Counseling Chapter 7 Misuse The Benzodiazepines And Similar Agents Learning Objectives After Studying This

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CHAPTER 7

Misuse of the Benzodiazepines and Similar Agents

LEARNING OBJECTIVES

After studying this chapter, students should be able to:

•

7.2: Understand the pharmacology, subjective effects, and complications of

benzodiazepines at appropriate prescribed levels

•

7.3: Contrast the pharmacology, subjective effects, and complications of

above-normal use of benzodiazepines with normal prescribed levels of use

•

7.4: Describe neuroadaptation to benzodiazepines

•

7.6: Understand the DSM criteria for sedative, hypnotic, or anxiolytic-related

disorders

CHAPTER OUTLINE

Scope of Prescribed Benzodiazepine Use

Medical Uses of the Benzodiazepines

The Pharmacology of the Benzodiazepines

Subjective Effects of Benzodiazepines at Normal Dosage Levels

Benzodiazepines and Suicide Attempts

Side Effects of the Benzodiazepines When Used at Normal Dosage Levels

Neurocognitive Impairment

Neuroadaptation to, Misuse of, and Addiction to the Benzodiazepines

Benzodiazepine Misuse

Drug Interactions Involving Benzodiazepines

Long-Term Consequences of Chronic Benzodiazepine Use

Section Summary

The Benzodiazepine Receptor Agonists (Z-Compounds or BRAs)

Buspirone

Zolpidem

Zaleplon

Lunesta®

Ramelteon

Rohypnol

CHAPTER OVERVIEW

The purpose of this chapter is to explore how the benzodiazepines were first introduced in the

United States, how they came to dominate the market for anxiolytic and hypnotic medications

in the 1970s and 1980s, and how questions about their efficacy and safety started to be raised

in the 1990s and in the 21st century. The actions of these compounds and the effects of and

incentive for their misuse will be reviewed. The effects of and growing awareness of the misuse

of these newer compounds—many of which use many of the same receptor sites as the

benzodiazepines—are also reviewed.

Break-Out Discussion #1:

Should the benzodiazepines continue to be used? In the time since they were introduced, a

growing body of evidence suggests that benzodiazepines have serious side effects. Some

Questions

1. How do you tell the difference between one form of anxiety and the other?

2. Many patients (and physicians) assume that anxiety is anxiety, and that anxiety should be

controlled by medications. However, under what circumstances might anxiety be beneficial?

Considering the above information, what might some of the negative consequences be for a

patient who was prescribed a benzodiazepine?

3. Imagine a patient who had been taking a prescribed benzodiazepine for so long that she

became tolerant to its effects and would enter the BWS if she stopped taking the medication.

How is her experience different from that of the person who has misused a benzodiazepine for

so long that to try to stop taking the drug would mean that entering the BWS? Why? Would you

have different reactions to individuals in each of these two situations?

4. Is there a difference between a compound labeled “habit forming” and one labeled

“addictive?” Under what circumstances might these labels be used, and who might want to

differentiate between them? Do compounds labeled as “non-habit forming” really mean that

there is no potential to form a psychological or physiological habit?

Break-Out Discussion #2:

Does the Food and Drug Administration (FDA) protect the consumer or the producer? Breggin

(2008) stated that the FDA’s protective role is a fiction. This view is clearly represented in the

How might a pharmaceutical company hide adverse drug effects? Imagine that the company

applies for permission to sell a new blood pressure medication, which we will call “Compound

Questions

1. Have you ever become aware of similar failures by the FDA to protect the consumer? How did

this occur? Were the victims of this failure-to-enforce situation reimbursed, and, if so, was such

reimbursement voluntary, or only after legal action had been brought against a pharmaceutical

company?

2. How safe do you feel taking a medication? What factors might influence your answer?

3. List all the factors you know that influence the path of a new pharmaceutical. Which do you

think influence the process most? Which do you think should influence the process most?

