Treatment of sedative-hypnotic dependence

by: Karim Dar and Manoj Kumar

Misuse and dependence upon benzodiazepines, despite much greater awareness of the dangers of these drugs, still appear to be growing problems. Misuse occurs because of dependency upon these drugs that have been prescribed for extended periods with some increasing tolerance on the part of the patient. Misuse also occurs by people who purchase or obtain these drugs by means other than prescription. The growing emphasis on insomnia and the increasing competition among various drug companies to capture the prescription sleeping pill market appears to exacerbate this problem. At the moment, a gradual tapering of the prescribed or illegally used drug, especially by substituting a longer-acting drug for a shorter-acting drug, appears to have the most supporting evidence. Little research has been done on hypnotics compared with the benzodiazepines, and this is a bit of a puzzle.

Introduction

Sedative hypnotic drugs are central nervous system depressants traditionally used to reduce anxiety and induce sleep. The sedatives under consideration in this chapter are benzodiazepines, the Z-drugs (zopiclone, zolpidem and zaleplon) and barbiturates. After their introduction in 1903, barbiturates were supplanted by the benzodiazepines which were introduced in the early 1960s. This was primarily due to concerns about the obvious toxicity of barbiturates, particularly in overdose, and knowledge of their propensity for dependence. After reaching a peak in the early 1980s, prescriptions for benzodiazepines in the UK have shown a substantial reduction; however, while annual prescriptions for benzodiazepines in England fell from 10 million to around 6 million between 1993–2003, those for the Z-drugs rose from 0.3 million to over 4 million over the same time period, mainly in older people (DoH, 2003), and this is a worldwide phenomenon.

Expert bodies have long advised that use of all these group of drugs be limited to short periods and should be generally avoided in elderly people (BNF, 2004; CSM, 1988; Priest & Moutgomery, 1988). Around 80% of all such prescriptions in England are for those aged 65 years or over (Curran et al., 2003), and many patients remain on the drugs for months or years (Taylor et al., 1998). This prescribing is likely to lead to development of dependence and many other adverse effects on health (Ashton 1995). All currently marketed hypnotics have been associated with at least some features of dependence and have demonstrated a potential for misuse and dose escalation in at least a minority of patients (Ashton, 1995; Hajak et al., 2003; Lader, 1999).

Manifestations of anxiety and of sedative-hypnotic abstinence syndromes

It is important to note that the symptoms of anxiety and withdrawal syndromes from benzodiazepines overlap greatly. The psychological manifestations of anxiety include irritability, restlessness, insomnia, agitation, nightmares and difficulty in concentration. Physiological symptoms include tremors, shakiness, profuse sweating, palpitations and lethargy. In addition, in withdrawal syndromes in particular, there is hyper-excitability of voluntary musculature and hyperacuity of sensation leading to muscle twitching, aches and pains, hypersensitivity to light, smell and sounds, a metallic taste in one’s mouth and, very rarely, convulsions (Tyrer et al., 1990). Other physical reactions include nausea, loss of appetite, weight loss and feeling like one has a ‘flu-like’ illness. Other mental status changes can involve dysphoria, impaired memory and possibly confusion, depersonalisation and derealisation, psychotic reactions, and hallucinations (APA Task Force, 1990).

Summary and Conclusions

The treatment of tranquilliser dependence is not especially satisfactory, with only gradual withdrawal, often using a different benzodiazepine, over a variable time scale, showing satisfactory levels of efficacy in almost all studies. Other forms of pharmacological substitution are of limited value, with only carbamazepine showing some hint of real benefit, and psychological treatments such as cognitive-behaviour therapy are disappointing. The best evidence for a psychological intervention is for brief self-help packages and other forms of bibliotherapy, which also have the advantage of being accessible for booster purposes at all times. However, the evidence for efficacy is better in those who are in primary care and with less intractable dependence. Interestingly, these approaches
do not seem to differ in effectiveness for those who are dependent through prolonged therapeutic prescription or though deliberate misuse. The lack of information about the dependence problems of the Z-drugs (zopiclone, zolpidem and zaleplon) is troubling.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

Read Also

Cambridge Textbook of Effective Treatments in Psychiatry

Evidence-Based Practice in Psychology
Introduction to Empirically validated psychological therapies for drug dependence
Educational interventions for alcohol use disorders
An Introduction and Conclusions to Psychological treatments of alcohol use disorders
Psychological therapies and amphetamine and methamphetamine dependence
Psychological therapies and cocaine dependence
Goals of psychological therapies in treating drug dependence
Evidence-based cognitive-behavioral and behavioral treatments for drug dependence
Psychological therapies and cannabis dependence
Complex interventions for alcohol use disorders
The Minnesota model of care for alcohol use disorders
Therapeutic communities for alcohol use disorders
Combined pharmacotherapy and psychotherapy for alcohol use disorders
An Introduction to Pharmacotherapy of alcohol misuse, dependence and withdrawal
Treatment of nicotine dependence
Treatment of co-occurring psychiatric and substance use disorders