Benzodiazepines, opioid analgesics and other sedatives have indispensable medical uses, but they can also stimulate the reward center in the brain. In susceptible individuals, this can lead to sedative abuse and misuse (defined as any use of those prescription medications outside of the intent for which it was prescribed), and create a plethora of serious consequences.
Sedative use disorders are regarded as considerable contributors to disability and mortality worldwide. Despite strict government regulation of these drugs in most of the countries, their abuse and its consequences have not only persisted, but also increased. Therefore physicians who are in charge of prescribing sedatives have a significant role in reversing such trends.
One or more criteria must be satisfied in the 12-month period in order to diagnose sedative abuse (but also substance abuse in general). Those are failure to fulfill major obligations due to sedative use, their recurrent use in physically dangerous situations, recurrent legal problems, as well as continued sedative use despite social or interpersonal issues.
Epidemiology and most frequent type of abuse
Benzodiazepines are one of the most frequently prescribed psychotropic medications in the world. Abuse of benzodiazepines is commonly defined as non-medical, recreational use for the sole purpose of creating an intoxicated or “high” state of mind. The National Survey on Drug Use and Health conducted in the United States in 2010 revealed an estimated 186,000 new abusers of benzodiazepine drugs.
Studies suggest that the abuse burden of benzodiazepines may only be evident in specific clinical populations, most notably in detoxified alcoholics and recreational users of other types of drugs. In addition, the abuse of benzodiazepines among individuals kept on opioid agonists (e.g. methadone and buprenorphine) has been repeatedly described in the medical literature.
In accordance with the latter claim, the U.S. Treatment Outcome Prospective Study showed that 73% of heroin users entering into treatment reported some extent of benzodiazepine use in the preceding year, with substantially lower rates of barbiturate use. Furthermore, almost 25% of such patients reported daily benzodiazepine use.
Flunitrazepam is a benzodiazepine largely prescribed to individuals with insomnia in many different countries; nevertheless, this drug also gained popularity among alcohol and drug abusers. A myriad of reports point to the use of flunitrazepam as a date rape drug, and it is also involved in many accounts of fatal intoxications.
Alcohol abuse is an important issue as well, since 25% of adults are found to consume alcohol in quantities surpassing recommended limits. Harmful consequences such as acute injury or chronic disease are seen in approximately 10% of individuals with an alcohol use disorder, which makes it the third largest cause of potentially preventable deaths in the United States.
Management of overdose cases
Overdose with sedative drugs usually result in hemodynamic instability, which can be a cause of death due to a cardiorespiratory collapse. Attention should be focused on maintaining adequate oxygenation, airway, as well as hemodynamic support. Supplemental oxygen and aspiration prevention are considered the cornerstones of treatment.
Invasive therapy (other than respiratory support) is rarely required in patients with sedative overdose. Hemodialysis is sometimes considered when patients who overdose with large quantities of chloral hydrate develop life-threatening cardiac symptoms. 24 hours of observation is required for patients overdosed with long-acting sedative hypnotics such as clonazepam.
The effectiveness of delayed orogastric lavage is not confirmed, this approach is often considered in overdoses with sedatives that slow the motility of the gastrointestinal tract or those that develop concretions (namely meprobamate and phenobarbital). The use of orogastric lavage in overdose cases should always be done with caution.
If we want to meet challenges posed by sedative use disorders, the development of better biomarkers that will allow early detection of abuse and improved measurability is of utter most importance. Ideal biomarkers should have high sensitivity and specificity, high positive predictive value, as well as high area under the curve in a receiver-operator characteristic analysis.
- Gitlow S. Substance Use Disorders: A Practical Guide. Lippincott Williams & Wilkins, 2007; pp. 1-84.
- Burchum J, Rosenthal L, editors. Lehne’s Pharmacology for Nursing Care, 9th edition. Elsevier Health Sciences, 2014; pp. 373-387.