International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Misuse and Abuse of Diazepam: An Increasingly Common Medical Problem George E. Woody, Charles P. O'brien & Robert Greenstein To cite this article: George E. Woody, Charles P. O'brien & Robert Greenstein (1975) Misuse and Abuse of Diazepam: An Increasingly Common Medical Problem, International Journal of the Addictions, 10:5, 843-848, DOI: 10.3109/10826087509027342 To link to this article: http://dx.doi.org/10.3109/10826087509027342
Published online: 03 Jul 2009.
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Citing articles: 16 View citing articles
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Date: 19 April 2016, At: 04:58
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The International Journal of the Addictions, 10(5), 843-848, 1975
Misuse and Abuse of Diazepam : An Increasingly Common Medical Problem George E. Woody, * M.D. Charles P. O’Brien, M.D., Ph.D.
Robert Greenstein, M.D. Drug Dependence Treatment Center Philadelphia VA Hospital and University of Pennsylvania Philadelphia, Pennsylvania
Recent legislation has been proposed to restrict chlordiazepoxide and diazepam by moving them to Schedule IV (Psychiatric News, September 19, 1973). Implicit in this legislation is that these drugs are subject to abuse or misuse. A few authors have documented instances of abuse and physical addiction to chlordiazepoxide and diazepam (Smith and Wesson, 1970; Clare, 1971; Edgley, 1970; Finer, 1970). Kaufman et al. (1972) have shown that these drugs can be overprescribed in a general medical practice. Other authors have raised the possibility of more widespread
* To whom requests for reprints should be addressed a t VA Hospital, 39th and Woodland Avenues, Philadelphia, Pennsylvania 19104. 843 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
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WOODY, O’BRIEN, AND GREENSTEIN
abuse or misuse of these and other minor tranquilizers (Ditzion, 1971; Blackwell, 1973). During the past 18 months, we at the Philadelphia VA Drug Dependence Treatment Center have witnessed an increasing amount of diazepam misuse and abuse among addiction-prone individuals (Woody, O’Brien, and Simon, 1973). Abuse of this drug was not reported in our surveys during 1971. Beginning in late 1972 and increasingly over the past 1-1/2 years, it has become one of the most popular “street-drugs.’’ A survey of 113 drug abuse patients completed in March 1974 indicates that 33 (29.2%) used street-purchased diazepam in the preceding month. Only three of these 113 patients reported using diazepam on a doctor’s prescription. The purpose of this paper is to familiarize physicians with this problem and to stress the importance of giving careful attention to the prescribing and distribution of diazepam.
BACKGROUND The Philadelphia VA Drug Dependence Treatment Center is a multimodality drug abuse treatment program located in a general hospital. Treatment options include detoxification, methadone maintenance, therapeutic community, and narcotic antagonists. About 1,600 patients have been treated since the program began in July 1971. Theactive caseload at any one time is about 250. Ninety percent of the patients are narcotic addicts and live in the inner city. During the summer and fall of 1972, we began hearing reports from patients that diazepam was being sold on the streets at prices ranging from $.20 to $l.OO/lO mg tablet. At about the same time many patients began requesting diazepam. Most of those asking for it were also receiving methadone. They commonly said they were “nervous” and it was the only drug that helped. Within a few months we learned of two instances in which our prescriptions for diazepam were altered to read 100 and 140 ten milligram tablets instead of 10 and 14. On several occasions staff members observed patients purchasing diazepam tablets in the clinic or on the hospital grounds. In checking prescriptions given during 1 week, the hospital pharmacy discovered that five patients had obtained multiple diazepam prescriptions from different medical or surgical clinics. None of these patients were identified as drug abusers or were enrolled in the drug abuse program. One patient obtained 4,800 mg in 1 week from five different doctors.
