軍Å第持号証の−MedicalReport
Re：WayneDouglas−BenzodiazeplneDependence

Preparedby：Dr・GraemeJudson

ClinicalServiceDirector
AIcohol＆DrugServiceTaranaki

Preparedfor‥

TokyoDistrictCourt

Date：

e

卯

血

S
i

託 け 琶 邑 巨 巳

Contents

00
0
1

2

1

4

3・l ReductionHistoryS

Di脆rentialDiagnosis

1

2・5

1

ICD−10Criteria

1

Summary

DSMⅣTRCriteria

2．4

〜
〜
1
2
5 6

（3）FormalReductionProgram

0verallClinicalPicture

1

2．3

〜． 1

2．2

DiagnosticProcedure

9

2．1

〜

HistoryofSymptoms

4

l・4

3

SubstanCe／PrescrlPtionHistory

2（2）D甲endenceDiagnosis

PatientPro丘lel・3e

1・l PriorMedicalHistoryl．2g（1）PatientBackgroundSllbject

2

I

a
h
r

Section

17〜19

20

ん，il￣・Introduction

Ⅰ，GraemeJudson，havebeeninvitedtoprovidethisreportregardingMi・WayneDouglas，sBenzodiazepinedependency・

IamtheClinicalServiceDirectoroftheAIcohol＆DrugServiceTaranaki・Ihavebeenworkingln

AIcoholandDrugRehabilitationfor16yearsandIhavebeeninvoIvedinassesslngPatientsfor
BenzodiazeplneandothersubstanCedependencies・Myquali丘cationsincludemyundergraduate

degreesBHB，MBChBaswellasmypost−graduatequalincationsofMHScandFAChAM．

ThisreportincludescontentfiomthelettersthaHhaveprovidedthusfartogetherwithmore
detailedinformationregardingWayne，sBenzodiazepinedependence．

＞

Thisr甲OrtCOnSistsof3mainsectionsasfollows：
l・PatientBackground

2・TheDependenceDiagnosis／DSMIVTRCriteria
3・FormalReductionProgram

Inordertogalnanunderstandingoftheoverallclinicalpictureandthediagnosisfor
Benzodiazepinedependencewemust鮎stexaminethePatientBackground，including，Prior
MedicalHistory，PatientPronle，Substance／PrescriptionHistory，HistoryofSymPtOmSetC，aS

OutlinedinSectionlofthisr甲Ort・

NB：SectionlalsoconsistsofinformationprovidedbyWayneandhislawyer，Mr−

ARerexamlnlngthePatientBackgroundwecanthenseehowtheoverallclinicalpicturerelatesto
thediagnosticcriteriaforBenzodiazepined印endence，WhichinthiscaseisbasedontheDSMIV
TR，aSOutlinedinSection20fthisreport・

l section3coverstheformalreductionprogram．

Thereportisconcludedwithasummaryofnndings・−1−SectionOme
l・PatientBackgroundl・l PriorMedicalHistory

l・1・l PriOrtotravelingtoJapan，forhis5thtime，inMay1999Waynewas負t
healthyandwell（re蝕Dr・BarryterHaarletterdated19／10／06）．

1．2

PZ旺ientPro重lel・2・1WhenWaynepresentedtoourservice，withtheexc甲tionofWayne，suse
OfCannabis（asnotedinpointl・2・3），uSeOfNicotineandalcohol（asnoted

inpointl・2・4）theonlyhistoryofnotewithWayneregardingsubstanCeuSe
WaStheBenzodiazeplnereglmethathewasinitiallyprescribedbyDr．

『−h2000・
1・2・2

0ndetailedquestioningbybothmeandtheDetoxNurse，Whointerviewed

Wayme，hehadnopriorhistoryofhallucinogenuse，nOhistoryofopiateuse，
nohistoryofsoIventuse，nOhistoryofstimulantuSeandhadabstainedfrom

alcohoIsinceMay2000．
1・2・3

Waymedoesacknowledgethatheusedcannabisbetweenagesof15and21

buthashadnocarmabissincetheageof21・WaynereportedthathesmokedaboutlmaruuanaClgarettebetweenabout5peOPleatparties・

1・2・4

0therhistoryincludedsmokingcigarettes，aSaminor，andtheoccasional

drinkingofalcohol・Waynereportedthathe

blayedwithcigarettesacoqple

OftimesMasanineyearoldwithoutactuallyinhalinganything・Thenhe

SmOkedregularlybetweentheagesof14and17，butonlyabout5perday・
Hehasnotsmokedatallsincethen・Regardingalcohol，Waynereportsthat
hedrankabout4OessthanSixstandarddrinks）glassesofbeeroccasionally

