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BRIEF REPORT

SUBSTANCE DEPENDENCE AND THE USE OF

PRO RE NATA

ANXIOLYTIC/HYPNOTIC DRUGS IN A HOSPITAL SETTING

DALE A. D’MELLO,* DAVID E. LYON,* CHRISTOPHER C. COLENDA,* and COLIN L. FERNANDES†

*Michigan State University; and †The Western Pennsylvania Hospital

Abstract —

Patients hospitalized for treatment of psychiatric illness commonly receive

pro re nata

(p.r.n.) anti-anxiety and hypnotic agents. The relationship between illicit drug use and p.r.n. anti-anxiety/hypnotic drug use in hospitalized psychiatric patients has not been exten- sively examined. The purpose of the present study was to examine this relationship. A retro- spective review of 99 randomly selected hospitalized patients abstracted information regard- ing the utilization of p.r.n. anxiolytic and hypnotic medications. Seventy percent of the patients surveyed evidenced substance dependence. The substance users utilized p.r.n. anxi- olytics (

2.29,

81,

.05) and bedtime hypnotics (

4.23,

90,

.0001) more frequently than the nonusers. Hospitalized substance abusers appear to continue their sub- stance abuse in the hospital, substituting prescription preparations for illicit drugs. Neverthe- less, cumulative literature now suggests that p.r.n. anxiolytic and hypnotic agents play a criti- cal role in the management of aggressive behavior and insomnia in patients hospitalized with psychiatric illness. © 2000 Elsevier Science Ltd.

Key Words.

Anxiocytics, Hypnotics, Drug dependence.

A substantial number of patients hospitalized with psychiatric illness have comorbid illicit substance use disorders (Lehman, Myers, & Corty, 1989). The consequences of concurrent substance abuse in this population include noncompliance with treatment, more frequent illness relapse, homelessness, aggression, and suicide (Osher & Kofoed, 1989). Hospitalized patients commonly receive potentially addictive

pro re nata

(p.r.n.) anti-anxiety and hypnotic agents (Clift, 1972; Salzman, 1981). To the best of our knowledge, the clinical profile of psychiatric patients who receive p.r.n. medica- tions has yet to be systematically examined. The purpose of the present study was to examine the association between concurrent illicit drug abuse and the utilization of p.r.n. anxiolytic and hypnotic agents.

M E T H O D

The authors completed a retrospective review of a randomly selected sample of 99 patients who were hospitalized on the psychiatric unit of a university-affiliated general hospital in mid-Michigan. The sample represented 12% of the 844 patients admitted to that service during calendar year 1997. All of the patients received a routine history and physical examination. Comprehensive psychiatric assessments yielded

DSM-IV

(American Psychiatric Association, 1994) psychiatric diagnoses. The authors gathered demographic and diagnostic information. They abstracted information regarding rec-

Requests for reprints should be sent to Dale A. D’Mello, St. Lawrence Hospital, 1210 West Saginaw, Lansing, MI 48915.

442 D. A. D’MELLO et al.

reational drug abuse. For the purpose of the present study (unlike caffeine), nicotine, alcohol, cocaine, cannabis, LSD, and stimulants were considered to be “abused” sub- stances. The authors obtained information regarding the utilization of hypnotics and anxiolytics from the hospital pharmacy log. The patient cohort was stratified into sub- stance users and nonusers. The substance users were further subgrouped into those who acknowledged using one, two, and three or more substances. The authors entered all of the data into a statistical software program for analysis. Differences between the patterns of p.r.n. drug usage in substance users and nonusers were assessed using the Student’s

test. Multivariate analysis was used to establish the relationship between il- licit drug use and utilization of prescription medications.

R E S U L T S

The cohort of 99 patients included 57 men and 42 women. They ranged in age from 19 through 73 years. Seventy percent of the patients acknowledged recreational drug use. Among the substance abusers, 50% admitted using one substance, 25% used two substances, and 25% used three or more substances. The substance users utilized p.r.n. anxiolytics (

2.29,

.05) and bedtime p.r.n. hypnotics (

4.23,

.0001) more frequently than the nonusers (Table 1). Demographic variables such as age, gender, and ethnicity did not influence the utilization of p.r.n. drugs (Table 2). Patients with a history of substance abuse were eight times more likely to request a p.r.n. hypnotic than the others. Patients with bipolar disorder were more likely to utilize hypnotics than the others. The two most commonly prescribed hypnotics were temazepam and zolpidem. The anxiolytic of choice was lorazepam. This was reflective of the prescrib- ing practices of the individual physicians.