MISUSE AND ABUSE OF DIAZEPAM
845
Until September 1973 we had encountered no known cases of physical dependence to diazepam. Since that time we have seen two. They are as follows.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
CASE REPORTS Case #I. A 26-year-old White male heroin addict had been treated with methadone for about 1 year. He had kept weekly appointments and his urines were clean. At no time in the last 2 months had he appeared sedated. He came to clinic one day complaining of uneasiness and tremors. He said that he had been using 150 mg of diazepam per day for 3 weeks. He then changed to secobarbital (400-600 mg/day) and had used this for the last 5 or 6 days. His supply of secobarbital ran out 2-1/2 days previously and since that time he had become increasingly anxious with insomnia and fine tremors of the extremities. On exam he was tense and had a fine tremor of the right hand. Deep tendon reflexes were not hyperactive. He refused to enter hospital for detoxification and requested outpatient treatment. At the end of the interview, and only minutes after he left the office, he gave a high-pitched cry, collapsed, and had two grand ma1 seizures. After regaining consciousness, he agreed to hospitalization and was treated with phenobarbital according to the technique outlined by Smith et al. (1970). He left against medical advice after 5 days, completing the last part of his detoxification as an outpatient. There was no history of epilepsy or head trauma, and there has been no recurrence of seizures during the past 8 months. He is continuing in outpatient treatment. Case #2. A 25-year-old White male was seen in clinic 2 weeks after having been discharged from a closed unit where he was partially detoxified from methadone. Since discharge he had been receiving methadone (20 mg/ day). He stated that in the 2 weeks since discharge he used 100 to 150 mg diazepam per day. His supply ran out and he requested hospital treatment for detoxification from diazepam. He was admitted and given 90 mg phenobarbital every 8 hours as outlined by Smith (1970). At the end of the second day he became tense and tremulous. Upon awakening on the morning of the third day he felt light-headed and dizzy as he sat up in bed. He had never experienced this symptom before. He was given an additional 90 mg phenobarbital p.0. and placed on a total of 360 mg of phenobarbital per day in divided doses. He felt more relaxed and had no recurrence of dizziness. The rest of his detoxification proceeded uneventfully.
846
WOODY, O’BRIEN, AND GREENSTEIN
Downloaded by [RMIT University Library] at 04:58 19 April 2016
DISCUSSION Case #I appeared to have had a withdrawal seizure. Since he was taking secobarbital for only a few days and diazepam in high doses for 3 weeks, it appeared that his physical addiction was produced by his misuse of diazepam. Supporting this inference are two facts. First, he was seen regularly while reportedly taking 150 mg diazepam per day and was not sedated, thus indicating a high level of tolerance. Second, urine tests taken every week for the previous 6 weeks were negative for barbiturates. The secobarbital probably prevented withdrawal seizures from diazepam which occurred when it was stopped. Case #2 appeared physically addicted on the basis of anxiety, tremulousness, tolerance for phenobarbital, and what appeared to have been an episode of postural hypotension on the morning of the third day of hospitalization. Only one of six urine tests during the last 2 weeks had been positive for barbiturates, indicating that abuse of barbiturates did not cause his physical addiction. These clinical experiences and case reports indicate that diazepam abuse and misuse is an increasingly common problem among addictionprone individuals in this area. It is occurring among patients attending both general medical and drug abuse clinics. Patients abusing it are not always readily identified. The two cases of physical dependency indicate that its abuse can, in some cases, create serious health problems. In asking addicts why they take diazepam, three reasons are given. One is to produce relaxation, either during the daytime or as a night sedative. A second is to relieve withdrawal sickness when drugs are unavailable or during self-initiated detoxification. Patients sometimes