OnaSOCialbasisatparties・Thispattemofalcoholuseiswe11withinthe

recommendedsafeNewZealanddrinkingguidelinesofnomorethan6StandarddrinksonanyOneOCCaSionandnomorethan21standarddrinks
PerWeek．
1・2・5

Wayne，shistorydidnotsuggestthathehadanaddictivepersonality・

1・2・6

ThisisfurtherevidentinthefactthatWaynewasparticularlykeento

withdraw丘omhisBenzodiazeplnereglmeuPOnlearnlngOftheiraddictive

natureandthefactthattheywerelikelycontributingtosomeofhis
underlyingsymPtOmSatthetime．
1・2・7

Furthermore，Waynemade3attempts，althoughunSuCCeSSfu1，tOreducehis

drugintakeduringthecourseofthedrugtreatmentthathewasbeing

悪業怒簑慧窓悪，子nd血pt如b喝血血gof
−2一

1・3

Substance／PrescriptionHistory

NB：Thesubstanceusehistorybetween5thJuly2000and9thApri12001isbasedon

informationprovidedtomebyWayneandhislawyer，Mr・−
BelowisabreakdownfbrtheBenzodiazeplneCOmPOnentOftheprescriptions．

PrescribingDoctor （Hospital）

PeriodPrescriptionDrugS

TradeName
堕da山一Dr・−

5／7／00〜 23／1／01

Uli血C）

Dr．■■

22／1／01〜［

Dose （mg）

ChemicalName

ContolChlordiazepoxide

Rivo廿ilClonazepam

Grandaxin

To負sopam

9ノ4／01

ConstanRivotri1

15
0．9

150

Clonazepam

AIprazolam

1．2

1．2

Dr．Whtwell

9／4／01〜 19／4／01

Rivotril

Clonazepam

1．0 〜0．5

Dr．Judson

19／4／01〜 5／5／01

Rivotril

Clonazepam

0．5 〜0．0

NB：Theprescriptionsbetween9也Apri12001and5thMay200lwereallprescribedbyDr・Whitwell・MyrolewastohelpWaynewiththereductionprocess・

OntopoftheBenzodiazepines（Chlordiazepoxide，Clonazepam，andTo丘sopam）
Outlinedabove，WaynewasalsoprescribedthefollowingdrugSbyDr．−

Prescribing （Hospita

Doctor l）

Pedod

TradeName
Defbndant−Dr．

■』■

け

DnlgNむne

ChemiCalName

5／7／00〜 23／1／01

Ketas

Dose （mg）

To倉anilⅠmipramine

rbudilist

30

NB：IhavebeeninformedthattheBenzodiazepines（Chlordiazepoxide，

Clonazepam，andTo鮎opam）prescribedbyDr・−wereallmixedtogetherina
POWderformCOntainedinsachets．TheImipramlneWaSintal）letformandthe
Ibudilistwasincapsuleform・Thedosagesneverchanged．

−3−

10

NB：thedetailsunderl・4arebasedandcopiedfiomdetailsprovidedtomeinwrittenformby
Wayne，

1．4

Histo TOfS toms

Pre−DrugTreatmentSymPtOmS

l・4・1WaymeinformSmethatheeveriencedthebelowsymPtOmSWhilstworking
atastressfuljobinShizuoka・IcanCOn丘mthatthesesymPtOmSare
COnSistentwithstress．

AroundOctober1999
1・SweatypalmS
2．Shortnessofbreath．

3・Racing／scatteredthoughts
4・Sleq）disturbanCeS

5・Pressureintempleareas

6・Swellingoftemporalveins

7・Fatigue／lethargy

l・4・2

Waynereportsthatmostoftheぬovesubsequentlydis叩Pearedafter

ChanglngjobsattheendofMarch2000．

1・4・3

WaynereportedthebelowsymPtOmSfollowlnganaCuteVertigoattack．

11也Mav2000
1・Asingleattackofrotationalvertigo
2・Vomiting／Nausea
3．Flushes

4．hitiallyunabletostand5・DifncultywalkingforaweekthereaRer
6・OngolngunSteadiness

7・SubsequentanⅩietyovernotkn0wingwhatwaswrong

NB：Iunderstandtherearedi脆ringviewsastowhatexactlycausedthe
abovesymPtOmS．

ー4−1・4・4

Uponinitialpresentation，WaynehandedDr．■−alistofsymPtOmS

associatedwithhisvertigoattack；includingthoseabove（1．4．3）．

AsanadditionalpartofthislistWaynewrotethefbllowmggeneralhistory
underthetitleHOthern．
HEarlY1998〜
1．Stifhessinshoulders

NB：followingthisI（Wayne）beganthehabitofclickingmyOlis）neck

Apri11999〜
1．Badtooth（Currentlyreceivingtreatment）

NB：SincelateMay，thetoothachehascausedinnammationinmy（WayneS）cheek，eyePainandswellingofglands

