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Diagnosing and Treating Benzodiazepine Abuse in Older Adults

This information on benzodiazepine abuse is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only. Always consider the needs of individual patients and the resources available.

Prevelance
Risk Factors and Symptoms
Diagnosis
Management

Prevelance

  • Older adults represent only 14% of the U.S. population, yet they receive 27% of all prescriptions for anxiolytic benzodiazepines and 38% of hypnotic benzodiazepines.
  • Most benzodiazepine prescriptions for older adults in the United States are ordered for anxiety and insomnia, with only 5 percent used as adjuncts for general anesthesia, as muscle relaxants, or as anticonvulsants.
  • Data from the Veterans Affairs Hospital System suggest that elderly patients may be prescribed inappropriately high doses of medications such as benzodiazepines and may be prescribed these medications for longer periods than are younger adults.
  • A national survey of approximately 3,000 community-dwelling persons indicated that older persons were over represented among the 1.6 percent who had taken benzodiazepines daily for 1 year or longer:
    • 71% > 50 years of age
    • 33% > 65 years of age

D’Archangelo, E. Substance abuse in later life. Canadian Fam Physician 39:1986-1993, 1993.

Mellinger, G. D., Balter, M. B., & Uhlenhuth, E. H. (1984). Prevalence and correlates of the long-term regular use of anxiolytics. Journal of the American Medical Association, 251, 375 379.

National Institute on Drug Abuse, Research Report: Trends in prescription drug abuse(http://ncadi.samhsa.gov/govpubs/BKD250/26d.aspx)

Pincus HA, Tanielian MA, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry and other medical specialties. JAMA 1998; 279:526-531.

Salzman, C. Benzodiazepine treatment of panic and agoraphobic symptoms: Use, dependence, toxicity, abuse. J Psych Research 27:97-110, 1993a. Issues and controversies regarding benzodiazepine use. In: Cooper, J.R.; Czechowicz, D.J.; Molinari, S.P.; and Petersen, R.C., eds. Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care. NIDA Research Monograph Series, Number 131. NIH Pub. No. 93-3507. Washington, DC: U.S. Government Printing Office, 1993b. pp. 68-88.

Substance Abuse Among Older Adults, Treatment Improvement Protocol (TIP) Series 26 http://ncadi.samhsa.gov/govpubs/BKD250/, developed by the Substance Abuse and Mental Health Services Administration (SAMHSA)

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Risk Factors and Symptoms


Risk factors for benzodiazepine abuse

Medical hospitalization is a significant risk factor for initiation and continuation of benzodiazepines.

  • As many as 12% of older adults who were given a prescription for benzodiazepines upon discharge from the hospital were prescribed the benzodiazepine at the time of admission, without a specific indication (Surendrakumar D, Dunn M, Roberts CJC. Hospital admission and the start of benzodiazepine use. British Medical Journal 1992; 304:88.)
  • As many as 38% of older adults will refill these benzodiazepine prescriptions for an additional 3 or more months following discharge from the hospital (Grad R, Tamblyn R, Holbrook AM, et al. Risk of a new benzodiazepine prescription in relation to recent hospitalization. Journal of the American Geriatrics Society 1999; 47:184-88.)

Older adults who are at risk of abusing benzodiazepines include those who:

  • drink alcohol in light to moderate amounts.
  • have abused sedatives and other drugs.
  • have taken methadone.
  • have developed physiological dependence on benzodiazepines after long-term use and are experiencing acute withdrawal effects following abrupt discontinuation.

Most patients who are exposed to long-term, continuous use of benzodiazepines will develop physiological dependence. Continuous use is defined as the daily consumption of at least one dose of benzodiazepines for 4 months or longer.


