Download Benzodiazepines (Tranquillisers and their risk)

Benzodiazepines
Tranquilisers and their risk
Benzodiazepines are also referred to as tranquillisers and are drugs mainly prescribed for anxiety and
insomnia. They are occasionally prescribed for epilepsy, as muscle relaxants, and as a detox from
alcohol. They should only be prescribed short term as they can have serious side effects, withdrawal
symptoms and addiction problems if overused. They should only be used short for the likes of anxiety
until the effects of longer term treatment options (eg. counselling, antidepressants, mood stabiliser
medication) starts working.
Benzodiazepines have been prescribed in Ireland for over 50 years and there has been a long history
of overprescribing. When they first came out, the likes of “valium” were seen as wonder drugs, their
potential problems and side effects were not realised initially and “mother’s little helpers” were
overprescribed by family doctors. Only in the last few years have efforts been made to reduce over
and inappropriate prescribing.
How they work?
Benzodiazepines work by increasing the efficiency of a natural brain chemical called GABA. GABA
works by reducing the excitability of transmitters (neurons) in the brain. This slows the communication
between neurons giving a calming effect to many functions of the brain. Benzodiazepines main effect
is to reduce anxiety and agitation, while it does this quickly (within half an hour); this effect is short
lived (a few hours only). They are quite effective in reducing anxiety and have few side effects if only
used short term at the lowest possible dose. Side effects can include drowsiness and slowing of
mental and bodily movements. These effects are more pronounced in the elderly so extreme care
must be taken if they must be prescribed for older people.
Benzodiazepines cause sedation so benzodiazepines can be dangerous if combined with other
sedative drugs or alcohol and can affect driving or operating machinery. Benzodiazepines may cause
confusion, slurred speech, coordination problems, impairment of judgement and memory loss in some
people, especially at higher doses. Paradoxically they can cause mood swings in some people
(perhaps this is more when the dose wears off). With long term use, tolerance can occur; this
involves needing higher doses to produce the same effects. Dependence can also occur with longer
term use (more than a week); symptoms can include feeling a constant need for the drug with the
feeling of not being able to function right without it and developing withdrawal symptoms if the drug is
stopped. A person’s tolerance to the effects of a benzodiazepine can develop quickly, even within a
couple of weeks. Withdrawal symptoms can be debilitating and can include nausea, vomiting, sweats,
low mood, and paranoia and panic attacks. The anxiety that occurs with detox (withdrawal) from
benzodiazepines is often worse than the original anxiety they were originally prescribed for; leading to
the vicious circle of the person needing to continue and then constantly need higher doses if not
monitored closely (as the person becomes tolerant to the drug if used long term).
Benzodiazepines combined with alcohol or other medication (even some common over the counter
medicines such as pain-killers and anti-histamines) can cause loss of consciousness and respiratory
failure. Side effects are rare if doses are kept low and courses are short (ideally 4 weeks maximum).
Paradoxical reactions (unexpected increases in agitated or aggressive behaviour) can occur but are
rare.
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Types of benzodiazepine
There are three main groups of benzodiazepine and they are categorised by how quickly they work
and are eliminated from the body. Short-acting benzodiazepines include midazolam (Hypnovel®), and
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Benzodiazepines are recommended for use for a maximum of 4 weeks; prescribing more than 4
weeks supply is not licenced (meaning it is not authorised or recommended by health authorities or
the manufacturers of these drugs). Prescribing for longer than 4 weeks is limited to consultants who
are familiar with all the alternatives and feel there is no other options despite the risks (eg) severe
cases of anxiety
triazolam (Halcion®). Intermediate acting benzodiazepines include alprazolam (Xanax®), clonazepam
(Rivotril®), lorazepam (Ativan®), nitrazepam (Mogadon®) and temazepam (Nortem®). Long-acting
benzodiazepines include diazepam (Valium®, Anxicalm®), flurazepam (Dalmane®, Dalmapam®) and
chlordiazepoxide (Librium ®). Some have a very sedative effect so are only used as sleeping tablets;
these include triazolam (Halcion®), nitrazepam (Mogadon®), temazepam (Nortem) and flurazepam
(Dalmane). They should only be used short term as sedatives due to the reasons like tolerance,
dependence and withdrawal symptoms described earlier.
Generally shorter acting compounds are better for the elderly as the longer acting compounds can
build up over time as elderly patients’ are less able to metabolise them. However short acting
benzodiazepines are more likely to become habit forming or create dependency so should only be
used in limited cases.
