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
What’s the Point of this Category?
Here’s something that you probably won’t see published anywhere else so here it goes…these abused medications overall represent poor prescribing practices. Drug users will never say I’m addicted to hypnotics, sedatives…that is medical terminology. What’s also unfortunate is how there’s NO medication treatment for “sedative use disorder” or benzodiazepines and this is what leads to a cycle of addiction.
Another purpose of this category is because this is what you will see in your office. The previous provider stopped prescribing the BZD so they get it off the street or from friends until they’re in your chair asking for the medication. If you say no, they’ll get it off the street, and if you say yes then you may be enabling an addiction. I did a separate post for treating BZD addiction/tapering and will use this space to talk about some key points to navigate out this dilemma.
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. 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.
Who I would NOT treat with a BZD?
- People with sleep problems: I simply tell patients that the treatment is so short-acting that it doesn’t work. None of my patients with sleep disorders are on BZD plus there are many other good options. Some people get prescribed Z meds from a sleep study, again it’s usually on a short-term basis. “A doctor prescribed them in 2001”, I’m still not going to restart it. I tell patients, it usually doesn’t work so people will turn to alcohol or other measures to sleep. Again, this group of people (with sleep problems) are at risk of relapsing or having another addiction.
- Non-adherence: if a patient doesn’t agree with regular rx testing, doesn’t like to follow-up, difficult personality, poor adherence to mental/medical care then I simply say, a BZD is not in our best interest at this time. I also tell patients non-adherence may also mean a possible relapse. However, humans change so if they start acting civil again then I would start with safer options to address the sleep/anxiety or whatever mood and with enough compliance, can use a BZD if needed.
- Certain Medical Conditions: seizures, sleep apnea, CVA, liver disease, pregnancy, memory problems, uncontrolled breathing problems, obesity, or severe underweight, or not being adherent to medications like insulin, I’m quite sure there are others but the main issue is that you don’t want to cause respiratory depression or risk aspiration. I have a small cancer patient who was prescribed a BZD for his radiation via PCP but he doesn’t have a substance abuse history so the point is for these chronic conditions, collaborate with the other providers if possible. Plus ask yourself if the benefits are greater than the risks? if not then I usually avoid them.
- Significant History of SI Attempts: with these medications a person can easily overdose or mix them with other drugs and quickly go lights out. This harm may or may not be intentional because you STILL have people who will assume “prescribed” medications aren’t harmful. Regardless of what’s being prescribed, typically a prescription monitoring report should limit prescribing mistakes (but not always). However, history of OD from pills, meds, or unstable situations, I usually just express, BZD and similar medications are not the safest options.
Stick to What Makes YOU Comfortable
Lastly, to contrast this with cocaine users who are like cowboys from hell, this hypnotic category, or those with past BZD addictions, you want to be more careful with… I can use many medications or experiment with cocaine users but with BZD, sedative/hypnotic medications you want to somewhat treat them like the elderly or with caution, and start low and go slow with increases.
Know your comfort zones and boundaries when dealing with medications and substance abuse. Try to be consistent to not cause confusion or unforeseen emergencies. I don’t feel comfortable putting someone on a BZD for short-term purposes, long-term yes for anxiety because it can be PRN’d but NO for sleep because the tolerance builds up too quickly. I call the z-meds a rich man’s Benadryl and use other great options to avoid worsening things or risking another addiction/relapse.
The main point I’m trying to make here is this is the population you DON’T want to experiment with because some providers will prescribe anything regardless, which is why many people get an addiction in the first place… the best outcome includes aiming for stability without using more drugs.
Working in substance abuse, everything goes back to the mood, emotions, and feelings or psych conditions. This person is in your office, finally stabilized, and has a clean slate to maintain sobriety. Use the follow-up meetings to your advantage to help them live a productive life by targeting sleep and mood. Of course, we want what makes the patient feel comfortable but with this group, you may have to override their demands for safety reasons.
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.
