hypnotic, or anxiolytic use disorders are frequently treated in the outpatient setting. BZDs are Food and Drug Administration (FDA) indicated for a number of conditions such as anxiety disorders, insomnia, acute status epilepticus, induction of amnesia, spastic disorders, and agitation. Non-FDA-approved indications include Tourette’s syndrome, delirium, delirium tremens, sleep disorders, and abnormal movements associated with other medications. 37 Sedative drugs decrease activity, diminish excitement, and calm the individual. Sedatives are often used to alleviate unwanted side effects of other substances. Hypnotic drugs produce drowsiness and facilitate the onset and maintenance of a state of sleep that resembles natural sleep in its electroencephalographic characteristics and from which the recipient can be easily aroused. 35 These medications have varying mechanisms of action but generally exert their most significant effect on the central nervous system. They act by facilitating the binding of the inhibitory neurotransmitter GABA at various GABA receptors throughout the CNS. 36 Nonbenzodiazepines including zolpidem, zaleplon, and eszopiclone, referred to as Z-drugs, were developed as alternatives to BZDs and have clinical effects similar to BZDs but may be more prone to misuse and dependence. Anxiolytics or sedative-hypnotic drugs can be viewed on a continuum based on sedating properties of the class. Physical and psychological dependence does occur, and all have withdrawal symptoms. Alcohol take along with drugs in this class has additive effects. The essential features of this drug class are maladaptive behavioral or psychological changes. In some, memory impairment causes anterograde amnesia similar to blackouts . BZDs are contraindicated in angle-closure glaucoma and have a black box warning with concomitant use with opioids, which lead to severe respiratory depression, coma, and death. However, in a supervised setting, BZDs can be used to quell the significant anxiety associated with stimulant intoxication and opioid withdrawal. Sedative, hypnotic, or anxiolytic intoxication Relatively low doses of sedatives, hypnotics, or anxiolytics can lead to intoxication during or shortly after use. Patients should be monitored closely for signs of intoxication, which include the following: ● Drowsiness or sedation. ● Slurred speech. ● Incoordination. ● Unsteady gait. ● Nystagmus. ● Impaired cognition. ● Stupor or coma. Treatment of acute sedative intoxication and overdose is primarily supportive and requires close
Several groups are at high risk for abuse, and caution is essential when prescribing BZDs. Individuals who consume large amounts of alcohol often present for treatment of anxiety and insomnia, and there is an elevated likelihood of abuse of this class of drug. Individuals may self-medicate for insomnia, anxiety, and withdrawal. Additionally, benzodiazepines increase the hedonistic effects of methadone. 39 Older individuals are at unique risk of significant cognitive impairment while using benzodiazepines, which may lead to gait disturbances and sedation causing injury. A risk versus benefit analysis must be calculated when deciding to use BZDs in clinical scenarios. Table 3: FDA Approved Benzodiazepines 38 Generic Trade Common Indication Alprazolam Xanax Anxiety, panic disorders, agoraphobia Chlordiazepoxide Librium Alcohol withdrawal syndrome Clonazepam Klonopin Panic disorder and agoraphobia; myoclonic and absence seizures Quazepam Doral Chronic insomnia
Temazepam Restoril
Onset and sleep maintenance in insomnia
Diazepam Valium Alcohol withdrawal management Lorazepam Ativan Anxiety disorders
Midazolam (in-patient) Triazolam
Versed Procedural sedation
Halcion Sleep onset in insomnia
monitoring of hemodynamic and respiratory status and observation until the drug is fully metabolized. A reversal agent exists. Flumazenil is a benzodiazepine antagonist. It competitively inhibits the activity of benzodiazepine and nonbenzodiazepine substances that interact with benzodiazepine receptors site on the GABA/benzodiazepine receptor complex. It must be used with extreme caution to prevent acute precipitated withdrawal in the patient with sedative habituation. Complications may include intractable seizures. The use of flumazenil should be limited to those clinicians with familiarity with the drug.
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Book Code: MDCO1025
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