Prevention of alcohol withdrawal seizures with oral diazepam loading

Twenty patients withdrawing from alcohol who had reliable histories of previous alcohol-withdrawal seizures and thus were at high risk for a subsequent seizure were treated in hospital with oral diazepam loading: 20 mg of the drug was given every hour to a minimum total of 60 mg. None of the patients had a seizure during the stay in hospital. We believe that phenytoin prophylaxis is not necessary in these circumstances. However, if the patient is already taking phenytoin, this drug should not be abruptly discontinued in the withdrawal period in favour of diazepam loading.     

The pentylenetetrazol model of anxiety detects withdrawal from diazepam in rats

This experiment tested whether benzodiazepine withdrawal could be detected in an animal model of anxiety. Rats were trained in operant chambers using food reward to press one lever after pentylenetetrazol (PTZ), 20 mg/kg, injection and the other lever after saline injection. Previously, the PTZ cue has been shown to be simulated by anxiogenic drugs and blocked by anxiolytic drugs. After rats reliably performed this discrimination, they were injected with diazepam, 20 mg/kg, from 1 to 4 times a day for six days. For one group of subjects, on the third, fourth and sixth days, they were also injected with 40 mg/kg of RO 15-1788, a benzodiazepine receptor antagonist, and tested for lever selection: 50–80% of the subjects selected the PTZ lever; these results are in contrast to those obtained prior to chronic diazepam treatment in which RO 15-1788 did not generalize to PTZ. A second group of subjects was also injected for six days with diazepam and then allowed to withdraw spontaneously for eight days: PTZ lever selection over this period varied from 20 to 60% of rats. These data indicate that animals trained to discriminate a PTZ cue: 1) generalize the benzodiazepine withdrawal state to the PTZ cue, and 2) discriminate the withdrawal state for long periods of time, agreeing with clinical observations of long-lasting anxiety signs during benzodiazepine withdrawal.     

Diazepam withdrawal syndrome: its prolonged and changing nature.

The diazepam withdrawal syndrome was studied in 10 patients who had abused the drug for 3 to 14 years. In the previous 6 months their consumption of diazepam had ranged from 60 to 120 mg daily; none had used other drugs during this period. The withdrawal period lasted about 6 weeks. The intensity of the symptoms and signs was high initially, fell during the first 2 weeks, then rose again in the third week, before finally declining. Three groups of symptoms and signs were identified. Group A symptoms occurred throughout withdrawal and included tremor, anorexia, insomnia and myoclonus. Group B symptoms and signs were largely confined to the first 10 days and were those of a toxic psychosis. Group C symptoms reached a peak in the third and fourth weeks of withdrawal and were characterized by sense perceptions that were either heightened or lowered. The symptom groups, the presence of tremor and myoclonus, and the relief of symptoms by a test dose permit diazepam withdrawal to be distinguished from anxiety. The biphasic course of the symptoms is probably related to the pharmacokinetics of diazepam.     

Diazepam withdrawal as demonstrated by changes in plasma corticosterone: a role for the hippocampus

Elevations in plasma corticosterone were shown to be a reliable indication of antagonist-precipitated withdrawal from diazepam in the rat. Dependence to the benzodiazepine was produced by a single daily injection for eight days at which time CGS-8216 was injected i.v. via a chronic indwelling catheter. This injection and subsequent serial blood samples were withdrawn from conscious, unrestrained animals that were placed previously in sound-attenuated one-way vision boxes. The magnitude of the hormone change was correlated with either the chronic dose of diazepam or the dose of the antagonist used to precipitate withdrawal. When CGS-8216 was administered chronically with the diazepam, antagonist-precipitated abstinence did not occur. Additional results showed that dependence could be produced by bilateral intracerebral placement of micropellets of diazepam into the dorsal and ventral hippocampus. These data show that dependence to diazepam can be demonstrated in a relatively short time using modest doses of drug, and, further, that exposure of the hippocampus, an area with a high concentration of benzodiazepine receptors, to diazepam will initiate dependence.     

