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Amnestic and anxiolytic effects of alprazolam in oral surgery patients
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DISCUSSION
27. Green BG, Shaffer GS, Gilmore MM: Derivation and evaluation of a semantic scale of oral sensation magnitude with apparent ratio properties. Chemical Senses l&683, 1993 28. Curran HV, Bond A, O’Sullivan G, et al: Memory functions, alprazolam and exposure therapy: A controlled longitudinal study of agoraphobia with panic disorder. Psycho1 Med 24:969, 1994 29. Kirk T, Roache JD, Griffiths RR: Dose-response evaluation of the amnestic effects of triazolam and pentobarbital in normal subjects. J Clin Psychopharmacol 10:160, 1990 30. Subhan Z, Hindmarch I: Effects of zopiclone and benzodiazepine hypnotics on search in short-term memory. Neuropsychobiology 12:244, 1984 3 1. Squire LR: Memory and Brain. New York, NY, Oxford University Press, 1987 32. Greenblatt DJ, Harmatz JS, Englehardt N, et al: Pharmacokinetic
J Oral Maxillofac 55:1070, 1997
33. 34.
35. 36.
determinants of differences among three benzodiazepine hypnotics: Flurazepam, temazepam, and triazolam. Arch Gen Psychiatry 461326, 1989 Milgrom P, Quarnstrom FC, Longley A, et al: The efficacy and memory effects of oral triazolam premeditation in highly anxious dental patients. Anesth Prog 41:70, 1994 Kaufman E, Hargreaves KM, Dionne RA: Comparison of oral triazolam and nitrous oxide with placebo and intravenous diazepam for outpatient premeditation. Oral Surg Oral Med Oral Path01 75:156, 1993 Bertolino A, Mastucci E, Porro V, et al: Etizolam in the treatment of generalized anxiety disorder: A controlled clinical trial. J Intern Med Res 17:455, 1989 Milgrom P, Weinstein P, Fiset L, et al: The anxiolytic effects of intravenous sedation using midazolam alone or in multiple drug techniques. J Oral Maxillofac Surg 52:219, 1994
Surg
Discussion Amnestic and Anxiolytic Effects of Alprazolam in Oral Surgery Patients James C. Phero, DMD Universityof Cincinnati,Cincinnati,Ohio The evaluation of oral alprazolam doses for reduction of anxiety without providing amnesia by Coldwell et al provides the practitioner with insight into the current tests available to researchers for studying anxiety, pain, and memory impairment. Their work shows the potential of these tools to enhance clinical care. Consideration should be given to evaluating patient anxiety management and amnesia with the drug combinations currently given for conscious sedation and general anesthesia. This presents an opportunity for practitioners to obtain better insight into their choice of agents. Additionally, research combining the authors’ techniques of amnesia and anxiolysis analysis preoperatively and postoperatively in combination with electroencephalogram (EEG) analysis has the potential to provide more extensive insight into pharmacologic patient sedation and anesthesia choices. The Aspect bispectral EEG A-1050 BIS monitor (Aspect Medical Systems, Natick, MA) has the capability to analyze hypnotic depth of patients preoperatively, intraoperatively, and postoperatively. This instrument may assist with optimizing satisfactory patient anesthetic management while enhancing recovery. Meta analysis to determine cost versus benefit can produce further validation and support of agents and techniques. Newer agents such as propofol and remifentanil offer the opportunity for exceptional patient control while significantly shortening the recovery period. The evolving practice of using infusions of these boutique drugs has shown that the transition from sedation/anesthesia to a “street fit” re-
covery can be accomplished in approximately 10 minutes. Unfortunately, there has been little work performed in evaluating the cost versus benefit ratio of using more expensive drugs and techniques capable of producing rapid recovery periods in the dental outpatient setting. Many practitioners currently believe that the typical patient facing oral and maxillofacial surgery benefits from acute administration of a benzodiazepine to provide sedation, anxiolysis, muscle relaxation, and amnesia. The authors’ findings using alprazolam support the clinical impression that a benzodiazepine dose that produces anxiolysis will also produce memory impairment. However, amnesia may not be optimal with adolescents and adults who wish to return to a functional status with no short-term memory loss surrounding the procedure day. This situation was demonstrated by the past popularity of triazolam as an antidote for jet lag. Unfortunately, travelers using single doses of triazolam frequently found memory gaps of their travels. Additionally, the authors point out that controlling anxiety and sedating a dental phobic without memory impairment is potentially beneficial in the long-term management of the patient’s phobia. In this instance, practitioners should also consider the support of a behavioral medicine specialist when managing a dental phobic patient. The question remains, if the pharmaceutical industry does provide the practitioner with agents that produce anxiolysis and sedation without memory impairment, will we want to use them? With local anesthetics, the backbone of pain management in dentistry, not always providing complete regional anesthesia, there can be benefit to assuring that the patient’s memory of the surgical procedure has been blunted. It would appear that diazepam, midazolam, lorazepam, triazolam, alprazolam and the other benzodiazepines continue to fill a niche in this arena.
