All About Sedatives, Hypnotics & Anxiolytics

Benzodiazepines, Barbiturates & Tranquilizers

All About Sedatives, Hypnotics & Anxiolytics    

Sedative-hypnotic and Anxiolytic drugs — sometimes called “depressants” and “anti anxiety” drugs slow down the activity of the brain.

Sedatives, hypnotics and anxiolytics are classes of prescription drugs that are commonly called “tranquilizers,” “anti-anxiety”, “sleeping pills,” or “sedatives.” They affect your central nervous system – your brain and spinal cord – and have a relaxing, calming effect. They are often prescribed for problems including anxiety and difficulty sleeping.

What are some commonly prescribed sedative-hypnotic drugs?

There are two main types of sedative-hypnotics – benzodiazepines and Z-drugs.

Common benzodiazepines include
  • Xanax (alprazolam)
  • Librium (chlordiazepoxide)
  • Valium (diazepam), and
  • Ativan (lorazepam).
Common Z-drugs include
  • Ambien (zolpidem)
  • Lunesta (eszopiclone), and
  • Sonata (zaleplon).

They are often prescribed for patients with anxiety and difficulty sleeping.

Are there non-drug alternatives that will help promote sleep?

There are a number of effective, non-drug approaches people can take to get better sleep, including avoiding caffeine, exercising, and maintaining a healthy bedtime routine.

Are there non-drug alternatives that may help prevent or treat anxiety?

Yes, there are a number of alternatives. Getting regular exercise can be very helpful. A type of talk therapy called cognitive-behavioral therapy is also very good for treating anxiety disorders.

Can people safely stop benzodiazepines and Z-drugs on their own?

Please talk with your doctor, nurse, or pharmacist before stopping these medicines. It’s important to reduce the dose gradually because stopping these medicines suddenly can cause unsafe and/or uncomfortable withdrawal effects.

Sedative, hypnotics, or anxiolytic use disorder is a misuse of sedative, hypnotics, or anxiolytic substances.  The addiction of these substances often occurs together with other drugs of abuse. This usually reflects an effort to counteract the effects of those other drugs. For example, people may abuse benzodiazepines to help them “come down” from the high of cocaine.

Sedative, hypnotics, or anxiolytic dependence causes withdrawal symptoms, which makes it difficult to stop taking them, consequently developing an addiction. Sedative, hypnotics, or anxiolytic use disorder can begin at any age, but problems with sedative, hypnotics, or anxiolytic use are most commonly first observed in early 20’s.

Sedative, Hypnotic, or Anxiolytic Use Disorder Defined

Sedative, hypnotics, or anxiolytic use disorder includes signs and symptoms that reflect compulsive, prolonged self-administration of sedative, hypnotics, or anxiolytic substances that are used for no legitimate medical purpose.

Sedative, hypnotics, or anxiolytics reduce arousal and stimulation in various areas of the brain. As a result, the user may experience a sense of calm or sedation, sleep, respiratory depression, or coma. Prolonged use of these medications can be addictive for some people and deadly at high doses.

These medications have also been linked to problems with depression and memory. Sedative, hypnotics, or anxiolytic use disorder severity is specified as mild, moderate, or severe, depending on the number of diagnostic criteria that have been met.  Very significant levels of tolerance and withdrawal can develop using sedative, hypnotics, or anxiolytics.

Different Types

There are not separate types of sedative, hypnotics, or anxiolytic use disorders, but there are levels of severity. These levels are based on which criteria is met, which is listed under symptoms.

Mild: Presence of 2-3 symptoms.

Moderate: Presence of 4-5 symptoms.

Severe: Presence of 6 or more symptoms.

