long as the patient is not mixing the drug with other sedative-hypnotics), the withdrawal syndrome can be severe and prolonged. Notably, as with alcohol, there is also risk for death during the acute withdrawal stage. If the patient is using benzos in high amounts medically supervised detox is indicated.

First line treatment in the US, UK, and Australia would then be to use motivational interviewing (http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5091432&fileId=S135246580001643X) to increase the patient's insight into the problematic nature of their drug use, and enhance the patient's motivation to change their behavior. This would be followed by cognitive behavioral therapy (delivered either on an inpatient or outpatient basis), and/or 12-Step informed treatment.

David

I believe that getting the patient to one or two kinds of medication in combination with psychotherapy is the better way here. Let us for instance consider a patient who is taking 20 mg of diazepam, 4mg of clonazepam for day time use and 2-3 zolpidem for sleep. The best option medication wise would probably be to go for something like this 

Diazepam (30-40mg) that would replace the clonazepam and can be built off after two weeks in small dosages to 20 in 1 or 2 months and 1 Flurazepam 27.42mg for sleep. Both of these medications have a long half life time making them good for anxiety, fear, insomnia... 

This is of course a case, every patiënt is different and acts different.

When it comes to psychotherapy I think cognitive therapy and self help programs do help. For example mindfulness for anxiety attacks, panic,... 

It is also very important to understand there needs to be trust between the caretaker, patient and the family as medication usage needs to be in control.

Best

Bert