Fw: NSW Concord dependency seminar summary on benzodiazepines.

Preston Peet ptpeet at nyc.rr.com
Tue Aug 9 14:52:17 EDT 2005




----- Original Message ----- 
From: Andrew Byrne
To: ajbyrne at ozemail.com.au
Sent: Tuesday, August 09, 2005 1:04 AM
Subject: NSW Concord dependency seminar summary on benzodiazepines.


  Benzodiazepine use in dependency patients.
  Concord Dependency Seminar Tuesday 26th July 2005.
  Presenters: Richard Hallinan and Andrew Byrne, Redfern Dependency 
Practice.
  Summary by Dr Jenny James.

  Richard Hallinan and Andrew Byrne, who are both committed to best practice 
in dependency medicine, presented this useful seminar on benzodiazepine use. 
The session began with an overview of the pharmacology of benzodiazepines, 
and some relevant comparisons were made with alcohol, opiates and major 
tranquillisers. Differences between the various benzodiazepines particularly 
in relation to half-lives were outlined, and indications, side effects, 
tolerance and withdrawal were all discussed. A handout was available 
detailing all of these points.

  Special mention was made of benzodiazepine (BZD) use by patients on 
methadone maintenance treatment (MMT) and it was noted that this group of 
people often have particularly high levels of psychopathology and 
psychosocial distress, including higher rates of unemployment, 
incarceration, HCV, and HIV/HCV risk-taking behaviour.  BDZ users on MMT 
also tend to be on higher methadone doses and to have higher blood levels, 
although methadone concentrations adjusted for dose are actually lower in 
this group. The reason for this is unclear as there is no evidence that 
diazepam increases the clearance of methadone. One hypothesis is that there 
is a tendency for rapid methadone metabolisers to seek BZDs, in which case 
split methadone dosing might be useful. It may also be that these people are 
self-medicating, or <just can't get enough of a 'good' thing>.

An approach to BZD abuse in MMT patients was outlined. It was suggested we 
make sure that psychopathology (eg anxiety and depression) is adequately 
treated, alcohol problems are addressed and information obtained from the 
Doctor Shoppers Hotline in appropriate cases.  Consideration should be given 
to moving from short to long acting forms of which diazepam is the most 
common.  Also, supervised dispensing should be considered where 'control' or 
impulsivity are problems.  It is also essential to optimise the methadone 
dose, being flexible about dosing times or, occasionally, split-dosing 
(which needs prior approval from the PSB).

  Reasons for BZD use were outlined, and are important to understand when 
looking at treatment options. People take BZD for many reasons, including 
alleviation of anxiety and insomnia, self-medication of depression, 
self-medication of withdrawal from opiates and BZDs, to come down off 
stimulants, and to get an increased "buzz".  So-called "Poly-drug users" 
swap from one drug like speed or heroin to another such as BZD, and may 
simply do this because BZDs are the cheapest or most available drug at the 
time. It was noted that BZDs in Australia are subsidised on the PBS, whereas 
they are very expensive and hard to obtain in the U.S. so it is no surprise 
that their use amongst the marginalized in the USA is far less.

  Aims of treatment of BZD dependence were clarified within the overall 
context of harm reduction goals. This includes abstinence and it was pointed 
out that harm reduction has sometimes erroneously been seen to include 
legalizing drugs, which while worthy of discussion, is quite a separate 
issue. Our first dictum should be "Do No Harm" and we shouldn't forget that 
an important part of this is just saying "no" when appropriate.

  When assessing a patient for treatment we need to understand their 
personal history of abstinence, by asking questions such as "when were you 
last abstinent?", "how many times have you achieved abstinence?", "how did 
you become abstinent?", and "what did it feel like when you were 
abstinent?". We need to understand that previous abstinence may not 
necessarily have been a happy and stable time for every patient.