appear to benefit from diazepam when it is used in these ways and, though buying it on the street, they often take it in the same manner as a nonaddict would when prescribed diazepam by a physician. The third, and what appears to be the most common reason, is to feel “high.” This practice involves taking 30 to 80 mg in a single dose, often at the same time they take methadone or other medications. The patients say that a large dose of diazepam, either taken alone or in conjunction with narcotics, produces a pleasant, relaxed sensation which they describe as a “high.” Patients admitting to this practice have been observed by us to appear sedated, ataxic, and uncoordinated during clinic visits. The common pattern of use appears to be intermittent ingestion of tablets and not the continuous ‘intake with steadily increasing intravenous doses that is seen with narcotic addiction.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
MISUSE AND ABUSE OF DIAZEPAM
847
Patient reports indicate that some of the diazepam being sold on the streets comes from physicians. Many are unaware that it is being misused and abused and give single prescriptions for as much as 500 or 1,000 mg. Industrious patients can visit several physicians and thereby obtain a large amount through multiple prescriptions. Patients report that a second source is theft. As a result of these experiences, we discontinued prescribing diazepam in the outpatient drug abuse program. The hospital staff was notified of this problem through meetings, and a memo was circulated by the chief of staff. House officers were informed in group seminars conducted by drug abuse staff. However, it is our impression that this approach has had little effect on prescribing practices. Pharmacy records indicate that the amount of diazepam prescribed each month during the last year has remained constant. The pharmacy estimates that about 300 patients are given a 30-day supply each month, and that this number (usual prescription is 90 tabs-one t.i.d. of either 2, 5 , or 10 mg size) has remained constant in the last year. A common problem encountered in trying to lower the amount prescribed is that patients pressure their physicians into prescribing large amounts of antianxiety agents. At this time it is our feeling that the best solution to this problem is to limit the amount prescribed to a 1-week supply. Multiple prescriptions for the same patient cannot be stopped unless a patient profile record is kept at the pharmacy. This system will be started at this hospital in the near future. We are also in the process of developing a sensitive urine test for diazepam. We feel that all physicians should be aware of the abuse potential of diazepam when used by addiction-prone individuals. Our experiences indicate that support should be given efforts to limit the amount of diazepam prescribed and to guard its distribution and storage so as to prevent diversion of this useful drug into the wrong channels.
SUMMARY Misuse and abuse of diazepam among addiction-prone individuals is reported. The most common pattern of abuse appears to be periodic ingestion of 30 to 80 mg of diazepam in one dose, either alone or in conjunction with methadone or other narcotics. Two cases of physical dependency to diazepam have been observed. Many addict patients using diazepam are buying it on “the streets.” All physicians should know that diazepam abuse and misuse is occurring, and careful attention should be given to prescribing, transporting, and storing this drug.
WOODY, O’BRIEN, AND GREENSTEIN
848
REFERENCES BLACKWELL, B. Psychotropic drugs in use today. The role of diazepam in medical practice. J . Amer Med. Assoc. 225: 1637-1641, 1973. CLARE, A.W. Diazepam, alcohol and barbiturate abuse. Brit. Med. J . 4: 340, 1971. DITZION, B.R. Illegal use of psychoactive drugs. J . Amer. Med. Assoc. 216: 2144, 1971.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
EDGLEY, R. Diazepam, nitrazepam and the N.H.S. Med. J . Aust. 1: 186-187, 1970. FINER, M.J. Habituation to Chlordiazopoxide in an alcohol population. J. Amer. Med. Assoc. 213: 1342, 1970.
KAUFMAN, A,, BRICHARES, P.W., VARNER, R., and MASHBURN, W. Tranquilizer control. J . Amer. Med. Assoc. 221 : 1504-1506, 1972. PSYCHIATRIC NEWS, Justice Department to Control Librium, Valium. September 19, 1973.