Sedative, Hypnotic, or Anxiolytic Use Disorder Symptoms

To be diagnosed with an sedative, hypnotics, or anxiolytic related disorder, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

  • A problematic pattern of sedative, hypnotics, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period.
  • Sedative, hypnotics, or anxiolytics are often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotics, or anxiolytic use.
  • A great deal of time is spent in activities necessary to obtain the sedative, hypnotics, or anxiolytic, use the sedative, hypnotics, or anxiolytic, or recover from its effects.
  • Craving, or a strong desire or urge to use sedative, hypnotics, or anxiolytics.
  • Recurrent sedative, hypnotics, or anxiolytic use, resulting in a failure to fulfill major role obligations at work, school, or home
  • Continued sedative, hypnotics, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedative, hypnotics, or anxiolytics
  • Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotics, or anxiolytic use.
  • Recurrent sedative, hypnotics, or anxiolytic use in situations in which it is physically hazardous
  • Continued sedative, hypnotics, or anxiolytic use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substances.
Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of sedative, hypnotics, or anxiolytics to achieve intoxication or desired effect.
  • A markedly diminished effect with continued use of the same amount of sedative, hypnotics, or anxiolytics.
Withdrawal, as manifested by either of the following:
  • The characteristic withdrawal syndrome for sedative, hypnotics, or anxiolytics.
  • Sedative, hypnotics, or anxiolytic (or a closely related substance, such as alcohol) is taken to relieve or avoid withdrawal symptoms.

Symptoms of sedative, hypnotics, or anxiolytic use disorder can include:

  • Craving
  • Sweating
  • Euphoria or general discontent
  • Chronic constipation
  • Small pupils
  • Nausea
  • Reduced sex drive
  • Sensitivity to pain
  • Shallow breathing or slurred speech

If you are taking sedative, hypnotics, or anxiolytics solely under appropriate medical supervision, an individual does not meet this criteria.

Sedative, hypnotics, or anxiolytic withdrawal causes brief, but severe, episodes of depression that can lead to suicide attempts and completed suicide. Accidental Sedative, hypnotics, or anxiolytic overdose is not uncommon, and should not be mistaken for a suicide attempt. Sedative, hypnotics, or anxiolytic use disorder can include periods of Sedative, hypnotics, or anxiolytic intoxication and symptoms of withdrawal.

Sedative, Hypnotics, or Anxiolytic Intoxication:

To be diagnosed with sedative, hypnotics, or anxiolytic intoxication, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

  • Recent use of an sedative, hypnotics, or anxiolytic.
  • Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, sedative, hypnotics, or anxiolytic use.
  • One (or more) of the following signs or symptoms developing during, or shortly after, sedative, hypnotics, or anxiolytic use:
    • Slurred speech.
    • Un-coordination
    • Unsteady gait
    • Nystagmus (an involuntary rhythmic side-to-side, up and down or circular motion of the eyes that occurs with a variety of conditions)
    • Impairment in cognition (e.g., memory, attention).
    • Coma or stupor.

The signs or symptoms that are not attributable to another medical conditioning are not better explained by another mental disorder, including intoxication with another substance.

Sedative, Hypnotics, or Anxiolytic withdrawal:

To be diagnosed with sedative, hypnotics, or anxiolytic withdrawal, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the following criteria must be met:

  1. Cessation of (or reduction in) sedative, hypnotics, or anxiolytic use that has been prolonged.
  2. Two (or more) of the following, developing within several hours or a few days after the cessation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A:
  • Hand tremor
  • Autonomic hyperactivity (e.g, sweating or pulse rate greater than 100 bpm)
  • Insomnia
  • Nausea or vomiting
  • Anxiety
  • Psycho-motor agitation
  • Grand-mal seizures
  • Transient visual, tactile, or auditory hallucinations or illusions.

The signs of symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Detox and Withdrawal

The first step in treatment is to engage with a medical professional to evaluate the medical needs and determine a safe and effective treatment for withdrawal. . People with even mild withdrawal symptoms may require medical, social and psychological support to help them overcome a strong urge to begin using the drug again to stop the feelings of anxiety.

People with severe withdrawal symptoms usually need to be treated in a hospital, sometimes in an intensive care unit, and be closely monitored. They are given low doses of the drug intravenously. Sometimes another similar drug that is easier to gradually withdraw is substituted. Even with the best treatment, people may not feel normal for a month or more.