  It was pointed out that the statistics regarding measurement of harm 
relating to BZD use are limited, but nonetheless worrying.  Doctors must 
weigh the harms and benefits of BZDs both in the community and in 
individuals (as we do with all other prescribing). PBS prescribing figures 
reached a peak in 1988 and have fallen since then. It is well accepted that 
some people function well on a small dose of diazepam, so this drug may have 
a useful place in legitimate treatment plans. It is gratifying that in 
Australia, appropriate regulation has seen the end of temazepam capsules, 
along with Mandrax (methaqualone and diphenhydramine), meprobamate 
(Miltown), bromides, barbiturates and high dose flunitrazepam, which have 
all vanished from scene.

  Harm from BZD dependency was discussed, and includes an array of physical, 
social and behavioural disturbances. Special mention was made of the damage 
to nerves and blood supply when subjected to pressure for prolonged periods 
of time. This scenario can occur with overdose and increased use which leads 
to long periods of reduced consciousness in fixed positions. Nerve palsies, 
skin necrosis and the compartment syndrome can occur. Thrombosis and 
infections from injecting, criminal activity including prescription fraud, 
convulsions from withdrawals, and deepening of depression are all possible 
consequences of BZD use. Rates of domestic violence are probably parallel 
with alcohol abuse.

  Treatment approaches to BZD use rely on an accurate diagnosis, which 
should depend on a detailed history with relevant physical examination. 
Urinary drug screening can be useful, along with information from 
pharmacists and reports from HIC services. Some unusual features of 
benzodiazepine users were noted, including possession of a Medicare card 
with a high terminal digit (8 or 9), fiddling with the position of furniture 
within the consulting room, talking to the GP with great familiarity and 
requesting the drug by specific name. The assessment of BZD use should 
parallel that which is done for opiate users, including the level of 
dependence and addressing resultant medical and social harms. Co-existent 
mental health issues should be treated and methadone treatment at optimal 
dosage. As with all other drug use, there is a spectrum of patterns of use, 
including non-dependent occasional use, irregular binge use, dual dependency 
(eg with opiates) and "pure" BZD dependency. It may be useful for the 
patient to keep a drug diary, as memory may fail in this patient group.

If considering regular prescribing of BZD with a view to abstinence, there 
are some useful "check-list" questions we can all ask ourselves. They 
include:
"What alternative strategies has the patient tried?", "have I seen their 
drug diary?", "what is their motivation for abstinence?", "have I seen a UDS 
result?", "have I sought information from the HIC hotline?", "are they on 
optimum doses of methadone or pain treatment?", "is treatment for mental 
health conditions adequate?"

  Prescribed BZD must be tailored for the individual, but it was emphasized 
that slow reductions in doses may take months in established dependency. It 
is unrealistic to expect a patient with long-term BZD dependency to be able 
to maintain abstinence following a 2-4 week reduction regime. Diazepam is 
the preferred BZD to use for reduction regimes owing to its long action and 
familiarity. Several case histories were discussed to help illustrate 
management plans.

  Australian Health Insurance Commission (HIC) services were also discussed. 
There are two separate services: firstly, "Prescription Shopping Information 
Service". Doctors must first register if they wish to access any 
information. Doctors are given a PIN number, and can find out information on 
numbers of BZD PBS prescriptions and numbers of doctors seen, above a 
certain threshold. No information is kept on private prescriptions. 
Toll-free phone is 1800 631181. The second HIC service is a "voluntary 
agreement" print-out of PBS items available after the patient signs the 
consent form. Forms available from 1800 420074. These services may be useful 
not only because of the information they provide, but because patients know 
their doctors can access certain information about their BZD use.

  The meeting ended after some complex but somehow familiar case histories 
with lively discussion about the various possible approaches.

Dr Jenny James. Daruk AMS.

Posted by Andrew Byrne ..