Adverse outcomes associated with benzodiazepine abuse include:

  • Adverse effects (sedation, inattention, memory loss, confusion, and lack of motor coordination) and toxicity from long-acting benzodiazepines due to poor absorption and metabolism of the drug. Higher doses of oxazepam, flurazepam, and chlordiazepoxide are associated with the greatest risk of injury in older adults.
  • Poor interactions with other prescription drugs.
  • Poor interactions with alcohol.
  • Withdrawal symptoms including anxiety, agitation, lethargy, nausea, loss of appetite, insomnia, dizziness, tremor, poor coordination, difficulty concentrating, or confusion.

Solomon, K.; Manepalli, J.; Ireland, G.A, et al. Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatric Society 41(1):57-69, 1993.; Fouts, M., and Rachow, J. Choice of hypnotics in the elderly. P & T News 14(8):1-4, 1994; Ray, W.A.; Thapa, P.B.; and Shorr, R.I., Medications and the older driver. Clin Geriatric Med 9(2):413-438, 1993; Winger, G. Other abused drugs: Benzodiazepines and sedatives. In: Fourth Triennial Report to Congress on Drug Abuse and Drug Abuse Research From the Secretary, Department of Health and Human Services. Rockville, MD: U.S. Department of Health and Human Services. 1993.

Tamblyn R, Abrahamowicz M, Berger R, et al., A 5-year prospective assessment of the risk associated with individual benzodiazepines and doses in new elderly users. J Am Geriatr Soc. 2005 Feb;53(2):233-41.


Symptoms of benzodiazepine abuse

  • Excessive daytime sedation
  • Ataxia
  • Problems with attention and memory
  • Anxiety, agitation
  • Impaired psychomotor abilities
  • Drug-related delirium or dementia (often mistaken for Alzheimer’s disease).

Other potential causes of symptoms

  • Alcohol or other substance abuse
  • Bipolar illness
  • Other medication
  • Stressful situation (e.g., loss of a loved one, traumatic incident, major life transition such as retirement)
  • Coexisting illness (e.g., diabetes, stroke, cancer)

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Diagnosis


Assessment

The following checklist is designed to assist the clinician in the assessment of benzodiazepine treatment. The four areas of assessment are:

  • Indication: What is the indication for benzodiazepine use and is it appropriate? Does the benzodiazepine improve the patient s quality of life and functioning?
  • Drug use: Is the dose escalating or stable? Is there evidence or history of abuse of other substances, particularly alcohol or prescription narcotics?
  • Toxic behavior: Is the patient experiencing adverse events as a result of benzodiazepine use? If so, to what extent do these drugs interfere with his or her daily functioning? Could these adverse events result in serious injury to the patient or others?
  • Family monitor: What impact, positive or negative, does a family member ascribe to the benzodiazepine use and how do they feel about continued use?

If there is no indication for the use of a benzodiazepine, a patient s daily functioning is impaired, the dose of medication is escalating, or use is in conjunction with alcohol or other psychotropics, discontinuation should be strongly considered and recommended.


DuPont RL. A practical approach to benzodiazepine discontinuation. Journal of Psychiatric Research 1990; 24:81-90.


DSM-IV diagnostic criteria

No specific diagnostic criteria for benzodiazepine abuse and dependence from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) exists. However, the general criteria for substance abuse and substance dependence from the DSM can be applied:


Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12--month period:

  1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance re-lated to substance use; substance-related absences; or neglect of children or household)
  2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
  3. Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
  4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights). The symptoms have never met the criteria for Substance Dependence for this class of substance.

Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impair-ment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  1. Tolerance, as defined by either of the following:
    1. A need for markedly increased amounts of the substance to achieve in-toxication or desired effect
    2. Markedly diminished effect with continued use of the same amount of the substance
  2. Withdrawal, as manifested by either of the following:
    1. The characteristic withdrawal syndrome for the substance
    2. The same (or a closely related) substance is taken to relieve or avoid with-drawal symptoms
  3. The substance is often taken in larger amounts or over a longer period than was intended
  4. There is a persistent desire or unsuccessful efforts to cut down or control sub-stance use
  5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance, or recover from its effects
  6. Important social, occupational, or recreational activities are given up or re-duced because of substance use
  7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

DSM-IV TR criteria: five axes

Evaluate patients using all five axes in the DSM-IV TR criteria:

  1. Axis I: Clinical Disorders, other conditions that may be a focus of clinical attention
  2. Axis II: Personality Disorders, borderline intellectual functioning or mental retardation
  3. Axis III: General Medical Conditions
  4. Axis IV: Psychosocial and Environmental Problems
  5. Axis V: Global Assessment of Functioning

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.


