Because of the wide range of drugs in this use disorder, it is difficult to describe a singular, typical user. While they can be used alone, they are more frequently abused in concert with other substances. Combining them with alcohol and opiates intensifies the desired high, while stimulant users often add benzodiazepines to their regimen to reduce the agitation that comes with stimulants. Elderly patients are frequently prescribed benzodiazepines to help with sleep, and patients often leave intensive care settings on high doses as well. This category also includes the so-called ‘date-rape drugs’, which sexual predators use to incapacitate unsuspecting victims.
But what do they all have in common? The drugs in this use disorder are commonly called “central nervous system depressants”. They slow brain function, promote muscular relaxation and sleep, decrease anxiety, and treat seizures by boosting the effects of GABA, the main inhibitory brain messenger. Because these drugs share their mechanism of action with alcohol, intoxication results in similar symptoms, such as slurred speech, difficulty walking, slowed reaction time, decreased reflexes, impaired thinking, reduced inhibitions, and stupor. However, the drugs’ effects are often distorted because they are mixed with other substances.
While benzodiazepines are quite safe alone, combination with alcohol or opiates can easily lead to respiratory depression, coma, and death, and the causative doses are variable and unpredictable. In the elderly, even moderate benzodiazepine doses can mimic dementia by impairing thinking and memory, as well as increasing risk of falls (and subsequent high-risk trauma like hip fractures). Most episodes of severe toxicity from sedatives are actually instances of attempted suicide, and most of those involve benzodiazepines because those are the most readily available sedatives.
Older sedatives, like barbiturates, Quaalude (methaqualone), Miltown (meprobamate), and GHB (gamma-hydroxybutyrate), are much more toxic alone than benzodiazepines. They have a lower threshold for interfering with breathing and motor control, and causing dangerously low blood pressure. GHB and the now-illegal benzodiazepine, Rohypnol (flunitrazepam), are the most well known ‘date-rape drugs’, which sexual predators slip into the drinks of unknowing victims to rapidly induce deep sedation and amnesia. GHB is especially dangerous as it can induce muscle spasms, heart rhythm abnormalities, and coma, sometimes necessitating intensive care monitoring.
Causes and Risk Factors
Who uses these drugs?
Sedatives are some of the most commonly used drugs in the U.S., with over 12% of the population receiving a prescription in a given year. There are two distinct patient groups in this use disorder, those who started taking them under a physician’s supervision and those who used them recreationally from the start, with the second group being the more common case. While there are plenty of people who take these drugs for valid medical reasons (anxiety, insomnia) and do not develop a use disorder, the risk increases with short-acting medications and in patients coming out of intensive care settings where they received frequent high doses.
Patients who have always taken them illegally mostly start in late adolescence. They use them occasionally at first, in addition to other substances, and then slowly progress to heavier use.
Compared to people who begin illegally using prescription drugs after age 21, those starting prior to age 13 are two and a half times as likely to develop a use disorder.
Perils in old age
One subset of those at high risk is the elderly, who frequently receive these medications to treat insomnia. They metabolize the medications slower and develop physical dependence easier. This is a risk factor for developing a use disorder. Rather than attempting to get ‘high’ (as is the case with younger people using sedatives recreationally), the elderly suffer a combination of the biological realities of advanced age and interactions from their multiple other medications.
Patients who abuse multiple drugs are at high risk for abusing sedatives. One third of opiate abusers (usually methadone) combine them with benzodiazepines because the resulting ‘high’ far exceeds that of either drug alone. Heavy drinkers are also at high risk for abusing these drugs. They are frequently prescribed these medications for anxiety and insomnia related to drinking (by unknowing physicians). They report more powerful effects than the general population, likely due to the similar mechanisms of action.
Diagnosing Sedative, Hypnotic, and Anxiolytic Use Disorder
What are all these drugs?
Drugs in this use disorder are usually taken orally, as tablets or liquids, or crushed and snorted. Benzodiazepines are a large class including drugs like Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), Klonipin (clonazepam), and Librium (chlordiazepoxide). They are used to treat anxiety, insomnia, and seizures. Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon), which work similarly to benzodiazepines, aid in sleep disorders as well.
Barbiturates, like Amytal (amobarbital) and Seconal (secobarbital), also treat anxiety, insomnia, and seizures, but are much less common since being replaced by safer benzodiazepines in the 1970s.
Rounding out the drugs in this disorder are Quaalude (methaqualone), Miltown (meprobamate), and GHB (gamma-hydroxybutyrate), all of which have similar effects to benzodiazepines, but abuse of these is far less common now. They have fallen out of favor in medical practice because of their much more dangerous side effect profiles and consequently are very hard to find.
