drugs decrease activity diminishes excitement, and calm the individual (Mihic & Mayfield, 2023). Sedatives are often used to alleviate unwanted side effects of other substances (APA, 2013). Hypnotic drugs produce drowsiness and facilitate the onset and maintenance of sleep that resembles electroencephalography where the individual is easily aroused (Mihic & Mayfield, 2023). The usual course of these disorders begins in the teens or 20s, with social patterns, moving into daily use with high tolerance levels (APA, 2013). A less frequent pattern begins with prescription use and reports of anxiety, insomnia, or other complaints (APA, 2013). Individuals demonstrating a problematic pattern of substance use that leads to significant impairment as manifested by two or more criteria over a 12-month period meet the criteria for sedative, hypnotic, or anxiolytic use disorder: 1. Sedatives, hypnotics, or anxiolytics often taken in larger amounts or over a longer period than was intended. 2. A persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use. 3. A great deal of time spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic or to use, or recover from the sedative, hypnotic, or anxiolytic. 4. Craving or a strong desire or urge to use the sedative, hypnotic, or anxiolytic. 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedative, hypnotic, or anxiolytic. 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic. 8. Recurrent sedative, hypnotic, and anxiolytic use in situations in which it is physically hazardous (driving, operating machinery). 9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic. 10. Tolerance: a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of sedative, hypnotic or anxiolytic. 11. Withdrawal: a. Characteristic withdrawal syndrome. b. Sedatives, hypnotics, or anxiolytics are taken to relieve or avoid withdrawal symptoms. (APA, 2013) Benzodiazepines (BZDs) are one of the most widely prescribed drug classes in the United States, known for depressant effects on the central nervous system (Edinoff et al., 2021). BZDs are Federal Drug Administration (FDA) indicated for anxiety disorders, insomnia, acute status epilepticus, induction of amnesia, spastic disorders, and agitation (Edinoff et al., 2021). Non-FDA-approved indications include Tourette’s syndrome, delirium, delirium tremens, sleep disorders, and abnormal medication movements (Edinoff et al., 2021). Barbiturates were popular before the introduction of benzodiazepines. Pentobarbital and secobarbital have short half-lives and are lethal, producing coma and death. Barbiturates produce profound respiratory depression, especially when added to another substance. These drugs are not widely utilized. Individuals with sedative-hypnotic or anxiolytic disorders are frequently treated in the outpatient setting as the overall stability requires less monitoring.
FDA Approved Benzodiazepines
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 eszopiclone (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 continuum 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 similar 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 behavior or psychological changes can lead to: ● Drowsiness or sedation. 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; 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 important clinical skill and the first goal of treatment in detoxification (Drugs.com, 2022). Certain individuals may not require long term BZDs. When deprescribing BZDs, consider duration of treatment, dose, ● Slurred speech. ● Incoordination. ● Unsteady gait. ● Nystagmus. ● Impaired cognition. ● Stupor or coma.
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Book Code: DFL3024
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