VAADA Conference 2015 Benzodiazepines: Are they making your client s life hell?

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Stanley Floyd
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1 VAADA Conference 2015 Benzodiazepines: Are they making your client s life hell? Stephanie Thwaites, Benzodiazepine Counsellor/ Mental Health Social Worker

2 Reconnexion A Service of EACH Reconnexion is a service of EACH Social & Community Health (as of Jan 2014), specialising in treating benzodiazepine dependency, anxiety disorders and depression Program was originally established in 1986 as TRANX Partly funded by Department of Health Telephone Information & Support Service; secondary consultation; community education Main office (Benzo program) Malvern East

was originally established in 1986 as TRANX Partly funded by Department of Health Telephone

3 Reconnexion Inc Initial telephone screening, in person assessment and ongoing counselling provided to assist with benzodiazepine dependency and address underlying issues Typical Client Presentation: prescribed tend to be longer term user, Benzos main presenting drug (themes: anxiety, insomnia, depression, complex trauma, personality disorders, history D&A use) Commonly some analgesic dependency (simple analgesics, weaker opioids and some stronger opioids)

term user, Benzos main presenting drug (themes: anxiety, insomnia, depression, complex trauma, personality

4 Quick Quiz Quick Quiz Handout Interesting Stat: During 2011, more than 1.45 million subsidized benzodiazepine prescriptions were dispensed through community pharmacies, with benzodiazepines continuing to be among the most widely prescribed drugs in Victoria (The Victorian Drug Statistics Handbook )

community pharmacies, with benzodiazepines continuing to be among the most

5 What are Benzodiazepines? Minor Tranquilizers and Sleeping Pills Relieve Anxiety, sedative, anticonvulsant, muscle relaxant, hypnotic Prescribing: anxiety disorders, insomnia, muscle relaxants, medical procedures, alcohol withdrawal Act on the ANS Parasympathetic branch GABA binding sites in brain Replace Barbiturates barbiturates now used in anaesthesia, dependency forming, overdose fatal

relaxant, hypnotic Prescribing: anxiety disorders, insomnia, muscle relaxants, medical

6 What are Benzodiazepines GABA controlling consciousness, coordination, emotions, memory, muscle tone & thinking When taking Benzos for continuous periods of time brain produces fewer GABA receptors, when drug is reduced, stopped or tolerance built brain has nothing to counter balance the increase in excitatory neurotransmitters withdrawal symptoms mimic initial complaint (anxiety, insomnia)

receptors, when drug is reduced, stopped or tolerance built brain has nothing to counter balance

7 Prescribing Guidelines RACGP Guidelines (new guidelines due April 2015) for prescribing short term (2-4 weeks) or intermittent use (only when other treatments have failed) Psychotropic Therapeutic Guidelines Version 7, 2013: benzodiazepines are not recommended for the treatment of Anxiety disorders other than in exceptional circumstances (avoid short acting, small quantities, short term, regular review)

Guidelines Version 7, 2013: benzodiazepines are not recommended for the treatment of Anxiety

8 Benzodiazepines 50-80% of people using benzos 6-12 months will become dependant (conservative stats - our experience has been less time to become dependant) Those who become dependant will experience withdrawal severity will vary Tolerance breakthrough withdrawal Most commonly prescribed to women and the elderly

dependant) Those who become dependant will experience withdrawal severity will

9 List of benzodiazepines Half life (hrs) Generic name Brand names Approx. equivalent dose to 5mg Diazepam short Alprazolam Kalma, Alprax (xanax) 0.5mg long Clonazepam Rivotril, Paxam 0.25mg long Diazepam Antenax, Valpam, Ranzepam 5mg long Flunitrazepam Hypnodorm, (Rohypnol) 1mg long Nitrazepam Mogadon, Alodorm 2.5mg short Oxazepam Serepax, Murelax, Alepam 15mg short Temazepam Normison, Temaze,Temtabs 10 mg

10 Quick Note: Z Class Drugs Hypnotics available by prescription that are not benzodiazepines Zolpidem (Stilnox) & Zopiclone (Imovane) most well known Same safe rules apply Same risk of dependency Follow benzodiazepine withdrawal guidelines

(Stilnox) & Zopiclone (Imovane) most well known Same safe

11 Benzodiazepine Withdrawal Onset: 2-3 days for short acting; 5-7 days for long acting (individual experience varies) Acute withdrawal 5-28 days with a peak in severity around 2 weeks following reduction Symptoms typically fluctuate (can gradually decline and then have peaks of recurrences), can be more intense and the beginning and end of a reduction Withdrawal can be protracted (10-15%) months/years Complicated often by pre-existing underlying mental health issues, traumas which re-surface during withdrawal

decline and then have peaks of recurrences), can be more intense and the beginning and end of a reduction Withdrawal can be

