Benzodiazepines

This article provides a comprehensive overview of benzodiazepines, including their benefits and uses, specific types, side effects and risks, and overall use in professional treatment plans.

Key Takeaways:

• Benzodiazepines are a group of drugs with sedative effects in the central nervous system. They act on benzodiazepine receptors, which increases the effects of GABA, in turn promoting mental calmness and physical relaxation.

• The most common approved uses of benzodiazepines are for panic, anxiety, insomnia, and seizures. Their effects start to occur within an hour, making them common options for immediate and short-term relief.

• Benzodiazepines can cause physical dependence, and may interact with several medications, drugs, and alcohol. Typical use is limited to several weeks, although long-term use may be beneficial in certain situations, if the benefits outweigh the risks.

Understanding Benzodiazepines

Benzodiazepines are categorized as depressants. In particular, benzodiazepines are a group of prescription drugs that affect benzodiazepine receptors in the brain and central nervous system (CNS), which causes sedative effects. They are commonly used for seizure disorders, as well as anxiety, panic, and other anxiety-related conditions. ^[1]

How Do Benzodiazepines Work?

GABA is a neurotransmitter that has inhibitory effects in the brain and body. Benzodiazepines work by activating benzodiazepine receptors in the brain and CNS, which leads to increased GABA receptor activity. In turn, this increases the effects of GABA in the brain and body, leading to several possible effects, such as mental calmness, relaxed muscles, and sleep promotion. ^{[1] [2] [3]}

Benzodiazepines typically work rapidly, in which individuals can feel the initial effects within 30 minutes to an hour after taking them. Peak effects differ depending on the type of medication, but generally occur after 1 to 2 hours.

Conditions Traditionally Treated with Benzodiazepines

Benzodiazepines have a long history of use for several conditions. Approved uses for benzodiazepines include: ^{[1] [4] [5]}

• Anxiety disorders, including:

• Agoraphobia

• Generalized anxiety disorder (GAD)

• Social anxiety disorder (SAD)

• Panic disorder

• Various types of seizures, such as):

• Myoclonic seizures

• Absence seizures

• Focal onset seizures

• Alcohol withdrawal management

• Insomnia disorders, including:

• Sleep-maintenance insomnia

• Sleep-onset insomnia

• Chronic insomnia

• Procedural sedation

Importantly, not every benzodiazepine is approved for all of these uses. Most benzodiazepines are approved for 1 to 2 indications. ^[1]

Off-Label Uses

Benzodiazepines are also used off-label for several conditions and symptoms, including: ^{[1] [5]}

• Sleep disorders

• Tourette syndrome

• Delirium

• Delirium tremens (alcohol withdrawal delirium)

• Restless legs syndrome

• Movement-related side effects from medications, such as:

• Tremors

• Tics

• Tardive dyskinesia

• Chorea

Types of Benzodiazepines

There are many types of benzodiazepines. They are commonly grouped into short-acting, medium-acting, and long-acting classes, based on how long their effects last in the body.

Specific benzodiazepine drugs are listed below by category, with brand names for some of the more common medications included as well : ^{[1] [4]}

Short-Acting (Typical half-life between 2-24 hours):

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• Midazolam: This drug is typically used intravenously for procedural/preoperative sedation and general anesthesia, and intramuscularly for seizures (including convulsive status epilepticus [CSE]).

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• Triazolam (Halcion®): Primarily used for insomnia, especially the sleep-onset form. It is taken before bedtime.

• Remimazolam: This drug is technically classified as very short-acting. It is used for procedural/preoperative sedation and relaxation.

Medium-Acting (Half-life between 10-24 hours):

• Alprazolam (Xanax®, Alprax®): This is one of the most commonly prescribed benzodiazepines, especially for anxiety and panic disorders. It is taken 1 to 3 times per day for these situations.

• Estazolam (ProSom®): Primarily used for insomnia (short-term). It is taken before bed.

• Lorazepam (Ativan®): Another very common benzodiazepine. Used for anxiety disorders, CSE, seizures, sedation, and insomnia (short-term). Dosage varies, but is typically taken 2 to 3 times per day.

• Quazepam: Used for short-term or chronic insomnia. It is taken at bedtime.

• Temazepam: Used for sleep-onset and sleep-maintenance insomnia. It is taken shortly before bed.

