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Sedative, Hypnotic, Anxiolytic Use Disorders Medication

  • Author: Lorin M Scher, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Feb 18, 2014
 

Medication Summary

A variety of drugs are used both in the acute and the long-term setting for the treatment of sedative, hypnotic, and anxiolytic use disorders. Drug selection depends upon whether toxicity or withdrawal symptoms are being targeted.

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Benzodiazepine antagonist

Class Summary

These agents are used in reversing the CNS depressant effects of benzodiazepine overdose. Its ability to reverse the benzodiazepine-induced respiratory depression is difficult to predict.

Flumazenil (Romazicon)

 

Benzodiazepine antagonist has a high affinity for the benzodiazepine receptor, making it a competitive antagonist. Flumazenil is short-acting, with a half-life of 0.7-1.3 h. Because most benzodiazepines have longer half-lives, multiple doses of flumazenil may be required to avoid relapse back into a sedative state.

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Barbiturates

Class Summary

These agents are used in some cases to facilitate smooth withdrawals in patients with benzodiazepines and barbiturate dependence.

Phenobarbital (Barbita, Luminal, Solfoton)

 

Chosen for withdrawal because of long half-life and wide therapeutic index. General principle is that sedatives with longer half-lives have less severe withdrawal symptoms. Arbitrary doses are given, and treatment is individualized to respect variable effects in different patients.

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Benzodiazepines

Class Summary

In dependent patients, these are used in a manner similar to phenobarbital to wean patients from short-acting benzodiazepines. The general principle is that sedatives with longer half-lives have less severe withdrawal symptoms. Various patient-specific dosing strategies are used. If symptoms are severe enough to require inpatient treatment, IV lorazepam or diazepam is used.

After stabilizing the patient, the tapering dose is calculated by dividing the total dose by 5 and reducing by this amount weekly.

Diazepam (Valium)

 

Depresses all levels of CNS (eg, limbic, reticular formation), possibly by increasing activity of GABA. Individualize the dosage and increase cautiously to avoid adverse effects.

Lorazepam (Ativan)

 

Sedative-hypnotic with short onset of effects and relatively long half-life.

By increasing the action of GABA, which is the major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.

Important to monitor patient's blood pressure after administering dose. Adjust dose as necessary.

Clonazepam (Klonopin)

 

Suppresses muscle contractions by facilitating neurotransmission of GABA and other inhibitory transmitters.

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Contributor Information and Disclosures
Author

Lorin M Scher, MD Director, Emergency Psychiatric ServicesHealth Sciences Assistant Clinical ProfessorDepartment of Psychiatry and Behavioral SciencesUniversity of California, Davis, School of Medicine

Lorin M Scher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Alpha Omega Alpha, American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

Siddarth Puri, MA University of California, Davis, School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Additional Contributors

Jennifer S Morse, MD Associate Medical Director, Optum Health

Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

Olakunle PA Akinsoto, MD, MBBCh Consulting Staff, Family Health Center, Jacksonville Medical Center

Disclosure: Nothing to disclose.

Amit Chopra, MD Resident Physician, Department of Psychiatry, Mayo Clinic, Rochester

Disclosure: Nothing to disclose.

Abhinav Rastogi, MBBS, MRCPsych Resident Psychiatrist, Stratford Road Day Centre, Birmingham, UK

Disclosure: Nothing to disclose.

Christopher L Sola, DO Assistant Professor in Psychiatry, Mayo Clinic School of Medicine; Medical Director of Inpatient Medical Psychiatry Program, Department of Psychiatry and Psychology, Mayo Clinic

Christopher L Sola, DO is a member of the following medical societies: Academy of Psychosomatic Medicine, American Medical Association, American Osteopathic Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Joji Suzuki, MD Fellow in Addiction Psychiatry, Department of Psychiatry, Boston University School of Medicine

Disclosure: Nothing to disclose.

References
  1. Lader M. Benzodiazepines revisited--will we ever learn?. Addiction. 2011 Dec. 106(12):2086-109. [Medline].

  2. Simon R. 2nd ed. Psychiatry and Law for Clinicians. 1998.

  3. Stahl SM. Anxiety disorders and anxiolytics. Stahl’s Essential Physcopharmacology-Neuroscientific Basis and Practice Application. 4th ed. Cambridge press; 2013.

  4. Sigel E, Lucher BP. A closer look at the high affinity benzodiazepine binding site on GABAA receptors. Curr Top Med Chem. 2011. 11(2):241-6. [Medline].

  5. Vinkers CH, Olivier B. Mechanisms Underlying Tolerance after Long-Term Benzodiazepine Use: A Future for Subtype-Selective GABA(A) Receptor Modulators?. Adv Pharmacol Sci. 2012. 2012:416864. [Medline].

  6. Bateson AN. Basic pharmacologic mechanisms involved in benzodiazepine tolerance and withdrawal. Curr Pharm Des. 2002. 8(1):5-21. [Medline].

  7. Fenton MC, Keyes KM, Martins SS, Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. Am J Psychiatry. 2010 Oct. 167(10):1247-53. [Medline].

  8. Novak SP, Calvin SL, Glasheen C, Edlund MJ. The epidemiology and treatment of prescription drug disorders in the United States. PSYCHIATRIC DISORDERS–TRENDS AND DEVELOPMENTS. 2011. 367.

  9. Kaplan, Sadock. Comprehensive Textbook of Psychiatry. 9th ed. 2009.

  10. McCabe SE, West BT, Morales M, Cranford JA, Boyd CJ. Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence? Results from a national study. Addiction. 2007 Dec. 102(12):1920-30. [Medline].

