Benzodiazepine Abuse

Benzodiazepines are commonly abused. This form of drug abuse is partially related to the toxic effects that they produce and also to their widespread availability. They can be chronically abused or, as seen more commonly in hospital emergency departments, intentionally or accidentally taken in overdose.

• Benzodiazepines are a type of medication known as anxiolytics or tranquilizers or minor tranquilizers, as opposed to the major tranquilizers used to treat psychosis. Familiar names of these drugs include:
  • diazepam (Valium),
  • lorazepam (Ativan),
  • clonazepam (Klonopin),
  • chlordiazepoxide (Librium),
  • temazepam (Restoril), and
  • alprazolam (Xanax).
• They are some of the most commonly prescribed medications in the United States. When people without prescriptions take these drugs for their sedating or intoxicating effects, then use turns into abuse.
  • Doctors may prescribe a benzodiazepine for the following legitimate medical conditions:
  • Anxiety and panic attacks
  • Insomnia (for only a brief period)
  • Alcohol withdrawal
  • Seizure control
  • Muscle relaxation
  • Inducing amnesia for uncomfortable procedures
  • Given before an anesthetic (such as before surgery)
• Benzodiazepines act on the central nervous system, produce sedation and muscle relaxation, and lower anxiety levels.
• Although more than 2,000 different benzodiazepines have been produced, only about 15 are currently FDA-approved in the United States. They are usually classified by how long their effects last. Types of benzodiazepines, therefore, include those the following:
  • Ultra-short acting: midazolam (Versed), triazolam (Halcion)
  • Short-acting: alprazolam, lorazepam
  • Long-acting: chlordiazepoxide (Librium), diazepam
• Benzodiazepines are commonly abused. This form of drug abuse is partially related to the toxic effects that they produce and also to their widespread availability. They can be chronically abused or, as seen more commonly in hospital emergency departments, intentionally or accidentally taken in overdose. Death and serious illness rarely result from benzodiazepine abuse alone; however, they are frequently taken with either alcohol or other medications. The combination of benzodiazepines and alcohol can be dangerous, even fatal.
• Benzodiazepines have also been used as a "date rape" drug because they can markedly impair and even abolish functions that normally allow a person to resist or even want to resist sexual aggression or assault. In recent years, the detection and conviction of people involved in this practice have increased dramatically. The drug is usually added to alcohol-containing drinks or even soft drinks in powder or liquid forms and can be hard to taste.
• The use of benzodiazepines during pregnancy is a risk factor for cleft lip or palate, lower muscle tone, and withdrawal symptoms in the developing fetus.

Although some people may have a genetic tendency to become addicted to drugs, there is no single cause for addiction. Some biological risk factors for benzodiazepine abuse include female gender and elderly age group. A noteworthy statistic about benzodiazepine abuse is that women are more likely than men to be prescribed and therefore exposed to a benzodiazepine compared to men. Being of the elderly age group is also a risk factor for the abuse of benzodiazepines since physicians may inappropriately prescribe benzodiazepines for elderly individuals with depressive symptoms.

There is little doubt that environmental factors also play a significant role. Some of the more common environmental influences for benzodiazepine abuse are low socioeconomic status, unemployment, and peer pressure.

At normal or regular doses, benzodiazepines relieve anxiety and insomnia. They are usually well tolerated. Sometimes, people taking benzodiazepines may feel drowsy or dizzy. This side effect can be more pronounced with increased doses.

• High doses of benzodiazepines can produce more serious side effects. Signs and symptoms of acute toxicity or overdose may include the following:
  • Drowsiness
  • Confusion
  • Dizziness
  • Blurred vision
  • Weakness
  • Poor judgment and decision making
  • Slurred speech
  • Lack of coordination
  • Difficulty breathing
  • Coma
  • Death from respiratory arrest (ceased breathing)
• Signs of chronic drug abuse can be very nonspecific and include changes in appearance and behavior that affect relationships and work performance. Warning signs in children include abrupt changes in mood or deterioration of school performance. Chronic abuse of benzodiazepines can lead to the following symptoms that mimic many of the indications for using them in the first place:
  • Anxiety
  • Insomnia
  • Anorexia
  • Headaches
  • Weakness
  • Tremors
  • Memory problems
• Despite their many helpful uses, benzodiazepines can lead to physical and psychological addiction. Dependency on benzodiazepines can result in withdrawal symptoms and even seizures when they are stopped abruptly. Dependence and withdrawal occur in only a very small percentage of people taking normal doses for short periods. The symptoms of withdrawal can be difficult to distinguish from anxiety. Symptoms usually develop at three to four days from last use, although they can appear earlier with shorter-acting varieties. In addition to withdrawal, some other signs and symptoms of benzodiazepine addiction can include the following:
  • The individual develops tolerance to the medication (for example, the same dose having diminishing effects/needing increasing amounts of the drug to achieve the desired effects).
  • Larger amounts of the drug are taken or the drug is taken for longer than intended.
  • The individual experiences a persistent desire to take the drug or has made unsuccessful attempts to decrease or control the substance use.
  • Significant amounts of time are spent either getting, using, or recovering from the effects of the substance.
  • The individual significantly reduces or stops participating in important social, recreational, work, or school activities as a result of using the substance.
  • The individual continues to use the substance despite being aware that he or she suffers from ongoing or recurring physical or psychological problems that are caused or worsened by the use of the drug.

