J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from Benzodiazepine Dependence And Withdrawal: Identification And Medical Management

Mimj. Landry, David E. Smitb, M.D., David R. McDuff, M.D., and Otis L. Baugbman III, M.D.

Abstract: Baejground: Primary care physicians prescribe benzodiazepines for the treatment of anxiety. Although most patients use the benzodiazepines appropriately, some patients experience benzodiazepine abuse, addiction, or physical dependence, each one of which is a distinct syndrome. Benzodiazepine dependence, which relates to the development of tolerance and an abstinence syndrome, can be produced by three disparate benzodiazepine use patterns. These distinct benzodiazepine use patterns can in turn create distinct withdrawal syndromes. High-dose benzodiazepine use between 1 and 6 months can produce an acute sedative-hypnotic withdrawal syndrome. In contrast, low-dose therapeutic range benzodiazepine use longer than 6 months can produce a prolonged, subacute low-dose benzodiazepine withdrawal syndrome. Daily, high-dose benzodiazepine use for more than 6 months can cause a combination of an acute high-dose benzodiazepine withdrawal and a prolonged, subacute low-dose withdrawal syndrome. In addition, patients may experience syndrome reemergence. Methods: Aliterature search was conducted using the medical subject headings benzodiazepines, substance abuse, substance dependence, substance withdrawal syndrome, and benzodiazepines adverse effects. The years 1970 to the present were reviewed. Results lind Conclusions: Medical management for acute benzodiazepine withdrawal includes the graded reduction of the current benzodiazepine dosage, substitution of a long-acting benzodiazepine, and phenobarbital substitution. However, the medical management of benzodiazepine dependence does not constitute treatment of benzodiazepine addiction. Primary care physicians can accept complete, moderate, or limited medical responsibility regarding patients with substance use disorders~ However, all physicians should provide diagnostic and referral services. U Am Board Fam Pract 1992; 5:167-76.)

The benzodiazepines have proved to be clinically group that takes benzodiazepines for medically http://www.jabfm.org/ effective and generally safe phannacotherapeutic prescribed and appropriate reasons does not gen­ tools for primary care physicians.l Although there erally experience dosage escalation or drug­ is some debate over the magnitude of inappropri­ related dysfunction. A second group abuses ate benzodiazepine use, investigators generally benzodiazepines, usually in a polydrug use pat­ find their use appropriate to the medical and psy­ tern, and experiences drug-related dysfunction. chiatric conditions for which they are pre­ The majority of patients take benzodiazepines on 28 September 2021 by guest. Protected copyright. scribed.2•3 Nevertheless, these drugs are psycho­ as prescribed and the majority of physicians ap­ active and mood altering; subject to misuse and propriately prescribe them. Even so, both physi­ abuse, they can be agents of addiction.4 cians and patients can contribute to the inappro­ Different responses to the benzodiazepines priate use of the benzodiazepines.s often reflect the presence of two separate, but Benzodiazepine abuse, addiction, and physical occasionally overlapping, groups of patients. The dependence are distinct clinical phenomena. Benzodiazepine abuse is defined as benzodiaze­ pine use that causes impairment and dysfunction Submitted, revised, 31 October 1991. From the Haight AshburyTraining and Education Project, San in the patient's social, occupational, emotional, Francisco; Haight Ashbury Free Clinics, San Francisco; Division psychological, or physical well-being.6 The im­ of Alcohol and Drug Abuse, Departtnent of Psychiatry, Univer­ pairment and dysfunction range from mild to se­ sity of Maryland School of Medicine, Baltimore; and the Family vere and often are self-limiting. Benzodiazepine Medicine Center, Spartanburg, SC. Address reprint requests to Haight Ashbury Training and Education Project, 409 Oayton addiction is a chronic, progressive, pathological Street, San Francisco, CA 94117. process with biopsychosocial components that

