Benzodiazepine abuse
Benzodiazepine abuse refers to the misuse of benzodiazepines, which are sedative medications commonly prescribed for anxiety and other conditions. These substances exert their effects by enhancing the action of gamma-aminobutyric acid (GABA) in the central nervous system, leading to relaxation and sedation. While they can be effective for short-term relief of acute anxiety, they also carry the risk of dependence and misuse, particularly when used without medical supervision or combined with other substances like alcohol or stimulants.
Abuse can manifest in various forms, including taking higher doses than prescribed, using benzodiazepines without a prescription, and combining them with other drugs to amplify effects. Symptoms of acute abuse may include mood changes, confusion, and impaired coordination, while chronic misuse might lead to more serious issues like cognitive decline and withdrawal symptoms upon cessation. Risk factors for developing benzodiazepine use disorder include a history of substance abuse, long-term use of the medication, and combining it with other controlled substances.
Treatment for benzodiazepine abuse usually involves a gradual tapering of the drug to minimize withdrawal effects, and in some cases, long-term management strategies may be necessary to address underlying anxiety disorders. Prevention efforts focus on reducing the availability of benzodiazepines and promoting safer alternatives for anxiety management. Understanding the complex nature of benzodiazepine use and the potential for abuse is essential for both individuals and healthcare providers.
Benzodiazepine abuse
DEFINITION: Benzodiazepine abuse involves the misuse of benzodiazepine, an anti-anxiety sedative and a controlled substance, often leading to dependence or benzodiazepine use disorder (BUD).
Causes
Benzodiazepine is used as an anti-anxiety sedative because of its rapid inhibitory effect on nerve activity via gamma-aminobutyric acid (GABA) receptors in the central nervous system (CNS). Benzodiazepines provide relaxation and hypnotic effects therapeutically and can be misused to get high or to come down from the effects of stimulants. Benzodiazepine abuse may be acuteillegal use or accidental overdose from a prescriptionor chronicrepeatedly and deliberately combining with cocaine or alcohol to get high or to self-medicate during alcohol withdrawal. Also, chronic misuse of prescribed benzodiazepines by increasing the dose, duration, or number of prescriptions can result in drug dependency.
Although modern CNS agents for anxiety treatment, such as selective serotonin reuptake inhibitors (SSRIs), are available for long-term treatment of anxiety disorders. However, quick-acting benzodiazepines may be prescribed on an as-needed basis for sporadic anxiety-inducing circumstances to relieve acute anxiety. However, some research indicates that this combination may increase an individual’s chances of developing a benzodiazepine use disorder. Additionally, because these drugs have historically been widely available, individuals without prescriptions often easily access them. Some have been used as date rape drugs.
Risk Factors
Although benzodiazepines have lower abuse potential than older psychotropic drugs, opioids, and stimulants, benzodiazepines remain popular for abuse in combination. Benzodiazepines with rapid onset, such as diazepam, are the most likely to be abused, although short- or intermediate-acting agents, such as alprazolam or lorazepam, may be abused too. Longer-acting agents, such as clonazepam, are associated with fewer cases of rebound anxiety or abuse.
Longer duration of prescription use than four weeksand higher prescribed dosages either of greater content or multiple daily doses both increase the risk of physical dependence and withdrawal symptoms upon drug discontinuation. As tolerance develops to the prescribed dosages, abusive self-medicating behaviors, such as increasing the number of pills or increasing the times a pill is taken without consulting a physician, can occur.
Additional risk factors for abuse of a benzodiazepine prescription are combining controlled substance prescriptions, particularly prescribed drugs that have similar CNS activity, and having a history of legal or illegal drug abuse. For example, methadone users often combine diazepam with methadone to increase the effect of the latter drug.
Symptoms
Acute symptoms of benzodiazepine abuse or misuse are less likely to be fatal than benzodiazepine abuse in combination with alcohol. Prominent acute symptoms of abuse are mood changes, increased sleep with trouble awakening, unusual behaviors, and poor focus. With high doses, possible symptoms include confusion, blurred vision, dizziness, weakness, slurred speech, poor coordination, shallow breathing, and even coma.
