prescribing controlled substances: problematic use of
TRANSCRIPT
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"Prescribing Controlled Substances: Problematic Use of Opioids and
Benzodiazepines in Clinical Care"
Daryl Shorter, MD Staff Psychiatrist
Michael E. DeBakey VA Medical Center March 2, 2017
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Objectives - By the completion of the presentation, learners will be able to: (1) List risk factors for misuse, diversion, and/or dependence upon opioid medications and benzodiazepines (2) Identify clinical scenarios in which there is problematic use/prescribing of opioid medications and benzodiazepines (3) Employ treatment algorithms to successfully taper opioid medications and benzodiazepines (4) Discuss strategies for patient monitoring and mitigating risk factors for opioid and benzodiazepine misuse
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Definitions
• Misuse
• Diversion
• Dependence
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Definitions
• Misuse
• Diversion
• Dependence
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Misuse (1) • Any medication use that occurs without
prescription (therapeutic benefit v intoxication?)
• Legitimately prescribed medication used for intoxication/euphoria
• Medication use in context of dependence (methadone, buprenorphine)
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Misuse (2) • Motives for Non-Prescribed Medication Use
– Intoxication
• High dose, intravenous
• Combined with alcohol or other drugs
– Therapeutic use
• Bona fide condition/appropriate indication
• Correct dosing pattern
Barrett SP et al. What constitutes prescription drug misuse? Problems and current conceptualizations. Curr Drug Abuse Reviews. 2008;1:255-62.
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Misuse (3) • Group differences
– Adolescents • Sedative/hypnotics, opiates = therapeutic > recreation
• Stimulant medications = recreation
– College students • Therapeutic benefit > recreation
– Older adults • Withdrawal, dependence
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Misuse (4) • Quasi-legitimate Reasons?
– Immediate/acute need
– Unable to seek formal medical consultation
– Barriers to access
• Socioeconomic
• Geographic
• Temporal
– Provider reluctance to prescribe
– Under-medication
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Misuse (5) • Clinical implications of different forms of
misuse
– Increased risk of overdose
– Mitigation of other substance effects
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Definitions
• Misuse
• Diversion
• Dependence
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Diversion • Exchange of prescription medications
• Leads to drug use by unintended persons
• Under conditions associated with
– “Doctor shopping”
– Misrepresentation of medical problems
– Theft
– Trading, selling, loaning, giving away
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Diversion (2) • Gender differences in diversion patterns
– 20% of girls, 13% of boys borrow and/or share medications
– Of the girls
• 16% borrowed
• 15% shared
• 7% shared meds more than 3 times
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Diversion (3) • Motivations for sharing drugs & gender
– Receiving person ran out of drug: 40% of girls, 27% of boys
– Received from family: 33% of girls, 27% of boys
Daniel KL et al. Sharing prescription medication among teenage girls: potential danger to unplanned/undiagnosed pregnancies. Pediatrics 2003;111:1167-70.
