Term
| What do you use benzos for? |
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Definition
| anxiety, insomnia, post-op amnesia, EtOH withdrawl. |
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Term
| Which benzos are high potency, short half life? |
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Definition
High potency
short half life
alprazolam (Xanax)
lorazepam (Ativan)
triazolam (Halcion) |
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Term
| Which benzos are high potency, long half life? |
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Definition
long half-life
clonazepam (Klonopin) |
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Term
| Which benzos are l0w potency, short half life? |
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Definition
long half-life
chlordiazepoxide (Librium)
Chlorazepate (Tranxene)
diazepam (Valium)
flurazepam (Dalmane) |
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Term
| Which benzos are low potency, short half life? |
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Definition
Low potency
short half-life
oxazepam (serax)
temazepam (Restoril) |
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Term
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Definition
Benzodiazepines bind to the benzodiazepine receptor which is part of the GABA A receptor complex. Benzodiazepines potentiate the effects of GABA. They do not activate the receptor by themselves
GABA is an inhibitory neurotransmitter so potentiation of its activity tends to result in reductions in anxiety, sedation and anticonvulsant activity.
Barbiturates and alcohol also stimulate GABA a receptors which accounts for the cross tolerance of these 3 sedatives and allows one to use benzodiazepines for the treatment of alcohol withdrawal.
Over time, compensatory changes occur in the GABA A receptor in the presence of benzodiazepines which renders them less efficient resulting in tolerance or less effect with the same dose.
When these compensatory changes are suddenly unopposed benzodiazepine withdrawal results. |
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Term
| do you get tolerance with benzos? |
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Definition
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Term
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Definition
| As with all drugs the withdrawal symptoms is the opposite of the intoxication symptoms so benzodiazepine withdrawal results in central nervous system activation including seizures and delirium |
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Term
| what are withdrawl symptoms? |
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Definition
Benzodiazepine withdrawal is similar to alcohol withdrawal but the timing differs based on the half-life of the particular drug.
Short half life drugs have an onset of withdrawal in 2-3 days. Long half life drugs the onset of withdrawal is 4-7 days.
Long half life drugs tend to have less severe withdrawal.
Withdrawal syndrome tends to vary with dose, length of time of treatment. Usually you won’t see withdrawal unless treatment exceeds 4 months.
Anxiety;
Agitation;
Increased sensitivity to lights, sound;
Paresthesias, strange sensations;
Muscle cramps;
Myocolonic jerks;
Insomnia;
Dizziness;
Seizures, delirium |
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Term
| can you commit suicide on benzo? |
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Definition
| generally really hard to kill yourself with just benzos. |
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Term
| which are more abused--benzos or cocaine? |
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Definition
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Term
| how can you properly prescribe benzos? |
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Definition
To avoid trouble using benzodiazepines here are some good rules of thumb.
Think about what you are doing. What is the diagnosis? What other treatments might work? How long do you think the patient will need it? Do you really want this patient on a medication to which they will become physically dependent?
If there is a history of substance abuse or dependence? If so you should consider every other nonabusable alternative. Antidepressants work just as well for panic as do benzos and also have efficacy for another anxiety disorders. For sleep there are nonabusable alternatives as well and we will talk more about this in a minute
Large prescriptions of benzo should be avoided especially if you do not know the patient very well. Many of these could end up on the street. Likewise don’t give refills. Keep track of the patient. Treat with lowest effective dose for the shortest period of time.
I don’t like to use the high potency short acting benzos like xanax. Xanax has the highest street value and is the most abusable. I am deeply suspicious of any patient who asks for it. If I have to use benzos I like to use oxazepam because it has very little street value or klonopin which has a longer half life and less street value. |
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Term
| How do you treat insomnia (and try to avoid benzos)? |
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Definition
First thing you do as always is get a history. Because very often insomnia is either a symptoms of an underlying psychiatric illness, medical illness or a side effect of a medication.
About 40% of insomniacs have a psychiatric disorder, mostly depression
About 10-15% will have a substance use disorder.
Other illnesses to think about: BPH, CHF, arthritis,
Common meds to think about: decongestants, B agonists, corticosteroids, diuretics, antidepressants, H-2 blockers
Sleep apnea should be considered especially if daytime sleepiness is prominent, snoring is present apnea is heard by bed partner, or BMI>35 These are the patients that need a sleep study.
Every insomniac should be taught good sleep hygiene. Lessons include a regular schedule, relax before bed only go to bed when tired, use the bed for sleep and sex only, avoid naps, reduce caffeine, nicotine and alcohol for a few hours before bed, exercise daily but not before bed. Sleep hygiene helps some but is unlikely to work with more severe insomniacs
Medication options start with the least offensive and progress to stronger and potentially more problematic medications.
Diphenhydramine is in most over the counter sleepers. It may cause dry mouth constipation and a morning hangover. Some will get tolerant to it fast. Most will have tried it before asking you for a sleeper. 50 mg is the standard dose.