Benzodiazepine Dependence 167 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from

generally include (1) a compulsion to use a benzo­ It is clinically useful to classify benzodiazepine diazepine, (2) a loss of control over benzo­ dependence into separate, but overlapping, phe­ diazepine use (or over drug-induced behavior), nomena that relate both to benzodiazepine use and (3) the continued use of the drug despite patterns and eventual withdrawal syndromes. adverse consequences.7 In contrast, benzodiaze­ First, high-dose benzodiazepine use longer pine dependence relates to the development of than 1 month but less than 6 months can cause a physical tolerance and withdrawal.s classic acute, sedative-hypnotic-type withdrawal Benzodiazepine abuse and addiction occur syndrome, similar in quality to an acute alcohol most often among patients who have a history of withdrawal. alcoholism9 or other drug abuse or addiction, usu­ Second, low-dose, therapeutic-range daily ally in a polydrug pattern.lO- 12 Also, individuals benzodiazepine use for more than 6 months can without a history of addiction, but with a first­ produce a prolonged, subacute low-dose degree relative who has a history of addiction, benzodiazepine withdrawal syndrome. This syn­ have been found to be at higher risk for addic­ drome is characterized by the symptoms of with­ tion,13 creating a compelling argument for physi­ drawal anxiety and insomnia and possibly a pro­ cians to obtain routinely a substance use history longed period of bursts of anxiety and insomnia. before prescribing benzodiazepines. In rare patients, primarily the elderly, low-dose Benzodiazepines can be misprescribed in terms withdrawal can have severe sequelae, including of (1) appropriateness of specific drug to specific seizure and psychosis most commonly seen with indications, (2) length of time, and (3) dosage. high-dose withdrawal. Furthermore, physicians' prescribing decisions Third, daily, high-dose benzodiazepine use might be based on nonclinical or inaccurate infor­ more than 6 months can produce not only the mation-for example, shift a patient from diaze­ acute high-dose benzodiazepine withdrawal syn­ pam to alprazolam in the mistaken belief that drome but also a prolonged, low-dose withdrawal alprazolam would be the less addicting drug. syndrome. 14 Similarly, a physician might suddenly discon­ Benzodiazepine dependence is often a sign of tinue prescribing benzodiazepine for all patients benzodiazepine abuse or addiction; however, de­ to avoid a benzodiazepine-related lawsuit, thus pendency alone is not a sufficient criterion for

precipitating patients into abrupt withdrawal diagnosing either abuse or addiction. Further http://www.jabfm.org/ syndromes. abuse and addiction history must be obtained for such diagnoses. IS Benzodiazepine Dependence Whereas the medical management of benzo­ Whatever the circumstances, some patients have diazepine dependence is an important step in the taken benzodiazepines for many months or years; treatment of benzodiazepine addiction, it does some have taken benzodiazepines at doses that not constitute treatment of the underlying addic­ exceed therapeutic range; and some have experi­ tive disease. Medical management of benzodi­ on 28 September 2021 by guest. Protected copyright. enced a full spectrum of addiction symptoms with azepine dependence should be understood as the therapeutic dosage of benzodiazepines. For all of management of physical sequelae of a larger ad­ these patients, benzodiazepine dependence prob­ diction process in which the primary care physi­ lems are a likely sequelae. cian can play an important role. Benzodiazepine dependence occurs when there When patients have taken benzodiazepines is adaptation to these drugs at the cellular and at higher doses and for longer periods of time tissue level, which would be followed by a with­ than recommended, they should be assessed for drawal syndrome upon cessation of the drug. The abuse, dependence, or addiction not only to biological alterations include receptor site benzodiazepines but also to alcohol and other changes in response to benzodiazepine use and drugs. Physical dependence can occur within or withdrawal. For some patients the distress re­ outside a pattern of polydrug abuse, and a major­ lated to benzodiazepine dependence and with­ ity of patients have a personal or family history of drawal is so severe that it becomes debilitating alcoholism. and their symptoms can be confusing to the treat­ A patient with uncomplicated benzodiazepine ing physician. dependence and tolerance usually can be detoxi-