Benzodiazepine (Anxiolytic) Abuse and Dependency

Benzodiazepine abuse is a common occurrence with prolonged use.  Left untreated, abusing these drugs can negatively impact your relationships, career, and your physical and emotional health. Benzodiazepines are some of the most commonly prescribed medications in the United States. When people without prescriptions obtain and take these drugs for their sedating effects, use turns into abuse. 

Sometimes people who have prescriptions misuse their medications, as well.  Taking too much and running out of the prescription, being overly focused on when you can take the next one and feeling you can’t live without it might also be signs of a problem. 

Doctors may prescribe a benzodiazepine for the following legitimate medical conditions:
  • Anxiety
  • Insomnia
  • Alcohol withdrawal
  • Seizure control
  • Muscle relaxation
  • Inducing amnesia for uncomfortable procedures
  • Given before an anesthetic (such as before surgery)

Benzodiazepines act on the central nervous system, produce sedation and muscle relaxation, and lower anxiety levels.

Although more than 2,000 different benzodiazepines have been produced, only about 15 are currently FDA-approved in the United States. They are usually classified by how long their effects last.

  • Ultra-short acting – Midazolam (Versed), triazolam (Halcion)
  • Short-acting – Alprazolam (Xanax), lorazepam (Ativan)
  • Long-acting – Chlordiazepoxide (Librium), diazepam (Valium), Clonazepam (Klonopin)

Benzodiazepines are commonly abused. This abuse is partially related to the toxic effects that they produce and also to their widespread availability. They can be chronically abused or, as seen more commonly in hospital emergency departments, intentionally or accidentally taken in overdose. Death and serious illness rarely result from benzodiazepine abuse alone; however, they are frequently taken with either alcohol or other medications. The combination of benzodiazepines and alcohol can be dangerous — and even lethal.

Benzodiazepines have also been used as a “date rape” drug because they can markedly impair and even abolish functions that normally allow a person to resist or even want to resist sexual aggression or assault. In recent years, the detection and conviction of people involved in this has increased dramatically. The drug is usually added to alcohol-containing drinks or even soft drinks in powder or liquid forms and can be hard to taste.

Benzodiazepine Abuse Causes

Although some people may have a genetic tendency to become addicted to drugs, there is little doubt that environmental factors also play a significant role. Some of the more common environmental influences are low socioeconomic status, unemployment, and peer pressure.

Benzodiazepine Abuse Symptoms

At normal or regular doses, benzodiazepines relieve anxiety and insomnia. They are usually well tolerated. Sometimes, people taking benzodiazepines may feel drowsy or dizzy. This side effect can be more pronounced with increased doses.

High doses of benzodiazepines can produce more serious side effects. Signs and symptoms of acute toxicity or overdose may include the following:

  • Drowsiness
  • Confusion
  • Dizziness
  • Blurred vision
  • Weakness
  • Slurred speech
  • Lack of coordination
  • Difficulty breathing
  • Coma

Signs of chronic misuse or dependence can be very nonspecific and include changes in appearance and behavior that affect relationships and work performance. Warning signs in children include abrupt changes in mood or deterioration of school performance. Chronic misuse of benzodiazepines can lead to the following symptoms that mimic many of the indications for using them in the first place:

  • Anxiety
  • Insomnia
  • Anorexia
  • Headaches
  • Weakness

Despite their many helpful uses, benzodiazepines can lead to physical and psychological dependence. Dependence can result in withdrawal symptoms and even seizures when they are stopped abruptly. Dependence and withdrawal occur in only a very small percentage of people taking normal doses for short periods. The symptoms of withdrawal can be difficult to distinguish from anxiety. Symptoms usually develop anywhere from 3-4 days after last use to up to two weeks, although they can appear earlier with shorter-acting varieties.

When to Seek Medical Care

If you have any questions, you could call your doctor, but if you are in doubt whether someone needs immediate medical attention, you should go directly to a hospital emergency department.

If you are concerned that you or someone else has taken an overdose, it is very important that you seek medical help immediately. You should go to the nearest emergency department or call 911 for help. After someone takes an overdose, the effects may not become immediately obvious.

