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 self- administration in humans and laboratory animals – implications for problems of long- term 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?