Benzo Megadoses (Case Reports)

A Case Report of Clonazepam Dependence

Utilization of Therapeutic Drug Monitoring During Withdrawal Period

 

We demonstrate a 40-year-old man with a 20-year history of psychiatric care with recently benzodiazepine dependence (daily intake of ∼60 mg of clonazepam and 10 mg of alprazolam). 

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782857/#R14

 

Megadose lorazepam dependence

 

"Mr G, a 39-year-old married male with no significant family history, with a past history of alcohol dependence, abstinent for the last 7 years, presented to the psychiatry services with complaints of excess consumption of lorazepam for the last 5 years."

 

"For the last year, he had been consuming 300 mg of lorazepam per day. He would take 20 mg every 2–3 hours and drink hot coffee immediately, smoking two cigarettes to enhance the euphoric and relaxing effects of lorazepam. Although on occasion the chemist had advised him not to continue, the chemist dispensed medication upon his daily request. After realization of its adverse social and occupational consequences, and under family pressure, he stopped abruptly. He had a generalized tonic-clonic seizure 14 hours after the last dose".

 

He was admitted to an intensive care unit and detoxification was accomplished with cross-tapering of diazepam. He recovered without any complications during the next 3 weeks. His initial withdrawal score, CIWA-B (Busto et al. 1989), was 60 and at the end of the third week there were no withdrawal symptoms apart from mild irritability.

 

http://onlinelibrary.wiley.com/doi/10.1046/j.1360-0443.2003.00559.x/full

I wonder how much Valium he was given. It's remarkable that there were no wd symptoms after three weeks other than mild irritability! Also, I wonder how long they watched him. As we all know, symptoms can carry on for long afterward.

 

 

Hi Terry, yes, it sounds incredulous, doesn't it?  That's the first question always on our minds, so often there's much more than meets the eye, isn't there? 

Crossed over to Valium? A 300mg dose of Ativan would be something like 3000mg of Valium. That's crazy.

Megadose Bromazepam and Zolpidem Dependence: Two Case Reports of Treatment with Flumazenil and Valproate

Addiction © 2012 Society for the Study of Addiction

 

Letter to the Editor

WHAT IS STOPPING US FROM USING FLUMAZENIL?

 

Some excerpts/highlights:

 

"The first study of the efficacy of FLU-SI dates back to 20 years ago[1]. One can only wonder why an innovative method which is rapid and effective has been so little used or studied over such a long period, despite the high prevalence and importance of BZD dependence. "

 

"We started using FLU-SI in 2003, never imagining that within less than 3 years it would become the principal activity of our Addiction Unit, involved in more than 50%of requests for admission for detoxification[2]. Since then it has been used to treat more than 300 patients, including many doctors, dependent on high doses of BZD [high-dose dependent (HDDs), with an average consumption 70 times higher than the defined daily doses (DDDs)]."

 

"The current situation of prevalence and negligence should not be allowed to continue.  After all, BZD addiction is the most typical form of iatrogenic dependence; or is that the real reason for the lack of interest in it?"

https://www.academia.edu/25015780/Megadose_Bromazepam_and_Zolpidem_Dependence_Two_Case_Reports_of_Treatment_with_Flumazenil_and_Valproate

Why isn't Flumazenil used in benzo cases more often? I'm confused about this, abcd.

Megadose lorazepam dependence

 

"Mr G, a 39-year-old married male with no significant family history, with a past history of alcohol dependence, abstinent for the last 7 years, presented to the psychiatry services with complaints of excess consumption of lorazepam for the last 5 years."

 

"For the last year, he had been consuming 300 mg of lorazepam per day. He would take 20 mg every 2–3 hours and drink hot coffee immediately, smoking two cigarettes to enhance the euphoric and relaxing effects of lorazepam. Although on occasion the chemist had advised him not to continue, the chemist dispensed medication upon his daily request. After realization of its adverse social and occupational consequences, and under family pressure, he stopped abruptly. He had a generalized tonic-clonic seizure 14 hours after the last dose".

 

He was admitted to an intensive care unit and detoxification was accomplished with cross-tapering of diazepam. He recovered without any complications during the next 3 weeks. His initial withdrawal score, CIWA-B (Busto et al. 1989), was 60 and at the end of the third week there were no withdrawal symptoms apart from mild irritability.