June1999〜

1．Becameabitlethargic
NB：HavebeenfbelinglethargicsincecomingtoJapan（dueto
di飽renceinenvironment）

E訂ly2000〜
1．Shortnessofbreath

2・Paininthetempleareasandswellingofthesurroundingveins（these
SymPtOmSdisappearedfollowingdentaltreatment）

LateApri1〜11Mav2000（timeofvertigoattack）
1．Veryle血argk
2．F如igue

3．EyesRelliketheyareswimmlngarOund−5−

Post−DrugTreatmentSymptoms

l・4・5

Followingabout2weeksofDr・j』■sdrugtreatmentWaynereportsthat

henoticedsomeinitialsettlingofsymPtOmSaSbelow．

Mid〜EndJuly20qQ
l・Settlingindizziness

2・SettlinginanXiety1evels

l・4・6Followingaboutl・ミmonthsofDr・−SdrugtreatmentWaynereported
thathehad；COrrtinulngSymPtOmS，WOrSenlngSymPtOmSandsomenew

SymPtOmSaSWell・WaynemaderegularcomplaintsofhisnewsymPtOmS，
bothinwrittenandverbalforms．

Mid〜EndAu印St2000
Continuing？ymPtOmSincluded（inWayne

swords）

1・ContinulngStaggering（especiallyfbelqueasywhenwashingdishes，
takingshower）

2・Lethargyandfatigue（stillthesame）
3・Shortnessofbreath（littleimproYement）

4・Eyesfbelinglikethey

reswimmlngarOund（now，Onlyatmomings）

5・Legsfbelingweak（theymomentarilycameright，butnowcan，tseemto
getmuchstrengthintothem）

6・Feelingwoozy
7・Summerlethargy
8・Stress＆fatigue
9．Stiffshoulders

SymPtOmSthatworsenedincluded
l．Dizziness

2・FeelingsofanXiety
3・Worsenlnglevelsoffatigue

4・（Worseningofhemorrhoids）

NewsymPtOmSincluded
l・Palpitations／Heartpounding
2・Lossinappetite

3．Mouthulcers
4．ChronicThirstiness
5・ReoccurrlngnauSea−6−

1．4．7

Followingabout4〜6monthsofdrugtreatmentWaynestatesthathis

COnditioncontinuedtodeteriorateandthathedevelopedseveralmorenew
SymPtOmSaSbelow．

BetweenOctoberandDecember2000（inWavne，swordsI

AdditionalnewsymPtOmSincluded
l・Timitus一丘omNovember，StartedtoeチPeriencelighttinnitus（whentryingtosleepanduponwakening）
2・

Vitreousopacities−Developedwi1ataPPearStObeasmearonthelens

Ofeyes（hrighteye，Canbeseenevenaftereyeisclosed）From

October
3・

BecameSenSitivetoheat（bodytemperatureseemstochangeal1the
time）

4．

Pulserateishigherthanusual

5．

Flushes6．

Lossinsexualinterest

7．

Developedhabitofalwaysclosingeyes

8．

Startingtofeeldetached9．

Pressureinchest

lO．Occasionalstomachpains

ll．Lossinappetite／Anorexia

12．Jawsti餓IeSSandpain
13・PainfuI＆Stiffjoints，muSClesfelttight，heavyandnumbed

14．Lostmorethan10kilosinweight
15．hsideofheadtwitchesandpulsates

16・Tightnessacrossforeheadandscalp
17．Physicalweakness
18．Paresthesias

19．Visualdisturbances
20．IncreaSedsleepdisturbanCeS

21．Slightlyef稔ctedspeech
22．Hypersensitivity

23・Sensitivitytosoundandlight
24・EmotionalInstability（includingpanicattacks，anXiety，depression，
moodswings，aggreSSion）

NB：Waynealsonoticedatthisstagethathewasnowsu飴ringfrom
feelingsofemotionalinstabilityandpanicattack−likeq）isodes−SOmething

hehadnotexperiencedbefore・ApparentlyWaynecontinuedtocomplainof

thesenewsymPtOmSinbothWrittenandverbalformS．

ー7−

1◆4●8慧≡慧言霊慧；監昆烹
むさIJa11uarJ2001

1．

Dizziness

2・

Staggerlng

3．

Shodnessofbre血4・

Lethargy

5・

F如igue6・Je11ylegsensation

7・Muscularpain／sti伍leSSinneckandback
8・Nausea（periodic）
9・

Sparklingsensationinvision

lO・Appearstobemarksoneyelenses

ll・Headseemstopulsatemorethanusual（especiallywhensleeping）
12．Sensationofheadrushes