40th anniversary of Dole and Nyswander's first report of methadone treatment 
in JAMA Aug 1965

Some terrorism facts without the opinions on ABC TV:
http://www.abc.net.au/7.30/content/2005/s1418817.htm

My grandfather Harry Gracie's letters from 1924 trip to Mayo Clinic:
http://bpresent.com/harry/code/mayo.htm



















              Benzodiazepine use in dependency patients.
  Concord Dependency Seminar Tuesday 26th July 2005.
  Presenters: Richard Hallinan and Andrew Byrne, Redfern Dependency 
Practice.
  Summary by Dr Jenny James.

  Richard Hallinan and Andrew Byrne, who are both committed to best practice 
in dependency medicine, presented this useful seminar on benzodiazepine use. 
The session began with an overview of the pharmacology of benzodiazepines, 
and some relevant comparisons were made with alcohol, opiates and major 
tranquillisers. Differences between the various benzodiazepines particularly 
in relation to half-lives were outlined, and indications, side effects, 
tolerance and withdrawal were all discussed. A handout was available 
detailing all of these points.

  Special mention was made of benzodiazepine (BZD) use by patients on 
methadone maintenance treatment (MMT) and it was noted that this group of 
people often have particularly high levels of psychopathology and 
psychosocial distress, including higher rates of unemployment, 
incarceration, HCV, and HIV/HCV risk-taking behaviour.  BDZ users on MMT 
also tend to be on higher methadone doses and to have higher blood levels, 
although methadone concentrations adjusted for dose are actually lower in 
this group. The reason for this is unclear as there is no evidence that 
diazepam increases the clearance of methadone. One hypothesis is that there 
is a tendency for rapid methadone metabolisers to seek BZDs, in which case 
split methadone dosing might be useful. It may also be that these people are 
self-medicating, or <just can't get enough of a 'good' thing>.

An approach to BZD abuse in MMT patients was outlined. It was suggested we 
make sure that psychopathology (eg anxiety and depression) is adequately 
treated, alcohol problems are addressed and information obtained from the 
Doctor Shoppers Hotline in appropriate cases.  Consideration should be given 
to moving from short to long acting forms of which diazepam is the most 
common.  Also, supervised dispensing should be considered where 'control' or 
impulsivity are problems.  It is also essential to optimise the methadone 
dose, being flexible about dosing times or, occasionally, split-dosing 
(which needs prior approval from the PSB).

  Reasons for BZD use were outlined, and are important to understand when 
looking at treatment options. People take BZD for many reasons, including 
alleviation of anxiety and insomnia, self-medication of depression, 
self-medication of withdrawal from opiates and BZDs, to come down off 
stimulants, and to get an increased "buzz".  So-called "Poly-drug users" 
swap from one drug like speed or heroin to another such as BZD, and may 
simply do this because BZDs are the cheapest or most available drug at the 
time. It was noted that BZDs in Australia are subsidised on the PBS, whereas 
they are very expensive and hard to obtain in the U.S. so it is no surprise 
that their use amongst the marginalized in the USA is far less.

  Aims of treatment of BZD dependence were clarified within the overall 
context of harm reduction goals. This includes abstinence and it was pointed 
out that harm reduction has sometimes erroneously been seen to include 
legalizing drugs, which while worthy of discussion, is quite a separate 
issue. Our first dictum should be "Do No Harm" and we shouldn't forget that 
an important part of this is just saying "no" when appropriate.

  When assessing a patient for treatment we need to understand their 
personal history of abstinence, by asking questions such as "when were you 
last abstinent?", "how many times have you achieved abstinence?", "how did 
you become abstinent?", and "what did it feel like when you were 
abstinent?". We need to understand that previous abstinence may not 
necessarily have been a happy and stable time for every patient.

