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Benzodiazepines are primarily
used to aid sleep and reduce anxiety and agitation. Anxiety is both mental and physical, and
benzodiazepines also relieve physical symptoms such as muscle tension,
racing heart and abdominal discomfort. Their main side effect, drowsiness,
can be used to help with sleep. Their effects come on soon after taking
them, and leave as the medicine leaves the body.
Upon their release in 1960, they
were seen as a safer alternative to their predecessor, the
barbiturates. In fact, with proper
use, the benzodiazepines are safe.
Problems occur when they are taken for too long, which can cause
dependence, or when taken in high doses or combined with alcohol, which can
cause unconsciousness and impair breathing.
Examples of “proper
use” include during a brief crisis to relieve insomnia and
anxiety. They can also be taken
while waiting for an antidepressant or mood stabilizer to work.
Benzodiazepines reduce the symptoms of depression and bipolar disorder, but
do not help the underlying problem when taken long-term. Many people with
panic disorder keep them on hand in case a panic attack comes on, and this
infrequent, but long-term, use is also safe.
When taking them for sleep, I
recommend following sleep
guidelines to reduce the risk of becoming
dependent on them.
Other medical uses of
benzodiazepines include treatment of seizures, tremor, headaches, nausea,
muscle tension, and detoxification from alcohol.
How do they work?
Benzodiazepines bind to and
regulate GABA receptors in the brain, which are involved in anxiety and
relaxation.
What types are available and how are they taken?
The benzodiazepines differ in
how fast they come on and how long their effects last. Exmples
include:
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duration
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Examples
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Short
Acting (<5 hr)
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Oxazepam
(Serax caps or tabs), flurazepam
(caps), triazolam (Halcion
tabs), alprazolam (Xanax,
tabs or slow-release caps*)
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Mid-Acting
(6-12 hr)
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Lorazepam
(Ativan tabs, liquid, injection), temazepam (Restoril caps), estazolam (Prosom, tabs)
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Long
Acting (>12 hr)
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Clonazepam
(Klonopin tabs, wafers), diazepam (Valium, Dizac; tabs or slow-release caps*), chlordiazepam (Librium tabs, caps), clorazepate (Tranxene,
regular or slow-release tabs*)
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*Do
not crush or chew slow-release pills.
If you miss a dose, take it
right away if you remember within an hour or so of the missed dose.
Otherwise, skip the missed dose and go back to your regular dosing
schedule. Do not double-up on doses.
How to take for sleep
Since benzodiazepines may cause
drowsiness the morning after they are taken, make sure you don’t have
something important to wake up to the next day. For most people, this isn’t a
problem. More concerning is the potential to become dependent, or unable to
sleep without them (described below).
To avoid this, take them only when needed and avoid regular use for
more than a month and follow sleep guidelines. They should
be taken 15-60 minutes before sleep, depending on how fast the
benzodiazepine you are using comes on.
How can I prevent dependence on them?
“Dependence”
means that withdrawal symptoms have made it hard to stop a medicine. This
effect is often purely physical, and does not mean that you are “psychologically
addicted” or have become and addict. If they are taken for less than
three months, and the dose is reduced gradually, most people can stop them
without experiencing withdrawal.
When benzodiazepines are stopped abruptly, withdrawal symptoms can
include:
Insomnia,
anxiety, tremor, irritability, headache, dizziness, depression, increased
or abnormal perception, feeling outside your body, paranoia, and
seizures.
After steady use for longer than
a year, it is harder to come off them, but this can still be accomplished
by switching to a long-acting benzodiazepine and lowering the dose
gradually. Rarely, people who take
benzodiazepines long term can have prolonged withdrawal symptoms that last
up to a year.
“Tolerance” means
that you need to take more of the medication to get the same effects as
when you first took it. This condition is a sign that dependence may be
occurring.
“Addiction” means
that you go out of your way to get a “high” from a
medicine. “Going out of your
way” often means behavior that is destructive to your life. Most people with anxiety are very
cautious about medicines and do not seek them out in this way, and people
without anxiety usually don’t like the sedation that benzodiazepines
cause. People with a personal or
family history of alcohol or drug addiction may become addicted to
benzodiazepines, and unfortunately taking them in an addictive way will
usually lead to physical dependence on them.
What side effects can I expect?
Benzodiazepines do not cause
weight gain or serious medical side effects (other than the dependence
described above). Common side effects include drowsiness, dizziness, and
poor coordination; these can cause problems while driving. Most side
effects will improve by reducing the dose.
Benzodiazepines can impair
concentration, attention and memory. This is similar to the effects of
alcohol: there is poor memory for events that occur after taking them. This impairment needs to be weighed
against the effect that untreated anxiety can have on mental performance.
Rarely, benzodiazepines can
cause agitation and poor judgment (called disinhibition). Like the effects of alcohol, people may
have less awareness of their actions and do things they regret in this
state.
Benzodiazepine overdose
Signs of overdose include
confusion, slurred speech, severe drowsiness or weakness, difficulty
walking, and loss of consciousness.
These effects are worse with alcohol (see “Drug
Interactions” below). If this
happens, go to your local emergency room.
Precautions
Driving: benzodiazepines
cause drowsiness and impair reflexes and coordination, so make sure you
know how you react to them before you drive, use machines, or do anything
else that could be dangerous if you are not alert and well-coordinated.
Pregnancy:
Birth defects (especially of the palate) are rare but have been
reported in infants exposed to benzodiazepines during the first
trimester. If used later in the
pregnancy, there is a risk of withdrawal and dependence effects in the baby.
They are best avoided during delivery, for they can lead to weakness and
other problems in a new born. Benzodiazepines
pose no known risks to the ovaries when taken before pregnancy.
Breast-feeding: They may pass into breast milk and cause
weakness, weight loss and difficulty feeding in a new born.
Allergies: Certain benzodiazepines may
contain lactose, parabens, or soybean oil.
Children: May be more sensitive to the side
effects of benzodiazepines and require lower doses.
Older adults: Benzodiazepines
may be removed from the body more slowly in people after age 65, so lower
dosages are recommended to prevent the drug from building up. Oxazepam and temazepam are less likely to build up. Dizziness and falls are also a problem
when they are used in the elderly.
Medical problem requiring caution with
benzodiazepines:
- Liver,
kidney or respiratory (lung) disease
- Sleep
apnea
- Epilepsy,
seizures, or serious neurologic illness
- Glaucoma
Drug Interactions
Below are drug interactions common to most
benzodiazepines.
Medicines
that increase benzodiazepine levels:
Fluoxetine (Prozac), fluvoxamine (Luvox), nefazodone (Serzone), birth control pills containing estrogen, isoniazid, cimetidine (Tagamet), disulfiram (Antabuse), erythromycin, isoniazid,
aprepitant, protease inhibitors.
(This increase usually doesn’t happen for lorazepam,
oxazepam, and temazepam)
Medicines
that lower benzodiazepine levels:
Tegretol (Carbamazepine), antacids,
rifampin, bosentan.
Medicines
that can increase their drowsy or sedative effect:
Alcohol, antihistamines (e.g.
Benadryl), barbiturates, heroin and opiate pain medicines, other medicines
with sedative effects (Seroquel, Remeron, Trazodone).
Storage
- Keep
out of the reach of children.
- Store
away from heat and direct light.
- Do
not store in the bathroom, near the kitchen sink, or in other damp
places. Heat or moisture may cause the medicine to break down.
- Do
not keep outdated medicine or medicine no longer needed. Be sure that
any discarded medicine is out of the reach of children.
Updated
6/9//4 by Chris Aiken, M.D
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