Effect of withdrawal of diazepam or morphine treatment on gastric motility (charcoal meal test) in mice: possible role of different central and peripheral receptors

Increased gastrointestinal motility in mice as one of the withdrawal symptoms of commonly abused drugs like diazepam or morphine and its possible mechanism of action was studied. Male Laka mice (20-25 g) were made addict to either diazepam (20 mg/kg, ip for 7 days) or morphine (10 mg/kg, sc for 9 days). Withdrawal symptoms were noted 24 hr after the last injection of diazepam or morphine. The animals were injected with Ro 15-1788 (flumazenil) (1 mg/kg, ip) or naloxone (2 mg/kg, ip) in the respective group to precipitate the withdrawal symptoms. Gastrointestinal motility was assessed by charcoal-meal test. Animals developed tolerance to acute sedative effect of diazepam, and similarly to the acute nociceptive action of morphine. On abrupt cessation of these drugs after chronic treatment the animals showed hyperlocomotion and hyperreactivity in diazepam withdrawal group and hyperalgesia on hot plate in morphine withdrawal groups, respectively. Increase in gastrointestinal motility was observed in all the drug withdrawal groups. Treatment with respective antagonists, Ro 15-1788 (flumazenil) and naloxone precipitated the withdrawal symptoms. The results suggest the involvement of both central and peripheral receptors of benzodiazepines and opioid (mu) receptors in the withdrawal symptoms of the benzodiazepines and morphine, respectively.     

Fine mapping of a sedative-hypnotic drug withdrawal locus on mouse chromosome 11

We have established that there is a considerable amount of common genetic influence on physiological dependence and associated withdrawal from sedative-hypnotic drugs including alcohol, benzodiazepines, barbiturates and inhalants. We previously mapped two loci responsible for 12 and 9% of the genetic variance in acute alcohol and pentobarbital withdrawal convulsion liability in mice, respectively, to an approximately 28-cM interval of proximal chromosome 11. Here, we narrow the position of these two loci to a 3-cM interval (8.8 Mb, containing 34 known and predicted genes) using haplotype analysis. These include genes encoding four subunits of the GABA(A) receptor, which is implicated as a pivotal component in sedative-hypnotic dependence and withdrawal. We report that the DBA/2J mouse strain, which exhibits severe withdrawal from sedative-hypnotic drugs, encodes a unique GABA(A) receptor gamma2 subunit variant compared with other standard inbred strains including the genetically similar DBA/1J strain. We also demonstrate that withdrawal from zolpidem, a benzodiazepine receptor agonist selective for alpha1 subunit containing GABA(A) receptors, is influenced by a chromosome 11 locus, suggesting that the same locus (gene) influences risk of alcohol, benzodiazepine and barbiturate withdrawal. Our results, together with recent knockout studies, point to the GABA(A) receptor gamma2 subunit gene (Gabrg2) as a promising candidate gene to underlie phenotypic differences in sedative-hypnotic physiological dependence and associated withdrawal episodes.     

A physician's guide to discontinuing benzodiazepine therapy.

Practicing physicians need to have practical techniques to help patients who want to stop using benzodiazepines. I have developed three approaches that usually work. The first, and most widely applicable, is gradually reducing the dose without adding any other medicine. Failing this, use one of the following two approaches, occasionally combining them: switch to a longer-acting, cross-tolerant medication (usually clonazepam or phenobarbital) or use medications to suppress the withdrawal symptoms, usually carbamazepine, propranolol, or clonidine. If this fails, use inpatient detoxification. Chemically dependent patients, including those abusing alcohol and taking higher than recommended doses of sedative-hypnotics, require special care during discontinuation. Aftercare is important for all long-term benzodiazepine users if they are to remain drug-free and live relatively comfortable lives.     

No changes in rat benzodiazepine receptors after withdrawal from continuous treatment with lorazepam and diazepam.

