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Source: Doering PL. Substance-Related Disorders: Overview and Depressants, Stimulants, and Hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 9, 2012.

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

  • Emergency department (ED) visits involving benzodiazepines outnumber those of other psychotherapeutic agents.
  • In 2006, approximately 195,625 ED visits involved nonmedical use of benzodiazepines.
  • Alprazolam and clonazepam implicated more frequently than diazepam and lorazepam.

Signs and Symptoms

  • Benzodiazepine intoxication
    • Manifests as:
      • Slurred speech
      • Poor coordination
      • Swaying
      • Drowsiness
      • Hypotension
      • Nystagmus
      • Confusion
    • Does not generally result in life-threatening respiratory depression.
  • Table 1: Characteristics of dependence on benzodiazepines
  • 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.

Table 1. Characteristics of Benzodiazepine Dependence

Laboratory Tests

  • 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.

Differential Diagnosis

  • Intoxication: Ingestion of other sedative-hypnotics or alcohol
  • Withdrawal:
    • Withdrawal from other sedatives
    • Cocaine intoxication
    • Delirium due to medical illness
      • Hypoxia
      • Hepatic encephalopathy
      • Thiamine deficiency
      • Bacteremia
    • Anxiety disorder
    • Hallucinosis from other causes
    • Seizure from other causes

  • Cessation of use of drug
  • Termination of drug-seeking behaviors
  • Return to normal functioning
  • Goals of treatment for withdrawal
    • Prevent progression of withdrawal to life-threatening severity.
    • Enable patient participation in treatment program.

  • Likelihood and severity of withdrawal function ...

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