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Definitions
• Misuse
• Diversion
• Dependence
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Dependence
• Physiological and/or psychological
• Compulsive
• Use despite negative consequences
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Risk Factors - Opioids • Personal Hx of Substance Abuse
– Rx drugs > Illegal drugs > Alcohol
• Family Hx of Substance Abuse
– Rx drugs > Illegal drugs > Alcohol
– Equivalent danger of illegal drugs and EtOH in men
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Risk Factors - Opioids • Age between 16-45 years
• History of preadolescent sexual abuse
• Psychological/mental health concerns
– ADD, OCD, Bipolar disorder, Schizophrenia
– Depression
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Opium poppy, Papaver somniferum
Naturally occurring - Opium - Morphine - Codeine
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Opioid Formulations
Morphine
Oral immediate-release: MSIR®
Oral extended-release: MS Contin®, Oramorph®,
Avinza®, Kadian®
Others: solution, suppositories, intravenous
Hydromorphone Oral immediate-release: Dilaudid®
Others: solution, suppositories, intravenous
Oxycodone Oral immediate-release: Oxy IR®, Roxicodone
Oral extended-release: Oxycontin®
Others: solution
Oxymorphone Oral immediate-release: Opana®
Oral extended-release: Opana ER®
Others: intravenous
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Opioid Formulations
Fentanyl Transdermal patch: Duragesic®
Oral lozenge: Actiq®
Others: intravenous
Methadone Oral immediate-release: Methadose®, Dolophine®
Others: solution, intravenous
Meperidine Oral immediate-release: Demerol®, Mepergan® Others: solution, intravenous
Mixed agonists/ antagonists
Butorphanol (Stadol®), Nalbuphine (Nubain®)
Pentazocine (Talwin®)
Partial agonists Buprenorphine (Subutex®, Suboxone®)
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Opioid Formulations • Combination Products
Hydrocodone Lortab®, Lorcet®, Vicodin®, Norco®
Oxycodone Percocet®, Endocet®, Roxicet®, Combunox®
Codeine Tylenol #3®, Tylenol #4®
Propoxyphene Darvocet®
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20.8 million Americans (~8%) current users of illicit substances
2.6 million persons with Opioid Use Disorder
2.0 million persons with pain reliever
abuse or dependence
591,000 persons with heroin abuse or
dependence
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ED Visits for Drug Misuse
0
50,000
100,000
150,000
200,000
250,000
2004 2005 2006 2007 2008 2009
Heroin
Hydrocodone
Oxycodone
Methadone
Morphine
http://DAWNinfo.samhsa.gov/data/report.asp?f=Nation/AllMA/Nation_2009_AllMA_ED_Visits_by_Drug
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DAWN (2009)
1.2 million ED visits involving nonmedical use of pharmaceutical or dietary supplement
Hydrocodone (alone or in combination) 104,490 ED visits
Oxycodone (alone or in combination)
175,949 ED visits
Methadone (alone or in combination)
70,637 ED visits
These 3 medications account for roughly 30% of the ED visits involving nonmedical use of pharmaceuticals/dietary supplements
http://www.nida.nih.gov/infofacts/hospitalvisits.html
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CASE – Steve • 62y Vietnam Era male veteran presents to PCP
• PMHx – HTN ─ GERD
– Hypercholesterolemia ─ Obesity
– Gout ─ Chronic back pain
– Chronic shoulder pain
• PSHx – Right knee arthroscopy x 2
– Left shoulder – rotator cuff repair
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CASE – Steve • PΨHx
– Major Depression ─ Generalized Anxiety
• Medications
– Lisinopril ─ Gemfibrozil
– HCTZ ─ Simvastatin
– Allopurinol ─ Omeprazole
– Citalopram ─ Trazodone
– Sildenafil PRN ─ Hydrocodone 10mg Q4H
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CASE – Steve • Family Hx
– Dad – CAD, MI, Alcohol Use Disorder
– Mom – HTN, DM, Dementia
– Brother – CAD, Obesity, Alcohol Use Disorder
• Substance Use Hx
– “Social” alcohol – two 6pks of beers on weekends
– Denies tobacco or illicit substance use
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CASE – Steve • Exam (pertinent findings)
– Appearance: Older than stated age, but NAD
– Gastrointestinal: protuberant abdomen, no TTP, HSM
– Musculoskeletal: TTP R shoulder (subscapular region); ↓(?) ROM with lateral arm raise; no ROM deficits for trunk/lower back; gait WNL
– Mental Status: Mild dysphoric mood, anxiety
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Strategic Focus
• Accurate diagnosis
• Appropriate pharmacotherapy
• Referral to specialty services
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Three Common Scenarios…
1. Patient presents with previous or self-diagnosis of Opioid Use Disorder (OUD)
2. Suspicion of OUD a) Self
b) Referring provider
c) Family
3. Incidental finding of OUD
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• Opioid Use Disorder
• Opioid Intoxication
• Opioid Withdrawal
• Opioid Delirium (Intoxication/Withdrawal)
• Opioid Depressive Disorder (I/W)
• Opioid Panic and Anxiety Disorder (W)
• Opioid Induced Sexual Dysfunction (I/W)
• Opioid Sleep Disorder (I/W)
DSM-5 Opioid Use Disorder
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DSM-5 Opioid Use Disorder • Tolerance
• Withdrawal
• Attempts to cut down
• Much time spent using
• Use larger amounts
• Neglecting roles
• Hazardous use
• Physical/psychological problems from use
• Social/interpersonal problems from use
• Activities given up
• Craving
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OUD Specifiers
• In early remission – none of the criteria met for at least 3 months, but less than 12 months
• In sustained remission – none of the criteria met for 12 months or longer
– Note: Craving may be present!
