Benzodiazepine use, abuse, and dependence

An analysis of 2008–2014 NSDUH data found that approximately 7.6% of those with AUD, including those with DSM-IV alcohol abuse or dependence, reported past-year sedative/tranquilizer misuse, a rate benzodiazepine withdrawal syndrome 3–4 times greater than among the U.S. general population (Votaw et al., 2019). Rates of misuse might be higher among those with greater AUD severity, as evidenced by an analysis of NSDUH data wherein approximately 12% of those with DSM-IV alcohol dependence reported past-year sedative/tranquilizer misuse (Hedden et al., 2010). Indeed, studies of people with AUD in treatment demonstrate even higher rates, with estimates of recent benzodiazepine misuse (self-reported past-month use or urine drug screen results) ranging from 19–40% (McHugh et al., 2018; Morel et al., 2016; Ogborne and Kapur, 1987; Ross, 1993). While precise data is unavailable, estimates suggest a lifetime prevalence of benzodiazepine use disorder to be less than 1%.

Benzodiazepine Abuse Causes

It is important to distinguish between addiction to and normal physical dependence on benzodiazepines. Benzodiazepines are usually a secondary drug of abuse-used mainly to augment the high received from another drug or to offset the adverse effects of other drugs. Pharmacologic dependence, a predictable and natural adaptation of a body system long accustomed to the presence of a drug, may occur in patients taking therapeutic doses of benzodiazepines. However, this dependence, which generally manifests itself in withdrawal symptoms upon the abrupt discontinuation of the medication, may be controlled and ended through dose tapering, medication switching, and/or medication augmentation. Due to the chronic nature of anxiety, long-term low-dose benzodiazepine treatment may be necessary for some patients; this continuation of treatment should not be considered abuse or addiction.

Other Respondent Characteristics

They found a 35% increased chance of developing a new non-melanoma cancer in users of hypnotics 48. In agreeing with some of the studies above, there was also a 4.6-fold increase in the hazard of death in patients on hypnotics over 2.5 years 48. This is more significant than the study by Weich et al. 47 which found a 2-fold increased hazard of death in 7 years.

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• Still, due to the severe potential for dependence and deadly withdrawal sequelae, guidelines for recommended use are no longer than a few weeks.
• While the study showed some teratogenic effects of BZDs on fetuses, the result is not statistically significant, and some of the malformations seen in fetuses in the study may have been due to the use of other medications such as antidepressants 24.
• The same rate of current benzodiazepine misuse was found in a 2008–2009 household survey of 2,280 individuals ages 15 and older residing in the Ubon Ratchathani Province region of Thailand (Puangkot et al., 2010).
• Agarwal and Landon 2019 stated that the prescription of BZD in outpatient settings significantly increased from 2003 to 2015 27.

He would like to see benzodiazepine prescription coverage denied to those on Medicare as occurred in the Prescription Drug, Improvement and Modernization Act (MMA) of 2003 and in effect since 2006. In support of this, he cherry picks evidence to support his position (even when it does not). He fails to cite a larger body of contrary evidence on several points and misrepresents evidence several times. The most frequently abused of the benzodiazepines in both the United States and Canada are alprazolam, clonazepam, lorazepam and diazepam.54 In Canada, bromazepam is marketed and is a highly effective anxiolytic, muscle-relaxant, and sedative. Bromazepam has shown itself to be at least as effective as alprazolam as anxiolytic, and a superior sedative.

• Abrahamsson et al. investigated the relationship between hypnotic drug overdose versus non-overdose deaths in patients on opioid maintenance therapy.
• Another potential explanation is that benzodiazepines are used as a means to attempt suicide by intentional overdose, a method that is common among those with SUDs (Darke and Ross, 2001; Neale, 2000).
• However, with this ongoing, widespread use comes the dark reality of BZD dependence 6.
• Patients with severe toxicity will present in a stuporous or comatose state, and immediate airway management and mechanical ventilation may be required.
• This may further support the hypothesis that higher misuse is partially a function of limited access to a prescribed option—limited for younger patients due to lack of insurance and for men due to minimal disclosure of mental health concerns to providers (42).

