Sedatives and related disorders

Definition

Sedatives are compounds that cause physiological and mental slowing of the body. They have many legitimate medical uses. However, people who use them improperly may develop symptoms of abuse, dependence, and withdrawal. Several other classes of compounds, including sleep-promoting drugs (hypnotics) and some anti-anxiety (anxiolytic) drugs produce effects and disorders similar to those of sedatives. Sedatives are often referred to as tranquilizers, and the similar classes of sedatives and hypnotics are sometimes thought of as one group: the sedative-hypnotics.

Description

Sedatives and similar drugs are available by prescription and have many medical uses. They are used in conjunction with surgery and are prescribed to treat pain, anxiety, panic attacks, insomnia , and in some cases, convulsions. Most people who take prescription sedatives take them responsibly and benefit from their use. Some people misuse these drugs. They may do so unintentionally by increasing their prescribed dose without medical advice. Intentional abusers buy these drugs off the street for recreational use or get them from friends or family members who have prescriptions. Sedatives are not popular street drugs, and when they are used recreationally, it is usually in conjunction with other illicit drugs or alcohol. When taken exactly as prescribed, sedatives rarely create major health risks.

A chemically diverse group of drugs are discussed together in this entry because they all appear to work in the body the same way and produce similar problems of abuse, dependence, intoxication, and withdrawal. These drugs work in the brain by increasing the amount of the neurotransmitter gamma-aminobutyric acid (GABA). Neurotransmitters help to regulate the speed at which nerve impulses travel. When the amount of GABA increases, the speed of nerve transmissions decreases. Thus these drugs depress the nervous system and cause reduced pain, sleepiness, reduced anxiety, and muscle relaxation.

The most widely prescribed and best-studied sedatives belong to a group called benzodiazepines. Prescription benzodiazepines and their relatives include alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium), estazolam (ProSom), flurazepam (Dalmane), halazepam (Paxipam), lorazepam , (Ativan), oxazepam (Serax), prazepam (Centrax), quazepam (Doral), temazepam (Restoril), triazolam (Halcion). Other drugs that act in a similar manner include the barbiturates amobarbital (Amytal), aprobarbital (Alurate), butabarbital (Butisol), phenobarbitol, (Nebutal), and secobarbital, (Seconal). In addition, chloral hydrate (Notec), ethchlorvynol (Placidyl), glutehimide (Doriden), meprobamate (Miltown, Equanil, Equagesic, Deprol) and zolpidem (Ambien) have similar actions.

Causes and symptoms

Sedatives and other drugs in this class are physically and sometimes psychologically addicting. People taking sedatives rapidly develop tolerance for the drugs. Tolerance occurs when a larger and larger dose must be taken to produce the same effect. Because sedatives are physically addicting, people with sedative dependence experience physical withdrawal symptoms when these drugs are discontinued.

Sedative abuse occurs when people misuse these drugs but are not addicted to them. Many people who abuse sedatives also use other illicit drugs. They may use sedatives to come down off a cocaine high or to enhance the effect of methadone , a heroin substitute.

Sedative dependence occurs when there is a physical addiction , when a person actively seeks sedatives (for example, by going to several doctors and getting multiple prescriptions) and when a person continues to use these drugs despite the fact that they cause interpersonal problems and difficulties meeting the responsibilities of daily life.

Sedative intoxication

Sedative intoxication occurs when a person has recently used one of these drugs and shows certain psychosocial symptoms such as hostility or aggression, swings in mood, poor judgment, inability to function in social settings or at work, or inappropriate sexual behavior. Because sedatives depress the central nervous system, physical symptoms include slurred speech, lack of coordination, inattention, impaired memory or "blackouts" and extreme sluggishness, stupor, or coma. Sedative intoxication can appear very similar to alcohol intoxication in its symptoms. Overdoses can be fatal.

Sedative withdrawal

Physical addiction is the main problem with sedative dependence. Sedative withdrawal is similar to alcohol withdrawal. Symptoms of sedative withdrawal are almost the reverse of the symptoms of sedative intoxication. They include:

• increased heart rate
• faster breathing
• elevated blood pressure
• increased body temperature
• sweating
• shaky hands
• inability to sleep
• anxiety
• nausea
• restlessness

About one-quarter of people undergoing sedative withdrawal have seizures . If withdrawal is severe, they may also have visual or auditory hallucinations (sedative withdrawal delirium ). Often people who experience these more severe symptoms are using other drugs and not just sedatives.

The timeframe for withdrawal symptoms to appear varies depending on the chemical structure of the drug being taken. Withdrawal symptoms can occur hours or days after stopping use. For example, people withdrawing from Valium may not develop withdrawal symptoms for a week, and may not have peak symptoms until the second week. Low-level symptoms may linger even longer. Generally the longer a person takes a drug and the higher the dose, the more severe the withdrawal symptoms. It is possible to have withdrawal symptoms when a therapeutically prescribed dose is taken for a long time.