SMITH, D.E. and WESSON, D.R. A new method for treatment of barbiturate dependence. J . Amer. Med. Assoc. 213: 294-295, 1970. WOODY, G.E., O’BRIEN, C.P., and SIMON, C . Phila. Med. p. 148, February 20, 1973, Letter to the Editor.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Misuse and Abuse of Diazepam: An Increasingly Common Medical Problem George E. Woody, Charles P. O'brien & Robert Greenstein To cite this article: George E. Woody, Charles P. O'brien & Robert Greenstein (1975) Misuse and Abuse of Diazepam: An Increasingly Common Medical Problem, International Journal of the Addictions, 10:5, 843-848, DOI: 10.3109/10826087509027342 To link to this article: http://dx.doi.org/10.3109/10826087509027342
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 31
View related articles
Citing articles: 16 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [RMIT University Library]
Date: 19 April 2016, At: 04:58
Downloaded by [RMIT University Library] at 04:58 19 April 2016
The International Journal of the Addictions, 10(5), 843-848, 1975
Misuse and Abuse of Diazepam : An Increasingly Common Medical Problem George E. Woody, * M.D. Charles P. O’Brien, M.D., Ph.D.
Robert Greenstein, M.D. Drug Dependence Treatment Center Philadelphia VA Hospital and University of Pennsylvania Philadelphia, Pennsylvania
Recent legislation has been proposed to restrict chlordiazepoxide and diazepam by moving them to Schedule IV (Psychiatric News, September 19, 1973). Implicit in this legislation is that these drugs are subject to abuse or misuse. A few authors have documented instances of abuse and physical addiction to chlordiazepoxide and diazepam (Smith and Wesson, 1970; Clare, 1971; Edgley, 1970; Finer, 1970). Kaufman et al. (1972) have shown that these drugs can be overprescribed in a general medical practice. Other authors have raised the possibility of more widespread
* To whom requests for reprints should be addressed a t VA Hospital, 39th and Woodland Avenues, Philadelphia, Pennsylvania 19104. 843 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
844
WOODY, O’BRIEN, AND GREENSTEIN
abuse or misuse of these and other minor tranquilizers (Ditzion, 1971; Blackwell, 1973). During the past 18 months, we at the Philadelphia VA Drug Dependence Treatment Center have witnessed an increasing amount of diazepam misuse and abuse among addiction-prone individuals (Woody, O’Brien, and Simon, 1973). Abuse of this drug was not reported in our surveys during 1971. Beginning in late 1972 and increasingly over the past 1-1/2 years, it has become one of the most popular “street-drugs.’’ A survey of 113 drug abuse patients completed in March 1974 indicates that 33 (29.2%) used street-purchased diazepam in the preceding month. Only three of these 113 patients reported using diazepam on a doctor’s prescription. The purpose of this paper is to familiarize physicians with this problem and to stress the importance of giving careful attention to the prescribing and distribution of diazepam.
BACKGROUND The Philadelphia VA Drug Dependence Treatment Center is a multimodality drug abuse treatment program located in a general hospital. Treatment options include detoxification, methadone maintenance, therapeutic community, and narcotic antagonists. About 1,600 patients have been treated since the program began in July 1971. Theactive caseload at any one time is about 250. Ninety percent of the patients are narcotic addicts and live in the inner city. During the summer and fall of 1972, we began hearing reports from patients that diazepam was being sold on the streets at prices ranging from $.20 to $l.OO/lO mg tablet. At about the same time many patients began requesting diazepam. Most of those asking for it were also receiving methadone. They commonly said they were “nervous” and it was the only drug that helped. Within a few months we learned of two instances in which our prescriptions for diazepam were altered to read 100 and 140 ten milligram tablets instead of 10 and 14. On several occasions staff members observed patients purchasing diazepam tablets in the clinic or on the hospital grounds. In checking prescriptions given during 1 week, the hospital pharmacy discovered that five patients had obtained multiple diazepam prescriptions from different medical or surgical clinics. None of these patients were identified as drug abusers or were enrolled in the drug abuse program. One patient obtained 4,800 mg in 1 week from five different doctors.
