There are well-recognised
harms from long-term use of benzodiazepines. These include dependency,
cognitive decline and falls. It is important to prevent and recognise benzodiazepine
dependence. A thorough risk assessment guides optimal management and the
necessity for referral.
The management of dependence involves either gradual
benzodiazepine withdrawal or maintenance treatment. Prescribing interventions,
substitution, psychotherapies and pharmacotherapies can all contribute. Unless
the patient is elderly, it is helpful to switch to a long-acting benzodiazepine
in both withdrawal and maintenance therapy.
The dose should be gradually
reduced over weeks to lower the risk of seizures. Harms from drugs such as
zopiclone and zolpidem are less well characterised. Dependence is managed in
the same manner as benzodiazepine dependence.
Benzodiazepine and z-drugs half-life and conversion table
| Drug | Approximate half-life (hours) | Dose of oral benzodiazepine approximately equivalent to diazepam 5 mg |
|---|---|---|
| Short- to intermediate-acting benzodiazepines | ||
| Triazolam | 1–3 | 0.25 mg |
| Oxazepam | 4–15 | 15 mg |
| Temazepam | 5–15 | 10 mg |
| Lorazepam | 12–16 | 1 mg |
| Bromazepam | 20 | 3 mg |
| Alprazolam | 6–25 | 0.5 mg |
| Flunitrazepam | 20–30 | 0.5 mg |
| Nitrazepam | 16–48 | 5 mg |
| Clobazam | 17–49 | 10 mg |
| Long-acting benzodiazepines (includes effects of active metabolites) | ||
|---|---|---|
| Clonazepam | 22–54 | 0.5 mg |
| Diazepam | 20–80 | 5 mg |
| Z-drugs | ||
|---|---|---|
| Zolpidem | 2.4 | 10 mg |
| Zopiclone | 5.2 | 7.5 mg |
Benzodiazepine withdrawal syndrome – clinical features
General
Headache
Palpitations
Sweating
Musculoskeletal
Tremor, fasciculations
Muscle pain, stiffness and aches (limbs, back, neck, jaw)
Neurological
Dizziness, light-headedness
Paraesthesia, shooting pains in neck and spine
Visual disturbances (blurred vision, diplopia, photophobia, vision lags behind eye movements)
Tinnitus
Faintness and dizziness, sense of unsteadiness
Confusion, disorientation (may be intermittent) – a common cause of confusion in older patients
Delirium (in the absence of autonomic hyperactivity) – particularly in older patients
Delusions, paranoia
Hallucinations (visual, auditory)
Grand mal seizures 1–12 days after discontinuing benzodiazepines
Gastrointestinal
Nausea
Anorexia
Diarrhoea (may resemble irritable bowel syndrome)
Psychological
Rebound insomnia, nightmares
Anxiety, panic attacks
Irritability, restlessness, agitation
Poor memory and concentration
Perceptual distortions – sensory hypersensitivity (light, sound, touch, taste), abnormal sensations (e.g. ‘cotton wool’ sensations)
Metallic taste
Distortions of body image
Feelings of unreality, depersonalisation, derealisation
Full article at: http://goo.gl/radrfW
- 1Clinical Pharmacology and Addiction Medicine, Drug Health Services, Royal Prince Alfred Hospital.
- 2Clinical Pharmacology and Addiction Medicine, Drug Health Services, Royal Prince Alfred Hospital ; Concord Repatriation General Hospital, Sydney.
- Aust Prescr. 2015 Oct;38(5):152-5. Epub 2015 Oct 1.
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