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OUD Specifiers
• On maintenance therapy
– Methadone
– Buprenorphine
– Naltrexone (oral or depot)
• In a controlled environment
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OUD Caveats
• Symptoms of tolerance and withdrawal occurring during appropriate medical treatment are not counted when diagnosing SUD
• Opiates are not listed in DSM-5 as causative agent for substance-induced psychosis
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Opioid Intoxication • Small, constricted pupils
• Slowed breathing
• Decreased alertness
• Decreased HR, BP
• Reports of fatigue
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Opioid Withdrawal • Dysphoric (sad) mood
• Muscle aches
• Lacrimation (tearing) or rhinorrhea (runny nose)
• Pupillary dilation, piloerection (goose flesh), or sweating
• Nausea/vomiting
• Diarrhea
• Yawning
• Fever
• Insomnia
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Assessment
• Resting heart rate
• Sweating
• Restlessness
• Pupil size (dilation)
• Bone/Joint aches
• Runny nose or tearing
• GI upset
• Tremor (outstretched hands)
• Yawning
• Anxiety
• Gooseflesh skin
Clinical Opiate Withdrawal Scale
Score 5-12 = Mild 13-24 = Moderate 25-36 = Moderately Severe More than 36 = Severe
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Assessment
• “Has a family member ever expressed concern about your Rx opioid use?”
• “Has a physician ever expressed concern about your Rx opioid use?”
• “Have you ever used your Rx opioid to treat other symptoms (e.g., sleep, irritability, sadness)
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Adapted from Prescription Drug Use Questionnaire (PDUQ)
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• Opioid Use Disorder
• Opioid Intoxication
• Opioid Withdrawal
• Opioid Delirium (Intoxication/Withdrawal)
• Opioid Depressive Disorder (I/W)
• Opioid Panic and Anxiety Disorder (W)
• Opioid Induced Sexual Dysfunction (I/W)
• Opioid Sleep Disorder (I/W)
DSM-5 Opioid Use Disorder
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Assessment
• Aberrant drug related behaviors
– Multiple prescribers
– Early prescription refills
– Dose/frequency escalation
– ER visits for analgesics
– Use of alcohol/psychoactive drugs
– Taking a family member’s medication
• Personal history of opioid detox 41
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Assessment
• PMP AWARxE
– Prescription drug monitoring program through Texas State Board of Pharmacy
– www.pharmacy.texas.gov/PMP
• Urine drug screening
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CASE – Steve • You are concerned that Steve may have OUD,
but decide a short-term prescription for opioids is appropriate while laboratory studies and imaging are obtained
– You decrease from Hydrocodone 10mg Q4H PRN to Hydrocodone 10mg Q6H PRN
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CASE – Steve • Lab WNL
• UDS +opiates; negative MJ, bzdp, coc
• Imaging
– Previous right shoulder procedure
– Mild osseous changes in lower spine
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CASE – Steve • Visit #2
– Reports ↓ hydrocodone ↑ shoulder/lower back pain
– Diminished activity, functioning
– ↑ Depression/anxiety
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Strategic Focus
• Accurate diagnosis
• Appropriate pharmacotherapy
• Referral to specialty services
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Patient diagnosed with OUD
No
Yes
Inpatient Admission
Outpatient Management
Overdose? Naloxone
Acute intoxication/withdrawal? Medical complications?