168 JABFP March-Aprill992 Vol. 5 No.2 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from fied on an outpatient basis by his or her primary care physician. In contrast, the patient who ex­ TREATMENT §~~~22::=-_ hibits signs and symptoms of addiction (which may include benzodiazepine use) would benefit from a multidisciplinary team approach at a chemical dependency treatment program that of­ INTENSITY fers medical, psychiatric, psychological, nursing, OF counseling, education, and self-help elements. SYMPTOMS Benzodiazepine abstinence can be enhanced greatly by a combination of inpatient treatment followed by close medical and psychosocial follow-up. 16 In either situation, it is critical that the patient DAYS OF ABSTINENCE be detoxified from the benzodiazepine slowly. A Figure 1. Treatment ofbenzocUazepine withdrawal tapered withdrawal should take place over a mini­ syndromes. mum of 1 month, and it could range from 4 to 12 Adapted, with permission, Smith DE, Wesson DR. weeks. In no instance should a physician abruptly Benzodiazepine dependency syndromes.,PsycbotlcUve Drugs 1983; 15:93. discontinue patients' benzodiazepine use, nor should patients be allowed to quit "cold turkey" on their own, despite their possible arguments to toms, including seizures, at about 5 to 7 days. the contrary. Onset of symptoms occurs in 1 to 2 days for short-acting benzodiazepines and in 2 to 4 days 8enzodiazepine Withdrawal: Clinical for the long-acting benzodiazepines.25 Treatment Syndromes of this phenomenon is described later in detail. In The primary care physician is likely to encounter general, acute benzodiazepine withdrawal symp­ the following three primary clinical syndromes toms are expected to be severe if daily benzo­ ; that can occur upon cessation of benwdiazepine diazepine use was high and especially if benzodi­ I therapy: (1) acute sedative-hypnotic-type benzo­ azepine use was prolonged.26 diazepine withdrawal, (2) subacute prolonged I benzodiazepine withdrawal, and (3) preexisting S"btu:ute, Prolonged Benzodlazeplne Wltbtlmwtll http://www.jabfm.org/ symptom reemergence.14 In response to high-dose and even therapeutic­ r range benzodiazepine therapy, some patients will Acute Sedtztitle-l/yJmollc-Type Benzodlazepine experience severe distress for extended periods Wltbdrtlwtll following the acute benzodiazepine with­ Dependence (and hence acute withdrawal) can drawal periodP It has been estimated that 7 9 develop to both high-dose1 -1 and therapeutic­ perhaps one-quarter of long-term, low-dose on 28 September 2021 by guest. Protected copyright. range benzodiazepine use. 20-23 The benzodiaze­ benzodiazepine users have problems with benzo­ pine sedative-hypnotic-type withdrawal is the diazepine withdrawal despite gradual reduction, nonna! cluster of anxiety-related symptoms that and perhaps one-third of these patients experi­ occur following cessation of alcohol, benzo­ ence severe and prolonged distress. I This distress diazepines, and other sedative-hypnotics. Acute is distinct from both acute withdrawal and symp­ benzodiazepine withdrawal signs include anxiety, tom reemergence. insomnia, tremors, agitation, nightmares, ano­ Figure 1 also shows the variation in intensity of rexia, and seizures; less frequently, nausea and low-dose withdrawal symptoms following detoxi­ vomiting, hallucinations, depersonalized feelings, fication, when the patient experiences fluctua­ delirium, and hypersensitivity to visual and audi­ tions in anxiety symptoms every few days. These tory stimuli can occur. \Vith abrupt cessation of symptoms, chiefly anxiety and insomnia, as well as high doses, patients can experience a psy­ possible tachycardia, increased blood pressure, chotic episode or grand mal seizures and death.24 muscle spasms, paresthesias, and, rarely, psycho­ Figure 1 shows the sedative-hypnotic-type with­ sis, can occur in bursts lasting several days be­ drawal syndrome, with peak liability for symp- tween periods of anxiety relief. The onset of

Benzodiazepine Dependence 169 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from

