Managing Diazepam Abuse in an AIDS-Related Psychiatric Clinic With a High Percentage of Substance Abusers

Managing Diazepam Abuse in an AIDS-Related Psychiatric Clinic With a High Percentage of Substance Abusers JEFFREY

F.

B.

FREEDMAN, M.D., MARY ALICE

O'Dowo,

M.D.

PATRICK MCKEGNEY, M.D., ISABEL J. KAPLAN, PSY.D.

GENYA BERNSTEIN, PSY.D., DAVID J. BIDERMAN, B.A. MARIA

F.

GOMEZ, M.D.

Controversy over using benzodiazepines in a human immunodeficiency virus (HIV)positive population to relieve sleep and anxiety has not been addressed in the literature. Serious problems with diazepam abuse emerged in a psychiatric outpatient clinic for a predominately HIV-positive and illicit drug-using population. which led to a review of patient characteristics and prescribing policies and to a systematic problemsolving effort. The patients originally prescribed diazepam were significantly more likely to be on methadone and have histories of intravenous drug use compared with the patients not on benzodiazepines. Thus, the patients asking for diazepam are likely to have histories of substance abuse and have a high potential for abusing the medication. The authors found that diazepam can be discontinued without causing a significantly greater drop-out rate in that group. (Psychosomatics 1996; 37:43-47)

A

lthough the safety and efficacy of benzodiazepines in relieving anxiety are well accepted,l.2 their potential for dependency and abuse remains a subject of debate. Although some authors feel that prolonged use of benzodiazepines may result in dependence in some patients,3.4 most minimize their abuse potential by patients who are not substance abusers. S-7 A few suggest that benzodiazepines can be prescribed rationally in substance abusers and argue that their dependence on benzodiazepines is not drug abuse. 8 .9 This practice may be akin to methadone maintenance. However, the illicit street market for these agents and their very common use, alone or in combination with other drugs, suggest that benzodiazepines are drugs of abuse, at least in some patients. 10- 12 Controversy over use of these agents in an VOLUME 37. NUMBER 1 • JANUARY - FEBRUARY 1996

HIV-positive (HIV+) population has not been addressed in the literature. Patients who are HIV+ or have the acquired immunodeficiency syndrome (AIDS) have been noted to have a high incidence of anxiety disorders or adjustment disorders with anxious mood,13.14 and benzodiazepines have been recommended as appropriate agents to treat that anxiety. IS A low incidence of benzodiazepine abuse in the HIV+ Received December 3, 1993; revised February 18, 1994; accepted April 7. 1994. From the Depanment of Psychiatry. Consultation-Liaison Service of the Montefiore Medical Center/Alben Einstein College of Medicine. Address reprint requests to Dr. Freedman. SI. Vincent's Hospital and Medical Center. Depanment of Psychiatry, 203 W. 12 Street, New York. NY 10011. Copyright © 1996 The Academy of Psychosomatic Medicine.

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Managing Diazepam Abuse

population in general has been described. 16 Regarding specific drugs, some authors have suggested a greater abuse potential among those benzodiazepines that have a more rapid onset of effect. Diazepam, alprazolam, and lorazepam may have a greater potential for abuse, whereas oxazepam, halazepam, and chlordiazepoxide are considered relatively low in this regard. I 1.17-19 Serious problems with benzodiazepine use and abuse, which emerged in a psychiatric outpatient clinic for a predominately HIV+ and illicit drug-using population, led to a systematic attempt to address these issues. CLINIC DESCRIPTION The Psychiatric AIDS Connected Ambulatory Program (PACAP) at Montefiore Medical Center in the Bronx County of New York City is a psychiatric outpatient clinic treating patients with HIV -related psychiatric distress. The clinic function and patient population have been previously described. IJ At intake, demographic data and diagnosis are recorded for all patients. Intravenous drug use (IVDU) is the HIV-transmission risk factor most frequently cited by the patients (49%), and 44% of the PACAP patients receive a substance abuse diagnosis at intake. Anxiety disorders and adjustment disorders with anxious mood or mixed features of anxiety and depression are together the most frequent psychiatric diagnoses, made in 70% of all patients. In addition to other measures, all patients complete the General Health Questionnaire (GHQ), a 28-item survey that has been used with other medically ill populations. 20 The GHQ provides a total score of emotional distress and four subscale scores (i.e., somatic, anxiety, social dysfunction, and depression). THE CLINICAL PROBLEM AND INTERVENTION Over the first few years of PACAP's operation, which began in 1987, it became increasingly clear that a number of its patients were selling or otherwise abusing their prescribed benzodi44