Sedative dependence is thought to be able to induce other mental health disorders, although there is some disagreement in the mental health community about how these disorders are defined and classified. Other disorders that may result from sedative dependence and withdrawal include:

• sedative-induced persisting dementia
• sedative-induced persisting amnestic disorder
• sedative-induced psychotic disorder (with or without hallucinations)
• sedative-induced mood disorder
• sedative-induced anxiety disorder
• sedative-induced sexually dysfunction
• sedative-induced sleep disorder

Demographics

Many people, including about 90% of those who are hospitalized, are given some type of prescription sedative. Of the people who use sedatives, only a few become dependent. People who become dependent usually fall into three categories. Some are drug addicts who use sedatives along with other street drugs. These are usually young people between the ages of 15 and 25. Others are alcoholics who use sedatives to treat chronic anxiety or sleep problems associated with their alcohol dependence. Still others use sedatives under the direction of a doctor to treat long-term pain, anxiety, or sleeplessness. These people may become dependent by increasing the amount of sedative they take as tolerance develops without telling their doctor.

Sedative abuse is not a major addiction problem with street drug users. Many people who are dependent on sedatives are middle-age and middle-class people who start taking the drug for a legitimate medical reason. Women may be more at risk than men for developing sedative dependence. Sedative dependence is the most common type of drug addiction among the elderly. Older people do not clear the drug from their bodies as efficiently as younger people, and thus may become dependent on lower, therapeutic doses.

Diagnosis

Diagnosis of sedative intoxication is made based on recent use of the drug, presence of the symptoms listed above, and presence of the drug in a blood or urine sample. Without a blood or urine test, sedative intoxication can be difficult to distinguish from alcohol intoxication except for the absence of the odor of alcohol. People experiencing sedative intoxication usually remain grounded in reality. However, if they lose touch with reality they may be diagnosed as having sedative intoxication delirium.

Diagnosis of sedative withdrawal is based on the symptoms listed above. It can be difficult to distinguish from alcohol withdrawal. Withdrawal may occur with or without hallucinations and delirium. Diagnosis depends on whether a person remains grounded in reality during withdrawal.

Diagnosis of other mental disorders induced by sedative dependence requires that the symptoms be in excess of those usually found with sedative intoxication or withdrawal. They cannot be accounted for by other substance abuse or another mental or physical disorder.

Treatments

Treatment depends on how large a dose of sedative the patient is taking, the length of time it has been used, and the patient's individual psychological and physical state.

Physiological treatment

Successful treatment of sedative dependence is based on the idea of gradually decreasing the amount of drug the patient uses in order to keep withdrawal symptoms to a manageable level. This is called a drug taper. The rate of taper depends on the dependency dose of the drug, the length of time the drug has been taken, a person's individual mental and physical response to drug withdrawal, and any complicating factors such as other substance abuse or other physical or mental illness.

For people dependent on a low dose of sedatives, the current level of use is determined, then the amount of drug is then reduced by 10 to 25 percent. If withdrawal symptoms are manageable, reduction is continued on a weekly basis. If withdrawal symptoms are too severe, the patient is stabilized at the lowest dose with manageable symptoms until tapering can be re-started. This gradual reduction of use may take weeks, and the rate must be adjusted to the response of each patient individually.

People dependent on high doses of sedatives are usually hospitalized because of the possibility of life-threatening withdrawal symptoms. A blood or urine test is used to determine the current level of usage. The patient is often switched to an equivalent dose of a different sedative or phenobarbitol (a barbiturate) to aid in withdrawal while controlling withdrawal symptoms. The tapering process begins, but more gradually than with low-dose dependency. Often other drugs are given to combat some of the withdrawal symptoms.

Psychological treatment

Cognitive-behavioral therapy may be used in conjunction with drug tapering. This type of talk therapy aims at two things: to educate patients to recognize and cope with the symptoms of anxiety associated with withdrawal, and to help patients change their behavior in ways that promote coping with stress . Patients are taught to mentally talk their way through their anxiety and stress. Some people find support groups and journal keeping to be helpful in their recovery. Recovering from dependency is a slow process, best achieved when a person has a good social support system, patience, and persistence.

Prognosis

The people who have the best chance of becoming sedative-free are those who became dependent through taking long-term therapeutic doses. Although stopping any addiction takes time and work, with a properly managed course of treatment, chances of success are good.

People who abuse multiple street drugs must receive treatment for their multiple drug dependencies. Sedative abuse is low on their list of problems, and the chances of their becoming drug-free are low. Alcoholics also have a difficult time withdrawing from sedatives.

Prevention

The best way to prevent sedative-related disorders is to take these drugs only for the exact length of time and in the exact amount prescribed by a doctor.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text revision. Washington DC: American Psychiatric Association, 2000.

Galanter, Marc and Herbert D. Kleber, eds. Textbook of Substance Abuse Treatment. 2nd ed. Washington DC: American Psychiatric Press, Inc., 1999.

Giannini, James. Drug Abuse: A Family Guide to Detection, Treatment and Education. Los Angeles: Health Information Press, 1999.

Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry. 7th ed. Vol. 1. Philadelphia: Lippincott Williams and Wilkins, 2000.

ORGANIZATIONS

National Clearinghouse for Alcohol and Drug Information. P. O. Box 2345, Rockville, MD 20852. (800) 729-6686. <http://www.health.org>.

National Institute on Drug Abuse. 5600 Fishers Lane, Room 10 A-39, Rockville, MD 20857. 1-888-644-6432<http://niad.nih.gov>.

OTHER

Benzodiazepine Recovery. <www.benzodiazepine.org>. This site offers chat and support groups for people recovering from sedative dependence and has links to many sources of information on these drugs.

Tish Davidson, A.M.