Understanding and Treating Benzodiazepine Dependence; How you as a nurse can best assist the addicted patient
Submitted by Joan Longwell, RN, MSN, CS
The phone call came from Anna Michels (name changed for this article), the wife of one of my patients with a history of polysubstance abuse. “I’m worried about Jim,” she said. “I found a bottle of Xanax in the glove compartment of his truck. When I asked him about it, he said that he got it from an emergency room doctor the other night for panic attacks. Is it OK for him to take this?”
Xanax belongs to a class of medications called Benzodiazepines, whose most common use is to treat anxiety. Xanax was the most popular psychiatric medication prescribed in the US in 2011. Over 112.8 million prescriptions for Benzodiazepines themselves were filled in 2007- 2008. Only drugs for chronic conditions like hypertension and hypercholesterolemia are prescribed more often.
Benzodiazepines can be addicting, however. According to the Royal College of Psychiatry Website, around 4 in every 10 people who take them every day for more than 6 weeks will become addicted. Patients with a history of addiction are particular vulnerable and often supplement street drugs with benzodiazepines.
I wasn’t OK with Jim being prescribed Xanax. A month ago, John had been laid off from his job. He’d come to see me, complaining of incapacitating anxiety and panic attacks. I’d prescribed him Klonopin, a longer acting benzodiazepine than Xanax. We had discussed the benefits and side effect of this medication and Jim had promised to be responsible with it. It was supposed to be a short term medication intervention, to be tapered down as Jim learned to manage his anxiety with a therapist and an exercise program. Now Jim was taking two benzodiazepines at once.
Primary Care and emergency room physicians and nurse practitioners are most likely to prescribe benzodiazepines, even more than mental health specialists. These drugs work quickly, usually in a less than matter of an hour; to relieve symptoms like anxiety, insomnia and muscle relaxant.
Benzodiazepines work by enhancing the function of GABA receptors in the brain. GABA is a neurotransmitter. Neurotransmitters are the chemicals which allow the transmission of signals from one neuron to the next across synapses. They are produced in the body of a neuron, the cells within the nervous system. They are also found at the axon endings of motor neurons, where they stimulate the muscle fibers3.
One of GABA’s many functions is to inhibit the actions of excitatory neurotransmitters, such as glutamate, norepinephrine and epinephrine. It is hypothesized that people with too little endogenous GABA are vulnerable to 4anxiety disorders. Some other drugs that influence GABA receptors include alcohol, anti- convulsants and barbiturates.
Benzodiazepines are most useful for anxiety and panic disorders when used in low doses, for short periods of time. But longer use can lead to tolerance and dependence.
This process is described as neuroadaptation.5With the increased amount of available GABA circulating around the nervous system, the body attempts to overcome the central nervous system depressant effects of a benzodiazepine. Endogenous GABA production slows down. Neuron receptors become less sensitive. At the same time, the production of excitatory neurotransmitter accelerates.
Many persons will try to increase the dose at this point to break through the tolerance cycle. After a while, the medication is no longer as useful for treating the anxiety. It is now being used primarily to prevent withdrawal.
When the dosage of benzodiazepines are withdrawn, these neurotransmitter systems go into overdrive due to the lack of inhibitory GABA-ergic activity. The person’s nervous system becomes hyper-excitable and within hours, begins to demonstrate signs of withdrawal. Some of the symptoms include severe anxiety, restlessness, muscle spasms, night mares or insomnia, elevated heart rate and blood pressure. In severe cases, confusion, feelings of unreality and even seizures can occur6, 14
A person who is overly dependent on benzodiazepines will have to be tapered off of them. This can be done in either an inpatient setting or a detox facility, or if you having a person who is reliable, outpatient. I usually taper patients very slowly off of benzodiazepines, usually half a milligram a month. That may seem slow, but my experience is that it’s less uncomfortable than a more rapid detox. It gives the patient sufficient time to recover. People who are detoxed too quickly often feel jittery and are unable to relax or even sleep. They are much more likely to relapse than those who are slowly detoxed.
It is important for staff at emergency rooms, primary care and other medical specialties to exercise caution when a patient present, requesting medication to relieve anxiety. Don’t simply base it on how a person presents that day and what they tell you. Based on appearance, my patient Jim wouldn’t necessarily draw suspicion in the emergency room. Clean cut and professional looking, a nurse could easily have felt comfortable with a Xanax prescription to relieve his panic attacks.
So, what should a nurse do, to safely treat a patient who is presenting with symptoms of an anxiety disorder who is requesting a benzodiazepine? I’ve put suggestions below:
- First of all, ask yourself, why is the person having so much anxiety? Anxiety doesn’t happen in a vacuum. What’s happening in the person’s life to cause so much anxiety? What have they done so far to relieve it? If it’s an emergency room setting, why are they coming here versus their primary care or specialist? If they’re being accompanied by a loved one, ask this person as well what they feel is going on.