More specialized assessments

Some patients also require evaluation for:

  • Medical problems
  • Psychological issues
  • Substance abuse

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Management


Education

Occasionally, simply educating patients that benzodiazepines are from a class of medications that are “habit-forming” may be an effective management strategy. Once educated about this fact, many older patients will spontaneously request discontinuation.


Psychotherapy

Immediately refer patients to a psychiatrist if they abuse benzodiazepines and have any of the following conditions:

  • Severe anxiety or anorexia
  • Significant psychomotor agitation or retardation
  • Psychosis or mania
  • Suicidal or homicidal thinking

Consider referring patients to a psychiatrist if they abuse benzodiazepines and have any of the following disorders:

  • Depression
  • Eating disorders
  • Post-traumatic stress or abuse
  • Obsessive compulsive disorders or personality disorders

Medication

If the patient has taken an overdose of a benzodiazepine, flumazenil (Romazicon) can reverse its effects.

If the patient is suffering from the effects of withdrawal from benzodiazepines, consider switching to a shorter-acting benzodiazepine (such as oxazepam [Serax] and lorazepam) that is not as likely to produce toxic or dependence-inducing effects with long-term use as longer-acting drugs.

Tapering the dose of a benzodiazepine rather than stopping it suddenly can ease most of the side effects of withdrawal. Even if the dose is tapered, however, 40 to 80 percent of people who discontinue benzodiazepines after 4 to 6 months of regular use have withdrawal symptoms. (Miller, F.; Whitcup, S.; Sacks, M.; et al. Unrecognized drug dependence and withdrawal in the elderly. Drug and Alcohol Dependence 15:177, 1985; Speirs, C.J.; Navey, F.L.; Broods, D.J.; et al. Opisthotonos and benzodiazepine withdrawal in the elderly. Lancet 2:1101, 1986).

Symptoms of withdrawal usually peak toward the end of the tapered discontinuation and disappear altogether within 3 to 5 weeks. Unlike withdrawal from alcohol, the difficulty in abstaining during the acute phase of benzodiazepine withdrawal is not followed by any further craving once the patient is drug-free. Most patients who have withdrawn from benzodiazepines can maintain abstinence. (Winger, G. Other abused drugs: Benzodiazepines and sedatives. In: Fourth Triennial Report to Congress on Drug Abuse and Drug Abuse Research From the Secretary, Department of Health and Human Services. Rockville, MD: U.S. Department of Health and Human Services. 1993).

In some psychiatric patients, the withdrawal syndrome lasts for several months (Solomon, K.; Manepalli, J.; Ireland, G.A.; et al. Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. J Am Geriatric Society 41(1):57-69, 1993).


Adapted from:

  • Brigham and Women’s Hospital. Depression. A guide to diagnosis and treatment. Boston (MA): Brigham and Women's Hospital; 2001. 9 p. [6 references]
  • Excellus/Identification and Treatment of Major Depression in Primary Care
  • Substance Abuse Among Older Adults, Treatment Improvement Protocol (TIP) Series 26 http://ncadi.samhsa.gov/govpubs/BKD250/, developed by Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Brief Interventions and Brief Therapies for Substance Abuse, Treatment Improvement Protocol (TIP) Series 34 http://ncadi.samhsa.gov/govpubs/BKD341/, by Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment
  • http://www.health.org/govpubs/BKD250/26f.aspx
  • Longo, LP and Johnson, B. Addiction: Part I. Benzodiazepines--Side Effects, Abuse Risk and Alternatives. Am Family Physician, April, 2000.