Five and 11 days after withdrawal from 8 weeks of treatment with 90 mg/kg/day of diazepam p.o. or 60 mg/kg/day of lorazepam p.o. there were no consistent changes in the number of benzodiazepine receptors or apparent affinity $\text{in vitro}$ for ³H-diazepam at 0°C in rat forebrain membranes. Daily exposure of rats from 10 days before birth until 7 days after birth was also without gross effects on the benzodiazepine receptor. Abstinence and tolerance to benzodiazepines were thus not attributable to changes in brain benzodiazepine receptors.     

Alterations in cerebral diazepam binding inhibitor expression in drug dependence: a possible biochemical alteration common to drug dependence

Mechanisms for formation of drug dependence and expression of withdrawal syndrome have not fully clarified despite of huge accumulation of experimental and clinical data at present. Several clinical features of withdrawal syndrome are considered to be common among patients with drug dependence induced by different drugs of abuse. One of them is anxiety. Recent investigations have revealed that diazepam binding inhibitor (DBI), a peptide consisting of 87 amino acids with molecular weight of about 10 kDa, serves as an inverse agonist for benzodiazepine (BZD) receptors with endogenously anxiogenic potential. These lines of data suggest that cerebral DBI expression in brain may participates in formation of drug dependence and/or emergence of withdrawal syndrome. Based on this working hypothesis, we have examined DBI expression in the brain derived from mice depended on alcohol (ethanol), nicotine, and morphine to investigate functional relationship between cerebral DBI expression and drug dependence. Cerebral DBI expression significantly increases in animals with drug dependence induced by these drugs, and in the cases of nicotine- and morphine-dependent mice concomitant administration of antagonists for nicotinic acetylcholine and opioid receptors, respectively, abolished the increase. Abrupt cessation of administration of drugs facilitated further increase in DBI expression. Therefore, these alterations in DBI expression have close relationship with formation of drug dependence and/or emergence of withdrawal syndrome, and are considered to be a common biochemical process in drug dependence induced by different drugs of abuse. Finding and elucidation of mechanisms for common biochemical alterations among drug dependence may provide a clue to clarify mechanisms for formation of drug dependence and/or emergence of withdrawal syndrome.     

Carbohydrate deficient transferrin: a marker for alcohol abuse.

OBJECTIVE--To assess the value of serum carbohydrate deficient transferrin as detected by isoelectric focusing on agarose as an indicator of alcohol abuse. DESIGN--Coded analysis of serum samples taken from patients with carefully defined alcohol intake both with and without liver disease. Comparison of carbohydrate deficient transferrin with standard laboratory tests for alcohol abuse. SETTING--A teaching hospital unit with an interest in general medicine and liver disease. PATIENTS--22 "Self confessed" alcoholics admitting to a daily alcohol intake of at least 80 g for a minimum of three weeks; 15 of the 22 self confessed alcoholics admitted to hospital for alcohol withdrawal; 68 patients with alcoholic liver disease confirmed by biopsy attending outpatient clinics and claiming to be drinking less than 50 g alcohol daily; 47 patients with non-alcoholic liver disorders confirmed by biopsy; and 38 patients with disorders other than of the liver and no evidence of excessive alcohol consumption. INTERVENTION--Serial studies performed on the 15 patients undergoing alcohol withdrawal in hospital. MAIN OUTCOME measure--Determination of relative value of techniques for detecting alcohol abuse. RESULTS--Carbohydrate deficient transferrin was detected in 19 of the 22 (86%) self confessed alcohol abusers, none of the 47 patients with non-alcoholic liver disease, and one of the 38 (3%) controls. Withdrawal of alcohol led to the disappearance of carbohydrate deficient transferrin at a variable rate, though in some subjects it remained detectable for up to 15 days. Carbohydrate deficient transferrin was considerably superior to the currently available conventional markers for alcohol abuse. CONCLUSION--As the technique is fairly simple, sensitive, and inexpensive we suggest that it may be valuable in detecting alcohol abuse.     

