A physical examination of potential benzodiazepine use disorder patients can reveal signs of benzodiazepine intoxication, such as unsteady gait, incoordination, slurred speech, and cognitive impairment. Diagnosis of benzodiazepine use disorder is based on the diagnostic criteria for substance use disorder, discussed earlier in this course. 201 Benzodiazepine Withdrawal Abrupt or rapid discontinuation of long term benzodiazepine use can lead to withdrawal symptoms. Symptoms typically develop within two to three days of discontinuing short acting agents, compared with five to ten days after discontinuing longer acting agents. In general, benzodiazepine withdrawal symptoms are physical, psychological and sensory symptoms related to the state of hyperexcitability in the brain that develops after the inhibitory effects of benzodiazepines wears off. These can include: 199 • Panic attacks • Irritability • Tremor • Restlessness • Agitation • Sleep disturbances • Sweating • Difficulty concentrating • Weight loss • Nausea or vomiting • Headache • Tachycardia • Loss of appetite • Muscle tension, spasms, or pain Severe cases of withdrawal can cause psychosis or seizures, which can be fatal. Seizures are more likely in patients with a history of alcohol addiction, brain damage, or abnormalities on an electroencephalogram. Other factors that can lead to more severe cases of benzodiazepine withdrawal include longer durations of benzodiazepine use before discontinuation, abrupt discontinuation after regular use, use of benzodiazepines with a shorter half-life, and use of higher benzodiazepine doses. 199 Treatment of Benzodiazepine Use Disorder Treatment of benzodiazepine use disorder involves tapering off benzodiazepines in a safe manner, and preventing patients from returning to benzodiazepine use after completing their taper. Many patients can successfully taper benzodiazepine use on an outpatient basis. However, inpatient treatment may be warranted for patients who have failed several tapering attempts, those taking very high doses of benzodiazepines, or those who have significant medical comorbidities that must be monitored during the taper, such as seizures. 199 When establishing a plan for tapering benzodiazepines, providers have a choice of tapering the agent that the patient is already taking, or switching to a long-acting agent to complete the taper. Short-acting benzodiazepines are associated with more severe withdrawal
symptoms, worse rebound anxiety after stopping the benzodiazepine, and higher dropout rates from discontinuation studies. Agents such as diazepam or chlordiazepoxide are commonly chosen to complete benzodiazepine tapers due to their longer duration of action. 199 Taper rates of 25 to 50 percent every 1 to 2 weeks over a course of 6 to 10 weeks are generally recommended. Tapering schedules should be individualized based on the starting benzodiazepine dose and duration of use, as well as patient’s ability to tolerate withdrawal symptoms. Patients who have used benzodiazepines for longer periods of time experience a higher likelihood of experiencing withdrawal symptoms while tapering. Patients are often recommended to follow up weekly with their providers for monitoring. If physical withdrawal symptoms are intolerable, it is recommended to return to the dose prior to the most recent reduction and slowing down the taper rate. This can help reduce withdrawal symptoms and increase the likelihood of success with the benzodiazepine taper. 199 Adjunctive therapies to aid in tapering benzodiazepines have been evaluated, such as antidepressants and mood stabilizers. In the absence of specific comorbidities, these agents are associated with a low quality of evidence supporting their use. However, patients with comorbidities such as depression, anxiety, insomnia, or opioid use disorder should receive proper treatment of these comorbidities to aid in the success of treatment of benzodiazepine use disorder. Psychosocial interventions such as cognitive behavioral therapy (CBT) are also recommended for patients undergoing benzodiazepine tapering; studies have shown higher rates of benzodiazepine discontinuation in patients undergoing CBT when compared with tapering alone. 199 Alcohol Alcohol is one of the most widely used intoxicants in the world. In 2020, the National Survey on Drug Use and Health found that 50% of adults have used alcohol in the past month, and 22.2% reported drinking five or more drinks on one occasion in the past month. 178 The use of alcohol occurs on a spectrum, ranging from occasional drinking to regular, heavy use. Alcohol use disorder is a medical condition characterized by an inability to control alcohol use despite adverse consequences. 202 Alcohol use disorder is a serious national health problem in the United States. It is estimated that more than 14 million American adults had an alcohol use disorder in 2019, as well as 414,000 adolescents aged 12 to 17. 202 There are over 95,000 deaths every year that are directly attributed to alcohol use, and the economic cost of alcohol use is astounding: excessive alcohol use in the United States is said to cost nearly $250 billion annually. The majority of these costs (77%) are associated with binge drinking, or drinking more than three alcoholic beverages per occasion for women, or more than four drinks for men. 203\
In the United States, alcohol use disorder has a lifetime prevalence of approximately 29%. Despite the high prevalence and common complications, alcohol use disorder is undertreated. Less than 10% of patients with a diagnosis of alcohol use disorder in the past 12 months receive any treatment, and only around 6% of patients with alcohol use disorder receive evidence-based care. 204 There is a clear need for improvement in the treatment of this common condition; this course serves to review the recognition, diagnosis, and treatment of alcohol use disorder.
Short- and Long-Term Effects of Alcohol
Inebriation Alcohol is a central nervous system (CNS) depressant, causing decreased reaction time, motor coordination, and mental performance. After ingestion, it is swiftly absorbed into the bloodstream through the stomach and small intestine. From there, it is slowly metabolized by the liver. A healthy liver typically metabolizes one standard drink per hour, which is equivalent to 12oz of 4% beer, 1.5oz of 80 proof liquor, or 5oz of table wine. The remaining alcohol continues to flow through the bloodstream until the liver is able to process it. 205 The amount of alcohol that was consumed determines the intensity of its effect on the body. Blood alcohol concentration, or the percent of alcohol in the bloodstream, typically increases as more drinks are consumed. Blood alcohol levels of 0.08% or higher are associated with mild balance, speech, and vision impairment, and are considered too high for driving in most states. Between 0.1 and 0.15%, motor coordination and balance are significantly affected, speech may be slurred, and major loss of balance can occur. Concentrations of 0.16 to 0.3% indicate severe intoxication, causing symptoms such as confusion, nausea, vomiting, and needing assistance walking. Blood alcohol concentrations of 0.35 to 0.4% are associated with a loss of consciousness and over 0.4% can cause a coma and increase the likelihood of death by respiratory failure. 205,206 A number of factors can impact a person’s response to alcohol consumption. The presence of food in the stomach can slow the absorption of alcohol; blood alcohol concentrations can be up to three times higher in a person with an empty stomach when compared to someone who ate a meal before drinking. In addition, up to 50% of people of Asian descent are less able to metabolize alcohol due to an inactive liver enzyme needed for metabolism, resulting in more rapid intoxication, flushing, dizziness, nausea, headache, and rapid heartbeat with alcohol use. Gender can also play a significant role on the effects of alcohol. Women have less body water than men to dilute alcohol, lower quantities of the liver enzymes needed to metabolize alcohol, and the effects of estrogen can slow down the rate of alcohol elimination from the body. In addition, with chronic use, tolerance to the CNS effects of alcohol develops, so the functional impact of a specific amount of alcohol can vary. 205
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