symptoms can occur shortly after benwdiazepine In many situations - such as with a new patient cessation and can emerge at seemingly random - the primary care physician would not be aware points up to about 1 year. Although these fluctu­ of the original pathologic disorder. ating peaks and bursts can be extremely distress­ For the person with anxiety disorder reemer­ ing, they will eventually fade. gence, the symptom course will differ from the Because these subacute bursts of anxiety, in­ fluctuating, prolonged, subacute benwdiazepine somnia, muscle spasms, and paresthesias can withdrawal syndrome by remaining at a relatively occur weeks and even months after acute stable and often clinically important level of sever­ benwdiazepine withdrawal, they can appear to be ity. Figure 1 illustrates symptom reemergence fol­ unrelated to benwdiazepine dependence. It is lowing detoxification from benwdiazepines. during these bursts ofsubacute, prolonged benw­ These symptoms increase in severity until they diazepine withdrawal symptoms that the physician establish a baseline of severity. In other words, may mistakenly prescribe psychoactive drugs, in­ following the acute withdrawal period, the patient cluding the benwdiazepines, for symptom relieE does not drop to a baseline of low symptom sever­ In the midst ofsuch an anxiety-related crisis, the ity or have fluctuating bursts of symptoms: the patient often will assume that the symptoms are symptoms become constant and follow the normal permanent. Thus, the physician should assure the course of the psychiatric disorder in question. In a patient that the symptoms are temporary and will previous article of this journal, we provided a de­ fade. During subacute anxiety bursts in an overall cision tree for discriminating among depressant anxiety-free period, the physician should not pre­ withdrawal-related anxiety symptoms, stimulant­ scribe benwdiazepines but, rather, use a non­ induced anxiety symptoms, and anxiety disorders. 33 psychoactive agent, such as propranolol, to miti­ A tentative diagnosis of a psychiatric disorder gate adrenergic discharge-related physiologic can be made only after the patient has been free symptoms of anxiety, including tachycardia. These of all drugs for 30 days. A period of 60 to 90 bursts of anxiety and insomnia can be distin­ drug-free days should pass before the physician guished from the reemergence of an underlying can make an accurate and formal diagnosis of the psychopathologic disorder, the symptoms of psychiatric problem. After such a baseline, the which tend to increase in severity and remain at a physician can be confident of an accurate diagno­ relatively high level. Again, Figure 1 indicates use sis and can treat using stepwise anxiety treatment. of propranolol during both acute and prolonged Stepwise anxiety treatment emphasizes the use of http://www.jabfm.org/ withdrawal syndromes. In this example, proprano­ nonpharmacological tools, such as psychotherapy lol (20 mg every 6 hours) was begun on the 5th day and stress reduction, as well as nonpsychoactive of acute withdrawal and continued for 2 weeks. anxiolytics, such as buspirone, for the treatment Following that, propranolol can be used as needed of anxiety in patients who have experienced sub­ for control of tachycardia, increased blood pres­ stance use disorders.34 sure, and anxiety during the subacute prolonged Table 1 provides a comparison of clinical syn­ on 28 September 2021 by guest. Protected copyright. withdrawal syndrome. Propranolol therapy for dromes related to benzodiazepine withdrawal as longer than 2 weeks is not recommended, because described above. Patients who are dependent discontinuation after prolonged propranolol use upon therapeutic-range doses of benzodiazepines can cause symptom rebound.28 Although buspi­ can become alarmed at the emergence of normal _ rone is not specific for benzodiazepine with­ anxiety, variations in sleep patterns, and musculo­ drawal suppression, 29 the use of this nonpsycho­ skeletal discomfort. Such patients might attribute active anxiolytic before and during benwdiazepine these normal stresses and strains as symptoms of tapering may significandy decrease anxiety symtr benwdiazepine withdrawal and seek medical toms, including psychic and cognitive symptoms.30 help. The primary care physician should be on guard for such symptom misinterpretation. AnxIety Reetnerge1lC6 Both the sedative-hypnotic-type withdrawal syn­ Acute Benzodiazepine Withdrawal: Medical drome and the low-dose withdrawal syndrome Management need to be distinguished from reemergence of the The most basic tenet that applies to the medical original, underlying psychopathologic state.B ,32 detoxification from benzodiazepines is that it