 

http://onlinelibrary.wiley.com/doi/10.1046/j.1360-0443.2003.00559.x/full

This is just nuts.  Let's see...at an equivalency of 1 mg Lorazepam = 10 mg's of Diazepam, that would mean a crossover to 3,000 mg of Diazepam per day.  Whoa, what a buzz that must have been!  And this guy lived to talk about it?

Why isn't Flumazenil used in benzo cases more often? I'm confused about this, abcd.

 

Terry, are you asking in general terms, or with regard to megadoses?  The authors are saying it probably works best with high doses but that nobody's bothering to study it, it's being ignored in both research and the clinical setting. 

 

"Even at conferences on addiction or psychiatry little is said about BZDs, and even less about FLU-SI, although the method also works very well in situations of co-addiction and in patients with personality disorders [4]."

 

I think, either way, it points to the very question the authors are honing in on.  I liked their letter a lot, they didn't mince their words.  It would open up a whole can of worms - much easier and more convenient to leave it swept under the rug.  Accountability?  Litigation?  Big Pharma $$.  All the usual suspects. 

 

"Pharmaceutical companies have no interest in highlighting these phenomena: all the old molecules are still the best-sellers."

Thanks for that, abcd!!

 

It's just terrible that so little is being done for something as debilitating as benzo wd and the aftermath. I shake my head in disbelief and anger that this has gone on so long without anything of substance from the medical community. And of course Big Pharma doesn't care. It's all money.

Terry,

 

Because it just doesn't work !

 

That's the short answer.

 

I've read the case studies. Typically, it's about addicts, of whom most are poly drug users, or who take multiple benzodiazepines. Usually, they are on the drug for some time, then the supply runs out.

 

Up to a point, intermittent use.

 

Flumazenil as an antidote to 'addiction' like naltrexone ... right ...

 

The people who got off with flumazenil usually would have been able to stop without restorting to that drug.

 

And Italy ? They get addicts off their benzo with flumazenil, then put them on a maintenance dose of clonazepam (like methadone!), then they do a slow taper.

 

Addiction medicine ... it's all about drug cravings and addiction behavior.

Thank you, Liberty! I just wish there was something for the regular people who take these drugs as prescribed by the doctor and don't know what they're getting into until it's way too late.

Another case report abstract.  (Turkish):

 

Mega-dose lorazepam addiction and withdrawal symptoms

http://www.scopemed.org/?mno=2994

 

"The patient has used lorazepam approximately for six months as he gradually increased dose up to 220 mg/day. His efforts to drop the drug was unsuccessful and subsequently he applied to emergency service because of disturbing withdrawal symptoms. He showed initial withdrawal symptoms of severe restlessness, hyperpnea, sweating, headache, anxiety, and irritability which were succesfully controlled in the second day. Seizure or any other life threatening adverse effect were not observed during treatment."

Megadose lorazepam dependence

 

"Mr G, a 39-year-old married male with no significant family history, with a past history of alcohol dependence, abstinent for the last 7 years, presented to the psychiatry services with complaints of excess consumption of lorazepam for the last 5 years."

 

"For the last year, he had been consuming 300 mg of lorazepam per day. He would take 20 mg every 2–3 hours and drink hot coffee immediately, smoking two cigarettes to enhance the euphoric and relaxing effects of lorazepam. Although on occasion the chemist had advised him not to continue, the chemist dispensed medication upon his daily request. After realization of its adverse social and occupational consequences, and under family pressure, he stopped abruptly. He had a generalized tonic-clonic seizure 14 hours after the last dose".

 

He was admitted to an intensive care unit and detoxification was accomplished with cross-tapering of diazepam. He recovered without any complications during the next 3 weeks. His initial withdrawal score, CIWA-B (Busto et al. 1989), was 60 and at the end of the third week there were no withdrawal symptoms apart from mild irritability.

 

http://onlinelibrary.wiley.com/doi/10.1046/j.1360-0443.2003.00559.x/full

 

I wonder if this guy still had the benzo's in his system at 3 weeks and so didn't have withdrawal?  It may have set in later when no hospital or clinic was monitoring him. 

So many unanswered questions, Becks, wish we could read the full details.