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Benzodiazepine use disorder

Definition
BUD is a chronic condition characterized by the excessive and uncontrollable use of benzodiazepine drugs, often leading to significant impairment or distress.
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Pathophysiology
BUD is characterized by neurobiological changes in the brain's GABA system. Benzodiazepines enhance the effect of GABA, leading to sedative, hypnotic, anxiolytic, and muscle relaxant effects. Chronic use can lead to the development of tolerance and dependence.
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Epidemiology
The prevalence of BUD in the US is estimated at 2.2%.
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Disease course
Clinically, BUD presents with a range of symptoms. These can include cravings for benzodiazepines, continued use despite negative consequences, inability to control or reduce use, and withdrawal symptoms when use is reduced or stopped. Withdrawal symptoms can include anxiety, restlessness, insomnia, and seizures. Complications can include cognitive impairment, increased risk of falls and accidents, and life-threatening withdrawal symptoms.
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Prognosis and risk of recurrence
The prognosis of BUD can vary widely and is influenced by several factors. These include the patient's overall health, the presence of co-occurring mental health disorders, and the patient's social support system.
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Key sources
The following summarized guidelines for the evaluation and management of benzodiazepine use disorder are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the American Heart Association (AHA 2023), the United States Department of Defense (DoD/VA 2021), the U.S. Preventive Services Task Force (USPSTF 2020), the Canadian Geriatrics Society (CGS 2020), the College of Family Physicians of Canada (CFPC 2018), and the British Association for Psychopharmacology (BAP 2012).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per VA 2021 guidelines, insufficient evidence to recommend for or against screening for drug use disorders in primary care to facilitate enrollment in treatment.
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2.Medical management

Withdrawal of benzodiazepines: as per VA 2021 guidelines, taper benzodiazepines gradually in patients requiring withdrawal management for benzodiazepines.
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  • Adjunctive therapy

3.Nonpharmacologic interventions

Mutual help programs: consider promoting active involvement in group mutual help programs (using peer linkage or 12-step facilitation), taking into account patient preference and availability, in patients with drug use disorder in early recovery or following relapse.
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  • Cognitive behavior therapy

  • Mindfulness-based therapies

  • Technology-based interventions

4.Specific circumstances

Elderly patients: avoid long-term use of benzodiazepine receptor agonists (> 4 weeks) in older adults, as these agents increase the risk of cognitive impairment, delirium, falls, fractures, hospitalizations, and motor vehicle crashes. Offer alternative management strategies for insomnia, anxiety disorders, and behavioral and psychological symptoms of dementia.
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  • Patients with benzodiazepine toxicity

5.Preventative measures

Avoidance of chronic use: avoid chronic benzodiazepine use to prevent serious adverse effects, including depression, falls, motor vehicle crashes, and cognitive deficits or dementia.
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