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Non-benzodiazepines, including zolpidem, zaleplon, and eszopiclone (Z-drugs), have clinical effects similar to BZDs but are more prone to misuse and dependence (Borland & Verduin, 2022). Anxiolytics or sedative-hypnotics drugs can be viewed on a continuum based on sedating properties of the class. Physical and psychological dependence does and occurs, and all have withdrawal symptoms. Alcohol and other drugs in this class have additive effects (Boland & Verduin, 2022). The essential features of this drug class are maladaptive behavioral or psychological changes. Memory impairment causes anterograde amnesia similar to blackouts (Boland & Verduin, 2022).

FDA Approved Benzodiazepines Generic Trade

Indication

Alprazolam

Xanax

Anxiety, panic disorders, agoraphobia

Chlordiazepoxide Librium

Alcohol withdrawal syndrome Panic disorder and agoraphobia; myoclonic and absence seizures

Clonazepam

Klonopin

Quazepam

Doral

Chronic insomnia

Temazepam

Restoril

Onset and sleep maintenance in insomnia Alcohol withdrawal management

Diazepam

Valium

Lorazepam

Ativan

Anxiety disorders

Midazolam (in- patient)

Versed

Procedural sedation

Triazolam

Halcion

Sleep onset in insomnia

(Bounds & Nelson, 2022)

Sedative, hypnotic, or anxiolytic intoxication Common sedative, hypnotic, or anxiolytic doses can lead to intoxication during or shortly after use. Clinically maladaptive behavior or psychological changes can lead to ● Drowsiness or sedation

● Impaired cognition ● Stupor or coma

Healthcare Consideration: In an emergency setting, treatment for benzodiazepine and barbiturate intoxication is primarily supportive. However, in cases of severe benzodiazepine intoxication, particularly if the patient is becoming hypoxic, flumazenil may be administered (Jahan & Burgess, 2022). The common adverse effects of BZDs include respiratory arrest, drowsiness, confusion, headache, syncope, nausea/ vomiting, diarrhea, and tremors (Bounds & Nelson, 2022). CNS adverse effects include euphoria, diplopia, ataxia, and cognitive impairment with long-term use. BZDs are contraindicated in angle-closure glaucoma and have a black box warning with concomitant use of opioids which leads to severe respiratory depression, coma, and death (Bounds & Nelson, 2022). Several groups are at high risk for abuse; caution is essential when prescribing. Individuals who consume large amounts of alcohol often present for the treatment of anxiety and insomnia, and there is a high likelihood of abuse (Ciraulo, 2014). Polysubstance use frequently involves benzodiazepines, especially in methadone clinics. Individuals self-medicate for insomnia, anxiety, and withdrawal; additionally, benzodiazepines increase the hedonistic effects of methadone (Ciraulo, 2014). Older individuals utilize benzodiazepines more than younger individuals. The most significant concern in this population is the risk of falls and cognitive impairment, which is not recommended according to Beers’ Criteria (Ciraulo, 2014).

● Slurred speech ● Incoordination ● Unsteady gait ● Nystagmus

Sedative, hypnotic, and anxiolytic withdrawal The severity of withdrawal varies with dose and duration; however, it can occur with short-term, relatively low-dose BZDs (Boland & Verduin, 2022). Withdrawal symptoms include ● Autonomic hyperactivity (diaphoresis, tachycardia) ● Hand tremors ● Insomnia ● Nausea/vomiting ● Transient visual, tactile, or auditory hallucinations ● Psychomotor agitation ● Anxiety ● Grand mal seizures Deprescribing benzodiazepines is an essential clinical skill and the first goal of treatment in detoxification (Drugs.com, 2022). Specific individuals may not require long-term BZDs. When deprescribing BZDs, consider the duration of treatment, dose, and half-life of the BZD. Consider a taper over several weeks or months. Switching to a long-acting BZD is effective for an individual with serious abuse problems. Tapering is effective in long-active benzodiazepines but not as effective in short-acting benzodiazepines. Example: An individual taking a BZD for 12 weeks tapers 10-25% per week (PsychDB, 2021).

STIMULANT RELATED DISORDERS

Stimulant use disorders include a range of issues related to illicit cocaine, methamphetamine, and ecstasy as prescription stimulants, including methylphenidate and amphetamine. Approximately 5 million individuals misused prescription amphetamines ages 12 and older (Jones et al., 2020). Stimulant

use and disorders are associated with physical, psychological, and societal harm. Acute adverse effects can cause acute conditions, including tachycardia, vasoconstriction, and bronchodilation, as well as hyperthermia. Psychological and neurological effects include panic attacks, hostility, paranoia,

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Book Code: AUS3024

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