13．DeteriorationinsenseofbalanCe
14．Shouldersti魚IeSS
15．Pressureinsinus

16・Havebecomepronetomouthulcers
17．Hemorrhoids

18・Palmofhandssweatabnormallyー8−SectionTwo
2・DepemdenceI）iagnosis

2・1

9皇a印OSticP嘘
2・1・l Testing

WhenmakingadiagnosisofsubstanCedq，endencethereisnospecinctest
thatgivesusaclearde血edresult・Rathersensibleuseofdiagnosticcriteria
requlreSSOmeinterpolationandjudgment，takingintoconsiderati。nthe

OVerallproblem，aShighlightedbyWesson，DR，Smith，DE・＆Ling，W・in

theirdiscussiononBenzodiazeplneandothersedativehypnoticaddictionin
Principlesofaddictionmedicinethirdedition）・Forthisreasonyehave
guidelineswhichassistusindetermlnlngadependencediagnosIS．

2・1・2

BasisUsedforDiagnosis

ThediagnosisthatwasarrivedatinWayme，scasewasbaseduponthe
bllowlng：

1．TheOverallClinicalPicture

2・TheHistory−thedocumentsandlettersthatWaynesuppliedincluding

PreSCriptionsandsymPtOmS
3・HowWaynePresented−bothphysicallyandmentallyingenera1
4・Other（thereferralletterfiomhisGeneralPractitioner）

TomakeadependencediagnosiswetakeintoconsiderationthePatient
Background，aSOutlinedinSectionOneofthisreport・Thishelpsustoform
theoverallclinicalpicture・Furthermore，Observationsaremadeduring
COnSultationtohelpinassessingthepatient，scondition．

2・1・3

Guidelines／CriteriaUsedtoMakeDiagnosis

InWayne，scasetheguidelines／Criteriausedtomakethediagnosiswasas
fbllows：

1．DSM−IVTRCriteria

2．ICDlOCriteria
TodiagnoseBenzodiazepinedependenceweusetheDSM−ⅠVTRCriteria

hereattheAIcohol＆DrugService・TheDSM−IVTBisthestandardused
bytheAmericanPsychiatricAssociation．

AsnotedintheDSM−IVm，drugdependenceisamaladaptivepattemof
druguSeleadingtoclinicallysigni鮎antimpalrmentOrdistress，Whichis

manifestedby30rmOreOftheCriteriaoccurrlngatanytimeinthesame12monthperiod．

hWayne，scasetheclinicalimpalrmentincludedbothphysicalandmental
SymPtOmS，andassociatedwiththisimpalrmentWaStheimpactonwayne，slife，Whichincludedhisinabilitytofunctionatwork．

−9−

Asaback−uPtOtheDSMIVTRWayne

sclinicalpicturewasmeasured

againsttheICDlOcriteriawhichisusedmorecommOnlyinEuropeto
diagnosesubstancedependence・

2・1・4

ProcedureUsedtoArriveatDiagnosis

TheBrstthingwehadtodowasconsiderthereferralreceived丘om
Wayne，sGP，WhichsuggestedtousthatWaynehadaproblemwith
Benzodiazepinedependence．

WethenproceededtoassessWayneandinterviewedhimto丘ndoutabouthishistory・Forexample：WhatkindofBenzodiazeplneShehadbeentaking，
dosages，Periodofuseetc．

NB：ThedependencediagnosisinWayne，scasewasmadeeasiersimplyby
thefactthathewasbeingprescribedBenzodiazepines（Chlordiazepoxide

15mg，Clonaz甲amO・9mg，Tofisopam150mgs）forovera6monthperiod．

WealsoanalysedWayne

shistoryofsymPtOmSinordertohelpusidentify

SymPtOmPattemSthatareconsistentwithBenzodiazepinedq，endence・For
examPle：tOlerance，Withdrawaletc．

0thergeneralhistorysuchasunsuccessfu1attemptsatreductionwasalso
noted．

OnceacompleteanalysisofWayne，sbackground／historyhadbeencarried

OutWethenmatchedthisinformationagainsttheDSMIVTRCriteria．

TheBrstcriteria−tOleranceandwithdrawalareevidentinhowWayne

PreSentedtotheserviceandinthatthesymPtOmSher印Ortedwere
COnSistentwiththese・Regardingthecriteriaoflossofcontrol，impacton

lifbandcontinueduse，itwasfoundthatWaynemetthesebaseduponthe
historyhegavebothmyselfandtheDetoxnurse．

BeforeconcludingthatWaynemetthesecriteriawecross−Checkedhis
Verbalselfreportswiththedocumentationthathepresented，hisDoctor−srefb汀alletterandreports丘omhisfamily・

MatchingWayne

sbackground／historyagainsttheDSMIVTRCriteria

enabledustocon鮎mthediagnosisofBenzodiazepined甲endence・

−10−

2．2

0verallClinicalPicture

Inordertodeterminewhetherapatientisdrugdependent，WemuStCOnSiderthe
historyprovidedbythepatienttohelpusformtheoverallclinicalpicture・In

