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Dr Ray Baker's Article on Addiction:
Benzodiazepines in Particular

Addiction (Drug Dependence: DSM IV-R) in General:
Benzodiazepines in Particular
Ray Baker MD

Addictive Drugs – especially sedative-hypnotics

All drugs with the potential to cause addictions share certain common neurobiological characteristics: they activate the mesolimbic system, principally the nucleus accumbens, causing increased dopaminergic activity in that area of the brain. This results in an increase in hedonic tone.

But addictive drugs come from various categories, affecting many other parts of the brain as well. Some cause excitation others cause inhibition, or diminution of neuronal activity in various areas of the nervous system.

Almost all mind and mood-altering drugs, with prolonged consumption, cause changes in structure and function, evidenced by development of tolerance or withdrawal upon cessation of the drug. In an attempt to maintain homeostasis the regulatory systems of the central and peripheral nervous system cause neuroadaptation, either upregulation – with creation of new neuroreceptor sites or downregulation, with changes in neurotransmitter-neuroreceptor synthesis and sensitivity.

The sedative-hypnotic categories of drugs (alcohol, benzodiazepines, barbiturates, and ether) are most notorious for the degree of neuroadaptation and hence the severity of withdrawal symptoms during reversal of the neuroadaptation process. The parts of the brain affected by these drugs include the cortex, the limbic system and the locus ceruleus in the brain stem. So after long-term suppression of these areas, by a depressant drug, the resultant neuroadaptation results in alarming overactivity on cessation or even decreasing dose of the drug. So withdrawal results in extreme excitability of all brain structures with irritability, insomnia, anorexia, confusion, memory loss, delirium and even seizures, cardiovascular excitation, gastrointestinal overactivity and hyperpyrexia.

Sedative-hypnotic withdrawal is far more dangerous
than opioid (heroin) withdrawal.

Unfortunately in a small proportion of people prescribed these drugs, with prolonged benzodiazepine use, the neuroadaptation is sometimes very slow to reverse, and may even leave permanent synaptic (neuroanatomical) changes. This can result in a prolonged protracted withdrawal syndrome characterized by irritability, paresthesias, cognitive impairment, insomnia, and dysphoria, increased sensitivity to sound and light and even psychosis.

It is important not to confuse physical dependence as evidenced by benzodiazepine withdrawal syndromes with addiction or drug dependence (DSM-IV). The majority of people suffering with prolonged withdrawal syndromes from benzodiazepines do not meet sufficient criteria to make the diagnosis of addiction. They are NOT addicts.

Addiction is a biopsychosocial syndrome. Less than ten percent of the population is at risk. Although there are eight diagnostic criteria, three of which must be present for a year; the syndrome can best be described by "the 3 Cs".

  1. Control: when the addicted person starts using their drug they episodically lose control over their ingestion.

  2. Compulsion: getting and using the drug takes on more and more importance or salience in the person's life, crowding out relationships and activities that were once important to them.

  3. Consequences: they continue using the drug despite the drug causing problems at home, problems in relationships, medical problems, legal problems, emotional and psychiatric problems and finally vocational problems.

Physical dependence is simply a neurobiological phenomenon due to continued exposure to a drug. It happens to all human brains exposed to drugs such as benzodiazepines and opioids. It is not addiction.

Treatment of Benzodiazepine Withdrawal:

Avoidance of benzodiazepine physical dependence is the most important tactic. There are very few medical indications for the prolonged administration of benzodiazepines. They are best used as we use steroids such as prednisone: short courses for definite indications. Once physical dependence has occurred it is important to proceed cautiously. Generally short acting sedative-hypnotic drugs (triazolam [Halcion], alprazolam [Xanax]) should be replaced by long-acting drugs (diazepam [Valium]) or phenobarbital. This allows blood and brain levels to stabilize and then the drug may be slowly tapered, in cases of long-term benzodiazepine use, over several months. There are exceptions, such as in the elderly or those with liver function impairment, drugs such as oxazepam [Serax], although not long-acting, are cleaner and easier to metabolize. Very important during treatment of benzodiazepine withdrawal are the physical, behavioural and psychosocial therapies used by the person: regular aerobic exercise, maintenance of good nutrition, including B complex vitamins, rest and sleep hygiene (even if sleep quality is poor), social and emotional support, meditation, relaxation and some would add a variety of spiritual activities.

Dr Ray Baker's Comments on the Benzo FAQ

Date: Fri, 07 Jul 2000 02:38:51
From: Ray Baker MD
To: The Benzo Group
Subject: FAQs

I would like to congratulate the members of this group who contributed to a thorough and remarkably helpful document on benzodiazepines and benzo withdrawal.

A "must read" for anybody considering coming off benzos. More important, a must read for my colleagues who keep putting more on benzos!

Well done!

Ray Baker

Profile of Dr. Ray Baker, BSc (Hon), MD, FCFP, FASAM

Dr. Ray Baker is Assistant Clinical Professor in the Faculty of Medicine at the University of British Columbia. He has been awarded fellowships in both Family Medicine and Addiction Medicine. He has been a practicing physician for over 23 years. As Assistant Professor, he won a national teaching award from the Association of Canadian Medical Colleges for designing and implementing the first comprehensive Addiction Medicine Curriculum at The University of British Columbia. From 1993 to 1997 he represented Canada on the Board of Directors of the American Society of Addiction Medicine, North America's credentialling body in this specialized area of medicine. He served as principal author for the British Columbia standards of practice in Addiction Medicine, adopted as policy by the College of Physicians and Surgeons of B.C.

He serves as medical Director of HealthQuest Ltd., a health corporation offering assessment services, expert testimony, treatment planning, occupational health, disability management, research and vocational rehabilitation services to organizations and individuals. His area of special clinical expertise is in assessment and treatment planning of the worker disabled by one of the "invisible disabilities", stress, depression, chronic pain syndrome or substance use disorder.

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