Benzodiazepine Abuse

Aka: Benzodiazepine Abuse, Benzodiazepine Use Disorder, Benzodiazepine Dependence

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II. Epidemiology

  1. Benzodiazepine misuse in up to 17% of those in the U.S. taking Benzodiazepines
    1. Obtained from family or friends in 70% of misuse cases
  2. Peak Age of Benzodiazepine misuse: 18 to 25 years old
  3. Benzodiazepines are among the most prescribed controlled substances in the United State
    1. Prescribed at >30 million office visits 2014-2016
    2. Santo (2020) Natl Health Stat Report (137): 1-16 [PubMed]

III. Background

  1. Benzodiazepines have rapid and effective anxiolysis and sedation of Benzodiazepines
    1. May be indicated for short-term use (<1 month) in refractory, severe anxiety and Insomnia
  2. However, Benzodiazepines have little evidence of longterm, chronic use benefit
    1. Wright (2022) J Fam Pract 71(3): 103-7 [PubMed]
  3. Continued Benzodiazepine use significantly increases patient risk
    1. See Benzodiazepine
    2. High risk of tolerance, dependence and misuse (see below)
    3. Significant adverse effects, especially in over age 65 years (e.g. sedation, confusion, depression)
    4. Falls, Fractures and Motor Vehicle Accidents risk significantly increases on Benzodiazepines
    5. Risk of Benzodiazepine Overdose death when combined with Alcohol or Opioids
  4. Benzodiazepine Dependence
    1. Benzodiazepine Dependence and tolerance may start within days to weeks of regular use
      1. BenzodiazepineGABA ReceptorAgonist activity triggers receptor down regulation
    2. Seizures may occur, especially if underlying Seizure Disorder
    3. See Benzodiazepine Withdrawal for taper schedules
  5. Benzodiazepine misuse and abuse is common
    1. Hospital admissions for Benzodiazepine Abuse have increased three-fold since the early 2000s
    2. Misuse in up to 17% of those in the U.S. taking Benzodiazepines
      1. Obtained from family or friends in 70% of misuse cases
  6. Alprazolam (Xanax) is among the most addictive Benzodiazepines
    1. Responsible for 10% of drug-misuse related visits to the Emergency Department
    2. Rapid onset is associated with euphoria, short Half-Life is associated with rebound symptoms

IV. Risk Factors

  1. Other Substance Use Disorder
    1. Opioid Use Disorder (70%)
    2. Alcohol Use Disorder (27%)
    3. Tobacco Abuse (OR 1.8)
  2. Other associated factors
    1. Young adults (esp. age 18 to 25 years)
    2. Chronic Sleep Disorders
    3. Chronic illness

V. Diagnosis: DSM5 Criteria for Sedative, Hypnotic or Anxiolytic Use Disorder

  1. Background
    1. Sedative, Hypnotic or Anxiolytic Use Disorder is a subset of Substance Use Disorder
      1. See Substance Use Disorder
  2. Sedative, hypnotic or Anxiolytic use leads to significant Impairment or distress
    1. "Sedative, hypnotic or Anxiolytic" are abbreviated as Sedatives in the criteria below
  3. Criteria: At Least 2 of the following over the last 12 months
    1. Sedatives taken in larger amounts or over longer period than initially intended
    2. Persistent desire or unsuccessful attempts to control or cut-down Sedative use
    3. Considerable time spent to obtain, use or recover from Sedative use
    4. Craving or strong desire to use Sedatives
    5. Recurrent Sedative use results in failure to fulfill major obligations at work, school or home
    6. Continued Sedative use despite social or interpersonal problems caused or exacerbated by Sedatives
    7. Important social, occupational or recreational activities reduced or eliminated due to Sedative use
    8. Recurrent Sedative use in physically hazardous settings
    9. Continued Sedative use despite being aware of a physical or psychological complication of its use
  4. Additional Criteria (if Sedatives NOT taken under medical supervision)
    1. Tolerance
      1. Need to markedly increase Sedative amounts to achieve Intoxication or desired effect
      2. Markedly decreased effect with continued use of same amount of Sedative
    2. Withdrawal
      1. Classic Sedative withdrawal symptoms (see Benzodiazepine Withdrawal)
      2. Sedatives or other related substances (e.g. Alcohol) are used to relieve withdrawal symptoms
  5. Severity
    1. Mild: 2 to 3 criteria present
    2. Moderate: 4 to 5 criteria present
    3. Severe: >=6 criteria present
  6. References
    1. (2022) DSM 5, APA, p. 620-22

VI. Management

  1. Mental health referral
    1. Chemical Dependency programs
  2. Taper off Benzodiazepines
    1. See Benzodiazepine Taper Schedule
    2. Do NOT abruptly stop Benzodiazepines
    3. Refer to Benzodiazepine detox program in unreliable patients
  3. Other adjunctive medications for Benzodiazepine Withdrawal symptoms
    1. Valproate
    2. Tricyclic Antidepressants
    3. Beandrup (2018) Cochrane Database Syst Rev (3): CD011481 [PubMed]

VII. Prevention

  1. Avoid prescribing Benzodiazepines if possible (maximize alternatives)
  2. Limit Benzodiazepine prescriptions to lowest effective dose and frequency for the shortest course (<1 month)

VIII. References

  1. Robertson (2022) Am Fam Physician 108(3): 260-6 [PubMed]

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