170 JABFP March-Aprill992 Vol. 5 No.2 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from

Table 1. Comparison of Syndromes Related to BenzodiazepJne Withdrawal. *

Syndrome Symptoms Course Acute sedative-hypnotic-type Anxiety, insomnia, nightmares, seizures, Onset 1-2 days after stopping short-acting withdrawal psychosis, hyperpyrexia, death benzodiazepines; onset 2-4 days after stopping long-acting benzodiazepines Subacute, prolonged benzodiazepine Anxiety (including somatic manifestations) Symptoms begin 1 day after stopping of withdrawal insomnia, nightmares, muscle spasm, benzodiazepines; can continue for weeks to psychosis months, but will improve with time Symptom reemergence Variable but should be the same as symptoms Symptoms emerge when benzodiazepine is prior to taking benzodiazepines stopped and will continue unabated *Adapted, ~ith permision, Smith DE, Wesson DR. Benwdiazepine dependency syndromes. J Psychoactive Drugs 1983; 15:88. should be slow and gradual. Under no circumstances A preferred long-acting benzodiazepine is should a patient be abruptly terminated from a chlordiazepoxide, which is an effective substitute benzodiazepine. For patients who have developed for such short-acting agents as alprawlam or for tolerance to and dependence on benwdiazepines, alcohol-benwdiazepine combinations. Chlordi­ there are three primary options for the gradual azepoxide has a relatively low street value when detoxification process: (1) graded reduction of compared with other benwdiazepines, such as the current benwdiazepine, (2) substitution of a diazepam, and it has a more rapid onset of action long-acting benzodiazepine for the original than diazepam. Chlordiazepoxide and diazepam benwdiazepine, and (3) substitution of phenobar­ are two popular benwdiazepines used for substi­ bital for the benzodiazepine (or benzodiazepine­ tution and withdrawal, and Table 2 can be used to polydrug combination). calculate equivalency. Clonazepam has also been The selection of detoxification strategy de­ suggested for use in alprawlam withdrawal and pends upon (1) the detoxification setting, (2) the may provide better protection against withdrawal severity of the tolerance and dependence, (3) phy­ seizures.24,39,4O sician expertise specific to benzodiazepine de­ The key to success for substitution or graded pendence, and (4) the total drug combinations withdrawal in an outpatient setting is time. For a used by the patient. patient who has been on a short-acting benw­ diazepine for 1 to 2 months, a tapered with­

Graded Reduction ofCurrent Benzodiazepine drawal can take 2 to 3 weeks. If a patient has http://www.jabfm.org/ Gradually reducing the benwdiazepine dosage been taking benwdiazepine for months or is primarily useful when the dependence has de­ years, a gradual reduction lasting 2 to 4 months or veloped in patients who (1) take only ben­ more will be necessary. If breakthrough anxiety zodiazepines, (2) become dependent when taking or frank withdrawal symptoms occur, the physi­ doses within a therapeutic range, and (3) are being cian should increase the dose until the symptoms treated in primary care medical settings.35 The resolve and begin an even more gradual reduc­ on 28 September 2021 by guest. Protected copyright. process involves a planned fixed-dosage reduction tion. Close, consistent follow-up and support are of the benzodiazepines in a flexible time frame. 36 needed. We recommend a dosage reduction of 10 to 15 As the reduction proceeds, underlying sup­ percent each week, maintaining a divided dosage pressed or masked psychiatric symptoms may be­ schedule. DuPont37 recommends a 6- to 12-week come more readily apparent. At this time, adding tapering period for outpatient detoxification. Faster reductions are possible but require regular llIble Z. BenzocIiazepioe EquJvaleacy. physician contact and support. Benzodiazepine Dosage(mg) Chlordiazepoxide 25 Qonazepam 2 Substitution of(I Long-Acting Benzodiazepine Diazepam 5 The substitution of a long- or longer-acting Oxazepam 30 benwdiazepine allows for a more gradual re­ F1urazepam 15 duction of the serum levels, thereby greatly Lorazepam 1 Triawlam 0.5 reducing withdrawal symptoms and symptom Chlorazepate 3.75 reemergence.38 AIprawlam 0.25

