Successful withdrawal from high-dose benzodiazepine in a young patient through electronic monitoring of polypharmacy: a case report in an ambulatory setting

Abstract

Background: Dependence on high-dose benzodiazepines (BZDs) is well known and discontinuation attempts are generally unsuccessful. A well established protocol for high-dose BZD withdrawal management is lacking. We present the case of withdrawal from high-dose lorazepam (>20 mg daily) in an unemployed 35-year-old male outpatient through agonist substitution with long-acting clonazepam and electronic monitoring over 28 weeks.

Methods: All medicines were repacked into weekly 7 × 4 cavity multidose punch cards with an electronic monitoring system. The prescribed daily dosages of BZDs were translated into an optimal number of daily tablets, divided into up to four units of use. Withdrawal was achieved by individual leftover of a small quantity of BZDs that was placed in a separate compartment. Feedback with visualization of intake over the past week was given during weekly psychosocial sessions.

Results: Stepwise reduction was obtained by reducing the mg content of the cavities proportionally to the leftovers, keeping the number of cavities in order to maintain regular intake behavior, and to determine the dosage decrease. At week 28, the primary objectives were achieved, that is, lorazepam reduction to 5 mg daily and cannabis abstinence. Therapy was continued using multidrug punch cards without electronic monitoring to maintain the management system. At week 48, a smaller size weekly pill organizer with detachable daily containers was dispensed. At week 68, the patient's therapy was constant with 1.5 mg clonazepam + 5 mg lorazepam daily for anxiety symptoms and the last steps of withdrawal were started.

Conclusions: Several key factors led to successful withdrawal from high-dose BZD in this outpatient, such as the use of weekly punch cards coupled with electronic monitoring, the patient's empowerment over the withdrawal process, and the collaboration of several healthcare professionals. The major implication for clinical care is reduction by following the leftovers, and not a diktat from the healthcare professionals.

Keywords: addiction; benzodiazepine; community pharmacy; electronic monitoring; multidrug punch card; printed electronics; substance withdrawal.

Figure 1.

Graphical representation of the intakes of week 20 (16 July–22 July 2015), filled with clonazepam (black circle), lorazepam (white circle). The white square indicates an additional lorazepam tablet (one per week); a larger circle indicates double intake.

Figure 2.

Mean weekly intake time of the content of the different punch card cavities filled with clonazepam (a) and lorazepam (b) over 28 weeks. The daily amount of benzodiazepine taken is indicated with a bold grey line. The four different cavities per punch card are marked with a bold line (first cavity —); spotted line (2nd cavity …); dotted line (3rd cavity –); double line (4th cavity ==). Standard deviations are given as half bars (minus for first cavities; plus for the other cavities).