azepine medication. This information came from family members, other health care providers, and even the police. Refill requests for lost medication were frequent, despite a clinic policy prohibiting such replacements. Some patients came to the clinic only when scheduled for a prescription refill and were resistant to participating in group therapy or other therapeutic modalities. Threats to doctors of harm and legal suits were made when benzodiazepine prescriptions were denied. A few patients were actually caught selling their medications or altering prescriptions. After several such flagrant incidents of abuse, benzodiazepine prescribing practices at PACAP were reviewed. Because most of the problems seem to involve diazepam, a policy decision was made to discontinue all diazepam prescribing. A I-month warning period, starting August I, 1991, during which the patients had the opportunity to discuss their concerns about the change in medication with their therapists, would herald a ban on all diazepam starting September I, 1991. Diazepam would be replaced by equivalent doses of other benzodiazepines. The patients being medicated by one psychiatrist (JBF) were switched to chlordiazepoxide, whereas those seen by the other psychiatrist (MAO'D) were switched to one of several agents: oxazepam, lorazepam, alprazolam, or chlordiazepoxide. Choice of switched benzodiazepine was related to the preference of each psychiatrist. It was also decided that gradually tapering most patients from any benzodiazepine would be a long-term clinic goal, but it was not implemented during the 6-month study period. Demographic data and GHQ scores at baseline of the patients on diazepam were compared with those not on any benzodiazepines. Only patients who came for appointments at PACAP from August I, 1991 to September I, 1991 were studied. BASELINE COMPARISON OF TWO GROUPS As shown in Table 1,44 patients were receiving diazepam on August 1,1991, and 40 were not on PSYCHOSOMATICS

Freedman et al.

TABLE 1.

Psychiatric AIDS Connected Ambula· tory Program patients who attended clinic (811191-8131/91) On No Diazepam Benzodiazepines (n = 44)

(n=40)

Male,n(%) Average age. years Race, % White African-American Hispanic Asian History of IVDU, n (%)

23 (52) 38

20(50) 37

43 7 48 2 36(83)

38 23 40 0 15 (41)"

On methadone, n (%)

32 (73)

5 (l3)b

7 (16) 19 (43) 14 (32) 2 (5) 2 (5) 13 (30)

4 (10) 17 (43) 7 (18) 2 (5) 10 (25) 5 (13)<

39 (89) 46.5 ± 18.7

34 (85) 41.9 ± 17.9

significantly different between the two groups. These findings showed a strong association between a past history of drug abuse and presently being prescribed diazepam in our clinic. There was also a strong association between present methadone use and diazepam prescriptions in our clinic. OUTCOME ASSESSMENT

HIV diagnosis, n (%) AIDS HIV+ asymptomatic Other HIV (ARC) HIV-negative Unknown Axis II diagnosis, n (%) At intake, n (%): Mean ± so total GHQscore

=

Note: IVDU intravenous drug use; HIV = human immunodeficiency virus; AIDS = acquired immune deficiency syndrome; ARC = AIDS-related complex; GHQ = General Health Questionnaire. "x2 = 15.45, df = I, P = 8.48 x 10-5, diazepam> no benzodiazepine. bX2 = 28.44, df = I, P = < I0-8 , diazepam> no benzodiazepine. no benzodiazepine.

