Sedative, Hypnotics, Sleep, etc. Med Addictions
Medications that induce sleep, euphoria, or disorientation are all in a box called sedative-hypnotics. So people also put benzodiazepines (BZD), GHB, and alcohol in this category as well even though the treatment is different and put in other med classes. These medications are usually prescribed but most people link “prescription” meds with opioids. However, the most abused sedatives are alprazolam, diazepam, chlordiazepoxide, and zolpidem -CARLAT
Clinicians often face a dilemma with patients seeking BZDs, either as a result of previous prescriptions being stopped or accessing them illicitly. Refusing the medication may push patients to obtain it via riskier means, while prescribing may enable an addiction.
Clinical Significance
- Barbiturates are used in the treatment of epilepsy and anesthetics and respiratory depression can occur, thus the most deadly for withdrawals
- Gamma-hydroxybutyrate (GHB) also known as the date-rape drug is also a CNS depressant
- Symptoms are exacerbated when combined with EtOH and/or narcotics.
- In general, withdrawal from sedatives (e.g. ETOH, barbiturates, benzodiazepines) is life-threatening, whereas withdrawals from stimulants (cocaine) are not.
What About Outpatient?
Ironically, a BZD is used to treat withdrawals while in the hospital but outpatient is the complete opposite. When patients expressed well this is what they gave me in the hospital, I simply explained because they’re ONLY good short-term plus the patient is being monitored/regulated in the hospital. I treat people with anxiety with BZD’s and some with a substance abuse history but sometimes you have to figure out who qualifies for the short-term category versus long-term and weigh the pros and cons.
When to Avoid Benzodiazepine (BZD) Treatment?
- Patients with Sleep Problems:
- BZDs are short-acting and often ineffective for long-term sleep issues.
- Alternative treatments are preferred due to the risk of addiction or relapse.
- Patients with sleep issues may turn to harmful alternatives like alcohol.
- Non-Adherence to Treatment:
- Patients resistant to regular testing or follow-ups, or those with poor adherence to medical care, are unsuitable for BZD treatment.
- Non-adherence increases the risk of relapse.
- Reconsideration may occur if the patient demonstrates improved compliance and behavior.
- Certain Medical Conditions:
- Conditions such as seizures, sleep apnea, CVA (stroke), liver disease, pregnancy, memory problems, respiratory issues, obesity, or severe underweight.
- Risks include respiratory depression, aspiration, and other complications.
- Collaboration with other providers is essential to evaluate risks versus benefits.
- History of Suicide Attempts (SI) or Overdose:
- High overdose risk with BZDs, especially if mixed with other substances.
- Prior overdose history suggests heightened vulnerability to harm, intentional or accidental.
- Prescription monitoring should be employed to mitigate risks.
General Key Points
- Prioritize safer alternatives and assess patient stability and compliance.
- Engage in multidisciplinary collaboration when needed.
- Weigh benefits versus risks carefully, erring on the side of caution in high-risk scenarios.
Stick to What Makes YOU Comfortable
When dealing with patients with a history of BZD or sedative/hypnotic addiction, it is crucial to approach treatment with caution, similar to how you might treat elderly patients: start with low doses and increase gradually, if necessary. Unlike cocaine users, who may tolerate more experimental approaches, this population requires consistency and clear boundaries to prevent confusion or emergencies. Avoid using BZDs for short-term purposes or sleep issues due to the rapid tolerance buildup and risk of relapse. Instead, prioritize stability with safer alternatives, aiming to address mood and sleep without exacerbating addiction.
Providers must resist patient demands when safety is at stake and focus on long-term sobriety and productive living through consistent follow-ups and careful medication management. The risks of aspirating and respiratory depression are very serious. If you go in this direction, collaborate with other providers, have clear treatment goals/plans, some basis for discontinuation, comply with regular Rx screening and follow-ups…etc. hopefully, the above reasons and recommendations are helpful.