It will assist the doctors if you bring the pill containers with you because it helps them determine the number and type of pills taken.

Exams and Tests

The diagnosis is based on findings from your medical history, examination, and any lab tests performed.

In acute ingestion’s, diagnosis is often obvious because you or your family can tell the doctor exactly what was taken.

The diagnosis of chronic drug misuse can be much more difficult, because the suffering misuser and their family often try to cover up or hide what is going on.

The emergency department work-up of any possible toxic drug overdose consists of an initial evaluation. Doctors will assess how well you are breathing and ensure you have a normal heart rate and rhythm. The rest of the work-up depends on you and your symptoms. The physician will ask about many of the signs and symptoms. Unless you are willing to admit that you are misusing or overusing benzodiazepines or family members are present to help with the history, it is easy for you to cover up drug abuse.

Monitoring and testing:

In the emergency department, you will usually be placed on a monitor evaluating heart rate, blood pressure, and pulse oximetry (a measure of how much oxygen is in your bloodstream). An IV line will be started. Oxygen is given if you are short of breath or have a reduced level of consciousness.

Urine drug screens are sometimes performed. These lab tests can detect many of the commonly abused drugs, including benzodiazepines (but may not be able to discover them all). The urine drug screens do not, however, reveal a specific level or amount of the drug taken. Urine is also usually tested for pregnancy in all females of childbearing age.

Blood samples, ECGs, and chest x-rays may be obtained if there is concern that you may have taken other dangerous drugs.

Benzodiazepine Abuse Treatment Self-Care at Home

Drug abusers often deny their problem by playing down the extent of their drug use or blaming job or family stress. The most important thing that can be done at home is to recognize that there may be a problem and to seek help. 

The next step is to try to obtain help for the person. This can be done either through your doctor or by contacting many of the drug abuse helplines in your community. 

Medical Treatment

Acute toxicity: The treatment required usually depends on what drugs were taken and how much. Often, you need only a period of evaluation in a hospital emergency department:
  • If the drugs were taken within the previous 1-2 hours, the doctor may consider gastric lavage. With this procedure, a large tube is placed directly into your stomach through the mouth or nose. Large volumes of water can then be pushed into the stomach in an attempt to wash out the pill fragments. This is not used often and only if you are known to have swallowed other potentially more lethal medications.
  • A single dose of activated charcoal is recommended for people who come to the emergency department within 4 hours of taking drugs. This acts to prevent absorption of the medication. It is a black powder that is mixed with water and given to you to drink. Side effects can include nausea, vomiting, and abdominal cramps.

There is an antidote to counteract the toxic effects of benzodiazepines called flumazenil (or Romazicon). This reverses the sedative effect of benzodiazepines. It is, however, usually reserved for severe poisoning, because it can cause withdrawal and seizures in people who are chronic benzodiazepine abusers, and also may require repeated administrations, with careful monitoring, due to its fairly short duration of action.

Chronic abuse: The treatment of chronic abuse can usually be done at home with the help of your doctor or in specific drug rehabilitation centers. 
  • The first step consists of gradual reduction of benzodiazepines to prevent withdrawal and seizures. This is often much easier than the prolonged recovery phase in which the person attempts to stay drug-free. 
  • In addition to the medical care, someone abusing these drugs often requires social support and help in finding housing and employment. The involvement of family and friends can be very helpful in this difficult stage.

Next Steps Outlook

Although benzodiazepines are commonly abused, they rarely cause serious illness or death unless combined with other drugs, particularly sedating drugs such as alcohol or opioids. 

Consultation with poison specialists is usually unnecessary. A psychiatrist or addiction specialist, however, is often asked to interview anyone seen in the emergency department before sending the person home. This is done if there is any concern that the overdose was swallowed intentionally and that the person may be at risk of harming himself or herself or others. Inpatient treatment may be required.

Note:  Benzodiazepine Dependence is most often treated on an outpatient basis and is a slow process.  Abruptly stopping use can lead to serious medical complications including seizures up to four weeks following the last use.   This takes commitment on the part of the user and support from family, friends, and community groups.