II. Class

III. Preparations: Medical Uses

IV. Precautions: Fake Xanax

  1. Fake Xanax contains Fentanyl and Etizolam (Benzodiazepine analog)
  2. Presents as opiod Overdose with sedation and respiratory depression (Rhabdomyolysis was also associated)
  3. Management
    1. Naloxone 0.4 mg
    2. Supportive care
    3. Consult poison control
  4. References
    1. Swadron and Nordt in Herbert (2017) EM:Rap 17(2):18
    2. ThePoisonReview.com
      1. http://www.thepoisonreview.com/2016/08/24/case-series-8-patients-exposed-to-phony-alprazolam-xanax-containing-fentanyl-andor-etizolam/

V. Symptoms: Benzodiazepine Withdrawal

  1. Anxiety
  2. Insomnia
  3. Myalgias
  4. Tremors
  5. Seizures

VI. Signs: BenzodiazepineIntoxication

  1. Cardiopulmonary effects
    1. Respiratory Depression
    2. Hypotension
    3. Rarely lethal alone, but dangerous with Alcohol
  2. Neurologic effects
    1. Anterograde Amnesia
    2. Ataxia
    3. Confusion
    4. Slurred Speech
    5. Miosis
  3. Spectrum of Decreased Level of Consciousness
    1. Drowsiness
    2. Lethargy
    3. Sedation
    4. Coma

VII. Differential Diagnosis

  1. See Unknown Ingestion
  2. May present in similar fashion to Diabetic Ketoacidosis

VIII. Management: Toxicity

  1. Benzodiazepines Overdoses in isolation generally have good outcomes
    1. CNS Depression (and apnea) increases when combined with other agents (e.g. Opioids)
    2. Coingestion is common
  2. Supportive care with airway management for CNS Depression
  3. Flumazenil (Romazicon)
    1. Avoid in patients with chronic use (risks of severe withdrawal including Seizures)
      1. Most toxicology guidelines do not recommend Flumazenil in Overdose
      2. Potential harms appear to outweigh benefits in most cases
      3. Penningo (2016) Basic Clin Pharmacol Toxicol 118(1): 37-44 +PMID:26096314 [PubMed]
    2. May be indicated for acute Benzodiazepine Overdose (non-chronic use) with cardiopulmonary depression
    3. Read Flumazenil contraindications carefully

IX. Management: Taper Schedules

  1. Calculate Valium to Benzodiazepine Equivalents
    1. Start at 50% of calculated Valium dose
    2. Reduce dose by 25% each week for the first 2 weeks, until 50%, then decrease dose by 12.5% every 4-7 days
  2. Example
    1. Xanax 6 mg is equivalent to 60 mg Diazepam
    2. Xanax 10 mg is equivalent to 100 mg Diazepam
    3. Start taper at 50% or 50 mg Valium per day
    4. Decrease dosing per Valium taper below
  3. Valium Protocol
    1. Days 1-3: 10 mg tid (30 mg/day)
    2. Days 4-6: 5 mg qid (20 mg/day)
    3. Days 7-9: 5 mg tid (15 mg/day)
    4. Days 10-12: 5 mg bid (10 mg/day)
    5. Days 13-15: 5 mg qd (5 mg/day)

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Ontology: Tranquilizing Agents (C0040614)

Definition (MSH) A traditional grouping of drugs said to have a soothing or calming effect on mood, thought, or behavior. Included here are the ANTI-ANXIETY AGENTS (minor tranquilizers), ANTIMANIC AGENTS, and the ANTIPSYCHOTIC AGENTS (major tranquilizers). These drugs act by different mechanisms and are used for different therapeutic purposes.
Definition (CSP) drug with a calming, soothing effect.
Concepts Pharmacologic Substance (T121)
MSH D014149
SnomedCT 45604009
LNC LP30812-9, MTHU015319
English Agents, Tranquilizing, Agents, Tranquillizing, Ataractics, Tranquillizing Agents, tranquilizer, Tranquilizing Drugs, Drugs, Tranquilizing, Drugs, Tranquillizing, Tranquillizing Drugs, ataractic, tranquilizers, tranquilizer drug, anxiety reducing drugs, tranquilliser, drugs tranquilizer, anxiolytic drug, tranquillisers, anxiolytic drugs, Tranquilizers, Tranquilizing drugs, Tranquilizer drug, Tranquilizer (substance), Tranquilizer, Tranquilliser drug, Tranquilliser, Tranquilizer drug, NOS, Tranquilizer, NOS, Tranquilizer agent, Tranquilliser agent, Tranquilizing Agents, Anxiety Reducing Drugs, Anxiolytic Drugs, Ataractic Drugs, Ataraxic Drugs
French Médicaments tranquillisants, Agents tranquillisants, Tranquillisants
Swedish Lugnande medel
Czech ataraktika, trankvilizéry
Finnish Rauhoittavat lääkkeet
Italian Farmaci tranquillanti, Atarassici, Tranquillanti
Polish Środki ataraktyczne, Trankwilizatory, Środki kojące
Japanese 精神安定剤, 感情抑制薬, トランキライザ, 精神安定薬, 静穏薬, トランキライザー
Norwegian Not Translated[Tranquilizing Agents]
Spanish Efecto Tranquilizante, ansiolítico, fármaco ansiolítico, fármaco sedante, tranquilizante (sustancia), tranquilizante, Ataraxicos, Tranquilizantes
Portuguese Efeito Tranquilizante, Ataráxicos, Tranquilizantes
German Ataraktica, Tranquilizer

Ontology: Benzodiazepine dependence (C0338768)

Concepts Mental or Behavioral Dysfunction (T048)
SnomedCT 154914000, 191823005, 231473004
English benzodiazepine dependence, benzodiazepine dependence (diagnosis), Benzodiazepine dependence, Benzodiazepine dependence (disorder)
Spanish dependencia de benzodiazepinas (trastorno), dependencia de benzodiazepinas