Uses for benzodiazepines
Benzodiazepines are never recommended as a standalone treatment (eg for anxiety), but should be
used in conjunction with other treatments for any underlying condition. They should be avoided in
people with a tendency or history to misuse drugs or alcohol as they have more potential to develop
dependence on benzodiazepines and overdose due mixing with other substances.
Withdrawal from alcohol
Unlike other conditions, benzodiazepines are still used the treatment of choice for alcohol withdrawal.
Chlordiazepoxide (Librium ®) is the benzodiazepine of choice for alcohol withdrawal. The dose is
started high and tapered off and discontinued within one week. Addiction to alcohol increases the
likelihood of addiction to benzodiazepines due to their addictive nature so benzodiazepines should
only be used short term. The anticonvulsant properties of benzodiazepines also mean they can
prevent seizures which can occur in some people withdrawing from long term alcohol abuse. Detox
from alcohol is only the first step in staying dry from alcohol and the person will need long term
support such as counselling and other treatments to stay dry.
Anxiety Disorders
The main reason benzodiazepines are prescribed is for the short-term treatment (max of 4 weeks but
the shorter the period the better) of anxiety disorders or panic disorder. Benzodiazepines should only
be used for treatment resistant cases and should never be the first treatment option. They should be
used with care in post-traumatic stress disorder (PTSD) as studies indicate they can sometimes make
symptoms worse. Benzodiazepines should not be used for people experiencing bereavement as they
can inhibit psychological adjustment and reduce the normal mourning process. Benzodiazepines
should not be used as first treatment options of anxiety disorder but only as temporary treatment
during initial treatment while waiting for definitive therapy with longer term medications (eg. antidepressants) and psychotherapy (eg. counselling) to take effect. Taking benzodiazepines for more
than four weeks mainly results in effects described earlier such as loss of effectiveness, tolerance to
their effects, dependence, potential withdrawal syndromes, side effects, and reduced effectiveness of
the long term treatment plan (eg) antidepressants, counselling. Benzodiazepines taken for more than
2 weeks continuously should be reduced slowly instead of discontinuing suddenly to prevent
withdrawal symptoms.
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Insomnia
Benzodiazepines may be used as a short term treatment for insomnia. Non benzodiazepines (Z)
Hypnotics (such as zopiclone and zolpidem) may be associated with fewer side effects. The
recommendation is that all hypnotics are only prescribed for two to four weeks. Sleeping tablets
should only be considered if insomnia is severe and causing extreme distress. For severe insomnia,
only the short-acting benzodiazepines should be prescribed for the shortest possible time period such
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Benzodiazepines should be reserved for the treatment of patients who have not improved with
treatment by at least two therapies (eg. SSRI (selective serotonin reuptake inhibitor) and a
psychological treatment like counselling). However these concerns should not prevent their use in
those with persistent, severe, distressing and impeding anxiety symptoms. There are a small minority
(who do not develop a tolerance) who benefit from long term use of benzodiazepines as attempts to
reduce benzodiazepines causes a relapse.
as temazepam (Nortem®, Insomniger®), lormetazepam (Noctamid®), flurazepam (Dalmane®), and
triazolam (Halcion®).
The newer non benzodiazepine sleeping tablets such as zopiclone (Zimovane®, Zimoclone®) and
zolpidem (Stilnoct®, Zolnod®) may cause less side effects and are less addictive than older varieties
but it is still easy to become dependent on them. They tend to give a metallic taste in the mouth.
There is not much difference in effectiveness between the non-benzodiazepines and older
benzodiazepines. Sleeping tablets are best avoided in the elderly if possible as they cause confusion
and increase the likelihood of falls.
Acute Mania
Mania is the “high” phase that people suffering from bipolar disorder (also known as “manicdepression”) can experience; it is usually followed by period of deep depression. Benzodiazepines are
used in treating Acute Mania (the high phase) or Hypomania (low depressive mood stage), on a short
term basis until the longer acting medications such as antipsychotics (eg. quetiapine, olanzapine) or
mood stabilising medication (eg. lithium) kick in.