Wayne，scasethemainpointsareasfollows：

1・Thepatientwashealthyandwellupuntil1999
2・Thepatienthadnoprevioushistoryofpsychological，neurOlogicaloranXiety

disorders
3・Thepatientdidexperiencesomeworkrelatedstresssymptomsfromaround

October1999forthe丘rsttime
4・Thepatient，sworkrelatedstresssymPtOmSdidsubside，however，aRerhe

5

慧雷雲芸慧競露aSdiagnosedasanumeldedacuterotatbna1

6・ThepatientdevelopedanxietyrelatedsymPtOmSafternotbeingabletoreceiveanyClear−Cutdiagnosisforhisvertigoattack
7・ThepatientwasprescribedBenzodiazeplneS，Whichareaddictivemedicines，

eveninsmallprescriptiondoses，eSPeCiallywhentakenoverprolonged
Periodsoftime．

8・BenzodiazeplneShavenumerouscommonlyknownuntOWardside−e脆cts，e・g・
OCulare脆cts，lethargy，Palpitations

9・Thepatient，soveralldosewassufncientenoughtoformdependencelO・Thepatientexperiencedaninitialsettlingofsymptomsacoupleofweeksinto

thetreatment
ll・Thepatientsconditionceasedtoimproveafteraboutlmonthintothe

12・Thepatientcomplainedthathisconditionwasdeterioratingandthathehad
developedsomenewsymptomsa鮎raboutl．5monthsintothetreatment

13・Thepatientcontinuedtodevelopnewsymptomsinthismannerthroughout

theremalnlngPeriodofthetreatment
14・Thepatient，sadditionalpostdrugtreatmentSymPtOmSWereallconsistent

WithBenzodiazeplneWithdrawal
15・Thepatienthad3unsuccessfulattemptsatreducing−Thepatientshoweda

desiretoreducebutwasunabletodoso
16・ThepatientshowedanaWareneSSthathisconditionwasdeterioratingand
SOughtaltemativehelponatleast2di脆rentoccasions

17・Thepatientselfreportedthathisabilitytopartakeinsocialandrecreational

activitieswassignincantlyreduced
18・Thepatient，sGPreportedthatheeventuallyreachedastateofcomplete

exhaustionandconfusiontothepointwherehewasunabletoworkany
longer19・ThepatientGPrq〕Ortedthathisconditionwassuchthathewasforcedto

retumtohishomecountry，Whereittookabout15monthsbeforehewasfit

enoughtoworkagaln
20・ThepatientrequiredprofbssionalassistanCeinordertobeabletoreduceー11−

21・ThepatientdisplayedwithdrawalsymPtOmSduringtheformalreduction

prOCeSS
22・Thepatient，sconditioncontinuedtoimprovefollowingthecompletionofhis

formalwithdrawalprogram
23・Thepatienthadrecovered丘omalmostallofhispostdrugtreatment

SymPtOmSWithinthefirstyearofcessationwiththeexceptionofsome
residualanxietycomplaints，namelypanicattacks

24・Thepatient，sorlglnalcomplaintonpresentgtionbackinJapan，namely
dizziness，alsobegantOimprovesignificantlyforthefirsttimefo110wlng

COmPletecessationofthedrugreglme
25・Thepatient，soverallmentalandphysicalwe11beinglmPrOVedfollowlng
COmPletecessationofBenzodiazq）lneS

2．3

DSMIVTRCriteria
Aspreviouslymentioned，thecriteriaweusedtodiagnoseWayne，sBenzodiazeplne

dependenceisthatusedbytheAmericanPsychiatricAssociation，namelythe

DSMIVTR．TheDSMIVTRhas7Criteriaofwhich3needtobemetfora
diagnosisofsubstanCedependencetobedetermined．These7Criteriaareas
fbllows：

1・HasthisperSOndevelopedtoleranCetOBenzodiazeplneS？
2・HasthispersondevelopedwithdrawalSymptomstoBenzodiazqplneS
3・Wasthesdbstance（Benzodiazq）ines）takeninlargeram0untSOrOVerlonger

Periodsthanintended？
4・DoesthispersonhaveapersistentdesireormadeoneormoreunSuCCeSSful
effbrtstqCutdownOrCOntrOluse？
5・WasagreatdealoftimespentinactivitiesnecessarytogetBenzodiazeplneS，
takeBenzodiazeplneSOrreCOVeryfromitse脆cts？
6・HasthispersonreducedotheractivitiesasaresultoftheirBenzodiazeplneuSe？

7・HasthispersoncontinuedBenzodiazeplneuSedespiteproblemscausedbyor
exacerbatedbyuse？