Benwdiazepine Dependence 171 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from nonpsychoactive medications to the regimen is pine withdrawal and detoxification. Propranolol most useful. (20 mg every 6 hours) is used starting at the peak times of symptom intensity through the following Phenobarbital Substitution TecbnllJue 2 weeks. Propranolol can be also used during Smith and Wesson14 developed the phenobarbital periods of acute distress, such as those caused by substitution technique for benwdiazepine with­ tachycardia, increased blood pressure, and anxiety drawal because this technique (1) has the broadest related to low-dose or prolonged withdrawal utility for all benzodiazepines, (2) is useful for symptoms of anxiety and insomnia. Again, pro­ benwdiazepine-polydrug combinations, (3) is pranolol therapy used beyond 2 weeks is not rec­ useful for polybenwdiazepine combination de- . ommended. Carbamazepine is also being used pendence, (4) is useful for high-dose benzodi­ experimentally to attenuate prolonged with­ azepine dependence, and (5) can be used for drawal symptoms,42 although its utility for panic all sedative-hypnotics. Phenobarbital is cross­ disorder patients withdrawing from benw­ tolerant to all the benwdiazepines and all other diazepines may be poor, because it lacks anti­ sedative-hypnotics. It is long acting and effec­ panic efficacy. 43 Long-acting sedative-hypnotics tively prevents serious sequelae ofbenwdiazepine and long half-life benzodiazepines should be withdrawal, such as withdrawal seizures and with­ used cautiously for patients with severe liver drawal psychosis.41 disease because of the possibility of uneven doses Table 3 outlines the phenobarbital withdrawal and escalating side effects. Consideration should conversion for benwdiazepines and other seda­ be given to short half-life benwdiazepines. Simi­ tive-hypnotics. The phenobarbital substitution larly, propranolol is generally contraindicated method uses propranolol for acute and subacute for patients with history of allergy, bronchial somatic complaints and symptoms. Note that asthma, or emphysema, as it can promote bron­ phenobarbital is used during acute benwdiaze- chospasm and block the bronchodilating effect of epinephrine. 1lIbie 3. Phenobarbital WidJclrawai Conversioo for lIenzodiazepines and Other Sedative-HypnotiQll.* The Primary Care Physician and Addiction Phenobarbital Medicine . Withdrawal A fundamental principle of addiction medicine is Generic Name Dosage (mg) Conversion (mg) that the management of medical and psychiatric Benzodiazepines conditions that result from a substance use disor­http://www.jabfm.org/ Alprazolam 1 30 der, such as addiction, cannot be considered to be Chlordiazepoxide 25 30 Clonazepam 2 15 overall treatment for that substance use disorder. Clorazepate 15 30 Furthermore, a patient who has a substance use Diazepam 10 30 problem involving benwdiazepines could have a FIurazepam 15 30 Halazepam 40 30 preexisting anxiety disorder that needs to be

Lorazepam 1 15 treated as an additional, primary disorder. on 28 September 2021 by guest. Protected copyright. Oxazepam 10 30 The primary care physician should recognize Prazepam 10 30 Temazepam 15 30 that the medical management of drug-related in­ Barbiturates toxication, overdose, or withdrawal is merely the Amobarbital 100 30 beginning of the overall treatment of any sub­ Butabarbital 100 30 Butalbital 50 15 stance use disorder. Substance use disorders rep­ Pentobarbital 100 30 resent an interplay among pharmacological, envi­ Secobarbital 100 30 ronmental, and host susceptibility factors. Glycerols Consequently, multidisciplinary approaches in­ Meprobamate 400 30 Piperidinediones clude, but are not limited to, medical manage­ Glutethimide 250 30 ment issues. All patients with a substance use Quinazolines Methaqualone 300 30 disorder need a detailed history and a thorough physical examination and evaluation. Some of "Reprinted with permission, Smith DE, Wesson DR. Benzodiazepine dependency syndromes. J Prychooaive Drugs these patients will need serious medical inter­ 1983; 15:92. vention, while others will need primarily non-

172 JABFP March-April 1992 Vol. 5 No.2 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from medical support and psychosocial treatment and These physicians accept the responsibility of education. helping the patient attain a drug-free state. Ideally, a chemical dependency treatment pro­ At this level of responsibility, the physician gram or clinic is the best place to meet the specific should provide treatment of general medical needs of a patient who has a complicated addic­ problems, as well as treatment of substance-use tion problem. This setting allows a multidiscipli­ sequelae, including acute withdrawal manage­ nary team of allied health care professionals to ment. The physician should also assume the role address directly substance use issues in depth of patient educator, giving patients information through multiple interviews and assessments, spe­ about their substance use diagnosis, as well as an cifically tailored educational tools, and a group honest appraisal of the patients' responsibilities process. for continued treatment and recovery. The physi­ The American Medical Association has de­ cian should assist the patient in evaluating the scribed three levels of responsibility for physi­ available resources for treatment, at least to the cians regarding patients with substance use prob­ point of creating a preliminary treatment and lems.44,45 The lowest level covers the basic recovery plan, including the involvement of ap­ responsibility for all physicians engaged in clinical propriate family and friends. activities. A middle level covers responsibilities Although the patient will receive more inten­ for physicians who accept some addiction treat­ sive treatment at a chemical dependency treat­ ment chores, while the highest level covers re­ ment program, the physician can provide pre- and sponsibilities for physicians who engage in long­ post-treatment medical management consistent term addiction treatment. The basic concepts in with the treatment provided at that program. these guidelines are also appropriate for psychiat­ ric problems. Level 10: Pbysldllns Accepting Responsibility for Long-Tenn Treatment ofAddktion Levell: All PbyskitmS with Clinkal A physician who accepts this highest level of re­ Responsibility sponsibility must acquire a higher level of exper­ Not all physicians choose to provide primary tise and training in addiction medicine. Through treatment of substance use disorders. All physi­ direct medical care or through clinical supervi­ cians who treat patients, however, are responsible sion, this physician is responsible for establishing

