The Risk of Addiction With Sedative Prescriptions
In an earlier blog I outlined the health threat and addiction potential from non-prescription use of opioid painkillers. However, the problems do not stop with this class of drug. Sedative and hypnotic drugs also pose significant risk of physical and psychological dependence.
Sedative-hypnotics - often called tranquilizers since they depress the central nervous system - include: barbiturates, such as Seconal and Nembutal (rarely used today); benzodiazepines, such as Diazepam (Valium); and newer non-benzodiazepine "Z" drugs, such as Zopiclone and Zolpidem.
Perhaps ironically, the major drawback of benzodiazepines is that they work so well as sedatives and hypnotics. Over 30% of older people in the U.S. take a benzodiazepine or Z drug to help them get a good night’s sleep.1
When taken recreationally, sedative-hypnotics induce euphoria and enhance the effect of other drugs (or reduce withdrawal symptoms) - but long-term use leads to more significant problems. Acute adverse effects include sedation, drowsiness, psychomotor slowing and poor memory. The risk of motor vehicle accident rises by 60% to 80% - the increase is sevenfold when the drug is taken with alcohol.2
Over the longer term, depression and dementia are significant risks, as are worsening anxiety and falls. Dependence brings the problems associated with withdrawal. Associations have also been reported with cancer, pneumonia and other infections.
Features of benzodiazepines withdrawal include anxiety symptoms, such as irritability, tremor and sleep disturbance. Other features include altered perception, hypersensitivity, seizures, symptoms of depression or psychosis and even suicidality.
For years, the medical community suspected that benzodiazepines and Z drugs were associated with premature mortality. A large UK study confirmed mortality is significantly increased.3 In 2014, deaths involving benzodiazepines were up 8% from the prior year and totalled 372. This is the highest level since data was collected.4
Concerning the risk of overdose, benzodiazepines alone are relatively safe - but not in combination with other drugs, particularly opioid painkillers or alcohol. In one U.S. state, Alprazolam was implicated in 17% of drug-related deaths with a second drug identified in 97.5% cases.5
Treatment for benzodiazepine dependence involves switching to a long-acting form of the drug, and slow reduction over a prolonged period with support and monitoring. Treating co-morbid psychiatric conditions is a priority as is managing any chronic pain. Abstinence rates vary but range from 25% at 12 months in people with complicated dependency up to 80% in older adults.6
The prevalence of dependence is difficult to estimate internationally. Roughly one American adult in 20 has a prescription for these drugs - the estimate is three times higher in older people.7 During 2014, more than 10 million prescriptions for benzodiazepines were dispensed in England, where the concern over the illegal supply is growing. High dose use has been identified in 1.6% of the Swiss population.8 According to the first European comparative study on nonmedical prescription drug (Novak et al. 2015), Germany has the lowest level while the UK, Spain and Sweden have the highest.9
The disclosure of long-term benzodiazepine use raises concerns for insurers given the associations with premature mortality. Underwriters will seek clues of a personality characterised by organised psychological traits and behaviours appropriate to an applicant’s social and physical environment. Evidence of co-morbid psychiatric problems and chronic pain, misuse of other drugs or alcohol and especially poor insight to the problems drugs are causing – will be reviewed less favourably.
- Brett, J., Murnlon, B. (2015), Management of benzodiazepine misuse and dependence, Australian Prescriber: 38,152-5.
- Dassanayake, T. et al. (2011), Effects of benzodiazepines, antidepressants and opioids on driving: A systematic review and meta-analysis of epidemiological and experimental evidence, Drug Safety 34.125–56.
- Weich, S. et al. (2014), Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards, BMJ; 348:g1996 doi: 10.1136/bmj.g1996 (Published 19 March 2014).
- http://www.bbc.co.uk/news/uk-35124880 (accessed 15/8/2016).
- Gresham, C. (2015) Benzodiazepine toxicity, http://emedicine.medscape.com/article/813255-overview#a5.
- Brett, J. and Murnlon, B. (2015), Management of benzodiazepine misuse and dependence, Australian Prescriber: 38,152-5.
- Olfson, M. et al. (2014), Benzodiazepine use in the United States, JAMA Psychiatry. doi:10.1001/jamapsychiatry.2014.1763.
- Liebrenz, M. et al. (2015), High dose benzodiazepine dependence: a qualitative study of patients’ perception on cessation and withdrawal, BMC Psychiatry 15:116 DOI 10.1186/s12888-015-0493-y.
- Novak, SP. et al. (2015), Nonmedical use of prescription drugs in the European Union, BMC Psychiatry 16:274 DOI: 10.1186/s12888-016-0909-3