D I S C U S S I O N

Dependence upon prescription drugs is a widely recognized phenomenon. Benzodi- azepines, which are among the most widely prescribed psychotropic drugs, are also among the most commonly abused (Finch, 1993). Anxiolytic drugs are typically pre- scribed to relieve anxiety and agitation in hospitalized psychiatric patients. The present study identified an association between recreational illicit drug abuse and the utilization of potentially addictive prescription anxiolytic and hypnotic drugs.

There is a popular myth that because anti-anxiety and hypnotic drugs are poten- tially addictive, their use is injudicious. Substance abusers may in fact vicariously sub- stitute prescription preparations for illicit substances. Physicians who injudiciously prescribe benzodiazepines may inadvertently perpetuate substance dependence. Fur- thermore, the cognitive, behavioral, and neuropsychiatric adverse effects (Hemmel- garn, Suissa, Huang, Boivin, & Pinard, 1997) of these drugs may confound the clinical picture and impede clinical outcome.

Table 1. Correlation between substance abuse and anxiolytic/hypnotic utilization

Mean values Drug users (

= 70) Nonusers (

= 29)

-test statistic

Length of stay (days) 16 14 0.63 ns Age (years) 37 40 0.94 ns No. of hypnotic doses 5 1 4.23

.0001 No. of anxiolytic doses 5 1 2.29

.05

Pro re nata

anxiolytic/hypnotic drugs 443

Nevertheless, there is a growing consensus that benzodiazepines have a legitimate role in the management of anxiety disorders (

Benzodiazepine Dependence, Toxicity, and Abuse: A Task Force Report of the American Psychiatric Association

, 1990). Cu- mulative evidence has established their efficacy in the acute management of aggres- sion (Salzman, Green, Rodriguez-Villa, & Jaskiw, 1986), and rapid stabilization of hy- posomnia with hypnotics accelerates the resolution of mania (Nowlin-Finch, Altshuler, Szuba, & Mintz, 1994).

It is conceivable that when hospitalized, substance abusers experience more anxiety and insomnia than nonusers. This may reflect more severe psychopathology. It may also be symptomatic of drug withdrawal. Considering the ongoing controversy regard- ing the prescription of anxiolytic and hypnotic drugs, future systematic studies need to establish their safety and efficacy in hospitalized psychiatric patients.

R E F E R E N C E S

American Psychiatric Association. (1994).

Diagnostic and statistical manual of mental disorders

(4th ed.). Washington, DC: Author.

Benzodiazepine Dependence, Toxicity, and Abuse: A Task Force Report of the American Psychiatric Associ- ation

. (1990). Washington, DC: American Psychiatric Press. Clift, A. D. (1972). Factors leading to dependence on hypnotic drugs.

British Medical Journal

614–617. Finch, J. (1993). Prescription drug abuse.

Primary Care

231–239. Hemmelgarn, B., Suissa, S., Huang, A., Boivin, J., & Pinard, G. (1997). Benzodiazepine use and the risk of

motor vehicle crash in the elderly.

Journal of the American Medical Association

278

27–31. Lehman, A. F., Myers, C. P., & Corty, E. (1989). Assessment and classification of patients with psychiatric

and substance abuse syndromes.

Hospital & Community Psychiatry

1019–1025. Nowlin-Finch, N. L., Altshuler, L. L., Szuba, M. P., & Mintz, J. (1994). Rapid resolution of first episode

mania: Sleep related?

Journal of Clinical Psychiatry

26–29. Osher, F. C., & Kofoed, L. L. (1989). Treatment of patients with psychiatric and psychoactive substance

abuse disorders.

Hospital & Community Psychiatry

, 1025–1030. Salzman, C. (1981). Psychotropic drug use and polypharmacy in a general hospital.

General Hospital Psychi- atry

1–9. Salzman, C., Green, A. I., Rodriguez-Villa, F., & Jaskiw, G. I. (1986). Benzodiazepines combined with neu-

roleptics for management of severe disruptive behavior.

Psychosomatics

(Suppl. 1), 17–26.

Table 2. Multivariate logistic regression to determine the odd’s ratio for hypnotic use

Variable Odd’s ratio 95% Confidence

interval

Value

Length of stay 0.1 0–1.4 ns Age 0.5 0–4.7 ns Ethnicity 1.9 0.6–6.7 ns Gender 1.6 0.6–4.3 ns Previous drug use 8.2 2.7–28.6 .0004 Major depression 1.6 0.4–5.7 ns Bipolar disorder 5.2 1.2–25.4 .05 Schizophrenia 0.5 0.1–1.8 ns