Chronic symptoms of abuse are more difficult to identify. Signs of addiction to a prescribed product include requests for increased doses to provide the same anxiety-relieving effectsdrug toleranceand the use of multiple prescriptions and doctors for the same drugsdrug-seeking behavior. Persons who chronically abuse benzodiazepines may have a changed appearance, changed behaviors, or changed mood, and they may regularly display poor performance at work or home. At times, these symptoms may mimic anxiety disorders themselves.
Long-term benzodiazepine use may lower cognition permanently, with only partial recovery of cognitive abilities upon discontinuation of the benzodiazepine. Seizure risk exists during withdrawal, especially with drugs, such as alprazolam, in the class that have short half-lives.
Screening and Diagnosis
With the exception of acute overdose presenting in an emergency room, screening for benzodiazepine abuse requires subtle observation by family and healthcare providers. Chronic abuse or BUD may lead individuals to stop performing their normal duties at home and work as they increasingly neglect themselves and others. Individuals with BUD may take benzodiazepines even in unsafe circumstances, such as before driving a vehicle, and may experience legal or family problems. Repeated requests for prescriptions, early pharmacy refills, and hiding medications in different locations are signs of addiction and drug-seeking behavior.
Dependence may be identified as an aid in diagnosing benzodiazepine abuse. When benzodiazepines are used regularly for more than two to three weeks, even at low doses, they begin to lose their inhibitory GABA effects, and higher doses are required to relieve anxiety or to obtain a high. Once this tolerance develops, withdrawal symptoms upon drug discontinuation are also likely and may occur within days of stopping the benzodiazepine.
Individuals with a history of substance use disorders and those with a family history of such disorders are at an increased risk of developing BUD. Some research indicates that females are more likely than males to develop BUD, but further research is needed to confirm this finding. Other risk factors include unemployment, recent or unaddressed trauma, beginning to drink, smoke, or use drugs at a young age, and having a peer group that uses or supports the use of illicit substances. Screening tools are available for individuals and practitioners, including the Severity Dependence Scale (SDS), the Benzodiazepine Dependence Questionnaire (BDEPQ), and the Clinical Institute Withdrawal Assessment Scale - Benzodiazepines (CIWA-B).
Withdrawal symptoms also may contribute to a diagnosis of abuse because they differ from rebound anxiety symptoms and appear more similar to the symptoms of alcohol withdrawal. Tremors, insomnia, sweating, nausea, and vomiting are possible. Sensitivity to light and sound is common and directly distinguishes withdrawal from symptoms of an underlying anxiety disorder. More severe withdrawal symptoms include agitation, confusion, myoclonic jerks, and seizures.
Treatment and Therapy
Acute overdose treatment in an emergency room depends upon the amount of time passed since the benzodiazepine was ingested. Within one to two hours of a lethal dose, gastric lavage may be used to flush the stomach. Alternatively, one dose of activated charcoal can be given within four hours of ingestion to bind the drug in the stomach; severe cramps and nausea are possible, and vomiting is a risk. Flumazenil is an antidote to the sedative effects of benzodiazepines in cases of severe overdose and coma risk; however, its use may cause seizures when given to people who abuse benzodiazepines chronically and who may have become dependent.
Chronic abuse treatment is multifactorial and gradual. A slow tapering of dosage is key to avoiding rebound anxiety or withdrawal symptoms, which may take three to four days after drug discontinuation to begin. At the physician’s discretion, a short-acting benzodiazepine such as triazolam may be replaced with longer-acting agents in the class, such as chlordiazepoxide (Librium), or with a prescription agent from another class with a similar mechanism, such as gabapentinan antiseizure drug. Either replacement may be more safely tapered and stopped.
In some persons with chronic anxiety disorder, benzodiazepines cannot be fully discontinued. These persons may remain on very low dosages of the abused drug or another benzodiazepine, under strict observation, to avoid withdrawal and rebound risks and to minimize tolerance or abuse, which is likely with higher dosages, without sacrificing anti-anxiety therapy.
Prevention
The key to the prevention of acute or chronic benzodiazepine abuse is to lower its availability in prescribed and nonprescribed forms. When possible, the drug should be replaced as a prescription with safer and newer anti-anxiety agents. Physical dependence and acute misuse are less likely to occur if longer-acting or alternatively-acting agents are prescribed for short-term use with careful physician supervision.
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