Benzodiazepine Abuse

Aka: Benzodiazepine Abuse, Benzodiazepine Dependence, Tranquilizer, Benzodiazepine Withdrawal, Benzodiazepine Overdose, Benzodiazepine Toxicity, Fake Xanax

1. See Also
   1. Chemical Dependency
   2. Substance Abuse Evaluation
   3. Benzodiazepine
2. Class
   1. Sedative-Hypnotic
3. Preparations: Medical Uses
   1. See Benzodiazepines
4. 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/
5. Symptoms: Benzodiazepine Withdrawal
   1. Anxiety
   2. Insomnia
   3. Myalgias
   4. Tremors
   5. Seizures
6. 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
7. Differential Diagnosis
   1. See Unknown Ingestion
   2. May present in similar fashion to Diabetic Ketoacidosis
8. 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
9. Management: Taper Schedules
   1. Calculate Valium to Benzodiazepine Equivalents
      1. Start at 50% of calculated Valium dose
   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)