Benzos

Drug Class: Anti-Anxiety Agents (Anxiolytics)/Sedatives
Street names: tranks, downers, benzos
Synopsis:

Benzodiazepines are medications that are frequently prescribed for the symptomatic treatment of anxiety and sleep disorders. They produce their effects via specific receptors involving a neurochemical called gamma aminobutyric acid (GABA).

Because they are safer and more effective, benzodiazepines have replaced barbiturates in the treatment of both anxiety and insomnia. Benzodiazepines are also used as sedatives before some surgical and medical procedures, and for the treatment of seizure disorders and alcohol withdrawal.

The first benzodiazepine developed was chlordiazepoxide, which is sold under such trade names as Librium(R)* and Apo-Chlordiazepoxide(R). Diazepam (e.g.Valium(R)) was the next benzodiazepine to come on the market and, until the early 1980s, was the most widely prescribed benzodiazepine in the world.
Now, newer benzodiazepines, such as lorazepam (e.g., Ativan(R) ), alprazolam (e.g., Xanax(R)), and clonazepam (Rivotril(R) ), account for most benzodiazepine prescriptions. (Where a name of a medication is capitalized, it is a registered trade name of the manufacturer.)

There are 16 different benzodiazepines currently available in Canada. Some are prescribed primarily for the treatment of anxiety (e.g., lorazepam,alprazolam and diazepam); others are recommended as sleeping medications(such as triazolam [e.g.,Halcion(R) ] and flurazepam [e.g., Dalmane(R)].
They remain the most commonly prescribed group of psychoactive(mood-altering) medications in Canada.

Even though they are effective, benzodiazepines do has some limitations and drawbacks. They may produce physical dependence which results in a discontinuation or withdrawal syndrome when the medication is stopped. This syndrome is generally mild. However, stopping abruptly can produce a wide range of symptoms including convulsions, especially if high doses have been used for a prolonged period of time. Benzodiazepines may also be misused and abused.

Effects
The effects of any medication depend on several factors, including:
* the type and severity of the disorder for which the medication is prescribed
* the amount taken at one time
* the form in which the medication is taken
* the patient's age
* prior or concurrent use of psychoactive drugs
* the circumstances under which the medication is taken (i.e., the user's psychological and emotional state, simultaneous use of alcohol or other drugs, etc.)

A therapeutic dose of benzodiazepines (i.e., medically prescribed) can relieve anxiety and insomnia. Generally, benzodiazepines are well tolerated and have a wide margin of safety. But some people may experience drowsiness, lethargy dizziness or difficulty with co-ordination.
High doses lead to heavier sedation and can impair both mental sharpness and physical co-ordination. Lower doses are recommended for older people and for those with some chronic diseases, since they may be more sensitive to medications and may metabolise them more slowly. It has also been suggested that benzodiazepines can impair the ability to learn and remember new information.

Studies show that anti-anxiety agents, even when correctly prescribed, may interfere with the ability of some users to perform certain physical, intellectual and perceptual functions. Most side-effects usually occur early in treatment and wane over time. For these reasons, individuals should assess their response to benzodiazepines before they operate a motor vehicle or engage in tasks requiring concentration and co-ordination. Such activities may become more dangerous if benzodiazepines are used together with alcohol and/or other sedative-hypnotics or antihistamines (found in many cold, cough and allergy remedies).

Because some benzodiazepines (such as diazepam and flurazepam) are metabolised and eliminated from the body quite slowly, the medication can accumulate in body tissues with long-term use and may heighten such effects as lethargy in some individuals. Some users may feel drowsy or "hung over," even on the day after they take the medication. Seniors, in particular, may be at increased risk of falls, fractures and confusion. There have been very rare reports of unexpected stimulation resulting from benzodiazepine use, with cases ranging from agitation to violent behaviour.

Toxic Effects:
Overdoses of benzodiazepines, either accidental or intentional, do occur.
While death rarely results from benzodiazepine overdose alone, these medications may be fatal when used in combination with alcohol and other drugs that depress the central nervous system.

Tolerance and Dependence:
Tolerance is the need to increase the dose of a drug to maintain the desired effects. Tolerance to the anxiety-relieving effects of benzodiazepines is uncommon and most individuals do not increase their benzodiazepine dose. But tolerance to the sedative and other effects of benzodiazepines can develop in some people with regular use.