Diagnosis requires at least two symptoms over the course of one year. Patients exhibit the following behaviors:
- Take large doses of sedatives, hypnotics, and anxiolytics, or take them beyond the time prescribed
- Want or try to cut down, but can’t
- Make a full-time job out of finding, using and recovering from sedatives, hypnotics, and anxiolytics
- Crave sedatives, hypnotics, and anxiolytics or fight strong impulses to use them
- Shirk responsibilities at home, work or school
- Suffer socially and in relationships because of their sedative, hypnotic, and anxiolytic use
- Abandon once-important social, career, or leisure activities
- Risk life and limb under the influence of sedatives, hypnotics, and anxiolytics, such as when driving a car or operating machinery
- Don’t care that their drug use is harming their physical or mental health
- Need increasingly large doses to achieve the desired effect (and can’t get it on a lesser dose)
- Undergo withdrawal (nausea, vomiting, tremor, increased heart rate, hallucinations, difficulty sleeping, anxiety, psychomotor agitation, seizures) when they stop using sedatives, hypnotics, and anxiolytics, or use just to avoid the symptoms of it
Increasing numbers of symptoms determines the severity of the disorder. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more. Patients are in early remission if they have had none of those criteria for at least three months and not more than one year. Late remission extends beyond one year.
Treating Sedative, Hypnotic, and Anxiolytic Use Disorder
Withdrawal like alcohol
Because the effects of these drugs on the brain are similar to those of alcohol, the first step in treatment is seizure prevention during withdrawal. In heavy users, doses need to be slowly weaned down over several days with phenobarbital (a sedative chosen for its long period of action) in a hospital setting.
In mild cases, patients can detox in the outpatient setting using the long-acting benzodiazepine, clonazepam, over several weeks. In these cases, the addition of non-habit forming anticonvulsants like Tegretol (carbamazepine), Neurontin (gabapentin), and Topamax (topiramate) also shows promise in aiding detoxification. A study showed that adding Tegretol to a benzodiazepine taper significantly increased the chance of attaining and maintaining abstinence at least 5 weeks after the taper was completed. There is also some evidence that adding Topamax can reduce the symptoms of benzodiazepine withdrawal.
Romazicon (flumazenil) rapidly reverses the effects of benzodiazepines and can be life-saving in acute overdoses. However, if the patient is a long-standing user of benzodiazepines, Romazicon can induce seizures and should not be used. Overdoses of barbiturates require a special medication called sodium bicarbonate. This accelerates the drug’s excretion through urine, and severe cases may need temporary dialysis.
When patients who were prescribed benzodiazepines for anxiety were slowly transitioned to Lyrica (pregabalin), as part of detoxification, patients experienced fewer problems with sleep. Furthermore, Lyrica during detox cuts both anxiety and depression rating scores in half. If patients had received benzodiazepines as a sleep aid, melatonin can significantly improve sleep during and after detoxification.
Cognitive Behavioral Therapy
Patients often receive CBT as part of detoxification because of its success in treating anxiety. It is also helpful in patients who were taking these drugs for insomnia. In patients with Panic Disorder, the addition of CBT to benzodiazepine taper tripled the rate of successful detoxification compared to taper alone. However, in patients without an anxiety disorder, the few studies examining CBT’s efficacy show little added benefit from CBT.
Managing Sedative, Hypnotic, and Anxiolytic Use Disorder
Get help getting started
Patients who are avoiding treatment for financial reasons should be assured that detoxification can be relatively inexpensive because most people will not need to stay in the hospital. Weaning doses of benzodiazepines can be prescribed from the office of any general practitioner or psychiatrist. Patients should not attempt to stop alone or all at once. Because of the seizure potential when withdrawing from these drugs, it is critical that detoxification be conducted under a physician’s direction.
Options for free group-oriented support include Narcotics Anonymous and the more recently founded Pills Anonymous, which focuses specifically on those who abuse prescription medications.
Don’t neglect the original problem
In cases where patients started benzodiazepines for legitimate medical reasons like anxiety or insomnia, those conditions should be addressed as part of treatment. Failing to treat the original condition will hamper progress in recovery. Even if this is not the case, anxiety commonly presents a significant barrier during detoxification, and appropriate anxiety treatment increases chances of successful recovery.
Sedatives and the elderly
If you have an elderly loved one who is having memory and cognitive issues or has had a recent fall, rule out sedatives as a possible culprit medication before going forward with a workup for dementia or misattributing the nature of a fall.