Benzodiazepines in the Treatment of Alcoholism

This post comprises three sections that cover the main aspects of benzodiazepines and alcohol: (1) the basic pharmacology of benzodiazepines; (2) use of benzodiazepines in the treatment of withdrawal; and (3) the use of benzodiazepines in treating alcoholics. The basic studies suggest that a major site of action of alcohol may be the GABA/benzodiazepine receptor complex and that compensatory alterations in this complex may underly withdrawal. In the section on alcohol withdrawal, interactions between the GABA/benzodiazepine receptor complex, sympathetic nervous system, and hypothalamic-pituitary-adrenal axis are discussed. Use of benzodiazepines in the treatment of the alcohol withdrawal syndrome are reviewed, including the possibility that the benzodiazepines may prevent withdrawal-induced “kindling”. Lastly, we review indications for, and efficacy of, benzodiazepines in long-term treatment of patients with alcoholism. Benzodiazepines are not indicated for the treatment of alcoholism. Furthermore, they have very few indications in alcoholics and their dependency-producing potency has to be appreciated when they are used in patients with alcoholism. The benzodiazepines () are a group of compounds that were first Read more […]

Drug-Drug Interactions of Methadone

Antiretroviral drugs Methadone is often used for opioid replacement therapy in intravenous drug abusers. The incidence of HIV infection is significantly higher in this population than in the general public, and interactions with drugs used for the treatment of AIDS are therefore important. Methadone is predominantly metabolized by CYP3A4. Antiretroviral therapy with a non-nucleoside reverse transcriptase inhibitor (for example efavirenz, abacavir, and nevirapine) and/or a protease inhibitor (for example amprenavir) will induce the metabolism of methadone. This therapeutic combination is becoming increasingly common in HIV-positive substance misusers. Two studies have explicitly shown a significant reduction of methadone concentration by 28-87%. In the first study, 11 patients taking methadone maintenance therapy were given efavirenz and had a mean increase in methadone dosage requirement of 22%. In the second study, five methadone-maintained opioid-dependent individuals were given a combination of abacavir and amprenavir; the methadone concentration fell to 35% of the original concentration within 14 days. In a prospective study of 54 patients taking antiretroviral drugs who also took methadone and a further Read more […]

Alcohol-Related Disorders

Workers in the addiction field have attempted to more clearly define alcohol use problems, and accuracy is especially important for making a diagnosis in a medical setting. Several hospitalizations for alcohol-related illness can occur before a direct connection is made between a patient’s alcohol use and medical problems. Alcoholic patients tend to experience many alcohol-related problems before seeking professional help or attending AA meetings. Stigma associated with the term alcoholism frequently inhibits physicians and patients from exploring the connections between abuse and biopsychosocial consequences. Psychiatrists participating in a hospital survey positively identified alcohol abuse two-thirds of the time, whereas physicians treating gynecology patients diagnosed the disorder only 10% of the time. In primary care settings similar underdiagnosis is common; however, in studies that rely on chart review or screening instruments, investigators may underestimate what physicians really suspect to be the case. The official psychiatric nomenclature for alcohol abuse and dependence evolved from the view of alcoholism as a personality disorder (American Psychiatric Association 1952), through recognition of episodic, Read more […]

Opioid-Related Disorders

Opioid abuse manifests in various ways in patients in medical settings. Psychiatrists are frequently consulted regarding opioid therapy for patients who are prescribed methadone, are thought or known to be dependent on prescription or illicit narcotics, engage in drug-seeking behavior, exhibit personality problems that interfere with medical care, or have overdosed. Suspicion is heightened by exaggerated pain complaints, by visits to multiple providers for multiple pain complaints requiring a narcotic prescription (e.g., migraine, back pain, dental pain, fibromyalgia, and endometriosis), and by claims to be “allergic” to every analgesic except for particular opioids (e.g., hydro-codone or oxycodone). Opioid-dependent patients often provoke angry reactions from staff, which can result in discharging a patient prematurely or underprescribing pain medications. Chronic pain patients who develop tolerance to opioids and experience opiate withdrawal on cessation of use are often misla-beled addicts (see “Pain”). Tolerance and withdrawal alone are not sufficient for the diagnosis of either substance abuse or dependence. For example, cancer patients with painful bone metastatic lesions may need high doses of narcotics and Read more […]