Yes
No
Naltrexone (oral or sustained
release)
Opioid Agonist (Methadone,
Buprenorphine)
Abrupt Discontinuation Plus Clonidine
Opioid Substitution with Taper
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Clonidine Detoxification Day From short-acting opioid (heroin,
oxycodone) From methadone (25mg or less)
1 0.3-0.6 mg/day (includes 0.1-mg test dose)
0.3-0.6 mg/day (includes 0.1-mg test dose)
2 0.4-0.8 mg/day 0.4-0.6 mg/day
3-6 0.6-1.2mg/day, then reduce daily dose by 50% each subsequent day; daily reductions not to exceed 0.4mg
0.5-0.8 mg/day
6-10 0.6-1.2mg/day, then reduce daily dose by 50% each subsequent day; daily reductions not to exceed 0.4mg
Adapted from Kosten & Kleber, 1994
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Clonidine Most effective in suppressing autonomic signs of withdrawal, less
effective for subjective symptoms
Adjuvant therapy may be needed • NSAIDs (for myalgia)
• Trazodone (for insomnia) • Antiemetics (for GI distress)
• Propranolol (for restlessness)
Lethargy, restlessness, insomnia, craving are likely to persist
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Withdrawal Management (1)
• Symptom-triggered clonidine Rx
– For COWS > 8, give 0.1-0.2mg clonidine
– On day 1, target dose of 0.3-0.6mg
– May to 0.6-1.2mg/day, as necessary
– Once stabilized, reduce daily dose by 50% per day
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•Clonidine
•Agonist Opioid
Withdrawal
•Antagonist
•Agonist Long term Rx of OUD
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Withdrawal Management (2) Use opioid agonist to symptoms
• Methadone
– Up to 30mg/day
– 10-20% every 1-2 days over 2-3 weeks
– Better than α2-adrenergic agonist based Rx
• Buprenorphine – Up to 8mg/day
– ↓ by 2mg every 1-2 days over 7-10 days 52
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•Clonidine
•Agonist Opioid
Withdrawal
•Antagonist
•Agonist Long term Rx of OUD
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Long-term Rx of OUD • Opioid Antagonist Therapy
– Intramuscular naltrexone (Vivitrol)
• Administer every 30 days
• Prevents opioid high
• Low compliance
– No other FDA-approved medications
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Long-term Rx of OUD (2) • Methadone maintenance treatment (MMT)
– Taken daily by mouth
– Obtained through federally-regulated program
– Optimal dose varies (target = 80mg/day)
-- Must ↑ dose slowly to avoid OD
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MMT Drawbacks • Overdose common in early treatment
• Cannot be prescribed from general practice
• Strict government control and paperwork
• Stigma of daily clinic attendance
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Office-Based Buprenorphine
• Taken daily, sublingually
• Rx in offices of physicians with special training
• Individual dose varies (target = 16-24mg/day)
• Daily visits not necessary
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Buprenorphine Pharmacology • Partial agonist at μ-opioid receptor
• Slow dissociation from receptor
• Half-life = 24-36 hrs
• Metabolizes quickly, if give orally
• So Rx is sublingual or buccal
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Buprenorphine Pharmacology (2)
• Clinical impact
– Less subjective euphoria than methadone
– Long-lasting clinical action
– Partially blocks intoxication
– Reduced overdose risk 59 Alcohol Medical Scholars Program
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Formulations • Buprenorphine alone (Subutex)
• Buprenorphine + naloxone (Suboxone)
– Naloxone = antagonist
– risk of diversion and IV misuse
– Combined in 4 mg bup:1 mg naloxone
• Combo in sublingual or buccal film
60 Alcohol Medical Scholars Program
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More Buprenorphine Info
• Side effects – Neuro: Sedation, dizziness, headache
– GI: Constipation, nausea/vomiting
– Respiratory depression