12 Common Withdrawal Symptoms Anxiety & panic attacks Insomnia Heightened sensitivity of the senses Muscle twitching and spasm Pins and needles Nausea Dizziness Depression Loss of memory Loss of appetite Changes in Perception Agoraphobia

twitching and spasm Pins and needles Nausea Dizziness

13 Assisting Clients to Withdrawal Stabilise on a daily dose agreeable with the client and prescribing doctor (2-4 weeks) If on a short acting (Alprazolam) transition gradually over to long acting (Diazepam) helps with withdrawal symptom severity & cutting down tablets Gradual Reduction no more than 10% of overall daily dose per week or fortnight (rarely see weekly, many try for fortnightly but need breaks or once every three weeks) Monitor symptoms, reassure, encouragement, client in control of pace Cutting tablets: 10% a guide err on side of caution, smaller reductions rather than larger especially long term users

overall daily dose per week or fortnight (rarely see weekly, many try for fortnightly but need breaks or once every three weeks) Monitor symptoms,

14 Activities to Help in Withdrawal Gradual Reduction + Psychological Support = Greater success rate! Minimise alcohol Diet & minimise stimulants Exercise - gentle Relaxation, meditation, breathing techniques Counselling

Minimise alcohol Diet & minimise stimulants Exercise -

15 Benzodiazepines & other drugs /Alcohol

16 Benzodiazepines & other drugs /Alcohol Non medical benzodiazepine use remains widespread among people who regularly inject drugs in Melbourne. In 2011, 71 % reported use of either prescribed or illicit forms of benzodiazepines other than alprazolam on a median of 55 days in the preceeding 6 months, while 69% detailed recent use of prescribed or illicit alprazolam on a median 13 days (The Victorian Drug Statistics Handbook, Turning Point ) Non-medical benzodiazepine use was common among regular ecstasy users in Melbourne in 2011, with 56% reporting illicit use (The Victorian Drug Statistics Handbook, Turning Point ) Prescription medications were present in 82.8% (n=304) of deaths involving acute drug toxicity recorded by the Coroners Court in (Illicit drugs making up 35.7% and alcohol 21.8%). (Coronial data on Victorian deaths involving acute drug toxicity, Yarra Drug & Health Forum, Jeremy Dwyer, May 2013) There were 1676 benzodiazepine-related deaths identified as reported to an Australian Coroner across % of benzodiazepine related deaths were in combination with other drug classes (National Coronial Information System, April 2013)

prescribed or illicit alprazolam on a median 13 days (The Victorian Drug Statistics Handbook, Turning Point 2010-2011) Non-medical benzodiazepine use was common among regular ecstasy users in

17 Benzodiazepines & Other Drugs/Alcohol Dangerous when mixed with illicit drugs and alcohol, increases severity of benzodiazepine withdrawal Other CNS depressants: alcohol, heroin, other opioids cardiovascular depression, breathing difficulties, higher risk of overdose Alcohol commonly used with benzodiazepines, increase sedation effect, greater risk of falls, memory loss, black outs, withdrawal seizures, make withdrawal effects more severe Taken to assist with come down affect of stimulant drugs like amphetamines dependency cycle, strain on the body systems, effects of one masking the effects of the other - higher risk of overdose

benzodiazepines, increase sedation effect, greater risk of falls, memory loss, black outs, withdrawal seizures, make withdrawal effects more severe Taken to

18 Assisting Poly drug/illicit Users with Benzodiazepine Dependency Managing the withdrawal process: people need to be able to stabilise on a daily dose If illicit drug use is daily, heavy &/or going to impact on their ability to stabilise on a daily dose of benzos or manage the withdrawal symptoms then deal first with the illicit drug use Reconnexion Experience: some clients who use small daily amounts of marijuana, alcohol able to proceed with benzo withdrawal If client has been supplementing benzodiazepine scripts or solely using illicit benzodiazepines they will need to find a prescribing doctor to work with them to stabilise on a daily dose or attend inpatient detox then gradual reduction from there

Experience: some clients who use small daily amounts of marijuana, alcohol able to proceed with benzo withdrawal If client has been supplementing benzodiazepine scripts or

19 Questions? Questions?... Please remember: Reconnexion offers Secondary Consultation regarding the use and withdrawal of benzodiazepines Can work in tandem with other AOD counsellors to offer counselling focused more on the benzodiazepine withdrawal or assisting with the anxiety/depression Can offer in person assessments and create a withdrawal/ reduction plan is required Information sheets available on our website Telephone Support Volunteer Line (M-F business hours) Education and Training tailored for your organisation

tandem with other AOD counsellors to offer counselling focused more on the benzodiazepine withdrawal or assisting with the

Information About Benzodiazepines

Information About Benzodiazepines What are benzodiazepines? Benzodiazepines are psycho tropic drugs - drugs that affect the mind and are mood altering. They are commonly known as minor tranquillisers and