FDA Approved Benzodiazepines
Healthcare Considerations: In an emergency setting, treatment for benzodiazepine and barbiturate intoxication is primarily supportive. In cases of severe benzodiazepine intoxication, particularly if the patient is becoming hypoxic, flumazenil may be administered (Jahan & Burgess, 2022). Sedative, hypnotic, and anxiolytic withdrawal The severity of withdrawal varies with dose and duration; howev- er, 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 important clinical skill and the first goal of treatment in detoxification (Drugs.com, 2022). Certain individuals may not require long term BZDs. When depre- scribing BZDs, consider duration of treatment, dose, and half-life of the BZD. Consider a taper over several weeks or months. Of- ten switching to a long-acting BZD is an effective method in an individual who has serious abuse problems. Tapering is effective in cases of long active benzodiazepines, but not as effective in short-acting benzodiazepines. Example: An individual who has been taking a BZD for 12 weeks, taper for 10-25% per week (Psy- chDB, 2021). Common adverse effects of BZDs include respiratory arrest, drowsiness, confusion, headache, syncope, nausea/vomiting, di- arrhea, and tremors (Bounds & Nelson, 2022). Central nervous system (CNS) adverse effects include euphoria, diplopia, ataxia, and cognitive impairment with long-term use. BZDs are contrain- dicated 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 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 with- drawal; additionally, benzodiazepines increase hedonistic effects of methadone (Ciraulo, 2014). Older individuals utilize benzodi- azepines more than younger individuals. The greatest concern in this population is risk of falls and cognitive impairment and is not recommended according to Beers’ Criteria (Ciraulo, 2014).
Generic
Trade
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.
Note . Bounds & Nelson, 2022. Non-benzodiazepines including zolpidem, zaleplon, and eszopi- clone (Z-drugs) have clinical effects similar to BZDs but are more prone to misuse and dependence (Borland & Verduin, 2022). Anxiolytics or sedative-hypnotic drugs can be viewed on a con- tinuum based on sedating properties of the class. Physical and psychological dependence does occur, and all these drugs have withdrawal symptoms. Alcohol with other drugs in this class has additive effects (Boland & Verduin, 2022). The essential features of this drug class are maladaptive behavioral or psychological changes. Memory impairment causes anterograde amnesia simi- lar to blackouts (Boland & Verduin, 2022). Sedative, hypnotic, or anxiolytic intoxication Low doses of sedative, hypnotic, or anxiolytic drugs can lead to intoxication during or shortly after use. Clinically maladaptive be- havior or psychological changes can lead to: ● Drowsiness or sedation.
● Slurred speech. ● Incoordination. ● Unsteady gait. ● Nystagmus. ● Impaired cognition. ● Stupor or coma.
STIMULANT RELATED DISORDERS
Stimulant use disorders include a range of issues related to illicit cocaine, methamphetamine, ecstasy, as well as prescription stim- ulants, including methylphenidate and amphetamine. Approxi- mately 5 million individuals misused prescription amphetamines ages 12 and older (CDC, 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, hos- tility, paranoia, psychosis, and even violent behavior (SAMSHA, 2020). The highs and lows from these drugs create a binge and crash pattern (NIDA, 2019). Chronic stimulant use can alter brain structures with decreased attention span, confusion, impaired memory, inhibited impulse, and reduced motor skills (SAMSHA, 2020).
Stimulant Drugs by Schedules
Schedule I
Aminorex; methyl-aminorex; methcathinone, animal use only (3,4-Methylenedioxymethamphetamine) commonly known as MDMA. Amphetamines, dextroamphetamine; methamphetamine, methylphenidate; phentermine, cocaine. Clortermine, not currently in use Phendimetrazine, weight loss; benzphetamine, weight loss.
Schedule II
Schedule III
Schedule IV Schedule V
Diethylpropion, weight loss; Modafinil.
Pyrovalerone. Cocaine is a naturally occurring alkaloid obtained from the Eryth- roxylon coca shrub (Holstege et al., 2021). After its first use by an - cient Peruvians, Freud later proposed cocaine to treat depression, asthma, and cachexia (Holstege et al., 2021). Today, cocaine has
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