November 1995, Volume 45, Issue 11

Editorial

Misuse of Benzodiazepine

Muhammad Afzal Javed  ( Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore. )

The introduction of benzodiazepines in clinical use can no doubt be considered an important landmark in the field of psychopharmacology. The widespread use of these drugs in the 1960’s and 1970’s was attributed to their relative safety, efficacy and economy. Certainly when compared to the other anxiolytic predecessors like bromides, baibiturates and alco­hol, these substances did appear to have many advantages. Their efficacy for the treatment Of anxiety, insomnia, relief of tension and as anticonvulsants, made them very popular and one of the most prescribed drugs throughout the world. This trend however, got a note of caution in the late 1970’s when concerns were expressed about their potential hazards1-4. The first was related to the issue of addiction and dependence. Secondly the possible impairments in cognition and memory functions particularly in long term users, warranted their use to a large extent. The physical dependence and risk of withdrawal also provided more reservations for their general use. Furthermore, utilizing these drugs for problems like common day to day stresses, led to a more moral considera­tion, as the professionals were alanned by their misuse by the general public. The use and misuse of benzodiazepines both by practic­ing physicians and the general population, therefore, emerged as an important area in contemporary research, with a large number of studies focussing on this issue. Much is also known about the incidence of dependence of these drugs, the factors that predispose to its occurrence and management of the withdrawal syndrome5-7. Continued research into the psychological and biologi­cal factors underlying the process of dependence is also being undertaken very enthusiastically8. This vulnerability has been found to occur for several reasons. As anxious people are more likely to complain of symptoms, long term use of benzodiazepines tends to lower the coping abilities of these individuals. The pharmacological basis for both anxiety and poor ability to counteract stress has been attributed to low activity in limbic system pathways utilising r-amino butyric acid. This is related to the benzodiazepine receptors and explains the close relationship of psycho-biological basis of benzodiazepine dependence. Keeping in view the increased potential of misuse and dependence, the indications for use of benzodiazepines have also been reviewed extensively during the past few years7. In general, whenever these drugs are used, their benefits and risks should be determined. The committee on the Safety of Medicine has suggested that these compounds should only be given for disabling anxiety and not to be continued beyond four weeks. Benzodiazepines with a short half-life require more strict control ml9 In addition to rebound insomnia occurring when treatment is stopped, it has been observed that the rapid elimination of these short acting drugs result in acute with­drawal symptoms. The potential side-effects of benzodiazepi­nes such as, amnesia, associated psychiatric disturbances like confusion, restlessness, agitation, insomnia, behavioural and mood disturbances also require due attention. The withdrawal symptoms after discontinuation of these drugs affect a wide range of systems. Studies involving active treatment for as little as 4-6 weeks and even from low-dose therapeutic use and leading to dependence are: now well documented10. The persistence of the withdrawal syndrome furthermore compli­cates the matter. Surveys have shown that about 15-30% of the patients continue to report significant symptoms from 10 months to 3.5 years following the withdrawal of these drugs. This certainly requires increasingly energetic attempts to help patients to give up benzodiazepines11. It can be thus concluded that the misuse of ben­zodiazepines, one of the most prescribed drugs in general as well as hospital practice, accounts for major hazards in many areas. Contrary to the earlier reports, recent studies not only confirm the abuse potential of these substances but also suggest a long list of side effects, tolerance and dependence possibilities of these drugs. Although the prescribing of benzodiazepines is not going to stop in clinical practice, their indications in medical and psychiatric disorders will certainly require new recommendations for future use. As their misuse is closely associated with public health problems, a strong need is felt to bring more information both for the public and the professionals about the indications of these drugs. Effec­tive measures like rational and judicious use of these drugs, control of prescriptions and intensive research on the risks and benefits of benzodiazepine therapy would probably be a fruitful effort for further exploration to understand the benefit yielded by these compounds4.

References

1. Fleischhacker, U. W., Barnas, C. and Hackenberg, B. Epidemiology of benzodiazepine dependence. Acta Psychiatr. Scand., 1986,74:80.93.
2. Morgan, K., Dallasso, H., Ebrahim, S. et at. Prevalence, frequency and duration of hypnotic drug use among the elderly living at home. .Br. Med. J., 1988;296:601-603.
3. Ashton, H. Risk of dependence on benzodiazepine drugs: .A major problem of long term treatment. Br. Med. J., 1989;298:103-104.
4. Pedersen, W, and Larik, N. J. Adolescents and benzodiazepines, Prescribed use self-medication and intoxication. Acta Psychiatr. Scand., 1991 ;84:94-98.
5. Cole, J. 0. and Chiarello, R. J. The benzodiazepines as drugs at’ abuse. J. Psychiatr. Scand., 1991;84:94-98.
6. seivewright, N. A. and Dongal, W. Benzodiazepine misuse. Curr. Opin. Psychiat., 1992;5:408-411.
7. Dupont, R. L. Abuse of benzodiazepines: The problems and the solutions. Am. J. Drug Alcohol Abuse, 1988;14:1:1-69
8. Higgit, A., Fonagy, P. and Lader, M. The natural history of tolerance to the benzodiazepines. Psycho!, Med., 1988; Monograph 13.
9. Co’Donavan, M. and Guffin, P. Short acting benzodiazepines Br. Med. J. (Pakistan), 1993;3(4): 113-114.
10. Noyes, R., Gaivey, M. J., Cook, B. 2. eta!. Benzodiazepine with drawal: A review ofthe evidence. J. Clin. Psychiatry, 1988;49:382-89.
11. Higgitt, A. and Fonagy, P. Withdrawal from benzodizepines and the persistence benzodiazepine dependence syndrome. hi: Granville Grossman, K. (ed).      Recent advances in clinical psychiatry, No. 8, London, Churchill Livingston, 1992, pp. 49-59.

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