Benzodiazepines are frequently prescribed for anxiety and sleep disorders. They are also popular for self-medicating or abuse purposes; providing peace and euphoria for troubled individuals. They are rarely abused alone and often combined with alcohol or opiates. Those who abuse cocaine or methamphetamines may use benzodiazepines to ‘level off’ a high. An earlier post discusses the hidden nature of benzodiazepine misuse and the high potential for late withdrawal in many of our patients, especially women. Once identified, successful benzodiazepine withdrawal requires monitoring and management.
Signs of Impending Troubles
The symptoms and duration of withdrawal can be hard to nail down and are based on length of use, type (short-acting vs. long-acting), and underlying psychopathology. Symptoms can be as mild as some irritability and insomnia to as intense as seizures, panic attacks, and hallucinations. General body discomforts such as bloating, muscle aches, and restlessness are also common. The Federal Bureau of Prisons Detoxification Guidelines provide a helpful staging guide:
- Early Withdrawal: Increased pulse and blood pressure, anxiety, panic attacks, restlessness, and gastrointestinal upset.
- Mid Withdrawal: Progressing to include tremor, fever, diaphoresis, insomnia, anorexia, and diarrhea.
- Late Withdrawal: If left untreated, a delirium may develop with hallucinations, changes in consciousness, profound agitation, autonomic instability, seizures, and death
Monitoring and Protocols
Unfortunately, an extensively evaluated monitoring scale does not yet exist for benzodiazepine withdrawal. A scale modeled after the well-validated CIWA-Ar (for alcohol withdrawal) is currently being tested for widespread use. The CIWA-B is a 22-item instrument that monitors type and severity of benzodiazepine withdrawal symptoms such as irritability, fatigue, appetite, and sleeplessness. Objective assessment of sweating, restlessness (pacing), and tremor are also documented. A tally of points based on responses and observation can be used to determine treatment.
Another withdrawal monitoring option with some validation is the Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ). This tool is a 20-item self-report questionnaire that does not include scoring categories for level of treatment.
Because tools like the CIWA-B and BWSQ have had little validation, as yet, the FBOP recommends general evaluation of symptoms based on the withdrawal table above with vital signs at least every 8 hours for the first three days of therapy.
A tapered schedule of long-acting benzodiazepines to ease withdrawal is advocated. Under medical supervision, detoxification can be accomplished using clonazepam (Klonopin) or chlordiazepoxide (Librium). Some experts prefer the long-acting barbiturate phenobarbital for safe benzodiazepine withdrawal.
Unfortunately, benzodiazepine withdrawal is complicated by symptom reemergence and rebound. The anxiety and insomnia that caused the original drug use can return with greater intensity. Withdrawal can take many weeks or months to successfully accomplish and requires continued monitoring and attention.
What tools are you using to monitor and treat barbiturate withdrawal? Share your practices in the comments section of this post.
To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.
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