- What do you know about this person’s medical and psychiatric history? Could there be a medical reason for the anxiety? An overactive thyroid can have symptoms similar to an anxiety disorder. The feeling of being short of breath, common with Asthma, emphysema and COPD can leave a person full of anxiety, especially when it’s time to sleep. Corticosteroids such as Prednisone and hydrocortisone can also make people feel racy, anxious and can interfere with sleep. I’ve also known body builders who have used steroids and developed severe irritability and anxiety. If it’s possible, have the patient sign releases in order to talk her primary care physician. Find out what medications the person is currently taking.
- An experienced nurse doing a thorough assessment may find that benzodiazepine seekers will admit to going to other clinics, 24-hour urgent cares, etc. and expressing dissatisfaction regarding the service, medications, or treatment they received.
Always be aware of the red flags indicating benzodiazepine seeking behavior, as listed below7 10
- Be suspicious of the patient who shows unusual knowledge of benzodiazepines or a textbook like knowledge of a medical condition requiring a benzodiazepine.
- A benzodiazepine abusing patient often has no interest in a diagnosis, will fail to keep appointments for diagnostic exams or will decline to follow through with consultations. He may have been to the ER or primary care fifteen times over the winter but still hasn’t made it to a mental health clinic.11, 12
- Keep note of patients requesting early refills on their meds, citing multiple reasons. Frequent reasons are that it was stolen or they lost it, the pharmacy shorted their pills.
- Patients who come in and ask directly for drug x, which is a benzodiazepine. Patients who come in and say that only the benzodiazepine works and refuses to try an alternative drug, 13
The most humane way to deal with a benzodiazepine seeking individual is to be be up front about your concerns. Meet with them privately. Discuss what you have observed and offer ways to help. Every medical clinic and emergency room should have lists of available mental health clinic and detox facilities. Don’t give benzodiazepine prescriptions without getting a signed release from the patient allowing you to informing the person’s primary care physician and or mental health specialist.
Thirty seven states now offer an objective computerized state prescription drug monitoring program (PDMP)8 PDMP is an electronic database which collects information on controlled medications dispensed in the state. The program distributes data from the database to individuals who are authorized under state law to receive the information for purposes of:
- supporting access to legitimate medical use of controlled substances,
- identifying and detering or preventing drug abuse and diversion,
- facilitating and encouraging the identification, intervention with and treatment of persons addicted to prescription drugs,
- informing public health initiatives through outlining of use and abuse trends, and
- educating individuals about PDMPs and the use, abuse and diversion of and addiction to prescription drugs9.
Benzodiazepine abuse is a growing epidemic in this country. I encourage all nurses and health care personal to be alert to this issue and work with their facility to develop a systematic approach to help affected patients.
- IMS Health. Top 25 Medicines by Dispensed Prescriptions. 2012. (U.S.)http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/Press%20Room/2012_U.S/Top_25_Medicines_Dispensed_Prescriptions_U.S..pdf
- Royal College of Psychiatrists. Benzodiazepines. Updated July 2013. http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/benzodiazepines.aspx
- The Carlat Report. This Month’s Expert, Andrew Goddard, MD, on the Role of GABA in Anxiety. Andrew Goddard, MD. March 2006, Volume 4:3.
- Melinda J. Barker, Kenneth M. Greenwood, Martin Jackson and Simon F. Crowe. Cognitive Effects of Long-Term Benzodiazepine Use. CNS Drugs 2004; 18 (1): 37-48
- (Allison C, Pratt JA (May 2003). "Neuroadaptive processes in GABAergic and glutamatergic systems in benzodiazepine dependence". Pharmacol. Ther. 98 (2): 171–95. doi:10.1016/S0163-7258(03)00029-9. PMID 12725868.
- Nyett, S.R. The benzodiazepine withdrawal syndrome and its management. Journal of the Royal College of General Practitioners, April 1989,(39) 160-163
- US Department of Justice, Office of Diversion Control. Don’t Be Scammed by a Drug Abuser. December 1999. Volume 1 Issue 1. http://www.deadiversion.usdoj.gov/pubs/brochures/drugabuser.htm
- US Department of Justice, Office of Diversion Control. State Prescription Drug Monitoring Prgrams. October 2011. http://www.deadiversion.usdoj.gov/21cfr_reports/theft/index.html
- American College of Emergency Room Physicians. Emergency Room Physicians Use New Tool to Detect Drug Seekers in the ER. July 10, 2013. http://newsroom.acep.org/2013-07-10-Emergency-Physicians-Use-New-Tool-to-Detect-Drug-Seekers-in-the-ER
- Conley, Mikaela. Drug Seeking Behavior in ER Doubles, Feeds Growing Addiction to Pain Pills. October 28, 2010. ABC News. http://abcnews.go.com/Health/MindMoodNews/prescription-drug-addicts-find-fix-emergency-room/story?id=11976460
- Hansen, George, R. The Drug-Seeking Patient in the Emergency Room. Emergency Medicine Clinics of North America. (2005) 349–365.
- Goodnough, Abby. Abuse of Xanax Leads a Clinic to Halt Supply. New York Times Online. September 14, 2011. http://www.nytimes.com/2011/09/14/us/in-louisville-a-centers-doctors-cut-off-xanax-prescriptions.html?_r=1&
- Lader, M. Biological processes in benzodiazepine dependence. Addiction. 1994 Nov;89(11):1413-8.