• Availability and cost – Prescribed by MDs with special training
– Reimbursed by Medicaid, health insurances
─ But costs more than methadone
61 Alcohol Medical Scholars Program
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Buprenorphine Treatment • Initiation
– Goal: avoid precipitated withdrawal & OD
– Patient stops opioid misuse 12-36 hrs prior
– Patient demonstrates early withdrawal
• COWS rating > 8 62 Alcohol Medical Scholars Program
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CASE – Alfred • 57y Vietnam Era male veteran presents to PCP
• PMHx
– HTN ─ Migraine HAs
– Chronic pain ─ Gastritis
– Gastric neoplasm (benign)
• PSHx
– Tonsillectomy – childhood
– Multiple EGDs
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CASE – Alfred • PΨHx
– Major Depression
• Medications
– Lisinopril ─ Omeprazole
– ASA ─ Sumatriptan PRN
– Loratadine ─ Alprazolam (Xanax) 2mg TID
– Hydrocodone 5mg Q6H PRN
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CASE – Alfred • Family Hx
– Dad – CVA, DM
– Mom – Depression, HTN, obesity
• Substance Use Hx
– Alcohol – 3-4 12oz. beers/session ~1-2x/week
– Occasional marijuana (<1 joint/use)
– H/o cocaine use in 20s and 30s
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CASE – Alfred • Vague report
– “Do I have to answer that?”
– 6-year history of Alprazolam use
– Obtained from both providers and illicit sources
– Anxious between dosages
– Insomnia if he runs out
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CASE – Alfred • Exam (pertinent findings)
– Appearance: Older than stated age, fidgety
– Gastrointestinal: protuberant abdomen
mild TTP, no HSM
– Mental Status: Mildly dysphoric, anxious appearing and irritable
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BZD Formulations
Diazepam Oral immediate-release: Valium®, Diastat®
Others: intramuscular, intravenous, suppository
Alprazolam Oral immediate-release: Xanax®
Oral extended-release: Xanax-XR®
Others: solution
Clonazepam Oral: Klonopin®, Klonopin wafer®
Others: orally disintegrating tablet
Lorazepam Oral immediate-release: Ativan®
Others: intramuscular, intravenous, sublingual, solution
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Indications (FDA) • Alcohol withdrawal
• Insomnia
• Anxiety disorders
• Panic disorder
• Muscle relaxant
• Antiepileptic
• Anesthesia adjunct
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Clinical use (non FDA) • Catatonia
• Agitation
• Abnormal movements
• Tourette’s syndrome
• Delirium
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Epidemiology (1) • 2011: Alprazolam, Lorazepam, Diazepam were
the most common prescribed
• 2011: 47.8 million Alprazolam prescriptions written (137 million Hydrocodone Rx)
• 2.3% of adults in US report nonmedical use of sedatives – 10% of those meet criteria for abuse or dependence
From SAMHSA NSDUH (2012), DAWN (2010)
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Epidemiology (2) • 2011: 345,528 ER visits related non illicit drugs
– 25% related with non medical use of BZD • 10% Alprazolam
• 5% Clonazepam
• 3.5% Lorazepam
• 2% Diazepam
• 41,257 (3.3%) ER visits related non medical use of SSRIs
From SAMHSA NSDUH (2012), DAWN (2011)
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BZD & Mental Health (1)
• 30% of psychiatry pts receive BZD
–Affective disorders
–Long duration of illness
–High utilizers of psychiatric services
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BZD & Mental Health (2) • High risk patients
– Personal AUD history (15-20% misuse BZD)
– Family h/o of alcohol use disorder
– Personal h/o of opioid use disorder
– Methadone maintenance (47%)
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BZD and Suicide • 2009: 2nd most common class of drug used in
suicide attempt
• Alprazolam most commonly used BZD in SA (12%)
• Clonazepam second most common (8%)
• Zolpidem third most common (6%)
From SAMHA 2011.