If you have any questions, you could call your doctor, but if you are in doubt whether someone needs immediate medical attention, you should go directly to a hospital emergency department.

If you are concerned that you or someone else has taken an overdose, it is very important that you seek medical help immediately. You should go to the nearest emergency department or call 911 for help. After someone takes an overdose, the effects may not become immediately obvious.

It will assist the doctors if you bring the pill containers with you because it helps them determine the number and type of pills taken.

The diagnosis is based on findings from your medical history, examination, and any lab tests performed.

• In acute ingestions, the diagnosis is often obvious because you or your family can tell the doctor exactly what was taken.
• The diagnosis of chronic drug abuse can be much more difficult because an abuser and his or her family often try to cover up or hide what is going on.
• The emergency department workup of any possible toxic drug overdose consists of an initial evaluation. Doctors will assess how well you are breathing. The rest of the workup depends on you and your symptoms. The physician will ask about many of the signs and symptoms. Unless you are willing to admit that you are abusing benzodiazepines or family members are present to help with the history, it is easy for you to cover up drug abuse.
• Monitoring and testing
  • In the emergency department, you will usually be placed on a monitor that follows heart rate, blood pressure, and pulse oximetry. An IV line will be started. Oxygen is given if you are short of breath or have a reduced level of consciousness.
  • Urine drug screens are sometimes performed. These lab tests can detect many of the commonly abused drugs, including benzodiazepines (but may not be able to discover them all). The urine drug screens do not, however, reveal a specific level or amount of the drug taken. Urine is also usually tested for pregnancy in all females of childbearing age.
  • Blood samples, ECGs, and chest X-rays may be obtained if there is concern that you may have taken other dangerous drugs.

Drug abusers often deny their problem by playing down the extent of their drug use or blaming job or family stress. The most important thing that can be done at home is to recognize that there may be a problem and to seek help.

• Awareness of the signs and symptoms of abuse help with recognition.
• The next step is to try to obtain help for the person. This can be done either through your doctor or by contacting many of the drug abuse help lines in your community.

• Acute toxicity: The treatment required usually depends on what drugs were taken and how much. Often, you need only a period of evaluation in a hospital emergency department.
  • If the drugs were taken within the previous one to two hours, the doctor may consider gastric lavage. With this procedure, a large tube is placed directly into your stomach through the mouth. Large volumes of water can then be pushed into the stomach in an attempt to wash out the pill fragments. This is not used often and only if you are known to have swallowed other potentially more lethal medications.
  • A single dose of activated charcoal is recommended for people who come to the emergency department within four hours of taking drugs. This acts to prevent absorption of the medication. It is a black powder that is mixed with water and given to you to drink. Side effects can include nausea, vomiting, and abdominal cramps.
  • There is an antidote to counteract the toxic effects of benzodiazepines called flumazenil (Romazicon). This reverses the sedative effect of benzodiazepines. It is, however, usually reserved for severe poisoning because it can cause withdrawal and seizures in people who are chronic benzodiazepine abusers.
• Chronic abuse: The treatment of chronic abuse can usually be done at home with the help of your doctor or in specific drug rehabilitation (rehab) centers. The first step consists of gradual reduction of benzodiazepines to prevent withdrawal and seizures. This is often much easier than the prolonged recovery phase in which the person attempts to stay drug free. In addition to the medical care, someone abusing these drugs often requires individual and family psychotherapy, social support, and help in finding housing and employment. The involvement of family and friends in therapy and in other forms of treatment and support can be very helpful during this difficult stage.

Benzodiazepine abuse or addiction often occurs with other problems (comorbidity). For example, individuals who abuse benzodiazepines often also abuse opiates.

Although benzodiazepines are commonly abused, they rarely cause serious illness or death unless combined with other drugs. Consultation with poison specialists is usually unnecessary. A psychiatrist, however, is often asked to interview anyone seen in the emergency department before sending the person home. This is done if there is any concern that the overdose was swallowed intentionally and that the person may be at risk of harming himself or herself or others.

As is true in the prevention and treatment of most health problems, knowledge is power in preventing benzodiazepine abuse. Specifically, for example, educating individuals who are either being newly treated with benzodiazepines or have been prescribed a benzodiazepine for some time seem to be more often able to be appropriately taken off the medication when provided with sound information and encouraged to actively participate in the care for their condition and treatment.