These results corroborate the notion that sex differences exist in benzodiazepine-neuroactive steroid combinations, which could contribute to the different side effect profiles reported between sexes in the study by Koniuszewski et al.. Systems limitations in prescription monitoring in Australia reduce our ability to identify ‘doctor shopping’ so the presence of any aberrant drug-related behaviours should prompt further assessment and treatment. PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at marijuana addiction a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse.

Iatrogenic causes of toxicity can be seen when benzodiazepines are combined with other drugs during procedural sedation, particularly with opiates such as fentanyl. Many medications have been tested to alleviate withdrawal symptoms and make it easier for patients to discontinue BZD since a gradual taper does not always lead to successful discontinuation of the drug. Currently, a gradual taper with clonazepam is used as maintenance therapy for BZD-dependent patients. However, it still carries the risk for abuse and dependence since this is also a BZD, albeit a slow-acting one 67.

Treatment / Management

Flumazenil can precipitate acute withdrawal syndromes in those with chronic benzodiazepine dependence, which can be life-threatening. If a patient with a chronic dependence on benzodiazepines is given flumazenil, it can lower their seizure threshold and potentially cause life-threatening seizures. The treatment of seizures, which typically involves benzodiazepines, would be rendered useless, as the flumazenil has blocked the benzodiazepine receptors.

• The experimental treatment also included a BZD diary, a drinking diary, BZD withdrawal education, and assessments for ways of coping and “progressive relaxation exercise” 72.
• They showed that benzodiazepine increased the incidence of non-overdose death in these patients which may be attributed to its impairment of cognition, sensory, and motor skills and increased risk of fall leading to injuries 49.
• Existing data suggest that the lifetime prevalence of tranquilizer and sedative use, which includes benzodiazepines and barbiturates in the United States, are around 1% and 1.1%, respectively.
• Some people also use them to try to ease the comedown from cocaine or other stimulants.
• Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years.

Deterrence and Patient Education

BZDs are most commonly used for panic disorder and generalized anxiety disorder (GAD) regarding its indications for anxiety. Specifically, temazepam is commonly used for insomnia, clonazepam is commonly used for anxiety and seizures, lorazepam is commonly used for catatonia and seizure abortion when used intramuscularly or intravascularly, and diazepam is commonly used for anxiety, muscle spasms and rectally for seizures. In terms of anxiety, BZDs are used as a bridge when starting another medication or as https://ecosoberhouse.com/ abortive therapy for panic attacks. Given concerns for use dependence and withdrawal, SSRIs and antidepressants have been made mainstay therapy for these conditions. However, given their delayed onset of action, BZDs continue to be widely prescribed for these illnesses 12. Our findings that women, older, and non-Hispanic white respondents had higher use of benzodiazepines is consistent with previous work (1, 2, 39–41).

Some misuse may be for symptoms appropriately treated by a benzodiazepine, but clinicians should be mindful of other potential reasons for misuse. An uninsured young relative may use their older relative’s prescribed benzodiazepine for insomnia relieved by a benzodiazepine rather than to get high, but this certainly was not the intention of the prescribing clinician. Taken together, these misuse findings raise questions about the underlying contributors to misuse as defined and identified in NSDUH. Younger adults are more likely to lack health insurance (30), while the most common reasons for misuse (e.g., to relax/relieve tension) were all reasons for which a clinician might prescribe a benzodiazepine or refer for behavioral treatment.

In this second, more difficult stage, you may need help finding housing and employment. If doctors think you may have overdosed on purpose or are at risk of harming yourself or others, you may see a psychiatrist or addiction specialist before you leave the hospital. Taking too much and running out of your prescription, being overly focused on when you can take the next one, and feeling you can’t live without it could be signs that you’re developing a benzodiazepine use disorder.