=

any benzodiazepine. When demographic characteristics of these two groups of patients were compared, some statistically significant differences emerged. The patients on diazepam were much more likely to have a history of IVDU than the no-benzodiazepine group (P < 0.(00). The patients on diazepam were much more likely to be on methadone than the no-benzodiazepine patients (P < 0.(00). There was not a statistically significant difference between the two groups in having an Axis II diagnosis. AIDS-related staging and diagnoses were not VOLUME 37. NUMBER I. JANUARY - FEBRUARY 1996

Because we hypothesized that discontinuation of diazepam might cause patients to discontinue treatment at PACAP, 6-month follow-up data were examined to compare drop-out rates for those patients on diazepam before our policy change with the drop-out rates for those patients who had not been on benzodiazepines (Table 2). In addition, we compared certain baseline demographic characteristics and GHQ scores of those patients who dropped out with those who continued in treatment. Shortly after the policy change, 3 of the 44 patients originally on diazepam appeared to deteriorate when their medication was changed. The patients were restarted on diazepam, and their condition stabilized. These 3 patients were dropped from the follow-up study, leaving 41 patients in the group whose diazepam was discontinued on September I, 1991. RESULTS Of those initially on diazepam, 34% had dropped out 6 months later compared with 28% of those not on benzodiazepines, a slight difference not close to being statistically significant (P = 0.68). Although the patients originally on diazepam were more likely to be on methadone and have histories of IVDU, those diazepam patients who dropped out were only somewhat more likely to be in these groups than the diazepam patients who stayed (Table 2). Of those patients initially on diazepam who dropped out, 93% were on methadone, compared with 70% of the diazepam patients who continued. Similarly, of the patients initially on diazepam who dropped out, 93% had histories of IVDU, com45

Managing Diazepam Abuse

TABLE 2.

Six-month follow-up data On Diazepam 8/1/91 8 (N 41 ) Drop Out Continue (n= 27) (n 14)

=

Six·Month Follow·Up Male. % Average age. years History of (VDU. % On methadone. % HIV diagnosis. No. (%) AIDS HIV+ asymptomatic Other HIV (ARC) HIV-negative Unknown Axis II Diagnosis. % At intake. n (%): Mean ± SO total GHQ score

=

=

No Benzodiazepines 8/1/91 (N= 40)

DropOut (n

=11)

Continue (n 29)

=

71 37 93 93

41 38 77 70

45 40 36 18

52 36 39 10

1(7) 8 (57) 4(29) 0(0) 1(7)

5 (19) 10(37) 9 (33) 2(7) 1(4)

1(9) 4 (36) 2 (18) 0(0) 4(36)

3 (10) 14 (48) 4 (14) 2 (7) 6 (21)

29 13 (93) 50.9 ± 16.7

30 23 (85) 42.8 ± 18.4

9 9 (82) 42.4±17.3

14 25 (86) 41.6± 18.1

=

=

Note: IVDU intravenous drug use; HIV human immunodeficiency virus; AIDS acquired immune deficiency syndrome: ARC =AIDS-related complex; GHQ =General Health Questionnaire. "Three additional patients omitted from outcome study due to being put back on diazepam.

pared with 77% of the patients initially on diazepam who continued. The patients initially on diazepam who dropped out had slightly higher (more distressed) GHQ scores (mean total score = 50.9) than those on diazepam who stayed in treatment (mean total score = 42.8) and those not on benzodiazepines who dropped out (mean total score =42.4), but these differences were not significant (I = 1.345, P =0.186; 1 = 1.193. P =0.245). No differences in GHQ scores were seen between those dropping out and staying in treatment in the no-benzodiazepine group. There were no significant differences in AIDSrelated staging and diagnoses between the patients who dropped out and continued with treatment. DISCUSSION The patients in our study who were originally on diazepam were significantly more likely to be on methadone and have histories of IVDU compared with patients not on benzodiazepines. The choice of benzodiazepine prescribed to any given patient was partially related to his or her request or statements that a particular medica46

