eMedicine Specialties > Psychiatry > Addiction

Sedative, Hypnotic, Anxiolytic Use Disorders: Follow-up

Author: Joji Suzuki, MD, Fellow in Addiction Psychiatry, Department of Psychiatry, Boston University School of Medicine
Coauthor(s): Christopher L Sola, DO, Clinical Assistant Professor, University of Vermont, College of Medicine; Director of Consultation-Liaison Psychiatry, Department of Psychiatry, Maine Medical Center; Olakunle PA Akinsoto, MD, Consulting Staff, Family Health Center, Jacksonville Medical Center
Contributor Information and Disclosures

Updated: Jun 8, 2006

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.
  • Current thinking is that patients require a level of treatment based on severity of illness and their readiness to change. Precontemplative patients will have different motivators than those who are actively engaged in maintaining abstinence.
  • Acute 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.
  • Always follow inpatient treatment with outpatient treatment to facilitate the patient's return to the outpatient environment. Intensive outpatient services or even partial hospitalization may be appropriate.

Further Outpatient Care

• Patients with anxiolytic use disorders are frequently treated in the outpatient setting, as most are stable and require minimal monitoring. Some may benefit from enrollment in support groups, such as Pills Anonymous, and attending drug-free outpatient counseling.

Transfer

• After detoxification, the patient may be transferred to the psychiatric unit, if he or she meets criteria for inpatient psychiatric treatment.

Prognosis

• The prognosis for patients with sedative abuse is guarded. In an article by Allgulander, Borg, and Vikander (American Journal of Psychiatry, December 1984), 84% of primary sedative-hypnotic abusing patients had resumed use of sedative-hypnotics 4-6 years after hospital discharge; physical signs of alcoholism had developed in 22%, and 8% had committed suicide. Forty-two percent had been rehospitalized for sedative-hypnotic abuse.

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: Since the abuse and the symptoms affect the entire family, it is necessary to inform them of the issues. In certain cases, they can be enablers.
• Physician education: It is important that the doctor who prescribed the drug know of the effects. Often the patient will seek out many practitioners for the supply. Physicians benefit from feedback on the prescribing practices.

Miscellaneous

Medicolegal Pitfalls

• While no foolproof techniques to prevent malpractice exist, there are ways to reduce exposure to litigation. An estimated 7% of all malpractice claims against psychiatrists result from medication errors and drug reactions. The most common pitfalls are as follows:
  • Failure to evaluate properly
  • Failure to monitor and supervise
  • Negligent prescription practices
  • Failure to treat adverse effects that have been, or should have been, recognized
  • Failure to prescribe the appropriate level of medication for patient's requirements
  • 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
• 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 which 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 withdrawal symptoms and side effects from presumed underlying anxiety symptoms may be difficult; thus, prognosis for sedative abuse is guarded.

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