-Pam, Good for More Than Just Greasing Pans

I prefer Great Value brand non-stick cooking spray. Even as I work to be healthier, sometimes good 'ol superdehydrogenated uber processed oils are just what you need. Benzodiazepines (BZD). See the connection? Oils are fats. Fatty liver can be caused by alcohol. Alcohol can cause withdrawal and seizures, which you then treat with benzos. Bam, check mate. Aside from the first BZD, chlordiapoxide, the rest end with -pam or -lam; diazepam, lorazepam, alprazolam, etc... Hence the pam in the title. Genius I know, you don't need to tell me that. 

So I mentioned that BZDs can be used for withdrawal from alcohol but that is just one of many uses. Panic disorder, agoraphobia, epilepsy, anesthesia adjunct, insomnia, and many kinds of seizures are just a few, so BZDs really are a jack of many trades. They can be given PO, IM, IV, and rectally and are generally well absorbed, then they go on to work on receptors in the central nervous system to cause CNS depression. Makes sense given their myriad uses. The situation I most often see is a standing order in seizure protocols for patients, or ordered PRN for alcohol withdrawal patients. 

Given their effectiveness in reducing complications in alcohol withdrawal, BZDs may be given for those who are quitting drinking to prevent or suppress withdrawal symptoms. I do not know why this needs saying but even voluntary alcohol cessation is risky if not done properly. The seizures particularly are deadly and if that risk can be mitigated, the process should be safer. For hospitalized patients going through withdrawal, BZDs may be the only way to prevent harm to the patient who very well may be impulsive and delusional. Not to forget the fact that seizures can harm the person via flailing or falling, but cause irreparable damage to the brain and cause death. 

As a nurse, it is important to think about the respiratory depression in patients before use of BZDs. An example is a patient withdrawing who has trouble keeping his oxygen above 90% (no COPD), sure his respiratory rate was 30 but it was still struggling to get him the oxygen he needed. In a normal patient, reducing the rate to 26 may not be an issue, and maybe a good thing, but for him it could be an issue. We had to address the underlying issue with this respiratory system, which turns out was a healthy dose of furosemide. This patient was not on a concomitant CNS depressors but that is something to watch out for as they both have the same respiratory depression effects. 

More pearls, BZDs are metabolized in the liver so an alcoholic may be much less able to clear the medication. Increasing the risk for overdose, and though if the patient dies it won't matter, prolonged use may then lead to further liver damage. BZDs can cause dependance and have their own set of withdrawal symptoms, so talking to patients who may chronically use them should focus on how to eventually discontinue. For example, anxiety, BZDs may be needed initially but CBT and other forms of therapy, or less hazardous drugs like fluoxetine should be applied for long term benefit and to reduce the risks of BZDs.  The same can be said for insomnia, myriad other therapies such as sleep hygiene, melatonin, or even more comfortable sheets should be applied to hopefully discontinue the BZDs. 

Patients should be assessed for fall risk as with any CNS depressant given their propensity to make people drowsy and "out of it" at times. An alcohol withdrawal patient may already be unstable due to tremors or other issues, adding a BZD on top of that only makes a more risky proposition to walk the patient. Elderly patients are at greater risk of delayed metabolism and as such present a challenge in monitoring their health during BZD use. 

So what does this mean? I big thing I am learning from the OG nurses I work with are to think about ways to help reduce risk. Sure, I should know what I need to do if someone falls or has an MI or whatever, but can I prevent that in the first case. With CNS depression, am I paying attention to their mental status. For the respiratory depression, am I frequently or continuously monitoring their oxygen and breathing. Have protocols and know the parameters for use of PRN BZDs. Is it just the mustard I had for lunch or is the patient jaundiced? What else can I do to help this patient sleep aside from a dose of lorazepam? I can't stop the elderly from being a fall risk but how can I make sure every precaution I can use is in place? These are all questions I am learning to ask. It goes along with the principal of treating the patient's response to disease (in this case a drug), not just the disease itself. Love y'all, bye. 

References

Balancing the risks and benefits of of benzodiazepines from JAMA Network by Hirschtritt et al., in 2021

Benzodiazepines from the NIH: National Library of Medicine and from American Nurse

Image of a ball and stick model of diazepam from wikipedia