Risk of physical dependence increases if benzodiazepines are taken regularly(e.g., daily) for more than a few months, especially at higher than normal doses. However, problems have been reported after shorter periods of use.
The user's body adapts to the presence of the medication and experiences withdrawal symptoms when use is stopped. The frequency and severity of these symptoms depend on the dosage, the duration of use, and whether the medication is stopped abruptly or tapered off.

Stopping abruptly can bring on such symptoms as trouble sleeping,gastrointestinal upset, feeling unwell, loss of appetite, sweating,trembling, weakness, anxiety, and changes in perception (e.g. numbness and altered sensitivity to light, sound and smells ). In rare cases after high doses, psychosis and convulsions may occur. The onset and severity of withdrawal are often more marked for benzodiazepines that are rapidly eliminated from the body (e.g., triazolam, alprazolam) than for those that are slowly eliminated (e.g., diazepam). While most patients call tolerate such symptoms a physician may decide to gradually taper the benzodiazepine dose to minimize discomfort, especially after long-term use. Gradual discontinuation of the medication is preferred, but it may not entirely eliminate withdrawal symptoms.

Diagnostic manuals recognize the occurrence of psychological or behavioural dependence on benzodiazepines. The main signs of psychological dependence on any drug are:
* a strong desire or craving for the drug
* seeking out the drug, often at the expense of other activities
* difficulty Stopping or cutting down
* continued use despite physical or psychological consequences.
People who use benzodiazepines on a long-term basis to treat specific chronic disorders (such as panic disorder, social phobias or agoraphobia) rarely exhibit such symptoms or behaviours. On the other hand, psychological dependence has been clearly demonstrated among certain groups, such as poly-drug abusers and methadone-treated heroin addicts.

Benzodiazepines and Pregnancy:
A woman who is pregnant or thinking about becoming pregnant should know that benzodiazepines can affect her baby. Use of benzodiazepines during pregnancy may lead to withdrawal symptoms in the newborn. Also, they are passed on through breast milk and should be used with caution, if at all, while nursing. However, no-one should stop taking the medication without consulting their physician first.

Who Uses Benzodiazepines?
In 1994, the Addiction Research Foundation (ARF) surveyed Ontario adults about their use of tranquillizer and sleeping pills. Benzodiazepines are included in both categories. Reported use of tranquillizer was 3.7% - a steady decline from 1977, When the reported level of use was 12.1%. This trend corresponds with other sources, including nationwide surveys. In Ontario, this decline has been significant among women, whose use fell to 4.1 % in 1994 from 15.9% in 1977. In particular, women aged 50 and older have decreased their use (to 7.7% from 21%). This survey also indicated that use of sleeping pills has increased from 6.5% in 1991 to 9.1% in 1994.
However, rates of use between 1989 and 1994 do not vary significantly. Women are more likely than men to take sleeping pills, and their use increases with age. Of respondents who used tranquillizer and sleeping pills, 15.8% and 7.3%. (respectively) were classified as dependent. In a separate study done in 1993, ARF polled Ontario students from Grade 7 to OAC (formerly Grade 13). The findings showed that 2.2% reported using prescribed tranquillizers at least once in the preceding year; and 1.1% used non-prescribed tranquillizer. The self-reported rate of use was highest among 16- and 17-year-old students (3% for medical and 1.6% for non-medical purposes). These figures are less than half of those reported in 1987.

Certain segments of society may use benzodiazepines more frequently than others. For example, a 1990 ARF study found that many abused women report taking medications such as benzodiazepines to calm them or help them sleep.
Individuals with alcohol, opioid or polydrug dependence may be at higher risk than others for benzodiazepine abuse and dependence. Staff at alcohol treatment and methadone maintenance programs report that some of their clients abuse or are dependent on benzodiazepines. Individuals dependent on other drugs should receive benzodiazepines only when the therapeutic indication is clear. Responses to therapy should be carefully monitored, as should dose and duration of treatment.

Benzodiazepines and the Law:
Benzodiazepines are prescription drugs that are legally available to the public only through a physician's prescription.

Benzodiazepines - the facts

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