Officers in the women’s wing of a large urban jail call down to medical asking for assistance with an out-of-control inmate. The 22-year-old woman was booked in ten days ago and disclosed daily alcohol use. She was successfully withdrawn from alcohol during the first week. Now the officers describe her as totally out of control, hearing voices, and bouncing off the walls. As preparations are underway to do a cell-side evaluation, a Man-Down is called for the same wing. The emergency bag is pulled and the designated emergency nurse asks a second nurse to accompany her to the floor. They find the woman unconscious on the floor of her cell. The officers state that just after they phoned medical, the woman began to shake, her eyes rolled back, and she collapsed on the floor.
Delayed Benzodiazepine Withdrawal
Health care staff at this jail did a good job of withdrawing this woman from alcohol. They used a standard withdrawal protocol based on the Federal Bureau of Prisons Guidelines that included scheduled evaluations using the CIWA-Ar and administration of chlordiazepoxide (librium) based on scoring. Within 4 days she was symptom free and CIWA evaluations ended on Day 7.
However, intake screening questions missed this patient’s heavy dependence on diazepam (Valium) along with her alcohol intake. The benzodiazepine treatment for alcohol withdrawal held off drug withdrawal symptoms until later in her stay. Benzodiazepines are rarely misused alone. As in this case, they can be combined with alcohol use. In other situations they may be used in conjunction with opiates or cocaine. Women are twice as likely to misuse benzodiazepines as men.
Long-acting sedatives like diazepam may take longer for withdrawal symptoms to emerge, as indicated by this graph.
What’s in a Name?
Depending on your geographic region, you will hear many names for street drugs. Keeping up with the lingo is an important part of assessing for benzodiazepine dependence or misuse. Here are some common street terms for this drug class. Do any of these sound familiar?
- Benzos
- BZDs
- Stupefy
- Tranx
- Qual
- Heavenly Blues
- Valley Girl
- Goofballs
- Moggies
- Candy
- Z Bars
- Sleepers
- School Bus
- Dead Flower Powers
Seeing the Big Picture
Benzodiazepines have a calming effect and are often taken to reduce anxiety or to help sleep. The correctional patient population is less likely to frequent the health care system for these conditions and may obtain relief by self-medicating using street drugs. Asking questions about treatments used for anxiety or insomnia may reveal a need for benzodiazepine withdrawal monitoring. If regular use of a benzodiazepine is identified during intake, answers to the following questions will determine withdrawal treatment options:
- Type of medication
- Length of time used
- Amount used
- Reasons for use
- Symptoms that occur when doses are missed
- Date and amount of last dose
Benzodiazepine withdrawal may be a hidden problem because it is often mixed with other drug and alcohol withdrawal issues. Be particularly alert for this potential with female patients in combination with other primary concerns such as alcohol and opiates.
What are you using to screen and assess for benzodiazepine dependence? Share your thoughts in the comments section of this post.
Sue Smith says
Hi Lori, Thank you for making this much needed post. Many people, including nurses, simply do not understand how dangerous alcohol and benzodiazepine withdrawal can be. They are more likely to result in serious complications, including death, than most other types of substance withdrawal. In addition to probing deeper for benzodiazepine use, intake nurses should ask whether the patient ever had any serious withdrawal symptoms like blacking out, seizures and sever, uncontrollable shaking. These symptoms in a patient’s past history may be clues that the patient will have more serious withdrawal symptoms and complications.