for making a good-faith diagnosis and at least supportive, therapeutic, and nonjudgmental rela­ http://www.jabfm.org/ referral of patients with substance use problems. tionships with drug-addicted and -abusing pa­ Whatever the type of medical practice, all phy­ tients. Within that context, the physician is re­ sicians should be able to recognize substance sponsible for the medical management of general use disorders during the early stages of the dis­ medical problems, acute withdrawal syndromes, ease, not only late-stage medical and psychiatric and other substance-use-related sequelae, includ­ complications. ing relapse. on 28 September 2021 by guest. Protected copyright. During patient examinations, all physicians A physician practicing at this higher level of should include a substance use history. If a sub­ responsibility must keep abreast of ongoing de­ stance use problem is identified, the physician velopments in the pharmacological management should attempt to match available treatment op­ of substance use problems. Except for acute with­ tions in the community with the patient's treat­ drawal management, the physician will prescribe ment needs and personal resources. The physi­ psychoactive medication only in the event of an cian should become familiar with local medical obvious and severe psychiatric condition that resources for chemical dependency treatment in threatens to jeopardize the patient's well-being. preparation for appropriate referrals. This physician will actively participate in the patient's treatment and recovery plan, which in­ Level II: Physicians Accepting limited Addiction cludes, with the patient's participation, ongoing Treatment Responsibility evaluation and updating. The physician should Some physicians accept the responsibility of pro­ also involve the patient with an abstinent peer . viding medical care that will allow the patient to group and enlist the assistance of appropriate fam­ participate in a long-term treatment program. ilyand supportive friends as treatment participants.

Benwdiazepine Dependence 173 J Am Board Fam Pract: first published as 10.3122/jabfm.5.2.167 on 1 March 1992. Downloaded from Primary care physicians should evaluate all to. Smith DE, Wesson DR, Camber S, Landry M. Per­ anxiety disorder patients for substance use prob­ ceptions of benzodiazepine and cocaine abuse by lems and all substance-using patients for anxiety U.S. addiction medicine specialists. In: Prevention and control/realities and aspirations: proceedings of disorder. They can use their medical expertise to the 35th International Congress on Alcoholism and provide basic information about substance use Drug Dependence. Volume N. Oslo, Norway: In­ problems and explain the types and continuum of ternational Council on Alcohol and Addiction, treatment, as well as patient responsibilities for 1989:371-90. treatment and recovery. Physicians should moti­ 11. Marks]. The Benzodiazepines: use, overuse, misuse, abuse. 2nd ed. Lancaster, England: MfP Press, 1986. vate patients to accept appropriate treatment and 12. Chan AW. Effects of combined alcohol and referrals and make arrangements for specific ap- . benzodiazepine: a review. Drug Alcohol Depend pointments rather than merely make referral 1984; 13:315-41. suggestions. 13. Ciraulo DA, Barnhill JG, Ciraulo AM, Greenblatt Primary care physicians should seek the assis­ D], Shader RI. Parental alcoholism as a risk factor in tance of addiction medicine and psychiatric con­ benzodiazepine abuse: a pilot study. Am] Psychiatry 1989; 146:1333-5. sultants, especially in more difficult cases. Pri­ 14. Smith DE, Wesson DR. Benzodiazepine depend­ mary care physicians can train office nursing staff ency syndromes. ] Psychoactive Drugs 1983; 15: to become knowledgeable about substance use 85-95. problems. The physician and nursing office staff 15. American Psychiatric Association. 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