beta-Carbolines, psychoactive compounds in the mammalian body. Part II: Effects

The biochemical and the pharmacological effects of beta-carbolines in animals and man are reviewed. Biochemical studies have revealed beta-carbolines' several actions, including inhibition of MAO-A, competitive inhibition of 5-HT uptake, general inhibition of Na+ dependent transports, binding to benzodiazepine and opiate receptors and probable action on dopamine receptors, which may all participate to a variable degree in the actions of different beta-carbolines. Many early in vivo studies, however, have concentrated on some harmala alkaloids, particularly harmaline or harmine. The effects of beta-carbolines in man are compared in this review with the symptoms of alcohol withdrawal. However, no human studies have been reported with those tetrahydro-beta-carbolines shown to occur in human body in normal conditions or after alcohol intake. To prove any connections of beta-carbolines with the withdrawal syndromes or other neurological and psychiatric diseases means that these compounds have to be shown to have abnormal central nervous system concentrations in these diseases. The physiological role of beta-carbolines has yet to be shown. They may act as neuromodulators and some, especially 6-methoxytetrahydro-beta-carboline, may have an endocrinological function. It has been suggested that some beta-carbolines act as the physiological ligands (agonists) of the benzodiazepine receptors, but the physiological beta-carbolines so far known seem to have other effects, such as the inhibition of MAO-A or 5-HT uptake in low concentrations.     

Benzodiazepine - specific and nonspecific tolerance following chronic flurazepam treatment

Rats were given a flurazepam solution as their only water source for 4 weeks. The drug concentration was adjusted so the rats would consume 100–150 mg/kg daily. This treatment is known to cause a reduction in the number of specific benzodiazepine binding sites (receptor down-regulation) and tolerance to the locomotor impairment caused by the injection of a large test dose of flurazepam. Both the tolerance and the receptor down-regulation disappear within 24 hours after the end of chronic treatment. After 4 weeks of flurazepam treatment, rats were tested for locomotor impairment and loss of the righting response caused by pentobarbital, ethanol or diazepam. There was a small tolerance to pentobarbital. This lasted at least 4 days, but had disappeared by 7 days. Rats also had a small tolerance to ethanol, which disappeared between 24 and 48 hours after the end of chronic flurazepam treatment. In contrast, there was a large tolerance to diazepam, but this was gone by 24 hours after the end of chronic treatment. It appears that two types of tolerance develop during benzodiazepine treatment: (1) tolerance specific for benzodiazepines possibly mediated by receptor down-regulation, and (2) nonspecific tolerance, possibly analogous to that which develops during chronic barbiturate treatment.     

Stereoselective stimulus effects of 3-methylflunitrazepam and pentobarbital

Rats trained to discriminate 3.0 mg/kg of diazepam from saline in a two-lever operant choice task were challenged with the racemic mixture and optical isomers of 3- methylflunitrazepam or pentobarbital. Generalization of the diazepam stimulus was found to occur to (+/-)- and S(+)-3- methylflunitrazepam , with the S(+)-isomer being twice as active as the racemate. Diazepam stimulus generalization also occurred to (+/-)-, S(-)-, and R(+)-pentobarbital, with the S(-)-isomer being approximately twice as active as (+/-)- or R(+)-pentobarbital. In addition, the administration of the imidazobenzodiazepine Ro 15-1788, a selective benzodiazepine receptor antagonist, prior to benzodiazepine or barbiturate administration competitively antagonized the discriminative stimulus properties of the benzodiazepines but was completely ineffective in attenuating the discriminative stimulus effect of the barbiturates. The results of this study suggest that benzodiazepines exert their stimulus effects by a stereoselective interaction at a benzodiazepine receptor and that stereochemical factors are important in evaluating the stimulus properties of benzodiazepines or barbiturates.     

Alprazolam use and dependence. A retrospective analysis of 30 cases of withdrawal.