DISCUSSION
27. Green BG, Shaffer GS, Gilmore MM: Derivation and evaluation of a semantic scale of oral sensation magnitude with apparent ratio properties. Chemical Senses l&683, 1993 28. Curran HV, Bond A, O’Sullivan G, et al: Memory functions, alprazolam and exposure therapy: A controlled longitudinal study of agoraphobia with panic disorder. Psycho1 Med 24:969, 1994 29. Kirk T, Roache JD, Griffiths RR: Dose-response evaluation of the amnestic effects of triazolam and pentobarbital in normal subjects. J Clin Psychopharmacol 10:160, 1990 30. Subhan Z, Hindmarch I: Effects of zopiclone and benzodiazepine hypnotics on search in short-term memory. Neuropsychobiology 12:244, 1984 3 1. Squire LR: Memory and Brain. New York, NY, Oxford University Press, 1987 32. Greenblatt DJ, Harmatz JS, Englehardt N, et al: Pharmacokinetic
J Oral Maxillofac 55:1070, 1997
33. 34.
35. 36.
determinants of differences among three benzodiazepine hypnotics: Flurazepam, temazepam, and triazolam. Arch Gen Psychiatry 461326, 1989 Milgrom P, Quarnstrom FC, Longley A, et al: The efficacy and memory effects of oral triazolam premeditation in highly anxious dental patients. Anesth Prog 41:70, 1994 Kaufman E, Hargreaves KM, Dionne RA: Comparison of oral triazolam and nitrous oxide with placebo and intravenous diazepam for outpatient premeditation. Oral Surg Oral Med Oral Path01 75:156, 1993 Bertolino A, Mastucci E, Porro V, et al: Etizolam in the treatment of generalized anxiety disorder: A controlled clinical trial. J Intern Med Res 17:455, 1989 Milgrom P, Weinstein P, Fiset L, et al: The anxiolytic effects of intravenous sedation using midazolam alone or in multiple drug techniques. J Oral Maxillofac Surg 52:219, 1994
Surg
Discussion Amnestic and Anxiolytic Effects of Alprazolam in Oral Surgery Patients James C. Phero, DMD Universityof Cincinnati,Cincinnati,Ohio The evaluation of oral alprazolam doses for reduction of anxiety without providing amnesia by Coldwell et al provides the practitioner with insight into the current tests available to researchers for studying anxiety, pain, and memory impairment. Their work shows the potential of these tools to enhance clinical care. Consideration should be given to evaluating patient anxiety management and amnesia with the drug combinations currently given for conscious sedation and general anesthesia. This presents an opportunity for practitioners to obtain better insight into their choice of agents. Additionally, research combining the authors’ techniques of amnesia and anxiolysis analysis preoperatively and postoperatively in combination with electroencephalogram (EEG) analysis has the potential to provide more extensive insight into pharmacologic patient sedation and anesthesia choices. The Aspect bispectral EEG A-1050 BIS monitor (Aspect Medical Systems, Natick, MA) has the capability to analyze hypnotic depth of patients preoperatively, intraoperatively, and postoperatively. This instrument may assist with optimizing satisfactory patient anesthetic management while enhancing recovery. Meta analysis to determine cost versus benefit can produce further validation and support of agents and techniques. Newer agents such as propofol and remifentanil offer the opportunity for exceptional patient control while significantly shortening the recovery period. The evolving practice of using infusions of these boutique drugs has shown that the transition from sedation/anesthesia to a “street fit” re-
covery can be accomplished in approximately 10 minutes. Unfortunately, there has been little work performed in evaluating the cost versus benefit ratio of using more expensive drugs and techniques capable of producing rapid recovery periods in the dental outpatient setting. Many practitioners currently believe that the typical patient facing oral and maxillofacial surgery benefits from acute administration of a benzodiazepine to provide sedation, anxiolysis, muscle relaxation, and amnesia. The authors’ findings using alprazolam support the clinical impression that a benzodiazepine dose that produces anxiolysis will also produce memory impairment. However, amnesia may not be optimal with adolescents and adults who wish to return to a functional status with no short-term memory loss surrounding the procedure day. This situation was demonstrated by the past popularity of triazolam as an antidote for jet lag. Unfortunately, travelers using single doses of triazolam frequently found memory gaps of their travels. Additionally, the authors point out that controlling anxiety and sedating a dental phobic without memory impairment is potentially beneficial in the long-term management of the patient’s phobia. In this instance, practitioners should also consider the support of a behavioral medicine specialist when managing a dental phobic patient. The question remains, if the pharmaceutical industry does provide the practitioner with agents that produce anxiolysis and sedation without memory impairment, will we want to use them? With local anesthetics, the backbone of pain management in dentistry, not always providing complete regional anesthesia, there can be benefit to assuring that the patient’s memory of the surgical procedure has been blunted. It would appear that diazepam, midazolam, lorazepam, triazolam, alprazolam and the other benzodiazepines continue to fill a niche in this arena.