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Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring

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Abstract

Purpose

Many harms secondary to benzodiazepine (BZD) dependence force users towards detoxification treatment. However, even strongly motivated patients tolerate the process badly or experience early relapse. The detoxification procedure has not yet been standardized. The objective of this paper is to examine the hypothesis that faulty detoxification routines may have caused some failures.

Methods

The detoxification approaches found in the literature were compared stage by stage. The review was used to identify possible common, across-the-board systematic errors.

Results

The presented literature review confirms that the widespread divergence in the BZD metabolism rate is effectively neglected during detoxification routines. Without laboratory measurements, these differences, additionally interfered with by auxiliary drugs, undermine not only the scheduled but even the symptom-driven procedures. An initial substitution with a long-acting BZD, although recommended, may lead to over-accumulation. This excess, varying between patients and incompatible with the current tapering stage, may lead to repeated overestimation of the patient’s adjustments to reduced doses. Consequently, the patient’s good clinical presentation at withdrawal, resulting in a conclusion of detoxification, may actually reflect a persistently high serum BZD concentration. The low-concentration stage, if shifted past the end of treatment, exposes patients to unexpected, unassisted withdrawal crises. With laboratory feedback, these crises, unlike the symptoms related to deficient re-adaptation mechanisms, could be prevented. Moreover, by minimizing the high-concentration phase, time can be saved for properly assisted low-concentration challenges.

Conclusion

A customized detoxification procedure driven not only by the intensity of withdrawal symptoms but also by serum BZD monitoring may prevent some failures. As the standard regimen, it would make detoxification from BZDs more reliable and effective.

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Acknowledgements

The author acknowledges Mark Horowitz of Prince of Wales Hospital, Sydney for relevant comments and remarks contributing to the text, and expresses special thanks to Janet Machol of University of Colorado, Boulder for critical comments and help in editing the text.

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    Anna Basińska-Szafrańska

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Basińska-Szafrańska, A. Metabolic diversity as a reason for unsuccessful detoxification from benzodiazepines: the rationale for serum BZD concentration monitoring. Eur J Clin Pharmacol 77, 795–808 (2021). https://doi.org/10.1007/s00228-020-03048-y

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