tion helped in the past. Our findings suggest that we may have to be more wary of patients asking for diazepam. because they are more likely to have histories of substance abuse and may be abusing the medication. The drop-out rate did not seem related to the change in diazepam policy. because those on diazepam had only slightly higher drop-out rates than those not on benzodiazepines. This may be because all patients were offered an alternative benzodiazepine that was cross tolerant. The patients switched to chlordiazepoxide seemed to be somewhat more likely to drop out than those switched to lorazepam. perhaps due to the latter being similar to diazepam in having a more rapid onset of effect and higher abuse potential. It is not surprising that patients on methadone sought out benzodiazepine prescriptions in our clinic. The American Psychiatric Association Task Force Report on Benzodiazepine Dependence. Toxicity. and Abuse notes that there have been numerous reports attesting to the popularity of benzodiazepines. especially diazepam. among opiate abusers. Studies suggest that the benzodiazepines augment the euphoric effect of methadone as well as treat anxiety.21 PSYCHOSOMATICS

Freedman et al.

Our study illustrates some of the treatment dilemmas found in working with a triply diagnosed population with HIV infection, substance abuse, and other mental illness. The practice of prescribing benzodiazepines in this clinic was controversial for us, just as it is in the general medical community as described earlier. The opinion that benzodiazepines may become a substance of abuse in those with addiction histories might suggest that benzodiazepines should never have been prescribed to this group. Although it is tempting to dismiss their behavior as drug-seeking and manipulative, it is also possible to consider that these persons were unable to benefit from more interactive therapy.

They sought medication to alleviate their distress, and left treatment when getting their desired medication was no longer an option. Good treatment for those patients initially coming just for diazepam needs to be more comprehensive. A program that can treat the substance abuse problem as well as the severe biopsychosocial problems, reflected in their high GHQ scores, would be ideal. It is those patients who have already discontinued other types of drug abuse who have been most able to benefit from the treatment in our clinic. The HIV + person who is an active polysubstance abuser may remain beyond the treatment capabilities of an outpatient program.

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concerns justified? Postgrad Med 1990; 87: 187-203 13. O'Oowd MA, Natali C. Orr 0, et al: Characteristics of patients anending an HIV-related psychiatric clinic. Hosp Community Psychiatry 1991; 42:6 I5--{) 19 14. Fullilove MF: Anxiety and stigmatizing aspects of HIV infection. J Clin Psychiatry 1989; 50(suppl):5-8 15. Fernandez F: Anxiety and the neuropsychiatry of AIDS. J Clin Psychiatry 1989; 50(suppl):9-14 16. Fernandez F. Levy JK: Psychiatric diagnosis and pharmacology of patients with HIV infection, in American Psychiatric Press Review of Psychiatry. Vol 9. edited by Tasman A. Goldfinger SM, Kaufmann CA. Washington, DC. American Psychiatric Press. 1990 17. Griffiths RR, McLeod DR, Bigelow GE. et al: Comparison of diazepam and oxazepam: preference. liking and extent of abuse. J Pharmacol Exp Ther 1984; 229:501508 18. Ciraulo OA. Sarid·Segal 0: Benzodiazepines: abuse liability. in Benzodiazepines in Clinical Practice: Risks and Benefits, edited by Roy-Byrne PP. Cowley OS. Washington, DC. American Psychiatric Press, 1991 19. De Wit M. Griffiths RR: Testing the abuse liability of anxiolytic and hypnotic drugs in humans. Drug and Alcohol Depend 1991; 28:83-111 20. Goldberg DO. Hillier VF: A scaled version of the 28 questions General Health Questionnaire in hospitalized gastroenterology patients. Psychosomatics 1989; 30:290-295 21. American Psychiatric Association: Benzodiazepine Dependence, Toxicity. and Abuse. A Task Force Repon of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1990

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