II. Epidemiology
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Benzodiazepine misuse in up to 17% of those in the U.S. taking Benzodiazepines
- Obtained from family or friends in 70% of misuse cases
- Peak Age of Benzodiazepine misuse: 18 to 25 years old
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Benzodiazepines are among the most prescribed controlled substances in the United State
- Prescribed at >30 million office visits 2014-2016
- Santo (2020) Natl Health Stat Report (137): 1-16 [PubMed]
III. Background
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Benzodiazepines have rapid and effective anxiolysis and sedation of Benzodiazepines
- May be indicated for short-term use (<1 month) in refractory, severe anxiety and Insomnia
- However, Benzodiazepines have little evidence of longterm, chronic use benefit
- Continued Benzodiazepine use significantly increases patient risk
- See Benzodiazepine
- High risk of tolerance, dependence and misuse (see below)
- Significant adverse effects, especially in over age 65 years (e.g. sedation, confusion, depression)
- Falls, Fractures and Motor Vehicle Accidents risk significantly increases on Benzodiazepines
- Risk of Benzodiazepine Overdose death when combined with Alcohol or Opioids
- Benzodiazepine Dependence
- Benzodiazepine Dependence and tolerance may start within days to weeks of regular use
- BenzodiazepineGABA ReceptorAgonist activity triggers receptor down regulation
- Seizures may occur, especially if underlying Seizure Disorder
- See Benzodiazepine Withdrawal for taper schedules
- Benzodiazepine Dependence and tolerance may start within days to weeks of regular use
-
Benzodiazepine misuse and abuse is common
- Hospital admissions for Benzodiazepine Abuse have increased three-fold since the early 2000s
- Misuse in up to 17% of those in the U.S. taking Benzodiazepines
- Obtained from family or friends in 70% of misuse cases
-
Alprazolam (Xanax) is among the most addictive Benzodiazepines
- Responsible for 10% of drug-misuse related visits to the Emergency Department
- Rapid onset is associated with euphoria, short Half-Life is associated with rebound symptoms
IV. Risk Factors
- Other Substance Use Disorder
- Opioid Use Disorder (70%)
- Alcohol Use Disorder (27%)
- Tobacco Abuse (OR 1.8)
- Other associated factors
- Young adults (esp. age 18 to 25 years)
- Chronic Sleep Disorders
- Chronic illness
V. Diagnosis: DSM5 Criteria for Sedative, Hypnotic or Anxiolytic Use Disorder
- Background
- Sedative, Hypnotic or Anxiolytic Use Disorder is a subset of Substance Use Disorder
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Sedative, hypnotic or Anxiolytic use leads to significant Impairment or distress
- "Sedative, hypnotic or Anxiolytic" are abbreviated as Sedatives in the criteria below
- Criteria: At Least 2 of the following over the last 12 months
- Sedatives taken in larger amounts or over longer period than initially intended
- Persistent desire or unsuccessful attempts to control or cut-down Sedative use
- Considerable time spent to obtain, use or recover from Sedative use
- Craving or strong desire to use Sedatives
- Recurrent Sedative use results in failure to fulfill major obligations at work, school or home
- Continued Sedative use despite social or interpersonal problems caused or exacerbated by Sedatives
- Important social, occupational or recreational activities reduced or eliminated due to Sedative use
- Recurrent Sedative use in physically hazardous settings
- Continued Sedative use despite being aware of a physical or psychological complication of its use
- Additional Criteria (if Sedatives NOT taken under medical supervision)
- Tolerance
- Need to markedly increase Sedative amounts to achieve Intoxication or desired effect
- Markedly decreased effect with continued use of same amount of Sedative
- Withdrawal
- Classic Sedative withdrawal symptoms (see Benzodiazepine Withdrawal)
- Sedatives or other related substances (e.g. Alcohol) are used to relieve withdrawal symptoms
- Tolerance
- Severity
- Mild: 2 to 3 criteria present
- Moderate: 4 to 5 criteria present
- Severe: >=6 criteria present
- References
- (2022) DSM 5, APA, p. 620-22
VI. Management
- Mental health referral
- Chemical Dependency programs
- Taper off Benzodiazepines
- See Benzodiazepine Taper Schedule
- Do NOT abruptly stop Benzodiazepines
- Refer to Benzodiazepine detox program in unreliable patients
- Other adjunctive medications for Benzodiazepine Withdrawal symptoms
VII. Prevention
- Avoid prescribing Benzodiazepines if possible (maximize alternatives)
- Limit Benzodiazepine prescriptions to lowest effective dose and frequency for the shortest course (<1 month)