eMedicine Specialties > Psychiatry > Addiction
Sedative, Hypnotic, Anxiolytic Use Disorders: Follow-up
Updated: Jan 29, 2010
Follow-up
Further Inpatient Care
- Definitive treatment is a lengthy process, taking months or years. A return to drug use should not be considered a treatment failure, but rather a time to intensify treatment.
- After successful medical treatment of sedative/hypnotic withdrawal/intoxication, the patient may be transferred to the psychiatric unit, if he or she meets criteria for inpatient psychiatric treatment.
- Effective treatment requires a thorough evaluation of the patient's psychiatric problems and development of long-term treatment plans.
- Urine drug screens should be performed periodically to monitor illicit drug use.
- Family counseling should be completed to focus on the family's role in helping the patient develop a successful long-term treatment plan.6
- Referrals for long-term outpatient or residential treatment for sedative-hypnotic addiction should be made early in the treatment process to prevent relapse.
Further Outpatient Care
- Patients with sedative-hypnotic use disorders are frequently treated in the outpatient setting, as most are stable and require minimal monitoring. Inpatient hospitalization is reserved for the most severely impaired patients requiring complicated withdrawals, patients who have been unsuccessful as outpatients, or patients with medical and/or psychiatric comorbidity.
- A recent study confirms the efficacy of cognitive behavior therapy (CBT) in both hypnotic-abusing and nonabusing patients with chronic insomnia. The results of this study suggest that tapered withdrawal of third-generation hypnotics during CBT therapy for chronic insomnia could be associated with improvement rather than worsening of sleep continuity.9
- Some may benefit from enrollment in support groups, such as Pills Anonymous, and attending drug-free outpatient counseling.
Prognosis
- Some individuals respond to treatment and stay in remission, while others experience periods of relapse, in which they begin SHA use/abuse after a period of remission, and again meet the criteria for substance dependence. Some individuals are never able to abstain from use and do not experience any periods of remission.
- Only a handful of studies have looked into long-term success of benzodiazepine discontinuation programs. Most studies indicate a high relapse state; however, outcome is more favorable in those individuals who manage to complete a discontinuation program.10 A 4- to 6-year post discharge follow-up study of patients primarily admitted for primary sedative-hypnotic dependence showed that 84% of the patients had resumed using sedative-hypnotics, 52% were abusing drugs at follow-up, and 42% had been readmitted for drug abuse.11
- Outcome is better in individuals with good social support, absence of psychiatric co-morbidity or remission of preexisting psychiatric symptoms, and absence of dependence on other drugs.
Patient Education
- Excellent patient education resources are available at eMedicine's Substance Abuse Center and Mental Health and Behavior Center. Also, see eMedicine's patient education articles Benzodiazepine Abuse, Barbiturate Abuse, and Substance Abuse.
- Family education: Sedative-hypnotic abuse/dependence can affect the entire family, it is necessary to inform them of the pertinent issues. In certain cases, family members can be enablers.
- Physician education: It is important for the prescribing physician to know about the harmful effects and complications related to sedative-hypnotic use. Often, the patient will seek supply of these drugs from many practitioners. Physicians may also benefit from feedback on their prescribing practices.
Miscellaneous
Medicolegal Pitfalls
- While no foolproof techniques exist to prevent malpractice, there are ways to reduce exposure to litigation procedures. An estimated 7% of all malpractice claims against psychiatrists result from medication errors and drug-related reactions. The most common pitfalls are as follows:
- Failure to prescribe the appropriate dosages of medication for patient's requirements
Failure to monitor and treat medication adverse effects. - Negligent prescription practices
- Prescription of addictive drugs to vulnerable patients
- Failure to refer a patient for consultation or treatment by a specialist
- Failure to communicate with other medical professionals who are involved with the care of the patient
- Failure to prescribe the appropriate dosages of medication for patient's requirements
- All physicians are judged by certain standards of care and guidelines. Their actions are compared to the standards expected of an average physician in their community under the circumstances.
- When treating a patient with any medication, meeting certain expectations can minimize unnecessary litigation.
- Succinctly record the patient's history, in particular a history of alcohol use and any history of other substance-related disorders and results of physical examination. If possible, support this information with laboratory tests.
- Clearly instruct the patient about the use and potential side effects of medication. Obtain an informed consent from the patient, especially if the drug has unpleasant effects.
- Maintain relevant documentation, especially for changes in medication or instructions. Record the precise number of pills given potentially abused substances, such as sedative-hypnotics or anxiolytics.
- If the physician is uncomfortable prescribing a particular medication or treating a condition requiring that medication, it is advisable to consult a colleague or research the drug and situation through recently updated reference textbooks or other media.
- After starting the patient on any sedative, it is advisable to monitor his or her reaction to the medication.
- Remain aware of current guidelines, drugs recently approved by the Food and Drug Administration, current or recent literature (eg, alternative treatment approaches that do not require these medications), and relevant updates by pharmaceutical companies (eg, reports of surveillance of side effects of these medications). Ignorance is not an acceptable excuse in legal action.
- Be cautious about approving drugs over the telephone without seeing the patient, and always review the pertinent records.
- Because hypnotics, especially barbiturates, can mimic signs of brain death (eg, no doll's eyes movement or fixed, dilated pupils), be cautious when labeling an overdose patient with brain death.
Special Concerns
- Clinical features of sedative-hypnotic overdose or withdrawal syndromes may mimic other overdose and withdrawal syndromes. Distinguishing sedative-hypnotic withdrawal symptoms from underlying anxiety symptoms may be difficult; prognosis for sedative-hypnotic abuse is guarded.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Joji Suzuki, MD, and Olakunle PA Akinsoto, MD, to the development and writing of this article.
More on Sedative, Hypnotic, Anxiolytic Use Disorders |
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| Differential Diagnoses & Workup: Sedative, Hypnotic, Anxiolytic Use Disorders |
| Treatment & Medication: Sedative, Hypnotic, Anxiolytic Use Disorders |
 Follow-up: Sedative, Hypnotic, Anxiolytic Use Disorders |
| References |
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Further Reading
Keywords
sedatives, hypnotics, anxiolytics, benzodiazepine abuse, barbiturate abuse, drug abuse, addiction
