54 - Summary

Summary

Addictions and substance misuse CHAPTER 4 Polysubstance use Illicit benzodiazepines are often used in addition to a primary substance of abuse. People with non-­iatrogenic benzodiazepine dependence often consume doses greater than 100mg diazepam equivalent a day. There is no evidence that substitute prescribing of benzodiazepines ultimately reduces benzodiazepine misuse. Benzodiazepine dependence as part of polysubstance dependence should also be treated by a gradual withdrawal of the medication. Benzodiazepines prescribed at greater than 30mg diazepam equivalent per day may cause harm8 and so this should be avoided if at all possible. Pregnancy and benzodiazepine misuse Benzodiazepines are not major human teratogens but should ideally be gradually discontinued before a planned pregnancy. If a woman is prescribed benzodiazepines and found to be pregnant, the prescription should be gradually withdrawn over as short a time as possible, being mindful of the risk of withdrawal seizures and the potential consequences for the pregnant woman and fetus. A risk–benefit analysis should be undertaken and specialist advice sought (see pregnancy section in Chapter 7). As for all patients, it may be appropriate for a woman dependent on benzodiazepines to be stabilised on diazepam before any dose reduction.8 Summary ■ ■Benzodiazepines should be withdrawn using a hyperbolic tapering schedule (Table 4.24). ■ ■Discontinuation can sometimes be completed within 6 months. ■ ■Switching to an equivalent dose of diazepam before withdrawal is commonplace but not always effective. Table 4.23  Psychosocial and pharmacological interventions in benzodiazepine withdrawal. Psychosocial Pharmacological Contingency management and patient education have had some success at reducing benzodiazepine use A Cochrane review found evidence that supported the use of cognitive behavioural therapy (CBT) alongside dose reduction9 Evidence suggests targeted interventions with non-­pharmacological supportive therapies are more likely to result in successful deprescription10 Multifaceted prescribing interventions (usually including psychological interventions/support) are recommended for older patients11 A 2018 Cochrane review could find no pharmaceutical add-­on that could help facilitate the withdrawal process12 Withdrawal symptoms should not be treated with another dependence-­forming medicine or sodium valproate or buspirone6