References

KEY CONCEPTS AND TERMS

Benzodiazepine receptor agonists: Also called Z-compounds or BRAs; a newer class of

medications that are often used instead of benzodiazepines due to a lower misuse potential

Sleep latency: The period of time between when a person goes to bed and when she or he

finally falls asleep

Therapeutic window (or index): The difference between the minimal effective dose of a

medication and the level that will induce toxic effects. Alcohol, for example, has a “therapeutic”

window of 1:3, which is to say that the amount of alcohol necessary to be ingested for its

intended effect is about one-third of the amount necessary to induce toxic effects and possible

death

Rebound insomnia: A phenomenon resulting from discontinuation of benzodiazepines, forcing

the individual to endure episodes of insomnia until the body adapts to the absence of the

benzodiazepines

Discontinuance syndrome: The manifestation of the body’s reaction when a compound

regularly used as prescribed is either discontinued or markedly reduced. This is essentially a

withdrawal syndrome from that compound, a term that offended many patients who were

taking the compound as prescribed. To differentiate between the process of withdrawal from a

prescribed as opposed to an illicit substance, the term discontinuance syndrome is used with the

person who is withdrawing from a prescribed medication

Boost/boosting: This common process increases the CNS depressant effect of each class of

drugs to induce or reinforce drug-induced euphoria at the risk of potentially lethal results

Melatonin: Hormone produced by the pineal gland in the brain, the actions of which in the brain

are still not well understood. It is thought that this compound plays a role in the regulation of

human circadian rhythms

Serotonin syndrome: A potentially life-threatening drug-induced neurological condition. In spite

of the best medical care, up to 11% of patients who develop this condition will fail to survive.

Behavioral symptoms of the serotonin syndrome include irritability, confusion, increased

anxiety, drowsiness, hyperthermia, sinus tachycardia, dilation of the pupils, nausea, muscle

rigidity, and seizures.

The serotonin syndrome might develop up to 24 hours after a patient starts taking a

medication that affects serotonin. In 50% of cases, the patient begins to develop the disorder

within 2 hours of when she or he starts to take the medication.

All suspected cases of serotonin syndrome should be assessed by a physician immediately,

as this condition can potentially be fatal. There is no specific treatment for serotonin syndrome,

and the only treatment is supportive care (Boyer, 2005)

Priapism: Extended, painful penile erection, which may cause damage to the vasculature

network of the penis and possibly result in permanent erectile dysfunction

Anaphylactic shock: Severe, potentially fatal whole-body allergic reaction to a chemical that the

body views as an allergen. Various tissues in the body release massive amounts of histamine,

LO/STANDARDS CORRELATION CHART

A-head

Standard—CACREP

Scope of Prescribed

Benzodiazepine Use

Medical Uses of the

Benzodiazepines

7.1: Understand

the history of

benzodiazepines

3d: theories and etiology of addictions

and addictive behaviors

3e: biological, neurological, and

physiological factors that affect human

development, functioning, and behavior

The Pharmacology of the

Benzodiazepines

Subjective Effects of

Benzodiazepines at

Normal Dosage Levels

Side Effects of the

Benzodiazepines When

Used at Normal Dosage

Levels

7.2: Understand

the

pharmacology,

subjective

effects, and

complications of

benzodiazepines

at appropriate

prescribed levels

3d: theories and etiology of addictions

and addictive behaviors

3e: biological, neurological, and

physiological factors that affect human

development, functioning, and behavior

Neuroadaptation to,

Misuse of, and Addiction

to the Benzodiazepines

7.3: Contrast the

pharmacology,

subjective

3d: theories and etiology of addictions

and addictive behaviors

3e: biological, neurological, and

physiological factors that affect human

use of

benzodiazepines

with normal

prescribed levels

of use

Neuroadaptation to,

Misuse of, and Addiction

to the Benzodiazepines

7.4: Describe

neuroadaptation

benzodiazepines

3d: theories and etiology of addictions

and addictive behaviors

3e: biological, neurological, and

physiological factors that affect human

development, functioning, and behavior

The Benzodiazepine

Receptor Antagonists (Z-

Compounds or BRAs)

7.5: Describe

the

benzodiazepine

receptor

antagonists

3d: theories and etiology of addictions

and addictive behaviors

3e: biological, neurological, and

physiological factors that affect human

development, functioning, and behavior

Sedative, Hypnotic, or

Anxiolytic Use Disorders

and the Diagnostic and

Statistical Manual of

Mental Disorders, 5th

Edition

7.6: Understand

the DSM criteria

for sedative,

hypnotic, or

anxiolytic-

disorders

3d: theories and etiology of addictions

and addictive behaviors