Ofthe7Criteriaabove，Waynemetnumbers：1，2，4，6，7above，in0therwords，Waymemet50utOfthe7Criteria，forwhichonly3needtobemetinorderto
determinedependence．

1．Tolerance

ToleranCeWaSevidentinthefactthatWaynereportedsomesettlingofhis
SymPtOmS（1・4・5，Pg6），butsoonafterwardshissymPtOmSStartedtoretumalong

withtheothers（1・4・6，Pg6）・There−emergenCeOfsymPtOmSinthiscaseis
COnSistentwiththefactthathemetthecriteriafortolerance．
Drugdq）endence，OrinWayne，scase，Benzodiazepinedependenceisrelatedto

ChromicongoingdruguSe，WhichresultsinanalteredneurophysiologiCalstatethat
developsasaresultoftoleranCe．

−12−

ToleranCeisdeBnedasHthereductioninresponsetoaglVendoseofadrugaRer
repeatedadministrationsH・Thee脆ctsassociatedwithtoleranCeareeVidentinthe

directioncounteractingtheacutedrugeffbctstomaintainsystemlevelhomeostasis
intheindividualconcemed．

NB：ToleranCeCanbeformedinaslittleas4weeksonhigherdosesof
BenzodiazepinesandwiththerapeuticanXiolyticdoses（upto40mgsDiazepam

dailyequivalent）signi且Cantd印endencecanoccura鮎rfourtosixmonthsofdaily
dosing（TextbookofsubstanCeal）uSetreatmentSeCOndedition，Principlesof
addictionmedicinethirdedition）・lWayne，shistoryindicateshewasprescribed

therapeuticdosesofBenzodiazepinesforlongerthan6monthS）

2・WithdrawalSymPtOmS
AshighlightedbyDickensonetal（ManagementOfsedative−hypnoticintoxication
andwithdrawalinASAMPrinciplesofaddictionmedicine）；

aWithdrawal

Syndromecanfollowdiscontinuationofshortterm（2to3monthS）lowdose
therapeuticusebutmostsymptomsifpresentatall，areratedasmildandareeaSily

managed・Ondiscontinuationoflong−term（1year）therqpeutic（lowdose）us？，

WithdrawaliscommonandisaccompaniedbymoderatetoseveresymPtOmSln
20％tolO0％ofpatients．

hWayne，scase，aShehadbeenprescribedBenzodiazeplneSOngOlngforalmostlO
monthsbythetimehewasreviewedatourservice，itwasverylikelythathewould

havehadwithdrawalsymptomssimplybasedonthelengthoftimehewas
PreSCribedBenzodiazeplneSfor．

Waynemetthecriteriaforwithdrawal，Whichwasmadeevidentbythefollowlng
SymPtOmSWhichemergedduringthecourseofhistreatment，Orinitiallygotworse
Onreductionofhisoveralldose：

1・Tinglingsensationoverface
2．

Lossincoordination

3・

MyoclonlCjerks

4・Oilysmellinbodyodour
5・Increasedjointpains

6・Tighteningofmuscles
7・

WorsenlngOfdizziness

8・WorsenlngOfpulsatingtemporalarteries
9・WorsenlngOfvisualdisturbanCeS

lO・hcreaseinemotionalinstability
11・Increasedpalpitations

12・Tighteninginchest
13．Flushing
14・Hypersensitivity

ー13＿

4．LossofControI

WaynemetthecriteriaforlossofcontrolorunsuccessfulattemptstocutdownOr
COntrOlhisuse・Thiswasevidencedbythehistoryofunsuccessfulatternptstocut

downhisBenzodiazepineuseonhisown（1・2．7，Pg2），Whichremained
unsuccessfu1untilhesoughthelpinaformalwithdrawalprogramfromo。rService．

6・ImpactonLife
FollowlngthecommencementofBenzodiazeplneS，Wayneexperiencedanumber
Ofsignificantimpactsonhislifb，Whichincludedthefollowlng：

1・Lossinabilitytowork（over14months）
2・Relationshipdi餓culties，includingfamily，friendsandromance
3・Lossinabilitytotakepartinrecreationalactivities

4・Lossinabilitytosocialize

BasedontheaboveWaynemetthecriteriaforimportantSOCialoccupational
recreationalactivitieshavingbeenreducedduetohisBenzodiazeplneuSe．

NB：IunderstandthatWaynehasco叩rehensiveinformationregardinghishistory

Ofdifncultieswithoccupationalandrecreationalactivitiesduringtheperiodthathe
WaSPreSCribedhisBenzodiazeplneS・Furthermore，Iunderstandtheabovei叩aCtOnWayne，slifbhasbeencon丘rmedby
SeniorClinicalPsychologist，Dr・AlanGuy，WhohasbeenassessingWayne
PeriodicallysincehisinitialassessmentbackinAugust2001（referDr・AlanGuy，sletterdated27thApri12007）．