• Oxazepam: Used for anxiety disorders and alcohol withdrawal syndrome (AWS).

Long-Acting:

• Chlordiazepoxide: (Librax®, Librium®): A relatively common benzodiazepine used primarily for AWS, as well as anxiety. Repeated doses are often used for AWS.

• Clobazam: This medication is used for seizures associated with Lennox-Gastaut syndrome.

• Clonazepam (Klonopin®, Rivotril®): One of the more common benzodiazepines. It is used for panic disorder, agoraphobia, various seizure disorders, and neuralgia. Dosage varies, but is often administered up to 3 times daily.

• Clorazepate: Used for anxiety disorders, partial onset seizures, and alcohol withdrawal. It is typically administered 3 times daily.

• Diazepam (Valium®, Ducene®): A common benzodiazepine used for anxiety, sedation, muscle spasms, seizure disorders, and alcohol withdrawal management. It is sometimes used as often as every hour for severe AWS, and otherwise 1 to 3 times per day for other conditions.

• Flurazepam: Primarily used for short-term insomnia. It is taken before bed.

How are Benzodiazepines Prescribed?

Benzodiazepines are mostly available as tablets or capsules, which are taken orally. For regular/daily use, the vast majority of people will use tablet or capsule forms. Some benzodiazepines are also available as sublingual tablets or as a solution that is administered intramuscularly or intravenously. ^{[1] [3]}

To receive a benzodiazepine prescription, a professional health evaluation is necessary. Your doctor will conduct a full evaluation, including medical history, symptoms, lab tests, and other necessary steps. They will determine if a benzodiazepine medication is right for you.

Benzodiazepines are often only used for short-term, such as 2 to 4 weeks. This is due to their moderate to high risk of dependence. However, some individuals may require (and benefit from) benzodiazepines long-term, such as individuals with severe anxiety or panic disorder. ^{[3] [5]}

When to Seek a Prescription

There are many instances when it may be helpful to seek a prescription for benzodiazepines. For example, if you have severe anxiety, panic, and/or insomnia that causes significant distress and disruption to your daily life and ability to function. In these cases, benzodiazepines may be prescribed short-term to help normalize your sleep patterns, well-being, and overall function. ^[3]

They can also provide the relief you need while utilizing other slower-acting treatments too, such as psychotherapy or selective serotonin reuptake inhibitors (SSRIs). The initial period of benzodiazepine use helps severe symptoms settle, while the other treatments take effect. ^{[2] [3]}

Seizures and alcohol withdrawal syndrome are examples of medical conditions that may require benzodiazepines. Since these cases are often urgent and severe, it’s important to seek immediate medical attention if they occur.

Common Side Effects of Benzodiazepines

Benzodiazepines have numerous possible side effects, especially with higher doses. Common side effects are: ^{[1] [2] [3] [4] [5]}

• Drowsiness

• Headache

• Confusion

• Dry mouth

• Nausea

• Constipation

• Amnesia (forgetfulness)

• Vomiting

• Diarrhea

• Respiratory depression (slow or shallow breathing)

• Tremors

• Unsteadiness

• Especially in older adults. This can lead to falls and injuries

• Syncope (fainting)

• Disorientation

• Depression

The most common side effects out of all of these are drowsiness, sedation, and dizziness. Thus, individuals may not be able to drive, operate machinery, or perform other complex tasks when taking these medications. ^{[3] [4]}

Rare Side Effects

Paradoxical reactions, which are reactions that are the opposite of what one would expect, occur in up to 1%of individuals who take benzodiazepines. This can lead to arousal, agitation, aggression, trouble sleeping, heightened anxiety, and related symptoms. ^{[4] [5]}

Other rare side effects include: ^{[2] [3]}

• Hallucinations

• Nightmares

• Low blood pressure

• Increased saliva production

• Vision problems, such as blurred or double vision

• Rashes

• Incontinence

• Difficulty urinating

• Jaundice

• Blood disorders

• Gynecomastia

Injecting benzodiazepines not intended for injection (such as crushed tablets) may cause vein damage and scarring, infections, deep vein thrombosis, and clots. ^[6]

Are They Addictive?

Benzodiazepines are potentially addictive, especially when they are not used as prescribed. This is why they are primarily recommended for short-term use.