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CASE – Alfred • You are concerned about Alfred’s combined
use of BZD and opiates as well as his patterns of BZD use.
– You decide a taper off the BZD is appropriate
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Assessment “Legitimate” Prescription
• GOAL: Treat underlying illness
• FOCUS: Assess risk of SUD
BZD Use Disorder
• GOAL: Confirm SUD dx
• FOCUS: Safe discontinuation
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Clinical Approach (1) • Identify risk factors
– Co-occurring SUD or psychiatric d/o
– Highest abuse: diazepam, lorazepam, alprazolam
– Prior BZD treatment > 8 wks
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Clinical Approach (1) • Minimize potential harms
– Aggressive short-term treatment
• Use high dose over few weeks while SSRI/SNRI take effect
– Short-term treatment
• PRN versus continuous schedule
– Drug holiday implementation
• Intermittent use of medication
• Only during high demand situations
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Clinical Approach (2) • Recognize TYPES of BzUD
• Underlying (anxiety) disorder; tolerant
• Recreational user
• Complicated
– High-dose
– Poly-BZD use
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Clinical Approach (2) • DSM V Criteria for SUD
• Aberrant drug related behaviors
– Early refills, ER visits
– Multiple providers
– Taking the medication as prescribed
– UDS + for illicit substances
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BZD Discontinuation (1) • Convert from fast/short acting to slow/long acting BZD
over 2-4 weeks
Drug Comparative dose
Diazepam 5mg
Alprazolam 0.5mg
Clonazepam 0.25mg
Lorazepam 1mg
Chlordiazepoxide 25mg
Temazepam 10mg
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BZD Discontinuation (2) • Cross taper with alternative agent
– GABAergic
• Buspirone
• Valproate**
• Carbamazepine
• Gabapentin
• Pregabalin
– Serotonergic
• TCA (Imipramine)
**indicates improved rates of long-term abstinence
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BZD Discontinuation (3)
• Cross taper with medication for anxiety reduction
– Hydroxyzine
– Quetiapine
– Trazodone**
• Inpatient management
– Flumazenil
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Patient is overtaking
benzodiazepine
Does the patient have primary
anxiety disorder?
Yes
GAD PTSD OCD PANIC D/O
SOCIAL ANXIETY
No Wean patient gradually
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Use greater than 1 yr?
Decrease by 10% q1-
2wks
STEP 1
When 20% of the original
dose remains then decrease 5% reduction of dose q2-
4wks.
STEP 2
Yes No
Decrease the total daily
dose by 25% in the first
week
STEP 1
Another 25% on
week two
STEP 2
Followed by 10% per
week until d/c
STEP 3
Wean patient gradually
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Anxiety d/o
Currently taking an SSRI/SNRI?
Start SSRI/SNRI
+ Switch to long
acting BZD
Yes No
Imipramine, buspirone, gabapentin, VPA, CBZ. Cont to
wean off BDZ if possible
No
Yes
Continue AD +
Wean BZD, if possible
Continue AD +
Wean BZD, if possible
Yes Sx
controlled?
Maximize SSRI/SNRI +
Switch to long acting BZD & initiate taper
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Take Home Points
• Risk Factors for Opioid Misuse
– Personal or family h/o substance use
– Age (16-45y)
– Psychiatric conditions (such as MDD, OCD, SCZ)
– Preadolescent sexual abuse (women)
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Take Home Points
• Risk Factors for BZD Use Disorder
– Personal h/o substance use
– Long term BZD use
– High dose BZD use
– Concomitant opioid use (esp. Methadone)
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Take Home Points
• Screening and assessment should include urine drug screening
• Initiation of taper should take into consideration length of time patient has been on medication and may require patience