  11. Yeh HH, Chen CY, Fang SY, Chang IS, Wu EC, Lin KM. Five-year trajectories of long-term benzodiazepine use by adolescents: patient, provider, and medication factors. Psychiatr Serv. 2011 Aug. 62(8):900-7. [Medline].

  12. McCabe SE, Cranford JA, West BT. Trends in prescription drug abuse and dependence, co-occurrence with other substance use disorders, and treatment utilization: results from two national surveys. Addict Behav. 2008 Oct. 33(10):1297-305. [Medline].

  13. Sonnenberg CM, Bierman EJ, Deeg DJ, Comijs HC, van Tilburg W, Beekman AT. Ten-year trends in benzodiazepine use in the Dutch population. Soc Psychiatry Psychiatr Epidemiol. 2012 Feb. 47(2):293-301. [Medline].

  14. Fenton MC, Keyes KM, Martins SS, Hasin DS. The role of a prescription in anxiety medication use, abuse, and dependence. Am J Psychiatry. 2010 Oct. 167(10):1247-53. [Medline].

  15. Stern TA, Fricchione G, Cassem NH, Jellinek MS, Rosenbaum JF. Drug addicted patients. Massachusetts General Hospital Handbook of General Hospital Psychiatry. 6th ed. Saunders; 2010.

  16. O'brien CP. Benzodiazepine use, abuse, and dependence. J Clin Psychiatry. 2005. 66 Suppl 2:28-33. [Medline].

  17. Smink BE, Egberts AC, Lusthof KJ, Uges DR, de Gier JJ. The relationship between benzodiazepine use and traffic accidents: A systematic literature review. CNS Drugs. 2010 Aug. 24(8):639-53. [Medline].

  18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. Washington DC: American Psychiatric Press Inc; 2013. 5th ed:

  19. Beck O, Stephanson N, Sandqvist S, Franck J. Detection of drugs of abuse in exhaled breath using a device for rapid collection: comparison with plasma, urine and self-reporting in 47 drug users. J Breath Res. 2013 Jun. 7(2):026006. [Medline].

  20. Wiviott-Tishler L, Wiviott SD, Hyman SE. Sedative hypnotics and anxiolytics. Freidman L, Fleming NF, Roberts D, Hyman SE. Sourcebook of substance abuse and addiction. 1996. 203-17.

  21. Veiraiah A, Dyas J, Cooper G, Routledge PA, Thompson JP. Flumazenil use in benzodiazepine overdose in the UK: a retrospective survey of NPIS data. Emerg Med J. 2012 Jul. 29(7):565-9. [Medline].

  22. Dixon JC, Speidel BD, Dixon JJ. Neonatal flumazenil therapy reverses maternal diazepam. Acta Paediatr. 1998 Feb. 87(2):225-6. [Medline].

  23. Kawasaki SS, Jacapraro JS, Rastegar DA. Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification. J Subst Abuse Treat. 2012 Oct. 43(3):331-4. [Medline].

  24. Vissers FH, Knipschild PG, Crebolder HF. Is melatonin helpful in stopping the long-term use of hypnotics? A discontinuation trial. Pharm World Sci. 2007 Dec. 29(6):641-6. [Medline]. [Full Text].

  25. Bobes J, Rubio G, Terán A, Cervera G, López-Gómez V, Vilardaga I. Pregabalin for the discontinuation of long-term benzodiazepines use: an assessment of its effectiveness in daily clinical practice. Eur Psychiatry. 2012 May. 27(4):301-7. [Medline].

  26. Peles E, Hetzroni T, Bar-Hamburger R, Adelson M, Schreiber S. Melatonin for perceived sleep disturbances associated with benzodiazepine withdrawal among patients in methadone maintenance treatment: a double-blind randomized clinical trial. Addiction. 2007 Dec. 102(12):1947-53. [Medline].

  27. Allain H, Coz FL, Borderies P, Schuck S, Giclais BL, Patat A, et al. Use of Zolpidem 10 mg as a Benzodiazepine Substitute in 84 Patients with Insomnia. Hum Psychopharmacol Clin. 1998. 13:551-9.

  28. Oschman A, McCabe T, Kuhn RJ. Dexmedetomidine for opioid and benzodiazepine withdrawal in pediatric patients. Am J Health Syst Pharm. 2011 Jul 1. 68(13):1233-8. [Medline].

  29. Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009 Jun. 13(3):205-14. [Medline].

  30. Vicens C, Socias I, Mateu C, Leiva A, Bejarano F, Sempere E. Comparative efficacy of two primary care interventions to assist withdrawal from long term benzodiazepine use: a protocol for a clustered, randomized clinical trial. BMC Fam Pract. 2011. 12:23. [Medline].

  31. Rickels K, Case WG, Schweizer E, Garcia-Espana F, Fridman R. Long-term benzodiazepine users 3 years after participation in a discontinuation program. Am J Psychiatry. 1991 Jun. 148(6):757-61. [Medline].

  32. Allgulander C, Borg S, Vikander B. A 4-6-year follow-up of 50 patients with primary dependence on sedative and hypnotic drugs. Am J Psychiatry. 1984 Dec. 141(12):1580-2. [Medline].

  33. de Gier NA, Gorgels WJ, Lucassen PL, Oude Voshaar R, Mulder J, Zitman F. Discontinuation of long-term benzodiazepine use: 10-year follow-up. Fam Pract. 2011 Jun. 28(3):253-9. [Medline].

  34. Baillargeon L, Landreville P, Verreault R, Beauchemin JP, Grégoire JP, Morin CM. Discontinuation of benzodiazepines among older insomniac adults treated with cognitive-behavioural therapy combined with gradual tapering: a randomized trial. CMAJ. 2003 Nov 11. 169(10):1015-20. [Medline].

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