From 1986 to 1989, the Chemical Dependency Recovery Program at Kaiser Permanente Hospital, Fontana, California, admitted an increasing number of patients for alprazolam dependence. Severe withdrawal reactions and adverse consequences with use were reported in the literature. In this review of 30 cases of alprazolam dependence and subsequent withdrawal, there was a statistically significant increase in the number of patient hospital days, the subjective symptoms, and staff time spent with patients compared with those in alcoholic controls. Most patients with diagnosed alprazolam dependence used doses in the range recommended by the package information at the time of admission. Patients with low preadmission doses of 1 mg or less per day showed notable withdrawal symptoms. The average duration of use was 29.9 months, considerably longer than suggested effective ranges. Most patients (28) had a chemical dependence history before being placed on alprazolam therapy; 24 had a positive family history of chemical dependence; and 24 had previous or current psychiatric care.     

The effects of barbiturates upon the hemodynamic responses to intravenous methionine-enkephalin in dogs: modulation by the GABA complex

In conscious animals, the intravenous administration of enkephalins increases heart rate (HR) and mean systemic arterial blood pressure (MAP); however, when given during barbiturate anesthesia, enkephalins reduce HR and MAP. We have investigated the potential role of the gamma-aminobutyric acid (GABA) complex (consisting of chloride-ion channel and binding sites for GABA, benzodiazepine, and barbiturate/picrotoxin) as the site of modulation of enkephalin responses by certain anesthetic agents in our chronically instrumented dog model. In our model, methionine-enkephalin (Met5-ENK) (35 micrograms/kg intravenously) increased HR and MAP, but following induction of general anesthesia with barbiturate (pentobarbital) or of sedation with benzodiazepine (diazepam), Met5-ENK produced vasodepressor responses despite differing levels of consciousness in the treated animals. Subsequent administration of picrotoxin restored pressor responses to Met5-ENK in the barbiturate-treated dogs, but not in those treated with benzodiazepine; picrotoxin did not alter the level of consciousness. Picrotoxin had no effect upon Met5-ENK responses in the conscious state. In contrast, alpha-chloralose, a convulsive anesthetic agent which does not appear to alter GABA complex activity, blunted but did not reverse pressor responses to Met5-ENK, despite causing a level of anesthesia similar to that produced by barbiturate. The observed pressor response to Met5-ENK during alpha-chloralose anesthesia was totally inhibited by naloxone, indicating that this response was still mediated by opiate receptors. Our data are compatible with modulation of enkephalin responses by GABA complex activity. Systemic enkephalins may generate afferent signals which may subsequently undergo GABA complex processing; the state of activation of the GABA complex may then determine whether systemic enkephalin signals are translated as vasopressor or vasodepressor responses.     

Oral phenobarbital loading: a safe method of barbiturate and nonbarbiturate hypnosedative withdrawal.

We tested the efficacy and safety of oral phenobarbital loading, 120 mg/h until the end-point of mild intoxication is reached, for the treatment of hypnosedative withdrawal in 48 physically dependent patients, 14 of whom had a history of withdrawal seizures. None of the patients experienced seizures or any other symptoms of withdrawal during the study period, regardless of the phenobarbital half-life. The phenobarbital loading technique can be used in any hospital, not only those with access to specialized drug analysis laboratories. The method of treatment we describe allows the clinician to focus on issues such as rehabilitation instead of drug administration and manipulation of doses.     

Benzodiazepineverslaving; een stille verslaving onder ouderen

Benzodiazepines are frequently prescribed for a longer period of time for anxiety disorders and insomnia in spite of the many guidelines to prescribe these drugs only short-term. These guidelines are based on the risk-benefit balance between long-term effectiveness and side effects like addiction, anterograde amnesia, and increased risk on falling (resulting in hip fractures), traffic accidents and even mortality. Also low-dose benzodiazepine use can lead to benzodiazepine dependence. Although initially most attention has been paid to the physical withdrawal syndrome, psychological aspects of benzodiazepine dependence have received more and more attention in the past decades. Recently, a relationship between the brain-reward system, involved in addiction, and benzodiazepine use, was demonstrated. When long-term benzodiazepine use is recognised as problematic by both physician and patient, different treatment modalities are available to support patients in achieving abstinence. One of every four patients is able to stop by themselves with the aid of a minimal intervention providing psychoeducation and encouragement. Two out of three long-term uses are able to stop their usage with the aid of systematic tapering protocols guided by a physician or psychologist. In case of an underlying insomnia or anxiety disorder, cognitive-behavioural therapy should be added to the tapering protocol. In contrast to the general opinion, advanced old age has no negative impact on the treatment response.     

Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal

OBJECTIVE: To analyse the evidence for the efficacy and potential harmful effects of benzodiazepines compared with other therapies in the treatment of acute alcohol withdrawal. DATA SOURCES: MEDLINE and the Cochrane Controlled Trials Registry were searched for English-language articles published from 1966 to December 1997 that described randomized controlled trials (RCTs) of benzodiazepines in the treatment of acute alcohol withdrawal. Key words included "benzodiazepines" (exploded) and "randomized controlled trial." Bibliographies of relevant articles were reviewed for additional RCTs, and manufacturers of benzodiazepines were asked to submit additional RCT reports not in the literature. STUDY SELECTION: Articles were considered for the meta-analysis if they were RCTs involving patients experiencing acute alcohol withdrawal and comparing a benzodiazepine available in Canada with placebo or an active control drug. Of the original 23 trials identified, 11 met these criteria, representing a total of 1286 patients. DATA EXTRACTION: Data were extracted regarding the participants, the setting, details of the intervention, the outcomes (including adverse effects) and the methodologic quality of the studies. DATA SYNTHESIS: The meta-analysis of benefit (therapeutic success within 2 days) showed that benzodiazepines were superior to placebo (common odds ratio [OR] 3.28, 95% confidence interval [CI] 1.30-8.28). Data on comparisons between benzodiazepines and other drugs, including beta-blockers, carbamazepine and clonidine, could not be pooled, but none of the alternative drugs was found to be clearly more beneficial than the benzodiazepines. The meta-analysis of harm revealed no significant difference between benzodiazepines and alternative drugs in terms of adverse events (common OR 0.67, 95% CI 0.34-1.32) or dropout rates (common OR 0.68, 95% CI 0.47-0.97). INTERPRETATION: Benzodiazepines should remain the drugs of choice for the treatment of acute alcohol withdrawal.     

Effects of beta-carboline-ethyl ester on plasma corticosterone--a parallel with antagonist-precipitated diazepam withdrawal

Diazepam has been shown to produce physical dependence based on observations of behavioral stimulation or, in our laboratory, by increases in plasma corticosterone (CS) during antagonist-precipitated withdrawal. The behavioral excitation appears similar to that observed following the administration of beta-carboline esters--agents reported to interact with benzodiazepine receptors and termed "inverse agonists." The focus of the present study is to correlate the occurrence of changes in CS with behavioral excitation previously observed by others. Further, these studies are designed to show a parallel between the manifestations of benzodiazepine withdrawal and the pharmacologic effects of beta-carboline ethyl ester. Experiments were done in conscious unrestrained male Sprague-Dawley rats, with chronic i.v. catheters, using sound-attenuated one-way vision boxes. These studies compared the hormonal and behavioral changes induced by beta-carboline ethyl ester (beta CCE) with CGS-8216-precipitated withdrawal in rats treated with diazepam for 8 days. Rats treated chronically with diazepam (5 mg/kg/day), showed a significant increase in plasma (CS) following CGS-8216. Behavioral abstinence scores were also significantly elevated. beta CCE (0.5-5.0 mg/kg) showed a significant dose-related increase in plasma CS. Behavioral scores were also increased at doses of 0.5 and 2.0 mg/kg. beta CCE-induced plasma CS increases were antagonized by CGS-8216 at doses of 1.0 and 2.0 mg/kg but not by 0.5 mg/kg. In animals chronically treated with diazepam, beta CCE evoked a more prolonged plasma CS elevation than in vehicle-treated animals suggesting a dual agonist/antagonist effect. These data suggest a parallel between CS elevations and behavioral effects during withdrawal as well as similarities between the action of beta CCE and the manifestations of this withdrawal.