Benzodiazepine Abuse

Medically reviewed by:
Dr. Kimberly Langdon, M.D.

What is Benzodiazepine Abuse?

Benzodiazepines are psychoactive drugs that are widely used because of their sedative, anxiolytic, anticonvulsive, and muscle-relaxant properties. Since they produce immediate effects, they are often prescribed for short, intermittent, or “as-needed.” The therapeutic uses of benzodiazepines include anxiety disorders; sleep disorders, amnesia (i.e. procedural sedation), seizures, and muscular disorders.

Since benzodiazepines are often combined with other drug classes (i.e. sedatives, tranquilizers, and hypnotics) the rate of benzodiazepine abuse cannot be determined. However, it is estimated that the lifetime prevalence of benzodiazepine use disorder is one percent. Additionally, annual prescriptions increased by 2.5 percent between 1996 and 2013, thereby expanding their accessibility for diversion and misuse.

Although the exact mechanism of Benzodiazepine abuse is not fully understood with benzodiazepines, it is thought it involves increases in dopamine levels in the mesolimbic pathway, or the “reward system” of the brain.

Treatment with benzodiazepines can result in psychological and physical dependence. The level of dependence varies based upon the duration and dosage of treatment. A substance use disorder will develop usually within 1-2 months in those taking high potency benzodiazepines such as alprazolam vs. a patient taking a low-potency benzodiazepine like chlordiazepoxide. Often times, patients become reluctant to discontinue the drug due to a fear of anticipatory anxiety. Additionally, some find the need to combine their medication with alcohol in order to acquire the desired effect.

Types of Benzodiazepines

Benzodiazepines can be divided into short, intermediate, and long-acting groups. Long-acting benzodiazepines last 1-3 days, and include clorazepate, chlordiazepoxide, and diazepam. Intermediate benzodiazepines last 10-20 hours, and include alprazolam and lorazepam. Short acting benzodiazepines last 3-8 hours, and include oxaxepam and triazolam. Below are the most commonly abused benzodiazepines:

Alprazolam (Xanax)

Alprazolam is most commonly used in the treatment of anxiety disorder, panic disorders, and general anxiety disorders. The use of Alprazolam, or Xanax, should not be used by those who are pregnant or have previously struggle with substance abuse. Concomitant use of other central nervous depressants can result in somnolence, respiratory depression, coma, and death. The most common side effects of Xanax include xerostomia (dry mouth), headaches, and memory impairment. The symptoms of withdrawal can occur with a sudden decrease in medication. Thus, gradual tapering of the dosage is required.

Clonazepam (Klonopin)

Clonazepam is another benzodiazepine used in the treatment of panic disorders, movement disorders, and in the prevention of seizures. Clonazepam is prescribed orally, and has duration of approximately 8 to 12 hours and peaks in 1-4 hours. Long-term use of Clonazepam is associated with tolerance and dependence. Withdrawal is also common when the medication is stopped suddenly or the dosage is reduced too drastically. It is important to note that there is an increased risk of suicide on those withdrawing from Clonazepam who also have depression.

Lorazepam (Ativan)

Lorazepam is a benzodiazepine used in the treatment of anxiety disorders, insomnia, insomnia, alcohol withdrawal, status epileptics, and used during procedural sedation. Lorazepam is administered orally, IM, or IV. Common side effects include hypotension, weakness, decreased respiratory effort, and hip fractures in the elderly. Physical and psychological dependence may also occur, which can lead to withdrawal syndrome.

Diazepam (Valium)

Diazepam, commonly prescribed under the brand name Valium, is a benzodiazepine that is prescribed for restless leg syndrome, muscle spasms, anxiety, seizures, and occasionally substance withdrawal syndrome. Valium is administered orally, IM, or IV. The common side effects associated with valium are somnolence, impaired motor coordination (i.e. balance and coordination). Excessive use of Valium often leads to tolerance and dependence. Dependence is especially common in those with a history of alcohol or other substance abuse, and in patients with a borderline personality disorder.

However, benzodiazepines are rarely prescribed alone, and commonly used in combination with other drugs. Since the short onset of action, they are commonly the drugs of choice amongst addicts. Recreationally, they are used to boost the euphoric effect of opioids such as methadone, enhance cocaine highs, and to alleviate withdrawal between heroin fixes.

What are the Signs of a Benzodiazepine Overdose?

Since benzodiazepines are a central nervous system (CNS) depressants, the signs of a benzodiazepine overdose are rapid, generally occurring within 2-4 hours of ingestion. Patients with acute benzodiazepine toxicity classically present with various CNS) functioning. These include impairments in balance and coordination, slurred speech, anterograde amnesia, and hallucinations.

The physiological signs and symptoms of overdose from benzodiazepines are bradycardia or slow heartbeat, hypotension, hypothermia, respiratory depression, coma, and death.

Benzodiazepine withdrawal presents similar to alcohol and barbiturate withdrawal. Withdrawal occurs usually 1-4 days following the discontinuation of a Benzodiazepine.

The symptoms of benzodiazepine withdrawal include:

• Tremor
• Diaphoresis (excess sweating)
• Palpitations (racing heartbeat)
• Sleep Disturbances
• Muscle Pain and stiffness
• Irritability
• Poor concentration
• Anxiety
• Delirium
• Seizures

Withdrawal can also occur over several months. Symptoms include prolonged insomnia, depression, and anxiety.

Treatment Options for Benzodiazepine Abuse

Supportive measures are the mainstay treatment for benzodiazepine overdose. Rapid assessment of the patient’s airway, breathing, and circulation should be established. Oxygen should also be administered and endotracheal intubation will be used for definitive airway management. End tidal CO2 (capnography) is commonly used for monitoring patients at risk for hypoventilation which causes carbon dioxide retention and lowered oxygen intake. EMS will obtain intravenous access and employ cardiac monitoring. A fingerstick should be performed to monitor blood glucose levels.

Flumazenil is a GABA receptor antagonist that rapidly reverses the side effects of a benzodiazepine overdose. The drug is administered intravenously (IV) only. The onset is rapid, and the duration is about 1 hour. The most common side effects of Flumazenil are dizziness; nausea, vomiting, and agitation are other common side effects. Flumazenil is most commonly used to wake people up after general anesthesia or conscious sedation.

When administering flumazenil, it causes abrupt awakening, which may lead to agitation and dysphoria. If administered to those chronically using benzodiazepines, abrupt interruption by flumazenil can induce benzodiazepine withdrawal, which may include seizures. It is important to note that flumazenil has no effect on respiratory depression. It is better to taper benzodiazepines slowly under doctor supervision.

Benzodiazepine dependence, tolerance, and withdrawal have limited their use for long-term treatment of anxiety disorders in patients with substance abuse. Certain anti-hypertensive medications, antidepressants, and anticonvulsants (Buspar) have all been shown to be an effective alternative for the treatment of anxiety.