7・ContinuedUseDespiteKnowledgeofHarm

WeknOwWaynewasawarethathisconditionwasdeterior

WaSmakinglistsofnewsymPtOmSandhandingthem ミラこ≡二二十

hefactthathe

FurthermOre，Waynemade3attemptstoreducethedrugreglme，butfoundhimself
COntinulngtOtaketheBenzodiazeplneSthatwereprescribedforhim，despitetheknowledgethattheycouldpossiblybeharminghim．

Therefore，Waynealsomeetsthecriteriaforcontinuedusedegitepersistentor
recurrentpsychologicalproblemsduetohisuseofBenzodiazepmes．

NB：ThesesymPtOmSdidnotstarttoremituntilWaynesuccessfullywithdrewfiom
hisBenzodiazeplneSandhiswithdrawalsymPtOmSbegantosettle．

−14−

2．4

ICD−10Criteria

Altematively，iftheICD−10CriteriafordiagnosingBenzodiazq）inedependence（recommendedbytheWorldHealthOrganisation）isqpplied，WeCanSeethat

Waynealsometthecriteriaforthisaswell．
Asde血edbytheICD−10，thediagnosisofdependencylSmadeif30rmOreCriteria
aremet・lfonereviewstheICD−10CriteriaonecanseethatWaynemetthe

払uowhg：
1・DifncultiesincontrollingthesubstanCeintermsofitstermination．As
discussedabove，Waynehaddifficultyreducingandstoppinghis

BenzodiazeplneSOnhisownwithoutmedicalassistanCe．

2・AphysiologiCalwithdrawalstate，aSdescribedabove．

3・WaymehadevidenceoftoleranCeaSdiscussedpreviously・

4・Waynealsoneglectedhisaltemativepleasuresorinterestthathegotfromlife．

Thisisevidentinhispersonalstatementwherehedescribeswithdrawalandhis
Biends，reportsthatheappearstobelosingpleasure丘omlife．

5・HealsometthecriteriawithpersistingwithuseofBenzodiazeplneSdespite
evidenceofharmfu1consequences・

NB：AsWaymemet50ftheCriteria，heclearlyalsomeetstheICD−10Criteria
for郎SubstanceDq，endenceSyndrome的・

−15−

2・5

9i飴rentialDiagn型！旦

2・5・1Anxiety

BenzodiazeplneSareknOwntocausetheverysymptomsthattheyare
designedtotreat；i・e・anXietyrelatedsymPtOmS．ThisisduetotoleranCeand

SubsequentbreakthroughsymPtOmS・

Waynehadnopriorhistoryofsu脆ringfromananXietydisorder，WhichhasbeensupportedbyDr・terHaar，sletter，dated19thOctober2006．Hedid

experiencesomemildstresssymptomsatastressfuljobaroundOctober
1999，butthesemostlydisappearedaRerhechangedjobsafewmonthslater．

Inmyprofessionalopinion，theanxietysymptomsthatWaymedeveloped

followinghisBenzodiazepinebaseddrugtreatmentwerelikelytobethe
resultofBenzodiazepinedqpendence・

2・5・2

PreviousE脆ctsofTobacco，AIcoholandMarijuana

AsprヲViouslyoutlined（articlesl・2・3＆1・2・4，Pg2），WeknowthatWayne
experlmentedwithtobacco，drinkingandcannal）isduringhisteenageyears．

ThecurrentresearchtosuggesttheseareagatewaydrugtOOngOingfurther
SubstanCeuSeisnotyetconclusiveeitherway・

InWayne，SsituationtheyareunlikelytobegatewaydrugSaSWayne
OtherwisehadnootherPsycho−SOCialriskfactors（egpeergroup，his
PrOfession，familyhistoryofsubstanCeuSeetC）thatwouldmakeitmore
likelyofhimtodevelopsubstanCed甲endencies・

Furthermore，hallucinogenflashbacksymptomsarenotproventooccurinthosewhohavepreviouslyusedcannabisandceaseditsuse．

−16−SeetionThree
3．FormalReductionProgram

3．1

GeneralReductionHistorv

3・1・1孟…霊霊宝芸濃慧三笠意芸諾2品慧芸詰器芸慧冨
toourDetoxNumeandsubsequentlythefollowingdaytome．Hewas

refbrrdforassessmentforhisBenzodiazepinedependencewithaviewto
Subsequentreduction．

NB：AspartoftheevaluationprocessWaynewasalsoassessedbyaSemior
ClinicalPsychologist，Dr．AlanGuy，WhoIunderstandhasalsoprovided
reportsforWayne