MISUSE AND ABUSE OF DIAZEPAM
845
Until September 1973 we had encountered no known cases of physical dependence to diazepam. Since that time we have seen two. They are as follows.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
CASE REPORTS Case #I. A 26-year-old White male heroin addict had been treated with methadone for about 1 year. He had kept weekly appointments and his urines were clean. At no time in the last 2 months had he appeared sedated. He came to clinic one day complaining of uneasiness and tremors. He said that he had been using 150 mg of diazepam per day for 3 weeks. He then changed to secobarbital (400-600 mg/day) and had used this for the last 5 or 6 days. His supply of secobarbital ran out 2-1/2 days previously and since that time he had become increasingly anxious with insomnia and fine tremors of the extremities. On exam he was tense and had a fine tremor of the right hand. Deep tendon reflexes were not hyperactive. He refused to enter hospital for detoxification and requested outpatient treatment. At the end of the interview, and only minutes after he left the office, he gave a high-pitched cry, collapsed, and had two grand ma1 seizures. After regaining consciousness, he agreed to hospitalization and was treated with phenobarbital according to the technique outlined by Smith et al. (1970). He left against medical advice after 5 days, completing the last part of his detoxification as an outpatient. There was no history of epilepsy or head trauma, and there has been no recurrence of seizures during the past 8 months. He is continuing in outpatient treatment. Case #2. A 25-year-old White male was seen in clinic 2 weeks after having been discharged from a closed unit where he was partially detoxified from methadone. Since discharge he had been receiving methadone (20 mg/ day). He stated that in the 2 weeks since discharge he used 100 to 150 mg diazepam per day. His supply ran out and he requested hospital treatment for detoxification from diazepam. He was admitted and given 90 mg phenobarbital every 8 hours as outlined by Smith (1970). At the end of the second day he became tense and tremulous. Upon awakening on the morning of the third day he felt light-headed and dizzy as he sat up in bed. He had never experienced this symptom before. He was given an additional 90 mg phenobarbital p.0. and placed on a total of 360 mg of phenobarbital per day in divided doses. He felt more relaxed and had no recurrence of dizziness. The rest of his detoxification proceeded uneventfully.
846
WOODY, O’BRIEN, AND GREENSTEIN
Downloaded by [RMIT University Library] at 04:58 19 April 2016
DISCUSSION Case #I appeared to have had a withdrawal seizure. Since he was taking secobarbital for only a few days and diazepam in high doses for 3 weeks, it appeared that his physical addiction was produced by his misuse of diazepam. Supporting this inference are two facts. First, he was seen regularly while reportedly taking 150 mg diazepam per day and was not sedated, thus indicating a high level of tolerance. Second, urine tests taken every week for the previous 6 weeks were negative for barbiturates. The secobarbital probably prevented withdrawal seizures from diazepam which occurred when it was stopped. Case #2 appeared physically addicted on the basis of anxiety, tremulousness, tolerance for phenobarbital, and what appeared to have been an episode of postural hypotension on the morning of the third day of hospitalization. Only one of six urine tests during the last 2 weeks had been positive for barbiturates, indicating that abuse of barbiturates did not cause his physical addiction. These clinical experiences and case reports indicate that diazepam abuse and misuse is an increasingly common problem among addictionprone individuals in this area. It is occurring among patients attending both general medical and drug abuse clinics. Patients abusing it are not always readily identified. The two cases of physical dependency indicate that its abuse can, in some cases, create serious health problems. In asking addicts why they take diazepam, three reasons are given. One is to produce relaxation, either during the daytime or as a night sedative. A second is to relieve withdrawal sickness when drugs are unavailable or during self-initiated detoxification. Patients sometimes appear to benefit from diazepam when it is used in these ways and, though buying it on the street, they often take it