Lately I have become a fan of ambien and lunesta. These target one of the benzodiazepine receptor subtypes and are supposedly less likely to interfere with the sleep cycle. They are less abusable than xanax or valium but still have abuse liability.
Often it is easier just to use a sedating antidepressant like trazodone, sinnequan or remeron. Trazodone is the traditional one to use 50-150 mg which is much less than the antidepressant dose. You can get a morning hangover, dry mouth lightheadedness, and men sometimes rarely get priapism from trazodone. |
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Term
| what are examples of abused stimulant drugs? |
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Definition
Amphetamines (
Dextroamphetamine (Dexadrine)
Mixed (Adderall));
Diet Pills - Phentermine et al.;
Methylphenidate (Ritalin) |
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Term
| which stimulant is most abused? |
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Definition
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Term
| what type of prescription drug is rising the most quickly? |
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Definition
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Term
| what are favorite narcotics? |
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Definition
The most commonly abused narcotic analgesics are hydrocodone and oxycodone.
Hydrocodone is found mainly in the combination products vicodin and vicoprofen. In these medication hydrocodone is combined with either acetaminophen or ibuprofen.
Oxycontin is a relatively new opiate analgesic. It is designed to be a slow release oxycodone and it does have a long half life when used as directed. However if one breaks the capsule then the oxycodone is released immediately. Oxycontin is either abused by chewing and swallowing the powder or by snorting.
Oxycontin and oral opiate abuse in general are different from heroin abuse in that oral opiates are more common in suburban and rural areas. Oxycontin abuse is found almost exclusively in caucasians. One reason for this difference in distribution might be the price. Oxycontin is sold on the street for 1-2 dollars per mg. Most users will take 40-80 mg at a time and a 340-320 mg per day habit is not uncommon for those who become dependent. Heroin costs only a fraction of the price of oxycontin.
In a recent study it was found that 87% of oxycontin users had histories of previous drug abuse. So the current problem with Oxycontin has not resulted from drug naïve pain patients who subsequently become addicted but rather oxycontin is abused by drug abusers.
The combination drug products like vicodin are more likely to be abused because they are schedule 3 which increases their availability. Scripts for Schedule 3 drugs can be written for larger amounts. Refills can be authorized and the medications can be called in to the pharmacy. In contrast, schedule 2 medications can only be filled with a written prescription, the amount is limited to 30 days worth and refills are not allowed. |
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Term
| who is getting inadequate treatment of pain? |
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Definition
Even among cancer patients physicians have notoriously under treated pain.
40-60% of oncology patients receive inadequate pain medication.
The likelihood of receiving too little pain medication is increased in the groups you might suspect
Minorities are 3 times more likely to be undertreated for pain.
Women and the elderly too are more likely to be undertreated.
The three issues that come up as explanations of undertreatment are first fears of causing respiratory depression with high doses of opiates. This fear is unfounded for several reasons. Tolerance to the respiratory depressant effects of opiates reliable occurs along with tolerance to the analgesic effects so although there is a theoretical risk clinically it is not seen.
Analgesic tolerance is also feared and again clinically this is less of a problem than one might think.
Finally there is the fear of causing addiction which in some cases is nonsensical.
And there is also the confusion between physical dependence and addiction |
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Term
| what happens with physical dependance (normal response) |
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Definition
Physical dependence is a normal physiological response to treatment with a medication. Many medications cause physical dependence including opiates.
Physical dependence is characterized by two phenomena, tolerance and withdrawal.
Tolerance being reduction in the effect from a stable dose of a medication after repeated administrations.
Withdrawal is a syndrome of characteristic signs and symptoms that occur when a medication is abruptly stopped or the dose is significantly reduced. |
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Term
| what characterizes dependance (addiction)? |
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Definition
Tolerance;
Withdrawal;
More use than intended;
Unsuccessful efforts to cut down;
Spends excessive time in acquisition;
Activities given up because of use;
Uses despite negative effects |
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Term
| what is pseudo addiction? |
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Definition
Focus on obtaining opioids for pain relief;
Looks like addiction::
manipulation,
doctor shopping,
multiple ED visits |
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Term
| what distinguishes pseudoaddiction from real addiction? |
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Definition
| But it disappears with adequate meds |
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Term
| what produces chronic pain? |
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Definition
Headache (various types);
Backache (various etiologies);
Reflex sympathetic dystrophy;
Diabetic Neuropathy;
Fibromyalgia;
Tic douloureux;
Post-herpetic (Shingles);
Ulcerative colitis |
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Term
| what do you treat pain with? |
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Definition
opiates and non opiates:Acetominophen;
Ibuprophen;
Aspirin;
Combinations - caffeine adjuvant;
Tramadol (low opiate receptor activity);
Carbamazepine, Gabapentin;
Anti-depressants (amitryptiline et al) |
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Term
| what are nonmed strategies to relieve pain? |
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Definition
Biofeedback;
Hypnosis;
Group and individual psychotherapy;
Cognitive therapy;
Family therapy;
Exercise;
Acupuncture;
TENS and related stimulation;
Nerve blocks |
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