Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

236 III. SUBSTANCES OF ABUSEbinge may take 10–40 mg or more of diazepam, for example, “just to face theday.”Other common nonmedical patterns are to use benzodiazepines (oftenalprazolam or lorazepam) concomitantly with stimulants (often cocaine ormethamphetamine) to reduce the unpleasant experiences of the stimulant use,and/or to use benzodiazepines (often triazolam [Halcion]) to treat the insomniathat accompanies stimulant abuse.Benzodiazepines are occasionally used as primary drugs of abuse, in whichcase they are typically taken orally at high doses. Addicted patients report usingdoses of 20–100 mg or more of diazepam, or the equivalent doses of otherbenzodiazepines, for example, at one time. Such high-dose oral use is oftenrepeated several times a day for long periods or on binges. Although, in ourexperience, such primary benzodiazepine abuse without simultaneous use ofother drugs is unusual, it does occur.Daily use of benzodiazepines, even when there is no dose escalation and noabuse of alcohol or other nonmedical drugs has led to controversy. Clinicalexperience has shown that even over long periods of daily use, benzodiazepinestypically do not lose their efficacy and do not produce significant problems formost patients. An example of this experience was a study of 170 adult patientstreated for a variety of sleep disorders continuously with a benzodiazepine for 6months or longer over a 12-year period. The study found sustained efficacy,with low risk of dose escalation, adverse effects, or abuse (Schenck &Mahowald, 1996).Discontinuation of Benzodiazepine UseDiscontinuation of sedatives and hypnotics, including the benzodiazepines, canbe divided into three categories: (1) long-term low-dose benzodiazepine use, (2)high-dose benzodiazepine abuse and multiple drug abuse, and (3) high-doseabuse of nonbenzodiazepine sedatives and hypnotics (especially intermediateactingbarbiturates). The first group of patients can usually be discontinued onan outpatient basis. Some of the second and even the third group can be treatedas outpatients, but most will require inpatient care. Inpatient discontinuationtoday with managed care is generally reserved for patients who fail at outpatientdiscontinuation and for those who demonstrate acutely life-threatening lossof control over their drug use. The pharmacological management of inpatientbenzodiazepine withdrawal from nontherapeutically high doses of thesemedicines is covered in standard texts dealing with inpatient detoxification(Wesson et al., 2003).With respect to withdrawal from benzodiazepines in the context of addictiontreatment, the most common problem that addiction treatment professionalsexperience is that some of their patients who take benzodiazepines also sufferfrom underlying anxiety disorders and panic attacks. When these patients