Staged dispensing is effective in both withdrawal and maintenance. There are general principles that apply to both groups. High-risk patients are best managed with initial stabilisation and maintenance therapy in specialist residential or outpatient addiction services. Low-risk patients can be managed in general practice and may benefit most from attempting withdrawal. The choice of approach depends on an assessment of the risk of harm and relapse.

benzodiazepine withdrawal with the aim of abstinence.

If the patient is ready for change, there are two approaches to the management of dependence: If the patient is not ready to change, or is just considering change, then motivational interviewing techniques are recommended. Patient engagement in management is essential as without this any attempts to address harmful use may be hindered by non-adherence or even doctor shopping. Assessing the patient’s readiness to change guides the initial management. Supportive social networks and stable housing are positive prognostic indicators. Assess for benzodiazepine substance use disorder and the severity of aberrant drug-related behaviours.

It should include the indication for prescribing, dose, duration of use, age and any history of psychiatric or medical comorbidity as well as any other past or current substance misuse. The assessment determines the severity of misuse and informs the risk of relapse and of harm. Systems limitations in prescription monitoring in Australia reduce our ability to identify ‘doctor shopping’ so the presence of any aberrant drug-related behaviours should prompt further assessment and treatment. 10 Some patients prescribed benzodiazepines may have aberrant drug-related behaviours, ranging from double dosing to selling medicines illicitly or injecting them. The principles of management of dependence with ‘z-drugs’ such as zolpidem and zopiclone are the same as the management of benzodiazepine dependence.īenzodiazepine substance use disorder can be diagnosed using DSM-5 criteria, 9 but the Severity Dependence Scale is a simple screening tool validated for use in the community. A frail 70 year old with falls prescribed flunitrazepam as a sedative hypnotic for 20 years requires a different management approach from a 25-year-old intravenous drug user buying street alprazolam. The benzodiazepine-dependent population is heterogeneous and this influences management. However, there is a paucity of research on the optimal management of benzodiazepine dependence, so practice has to be guided by general principles. This barrier to prescribing has placed renewed focus on benzodiazepine dependence. The public health impact of this rescheduling is yet to be determined. It has greater toxicity in overdose, 7 and associated mortality 8 relative to other benzodiazepines.

In February 2014, in response to increasing illicit use, alprazolam was rescheduled to Schedule 8. 4, 5 There is evidence of increased mortality with long-term use. In older patients they have been associated with cognitive decline, dementia 3 and falls.

2īenzodiazepine-related problems include diversion, misuse, dependency, driving impairment, and morbidity and mortality related to overdose and withdrawal. There are few indications for long-term therapy and they are generally controversial. 1 Of particular concern are the patients who have been using benzodiazepines for more than six months. Alprazolam became the second most popular drug, increasing more than eightfold.

Over the last 20 years the quantity of benzodiazepines on each prescription has increased. Despite a modest decrease in the annual number of benzodiazepine prescriptions dispensed, the current level of prescribing probably represents significant overuse.

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