P4#1 AND P4#2 NRNP

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Stephanie East 

Anxiolytic Use Disorder

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Diagnostic Criteria

 

Anxiolytic use disorder (AUD) is a problematic pattern of use manifested by two or more of the following over a 12 month period:  1) anxiolytics taken in larger amounts or over a longer period than was intended, 2) persistent desire or unsuccessful efforts to cut down use,  3) great deal of time spent trying to obtain anxiolytic, 4) Cravings, 5) Impact of anxiolytic use is affecting work, school and/or home, 6) continued use despite negative impacts, 7) tolerance, 8) withdrawal (American Psychiatric Association, 2013).    Lifetime prevalence is around 1% and anxiolytic use is associated with other psychiatric Axis I and II comorbidities (Huang et al., 2006).  

Clinical Features

 

Clinical features of AUD include physical dependence and addiction, misuse of prescribed anxiolytic and use of diverted medication.  Misuse can be difficult to distinguish from untreated anxiety or insomnia.  Severity of withdrawal symptoms depends on the duration prior to discontinuation, higher doses, drugs with shorter half life and whether the drug was abruptly discontinued (Peterson, 1994).  Signs and symptoms of benzodiazepine withdrawal are nausea, vomiting, tremors, insomnia, headache, agitation and anxiety.  The onset of withdrawal symptoms typically occurs 1-3 days after last use.   Benzodiazepine withdrawal is can be life threatening as patients can develop seizures or status epilepticus (Sadock et al., 2017). Longer durations of use  are associated with a higher likelihood of symptoms during the taper (De Gier et al., 2011).

 

Psychotherapeutic and Psychopharmacological Treatment for Anxiolytic Use Disorder 

 

Anxiolytic tapers can be done on an outpatient basis unless there are complicated medical comorbidities or history of seizures.  Anxiolytic tapers can be done by gradual reduction of the medication by 25-50% every 1-2 weeks over a period of 6-10 weeks or by switching to a longer acting benzodiazepine such as Diazepam (De Gier et al., 2011). 

Clients undergoing benzodiazepine taper should be in cognitive behavioral therapy (CBT).  In one meta-analysis that included nine trials, adding CBT to a benzodiazepine taper resulted in higher rates of benzodiazepine discontinuation compared with taper alone at three months follow-up (Darker et al., 2015).  For patients who have successfully tapered off benzodiazepines, we continue counseling regarding the risks of benzodiazepine use disorder.   As above, prevention of recurrent benzodiazepine use disorder mainly consists of avoidance of benzodiazepines and psychosocial support. 

  

 

References

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing.  

 

Darker, C. D., Sweeney, B. P., Barry, J. M., Farrell, M. F., & Donnelly‐Swift, E. (2015). Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane database of systematic reviews, (5).

 

DeGier, N. A., Gorgels, W. J., Lucassen, P. L., Oude Voshaar, R., Mulder, J., & Zitman, F. (2011). Discontinuation of long-term benzodiazepine use: 10-year follow-up. Family practice, 28(3), 253–259.  https://doi.org/10.1093/fampra/cmq113

 

Huang, B., Dawson, D. A., Stinson, F. S., Hasin, D. S., Ruan, W. J., Saha, T. D., Smith, S. M., Goldstein, R. B., & Grant, B. F. (2006). Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 67(7), 1062–1073.  https://doi.org/10.4088/jcp.v67n0708

 

Peterson H. (1994). The benzodiazepine withdrawal syndrome. Addiction (Abingdon, England), 89(11), 1455–1459.  https://doi.org/10.1111/j.1360-0443.1994.tb03743.x

 

Sadock, B., Sadock, V. and Ruiz, P. (2017). Kaplan & Sadock’s Synopsis of