3．1．2

scase・

BreakdownOfDosagesDuringReduction
PeriodObseⅣ1ng Doctor

9April Mid April， 2001

MidApril 30April

30April
〜5May

5May

Dmg

Dose （mg）

Dr． Wもitwell

Clonazepam

1．0

Dr． Whitwell Dr．Judson

Clonazepam

0．5

Dr．Judson

Clonaz甲am

0．25

WithdrawalSymptoms

WorsenlngOft

1．Dizziness 2．Pulsatingtemporal a鵬eries

Dr．Judson

Clonaz甲am

01．Sometighteningln
muscles 2．Tinglingsensationover 払ce 3．Increaseinemotional instal）ility 4．WorsenlngOfvisual disturbanCeS 5．Slightlos in CO rdination 6．Myoclonicjerks 7．Increasedjointpains 8．0ilysmel inbodyodour 9．Generalinitialworsenlhg OfwithdrawalsymPtOmS Outlinedonpage13．

−17−

3・1・3

AtpresentationitwascleartousthatWaynedidnotunderstandaboutthenatureofthedrugShehadbeenprescribed，includingwhattheyare
nomallyusedbr．

3・1・4

Wayne，OnPreSentation，hadcorpprehensivedocumentationregardinghis

historyandpresentedittobothmyselfandtheDetoxNurse．Pointsofnote
inthishistorylnCludethatWaynereportedthefollowlngSymPtOmS：

1・Palpitations

2．Tightnessinthechest
3．Flushes

4・StomachpainS
5．PareSthesia

6．VisualdisturbanCeS
7．Anorexia

8・Episodesofemotionalinstability

3・1・5

0npresentationtousWaynewasbeingprescribedClonazepamO・5mg

tabletsonetwicedaily・Waynehadselfreducedthisinthepreviousweekto
O・5mgtablets，halfatablet，tWiceaday・Hehadreportedthathewasfbelinglousyatthatstageandwasencouragedtostayonthisdoseuntilhecould
rea句usttothislevel．

3・1・6

ThroughoutthereductionprogramweendeavouredtogiveWayneallofthe

adviceandsupportheneededtohelphimcopewithhiswithdrawal．This
included；theprovisionofinformationonBenzodiazeplneS，PraCticaladvice
Onreduction，dietaryandnutritionaladvice，lifbstyleadvice，etC．

NB：ThiswasthefirsttimeWaynerealizedthat，nOtOnlyare
BenzodiazeplneSaddictive，theyalsohavenumerousuntowardside−e飴cts．
Subsequently，Wayneexpressedstrongfbelingsofin3usticetowa，dsDr．

1−andhedemonstratedastrongdeteTinationtodistanCehimself
Permanently丘omtheuseofBenzodiazeplneS．

3・1・7IreviewedWayneon30thApri12001andatthatstagehehadreducedhis

Clonaz甲amtOOnehalfofaO・5mgtablettakeninthemomlng・Waynehad
noticedtheworsenlngOfsomeofthesy叩tOmSthattheClonaz印amWaS

initiallyprescribedfor，namely：

1．Dizziness

2・Pulsatingtemporalarteries．

一18−

3・1・80n21StMay2001WaynehadbeenBenzodiazepinefteefor16days・He

hadreportedatthisstagethathissleephadgenerallybeengoodex呼tfor
thedaybefore・HealsoreportedthefollowlngSymPtOmS：

1・Sometighteninginhismuscles
2・Tinglingsensationoverhisface
3・Increaseinemotionalinstability

Accordingly，thenatureofwithdrawalsymPtOmSWaSgenerallydiscussed
Withhimagainatthispoint・

3・1・9

WaynewasadditionallyworriedabouthisvisualsymPtOmS，Whichhad

WOrSened，anditwassuggestedtohimthatheseehisGPforacheckupln

CaSeOfanyotherunderlyingpathologycauslngthevisualsymptomsher甲Orted．

3・1・10Waynewassubsequentlydischarged丘omourServiceandreferredbacktohisGP，Dr・Whitwell，aShehadsuccessfu11ybecomeBenzodiazq，inefree．

3・1・llIngeneral，Waynemadeexcellentprogressinhiswithdrawalfrom
BenzodiazeplneS，althoughalittlequickerthanIwouldhaverecommended，

butwellwithinasafblevelofreduction．

ー19−

Summary

Insummary，Wayne，Spresentationwasconsistentwiththatofadiagnosismeeting

Benzodiaz甲inedq）endenceintermsofboththeICD−10criteriaandtheDSM−IVTRcriteria．

Basedontheabovetogetherwiththeoverallclinicalpicture，inmyprofessionaloplnlOn，Wayne

WaSindeeddependenttotheBenzodiazepinesthatwerehstprescribedtohimbyDr．−on5血July2000andthathehassu脆redasaconsequenceofthatdq，endence．

ー20−