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SOURCE

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Source: Doering PL, Li RM. Substance-related disorders I: overview and depressants, stimulants, and hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146064131. Accessed April 18, 2017.

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DEFINITION

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  • Substance-related disorders include disorders of:

    • Intoxication.

    • Dependence.

    • Withdrawal.

  • Intoxication is maladaptive behavior during waking state after recent ingestion and presence in body of substance that causes central nervous system (CNS) effects.

  • Substance dependence is continued pattern of substance use in spite of repeated adverse consequences related to repeated use.

  • Physical dependence is state of adaptation manifested by withdrawal syndrome after:

    • Cessation.

    • Rapid dose reduction.

    • Decreasing blood levels.

    • Administration of antagonist.

  • Withdrawal is development of substance-specific syndrome after cessation or reduced intake of substance that had been used regularly.

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EPIDEMIOLOGY

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  • Emergency department (ED) visits involving benzodiazepines outnumber those of other psychotherapeutic agents.

  • In 2010, approximately 408,021 ED visits involved nonmedical use of benzodiazepines.

  • Alprazolam and clonazepam implicated more frequently than diazepam and lorazepam.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Benzodiazepine intoxication.

    • Manifests as:

      • Slurred speech.

      • Poor coordination.

      • Memory impairment.

      • Swaying.

      • Drowsiness.

      • Hypotension.

      • Nystagmus.

      • Confusion.

      • Urinary retention.

    • Does not generally result in life-threatening respiratory depression.

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  • Table 1: Characteristics of dependence on benzodiazepines.

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  • Benzodiazepine withdrawal.

    • Presents similarly to alcohol withdrawal, with:

      • Muscle pain.

      • Anxiety.

      • Restlessness.

      • Confusion.

      • Irritability.

      • Hallucinations.

      • Delirium.

      • Seizures.

      • Cardiovascular collapse.

    • Onset of withdrawal from short-acting benzodiazepines (oxazepam, lorazepam, alprazolam) within 12–24 hours of last dose.

    • Withdrawal from long-acting benzodiazepines (diazepam, chlordiazepoxide, clorazepate) may be delayed for several days after discontinuation.

    • Patients in withdrawal may be in acute distress and should be treated with benzodiazepine taper to prevent seizures.

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Table Graphic Jump Location
TABLE 1.Characteristics of Benzodiazepine Dependence
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DIAGNOSIS

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LABORATORY TESTS
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  • When toxicology screens necessary, blood or urine should be collected immediately when patient presents for treatment.

  • Qualitative testing useful to confirm presence of benzodiazepines for diagnostic purposes.

  • Quantitative plasma concentrations not usually helpful.

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DIFFERENTIAL DIAGNOSIS
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  • Intoxication: Ingestion of other sedative-hypnotics or alcohol.

  • Withdrawal:

    • Withdrawal from ...

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