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Purpose: In benzodiazepine (BZD)-addicted patients, as in alcohol-dependent ones, the complicated withdrawal syndrome may be efficiently treated with accumulated long-acting benzodiazepine. The following work presents an alternative that can be used when the procedure fails. Case description: A midazolam-dependent patient (1500 mg/d) was admitted to the hospital due to a withdrawal-induced status epilepticus. After treatment with barbiturates and megadoses of diazepam, the seizures subsided, but during the continuation of BZD (diazepam, clorazepate), consciousness disorders gradually developed culminating in a full loss of contact with the patient. The breakthrough occurred when lorazepam was used instead of previously administered substitute BZDs. Comment: Extreme midazolam abuse (with a possible contribution of  barbiturates at emergency admission) induced hydroxylating liver enzymes. This meant a rapid conversion of nominally long-acting substitutes, as those are similarly metabolized. This extremely facilitated elimination hindered their accumulation to the needed satiation level. Lorazepam, short-acting but bypassing the accelerated metabolic pathway, at sufficient doses provided the satiation necessary to stabilize the patient.

Steering the pharmacological treatment along different metabolic pathways in response to outlying complicated benzodiazepine withdrawal – a case study