C
Cantopher T, Olivieri S, Cleave N, Edwards JG.
Chronic Benzodiazepine Dependence A Comparative Study of Abrupt
Withdrawal under Propranolol Cover Versus Gradual Withdrawal.
British Journal of Psychiatry 1990; 156: 406-411.

" Those who were successfully withdrawn in our study were no worse, and may even have been better, on every measure when off their benzodiazepines than they were at baseline. " [P. 410]

[Key words; addiction, dependence, withdrawal, detoxification]

Carney MWP, Ellis PF.
A Policy on Benzodiazepines.
Lancet 1987; ii: 1406.

" We agree with Professor Cohen that there is no place for benzodiazepines in the treatment of anxiety. There may be a place for them in anaesthesia, the management of epilepsy, or parenterally in states of acute psychiatric disturbance - but that is all. What is to replace them in anxiety management ? We suggest a personalised non-drug programme of anxiety management,
using liberal amounts of physical exercise alternating with relaxation for which the patient has been trained. Such programmes are already used in general practice and deserve to better known in the hospital outpatient department. "

Clare AW.
Diazepam, Alcohol, and Barbiturate Abuse.
BMJ 1971; 4: 340.

" It has been recognised for some time that dependence is a potential hazard of benzodiazepine use. This report is of a case of diazepam abuse in a woman who originally sought treatment for disturbed sleep and who over a period of six years became severely dependent on diazepam,
alcohol, and barbiturates. " [p. 340]

" It is suggested that the sanguine view held by many members of the medical profession towards the minor tranquillisers has been transmitted to the lay public and militates against attempts to remove patients from unnecessary and potentially harmful treatment with these drugs. "

[Key words; Valium, diazepam, addiction, abuse, dependence]

Closser MH.
Benzodiazepines and the Elderly A Review of Potential Problems.
Journal of Substance Abuse Treatment 1991; 8: 35-41.

Unrecognised, undocumented use and abuse of psychoactive drugs is frequent in this population and can lead to serious problems with untreated dependence and withdrawal. The elderly appear to be more sensitive to the effects of benzodiazepines, both because of changed
pharmacokinetics and pharmacodynamics with ageing and because of altered postreceptor cerebral response. All problems identified with benzodiazepines such as dependence, withdrawal, and cognitive impairment are proportionally greater among the elderly, who can least afford these
risks. Review of the literature leads to the conclusion that benzodiazepine prescribing for the elderly should be undertaken with the greatest caution and only with the recognition of all potentially disastrous effects. [ SUMMARY p. 35]

[Key words; addiction, abuse, dependence, cognitive impairment, the elderly]

Cochran PW.
Drugs for Anxiety.
JAMA 1974; 229: 521.

" Your editorial, "Drugs for Anxiety" (228: 875, 1974) prompts an uneasy feeling that has been growing on me for some time. Diazepam is cited as a safe drug not particularly subject to abuse when prescribed on an as-needed basis with a cover statement that some psychic distress should not be alarming. This is floridly at variance with my uncollated experience; in fact, so much so that I regard it as virtually a "once on, never off" preparation.

I have long prescribed it only for stressful circumstances of clearly brief duration. Despite this precaution, I never prescribe it without a heartfelt sigh, knowing how frequently the initial prescription will be followed not by the requested visits for discussion, but by calls from the pharmacist relaying ever more frequent requests for refills, and then psychotherapy-by-telephone as the patient attempts to justify his need for the drug in three minutes rather than come in to discuss problems.

Am I alone in the woods, or is there a silent plurality out there whose misgivings are not reflected in the usual recommendations published for psychotropics ? "

[Key words; addiction, abuse, dependence]

Cohen SI.
Phobic Disorders and Benzodiazepines in the Elderly.
British Journal of Psychiatry 1992; 160: 135.

" The natural history of anxiety symptoms following illness or trauma is towards natural resolution and when this does not happen one must always consider what may be keeping them going. In some patients, perhaps because of their individual vulnerability, the cause is benzodiazepine drugs
and if this is the case these patients can be totally relieved of their symptoms. This problem arises at all ages and is illustrated by the following example in an elderly patient.

Case report. A lady of 75 had always been rather phobic of lifts and of trains but for two years she had suffered from severe anxiety, panic, terror and misery. This followed an operation on her knee, since when she had taken lorazepam 2 mg daily. She was so frightened that when travelling
in the car with her husband she felt she wanted to jump out of the car if he stopped at traffic lights, and a measure of the intensity of this feeling was that her husband fixed a special lock on the door. She could not be left alone in the car while he went into a shop to buy a newspaper.
Her tablets were stopped over a period of four weeks with suitable explanation of what to expect by way of withdrawal symptoms, and at the end of five weeks she said it had been "the worst five weeks of my life". At eight weeks there had been a few spells of feeling normal and at 12 weeks
she had been in a lift although severe insomnia persisted. At 16 weeks she was completely well, happy and free of symptoms. She could sit in the car long enough for her husband to have his hair cut.

This is not a new idea. Ashton (1984) pointed out that many patients develop phobias for the first time after a period of regular benzodiazepine use and that these symptoms disappear when the drug is withdrawn. Her paper gives references to a similar view expressed previously by Lader,
Tyrer and others.

The above example is one among many such patients, of all ages, and although it is not always easy to wean patients from their tablets it can usually be done with appropriate support and explanation and these patients become some of the most grateful a psychiatrist can have. "

[Key words; Ativan, lorazepam, addiction, dependence, withdrawal, phobias, OCD]

Cohen SI.
Alcohol and Benzodiazepines Generate Anxiety, Panic and Phobias.
Journal of the Royal Society of Medicine 1995; 88: 73-77.

n almost half the patients seeking advice for anxiety, panic and phobias the cause was alcohol or benzodiazepines. In the remainder it was psychological, usually a state of conflict or a traumatic event. When symptoms are persistent following a distressing event it is often the case that alcohol or benzodiazepines are keeping them going. There is a large variation in individual vulnerability and the mechanism responsible for these symptoms is rebound arousal. [SUMMARY p. 73]

[Key words; addiction, dependence, withdrawal, phobias, OCD]

Committee on Safety of Medicines.
Benzodiazepines, Dependence and Withdrawal Symptoms.
Current Problems 1988; 21: 1-2.

