Benzodiazepines (Schedule IV) are prescribed for short-term use as anxiolytics and for insomnia. Benzodiazepines include: 58 ● alprazolam ● chlordiazepoxide
carisoprodol, or barbiturates, can cause significant morbidity and even death. 59 Acute withdrawal symptoms with sedative-hypnotics can include anxiety, tremors, tachycardia, fever, hypertension, insomnia, seizure, and delirium. 59-61 Scheduled sleep medications include zaleplon, zolpidem, and zopiclone (Schedule IV), known as “Z-drugs,” and brivaracetam, ezogabine, and lacosamide (Schedule V). Like benzodiazepines, Z-drugs enhance the effect of GABA, the major inhibitory neurotransmitter. Evidence shows they have reinforcing effects and carry risks for abuse potential, tolerance, physical dependence, and subjective effects. 62 While Z-drug addiction is uncommon, the risk increases at higher doses and in patients with an SUD history. 62 Z-drugs can cause withdrawal symptoms if abruptly discontinued after prolonged use. Side effects include nightmares, agitation, hallucinations, dizziness, daytime drowsiness, headache and gastrointestinal (GI) problems. Barbiturates include amobarbital, pentobarbital, phenobarbital, secobarbital, and tuinal. Some are very short-acting drugs with effects lasting only a few minutes while others may have effects that last up to 2 days. 63 Barbiturates have a history of medical uses as sedative-hypnotics for insomnia and anxiety but also have a history of recreational misuse and a narrow therapeutic index. 64 Current medical indications largely center on preoperative sedation and antiseizure, and misuse has dropped in recent decades as barbiturates have been largely replaced in practice by benzodiazepines. 64 With misuse at low doses, people feel drowsy, disinhibited, and intoxicated; at higher doses, they begin to stagger and develop slurred speech and confusion, possibly resulting in coma and respiratory depression leading to death. 63 Withdrawal symptoms include difficulty sleeping, agitation, tremor, hallucinations, high temperature, and seizures.
● clonazepam ● clorazepate ● diazepam ● estazolam ● flurazepam ● lorazepam ● midazolam ● oxazepam ● temazepam ● triazolam ● quazepam
Benzodiazepines appear to affect neurotransmitters in the brain, in particular, enhancing gamma-aminobutyric acid GABA with the effect of reducing anxiety. 58 Onset and duration of action vary among benzodiazpines. 58 Prescriptions for benzodiazepines have increased along with involvement in overdose deaths. 50 An FDA boxed warning details the risks of prescribing opioids and benzodiazepines together, a combination of medications that has increased in recent years but which is associated with extreme sleepiness, respiratory depression, coma, and death. 20,33 The CDC recommends against combining these 2 medications whenever possible but allows for rare instances when the combination may be indicated (e.g., severe acute pain in the presence of long-term, stable, low- dose benzodiazepine therapy). 13 The Department of Veterans Affairs/Department of Defense (VA/ DoD) practice guideline lists concomitant use of benzodiazepines as a contraindication to initiating a trial of long-term opioid therapy. 33 Benzodiazepines should be stopped gradually and perhaps with the help of a specialist. Abrupt cessation with not only benzodiazepines but also baclofen,
HALLUCINOGENS: LIMITED MEDICAL USES
Hallucinogens are synthetically made or plant-based and are marked by sensory and psychic effects that include perceptual distortions. 65 Physiological effects of the class can include elevated heart rate, increased blood pressure, dilated pupils, nausea, and vomiting. Medical research into the use of Schedule I hallucinogens has been increasing. Most are drugs that are used recreationally (e.g., hallucinogenic mushrooms, LSD, and MDMA or “ecstasy”). Few have medical indications with a notable exception being ketamine, a Schedule III drug with accepted medical uses for short-term sedation and anesthesia. 66 Ketamine is a dissociative anesthetic, distorting sight and sound and giving the patient a sense of
detachment from pain and the environment. For this reason, it has been researched as a treatment for some types of intractable pain. In addition, the FDA has approved a nasal spray version of the S(+) enantiomer of ketamine (esketamine) for treatment- resistant depression that is only available at a certified doctor’s office or clinic. 66 Ketamine misuse may lead to moderate or low physical dependence or high psychological dependence. Overdose can occur with ketamine and when serious can lead to respiratory depression, coma, convulsions, seizures, and death due to respiratory arrest. 66
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Book Code: TN24CME
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