However, addiction and abuse concerns tend to be exaggerated by the media, especially for individuals who use benzodiazepines judiciously and for legitimate medical reasons. When taken exactly as prescribed for legitimate indications, the risk of developing addictive use disorder is low, but physiological dependence and difficult withdrawal are common with prolonged daily use.

^[7]

However, taking benzodiazepines for longer than this time, especially at high doses, increases the risk of addiction. ^[3]

.Signs that you may be developing an addiction to benzodiazepines include: ^[3]

• Strong urges or cravings to experience the effects of the medication

• Taking higher doses than you’re prescribed

With long-term benzodiazepine use, you may also develop physical dependence. On its own, this is not the same as addiction.

Physical dependence is when your body adapts to the presence of a drug, which then requires higher amounts of the medication to experience the positive effects. You may also experience withdrawal effects when you’re not taking the medication, which typically are exacerbated symptoms related to why you started taking the medication initially (e.g. insomnia, anxiety, panic, spasms). ^{[3] [4]}

Risks vs Benefits

Benzodiazepines can be very helpful and offer numerous benefits when applied professionally and appropriately. However, there are also several risks to consider. Listed below is a table analyzing the main risks and benefits of benzodiazepine use.

Who Shouldn’t Take Benzodiazepines

Benzodiazepines are not for everyone. Several populations should not take benzodiazepines, or where greater caution is necessary.

For example, benzodiazepines increase the risk of birth defects. They should particularly be avoided during the first trimester of pregnancy. However, exceptions exist, such as women with seizures. ^[1]

Older adults often experience a heightened sensitivity to benzodiazepines, along with reduced drug clearance. Particular concerns in older adults include falls, fractures, vehicle crashes, and cognitive impairments. Therefore, they are used very cautiously in these cases. ^{[1] [3]}

Benzodiazepines may also be dangerous when taken by individuals with certain medical conditions, such as renal impairment, asthma, emphysema, and sleep apnea. And they may not be appropriate for individuals with a history of substance abuse or addiction. ^[6]

Lastly, children are typically not prescribed benzodiazepines, except in cases of seizures or sedation before surgery. ^[3]

Dangerous Drug Combinations

Benzodiazepines can be dangerous when combined with certain drugs. This includes: ^{[1] [2] [6]}

• Alcohol

• Opioids

• Other benzodiazepines

• Other sedatives

Combining benzodiazepines with the above medications may lead to oversedation and CNS depression, which can cause breathing difficulties, sedation, coma, and an increased risk of overdose and death. ^{[1] [3] [6]}

There are also possible drug interactions with certain anticonvulsants, antidepressants, antipsychotics, and anti-infective agents. ^{[1] [6]}

Long-Term Treatment Using Benzodiazepines

Benzodiazepines are typically not prescribed long-term due to their risk of dependence and addiction. However, long-term use may be necessary (and beneficial) in certain situations, such as chronic panic disorder or chronic, severe anxiety. ^{[3] [7]}

If you are in a situation where long-term treatment with benzodiazepines is deemed beneficial, regular check-ups with your doctor are essential. Your doctor will make sure you aren’t experiencing any significant adverse effects, you’re taking the medicine as prescribed, and that the benefits continue to outweigh the risks.

Final Thoughts

Benzodiazepines are often effective medications for anxiety, panic, and seizures. Unlike many other medications, their effects occur rapidly, which makes them potentially valuable options for situations requiring immediate relief. However, they come with a risk of physical dependence and can interact with many other medications. Ultimately, it’s essential to talk with your doctor to determine if benzodiazepines are an appropriate treatment for you.

Common Questions About Benzodiazepines

How long can you take benzodiazepines for?

Benzodiazepines are typically only prescribed on a short-term basis, such as 2 to 4 weeks. This is due to their risk of physical dependence. However, long-term use is also beneficial in certain situations, such as severe panic disorder. You and your doctor will work together to find the treatment plan that’s best for you. ^{[2] [6]}

Which benzodiazepines are most commonly prescribed?

The most commonly prescribed benzodiazepines are Xanax®, Valium®, Halcion®, Ativan®, and Klonopin®. ^[8]

What to do in the event of an overdose?

An overdose on benzodiazepines requires immediate medical attention. If you notice signs of overdose in yourself or someone else, contact your area’s emergency services number immediately.