" BENZODIAZEPINES, DEPENDENCE AND WITHDRAWAL SYMPTOMS
There has been concern for many years regarding benzodiazepine dependence (Br.Med.J. 1980:
280: 910-912). Such dependence is becoming increasingly worrying.

Withdrawal symptoms include anxiety, tremor, confusion, insomnia, perceptual disorders, fits, depression, gastrointestinal and other somatic symptoms. These may sometimes be difficult to distinguish from the symptoms of the original illness.

It is important to note that withdrawal symptoms can occur with benzodiazepines following therapeutic doses given for SHORT periods of time.

Withdrawal effects usually appear shortly after stopping a benzodiazepine with short half life, or up to sever al days after stopping one with a long half life. Symptoms may continue for weeks or months. No epidemiological evidence is available to suggest that one benzodiazepine is more
responsible for the development of dependency or withdrawal symptoms than another.

The Committee on Safety of Medicines recommends that the use of benzodiazepines should be limited in the following ways:

USES
As Anxiolytics
1. Benzodiazepines are indicated for the short-term relief (two or 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.

2. The use of benzodiazepines to treat short-term "mild" anxiety is inappropriate and unsuitable.

As Hypnotics
3. Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or subjecting the individual to extreme distress.

DOSE
1. The lowest dose which can control the symptoms should be used. It should not be continued beyond four weeks.

2. Long-term chronic use is not recommended.

3. Treatment should always be tapered off gradually.

4. Patients who have taken benzodiazepines for a long time may require a longer period during which doses are reduced.

5. When a benzodiazepine is used as a hypnotic, treatment should, if possible, be intermittent.

PRECAUTIONS
1. Benzodiazepines should not be used alone to treat depression or anxiety associated with depression. Suicide may be precipitated in such patients.

2. The should not be used for phobic or obsessional states.

3. They should not be used for the treatment of chronic psychosis.

4. In cases of loss or bereavement, psychological adjustment may be inhibited by benzodiazepines.

5. Disinhibiting effects may be manifested in various ways. Suicide may be precipitated in patients who are depressed, and aggressive behaviour towards self and others may be precipitated.
Extreme caution should therefore be used in prescribing benzodiazepines in patients with personality disorders. "

[Key words; addiction, dependence, withdrawal, depression, suicide, aggression, hostility, disinhibition, paradoxical effects]

Cormack MA, Owens RG, Dewey ME.
The Effect of Minimal Interventions by General Practitioners on Long-Term Benzodiazepine Use.
Journal of the Royal College of General Practitioners 1989; 39: 408-411.

" Given the evidence of cross-tolerance of some benzodiazepines with alcohol it might have been expected that subjects would have sought alcoholic alternatives when deprived of their usual drug. However, this was not the case according to the interview data and only one patient reported an increase in cigarette consumption. This parallels Ashton's finding that none of her subjects replaced benzodiazepines with other drugs or alcohol. "

" The evidence of the detrimental effects of benzodiazepines on cognitive and psychomotor performance following long-term use suggest that people may perform better in a number of ways without the drugs... Attempts to tackle the causes of the symptoms may not be initiated or may fail through decreased problem solving skills... Anecdotal evidence from patients seen by one of the authors... and other workers in the field supports the view that people feel that their capacities have been dulled by the drugs and that a new, or forgotten, self emerges when the drugs are discontinued. " [p. 410]

" In Mersey region, in 1984, the net ingredient cost of prescriptions for hypnotics, sedatives and tranquillisers issued by family practitioner services was \'9c 2 650 000. The majority of these drugs would be benzodiazepine compounds.

If, as a conservative estimate, one quarter of these prescriptions were for long-term users similar to those identified in this study, then with a success rate for stopping medication of one in four the saving could be around \'9c 160 000. For England as a whole, this saving could be nearly \'9c 3
million in one year. Against this must be set the doctor's time to write the letter or conduct the interview, and postage and secretarial costs. However, these costs need not exceed those of issuing repeat prescriptions over several years. The saving on drugs would continue as long as no further patients became long-term users. " [p. 410]

[Key words; dependence, cognitive impairment, psychomotor performance, long-term effects,
costs]

Crawford RJM.
Benzodiazepine Dependency and Abuse.
New Zealand Medical Journal 1981; 94: 195.

" The earlier drugs with longer half lives of several days have now been adequately researched, and two facts emerge:

(1) The longer a person takes them, the harder it is to stop, i.e. withdrawal symptoms (headaches; muscle cramps; light-headedness; vertigo; muscular in-co-ordination; paranoid reactions; epileptic fits, and malaise) occur which the patient learns can be stopped by another pill.

(2) These effects can occur in people who have had doses in the normal recommended clinical range.
" I particularly wish to draw to your attention that the newer, shorter acting tranquillisers such as oxazepam (Serepax), and lorazepam (Ativan) are associated with quicker development of the addictive state and more severe withdrawal problems, at least in the alcoholic population.
Triazolam (Halcion) is being marketed as a very short half life hypnotic. I predict it will have the highest abuse potential of all the benzodiazepines yet marketed. "

[Key words; Ativan, Serax, Serenid, Serepax, Halcion, lorazepam, oxazepam, triazolam,
addiction, abuse, dependence, withdrawal]

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