in the same manner as a nonaddict would when prescribed diazepam by a physician. The third, and what appears to be the most common reason, is to feel “high.” This practice involves taking 30 to 80 mg in a single dose, often at the same time they take methadone or other medications. The patients say that a large dose of diazepam, either taken alone or in conjunction with narcotics, produces a pleasant, relaxed sensation which they describe as a “high.” Patients admitting to this practice have been observed by us to appear sedated, ataxic, and uncoordinated during clinic visits. The common pattern of use appears to be intermittent ingestion of tablets and not the continuous ‘intake with steadily increasing intravenous doses that is seen with narcotic addiction.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
MISUSE AND ABUSE OF DIAZEPAM
847
Patient reports indicate that some of the diazepam being sold on the streets comes from physicians. Many are unaware that it is being misused and abused and give single prescriptions for as much as 500 or 1,000 mg. Industrious patients can visit several physicians and thereby obtain a large amount through multiple prescriptions. Patients report that a second source is theft. As a result of these experiences, we discontinued prescribing diazepam in the outpatient drug abuse program. The hospital staff was notified of this problem through meetings, and a memo was circulated by the chief of staff. House officers were informed in group seminars conducted by drug abuse staff. However, it is our impression that this approach has had little effect on prescribing practices. Pharmacy records indicate that the amount of diazepam prescribed each month during the last year has remained constant. The pharmacy estimates that about 300 patients are given a 30-day supply each month, and that this number (usual prescription is 90 tabs-one t.i.d. of either 2, 5 , or 10 mg size) has remained constant in the last year. A common problem encountered in trying to lower the amount prescribed is that patients pressure their physicians into prescribing large amounts of antianxiety agents. At this time it is our feeling that the best solution to this problem is to limit the amount prescribed to a 1-week supply. Multiple prescriptions for the same patient cannot be stopped unless a patient profile record is kept at the pharmacy. This system will be started at this hospital in the near future. We are also in the process of developing a sensitive urine test for diazepam. We feel that all physicians should be aware of the abuse potential of diazepam when used by addiction-prone individuals. Our experiences indicate that support should be given efforts to limit the amount of diazepam prescribed and to guard its distribution and storage so as to prevent diversion of this useful drug into the wrong channels.
SUMMARY Misuse and abuse of diazepam among addiction-prone individuals is reported. The most common pattern of abuse appears to be periodic ingestion of 30 to 80 mg of diazepam in one dose, either alone or in conjunction with methadone or other narcotics. Two cases of physical dependency to diazepam have been observed. Many addict patients using diazepam are buying it on “the streets.” All physicians should know that diazepam abuse and misuse is occurring, and careful attention should be given to prescribing, transporting, and storing this drug.
WOODY, O’BRIEN, AND GREENSTEIN
848
REFERENCES BLACKWELL, B. Psychotropic drugs in use today. The role of diazepam in medical practice. J . Amer Med. Assoc. 225: 1637-1641, 1973. CLARE, A.W. Diazepam, alcohol and barbiturate abuse. Brit. Med. J . 4: 340, 1971. DITZION, B.R. Illegal use of psychoactive drugs. J . Amer. Med. Assoc. 216: 2144, 1971.
Downloaded by [RMIT University Library] at 04:58 19 April 2016
EDGLEY, R. Diazepam, nitrazepam and the N.H.S. Med. J . Aust. 1: 186-187, 1970. FINER, M.J. Habituation to Chlordiazopoxide in an alcohol population. J. Amer. Med. Assoc. 213: 1342, 1970.
KAUFMAN, A,, BRICHARES, P.W., VARNER, R., and MASHBURN, W. Tranquilizer control. J . Amer. Med. Assoc. 221 : 1504-1506, 1972. PSYCHIATRIC NEWS, Justice Department to Control Librium, Valium. September 19, 1973.
SMITH, D.E. and WESSON, D.R. A new method for treatment of barbiturate dependence. J . Amer. Med. Assoc. 213: 294-295, 1970. WOODY, G.E., O’BRIEN, C.P., and SIMON, C . Phila. Med. p. 148, February 20, 1973, Letter to the Editor.