Use in Psychosis
Benzodiazepines are used in the treatment of psychosis (a short term psychotic state where a person
loses touch with reality; psychosis is often caused by other conditions like schizophrenia or bipolar
disorder). If a person with psychosis is very distressed and needs to be calmed quickly, then a
benzodiazepine may be required for what is referred to as Rapid Tranquillisation, either alone, or in
combination with an antipsychotic (a mood stabiliser medication). In some rarer cases, patients with a
psychotic illness may fail to respond sufficiently to antipsychotics, and can mean that
benzodiazepines may need to be prescribed longer term.
Catatonia
Benzodiazepines are the medication of choice in catatonia (also known as “neurogenic motor
immobility” which is a phenomenon characterised by muscle rigidity and a mental stupor).
Benzodiazepines are effective for catatonic symptoms because they have muscle relaxant properties
and are fast acting and easily administered.
Special populations:
Pregnancy
Benzodiazepines should be avoided during pregnancy if possible as they can cause problems like
hypothermia, reduced movement and respiratory depression in the unborn child. Ideally
benzodiazepines should be discontinued before a planned pregnancy. If a woman becomes pregnant
while taking benzodiazepines, they should be gradually withdrawn as soon as possible. However a
risk benefit analysis should be undertaken by a mental health professional, and if other treatments
such as avoidance of stress, relaxation, anxiety management, counselling and Cognitive Behaviour
Therapy (CBT) do not give sufficient relief, then benzodiazepines are justified. Severe and persistent
anxiety for a pregnant woman can be a risk to the unborn baby’s health so specialist advice is
required in this situation.
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Older people
In older people, benzodiazepines are associated with more severe side effects including marked
sedation and psychomotor impairment (slowdown of mental and physical activity), higher risk of
fractures (especially hip fractures) and driving accidents, and a quicker development of tolerance,
dependence and withdrawal symptoms (when compared to younger patients). Our bodies’ clear drugs
slower as we get older which is a major factor for the increased susceptibility to side effects from
drugs such as benzodiazepines. Side effects may be less is shorter acting benzodiazepines are
prescribed (eg) alprazolam instead of diazepam. Anxiety is often associated with depression in older
people and can be treated with anti-depressants and psychological therapies (eg. counselling, CBT)
instead of benzodiazepines. In general, older people have better quality of lives if not prescribed
benzodiazepines and benefits associated with successful reduction in rates of benzodiazepine use
include increased alertness, mobility, reduced incontinence and improved well-being.
People with an Intellectual Disability
Benzodiazepines cause sedation and hence an increased risk of falls. They also reduce the person’s
ability to engage with activities during the day so can reduce their quality of life.
Children
Benzodiazepines are rarely used for children but there are certain occasions where they play an
important in managing children with similar presentations seen in adults, eg. Manic symptoms, acute
agitation associated with psychosis, short term treatment of acute and debilitating anxiety, and part of
treatment for Post-Traumatic Stress Disorder. Children and adolescents may also present with severe
agitation or aggressive behaviour in situations like a learning difficulty, developmental disorders (such
as Autism and Asperger’s) or severe psychological reactions due to stressful events such as abuse
and trauma. Such rapid tranquilisation may be required for the safety of child or adolescent and those
around them. Benzodiazepine use for children and adolescents must be of the shortest duration
possible and must be reviewed regularly. Informed parental consent is preferable whenever possible,
unless one needs to act under common law due to the urgency of the situation. All psychotropic
medication (medication for mental health conditions) prescribed for children must be by a specialist in
Child Mental Health.
People with substance misuse problems
Benzodiazepines are abused as recreational drugs and there is a black market for them. Patients with
substance misuse problems often abuse multiple substances with benzodiazepines being one of the
most commonly abused, often in combination with other drugs in order to enhance their effects, to
experience euphoric effects and an altered state of consciousness. They are also used to ease
withdrawal symptoms associated with other drugs including alcohol, cocaine and heroin. Other
reasons substance misusers take benzodiazepines that are not prescribed (i.e. buy them on the
street) include underlying symptoms of anxiety, panic attacks, phobic disorders, depression, posttraumatic stress disorder, and psychotic symptoms due to the likes of schizophrenia or bipolar
disorder. Prescribing of benzodiazepines to substance misusers is best provided by specialist
treatment services. Withdrawal from benzodiazepines for people suffering from substance misuse
should be done extremely slowly and the dose should be reduced gradually every 2 to 4 weeks; this
can take up to a year in some cases to ensure adequate withdrawal.
Disclaimer: Please ensure you consult with your healthcare professional before making any changes
recommended
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