  It was pointed out that the statistics regarding measurement of harm 
relating to BZD use are limited, but nonetheless worrying.  Doctors must 
weigh the harms and benefits of BZDs both in the community and in 
individuals (as we do with all other prescribing). PBS prescribing figures 
reached a peak in 1988 and have fallen since then. It is well accepted that 
some people function well on a small dose of diazepam, so this drug may have 
a useful place in legitimate treatment plans. It is gratifying that in 
Australia, appropriate regulation has seen the end of temazepam capsules, 
along with Mandrax (methaqualone and diphenhydramine), meprobamate 
(Miltown), bromides, barbiturates and high dose flunitrazepam, which have 
all vanished from scene.

  Harm from BZD dependency was discussed, and includes an array of physical, 
social and behavioural disturbances. Special mention was made of the damage 
to nerves and blood supply when subjected to pressure for prolonged periods 
of time. This scenario can occur with overdose and increased use which leads 
to long periods of reduced consciousness in fixed positions. Nerve palsies, 
skin necrosis and the compartment syndrome can occur. Thrombosis and 
infections from injecting, criminal activity including prescription fraud, 
convulsions from withdrawals, and deepening of depression are all possible 
consequences of BZD use. Rates of domestic violence are probably parallel 
with alcohol abuse.

  Treatment approaches to BZD use rely on an accurate diagnosis, which 
should depend on a detailed history with relevant physical examination. 
Urinary drug screening can be useful, along with information from 
pharmacists and reports from HIC services. Some unusual features of 
benzodiazepine users were noted, including possession of a Medicare card 
with a high terminal digit (8 or 9), fiddling with the position of furniture 
within the consulting room, talking to the GP with great familiarity and 
requesting the drug by specific name. The assessment of BZD use should 
parallel that which is done for opiate users, including the level of 
dependence and addressing resultant medical and social harms. Co-existent 
mental health issues should be treated and methadone treatment at optimal 
dosage. As with all other drug use, there is a spectrum of patterns of use, 
including non-dependent occasional use, irregular binge use, dual dependency 
(eg with opiates) and "pure" BZD dependency. It may be useful for the 
patient to keep a drug diary, as memory may fail in this patient group.

If considering regular prescribing of BZD with a view to abstinence, there 
are some useful "check-list" questions we can all ask ourselves. They 
include:
"What alternative strategies has the patient tried?", "have I seen their 
drug diary?", "what is their motivation for abstinence?", "have I seen a UDS 
result?", "have I sought information from the HIC hotline?", "are they on 
optimum doses of methadone or pain treatment?", "is treatment for mental 
health conditions adequate?"

  Prescribed BZD must be tailored for the individual, but it was emphasized 
that slow reductions in doses may take months in established dependency. It 
is unrealistic to expect a patient with long-term BZD dependency to be able 
to maintain abstinence following a 2-4 week reduction regime. Diazepam is 
the preferred BZD to use for reduction regimes owing to its long action and 
familiarity. Several case histories were discussed to help illustrate 
management plans.

  Australian Health Insurance Commission (HIC) services were also discussed. 
There are two separate services: firstly, "Prescription Shopping Information 
Service". Doctors must first register if they wish to access any 
information. Doctors are given a PIN number, and can find out information on 
numbers of BZD PBS prescriptions and numbers of doctors seen, above a 
certain threshold. No information is kept on private prescriptions. 
Toll-free phone is 1800 631181. The second HIC service is a "voluntary 
agreement" print-out of PBS items available after the patient signs the 
consent form. Forms available from 1800 420074. These services may be useful 
not only because of the information they provide, but because patients know 
their doctors can access certain information about their BZD use.

  The meeting ended after some complex but somehow familiar case histories 
with lively discussion about the various possible approaches.

Dr Jenny James. Daruk AMS.

Posted by Andrew Byrne ..

40th anniversary of Dole and Nyswander's first report of methadone treatment 
in JAMA Aug 1965

Some terrorism facts without the opinions on ABC TV:
http://www.abc.net.au/7.30/content/2005/s1418817.htm

My grandfather Harry Gracie's letters from 1924 trip to Mayo Clinic:
http://bpresent.com/harry/code/mayo.htm




 




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