Ensuring Effective And Safe Use Of Benzodiazepines
Benzodiazepines are not ideal drugs for treating anxiety disorders. Like other pharmacological agents, they have advantages and disadvantages, but the latter have been emphasised at the expense of the former. Considering that a need for pharmacological management of anxiety disorders is not likely to disappear, it is time to reappraise the role of benzodiazepines in the treatment of anxiety disorders and make recommendations for their effective and safe use .
BOX 6 Measures to ensure safe, effective use of benzodiazepines for anxiety disorders
Careful selection of patients who might benefit from benzodiazepines
Administration of benzodiazepines in clinical situations in which they are more likely to be useful
If possible, administration in a lower dose, for a short period of time, and in conjunction with an antidepressant
Careful monitoring and management of side-effects
Right timing for benzodiazepine cessation
Careful, gradual and individualised benzodiazepine taper to prevent or alleviate withdrawal symptoms
Second, the administration of benzodiazepines should be considered in clinical situations in which they are most likely to be useful. These include presence of severe symptoms of anxiety and tension, frequent and severe panic attacks, sleep disturbance, restlessness and agitation, especially when patients have great difficulty tolerating these symptoms and request immediate relief.
History And Current Use Of Benzodiazepines
Benzodiazepines the prototypical anxiolytics were introduced in the early 1960s. They quickly became very popular for a variety of reasons. The most succinct explanation for their rise was the societal need for substances with calming effects. Over the centuries this need has been met mainly with alcohol. In the decade prior to the introduction of benzodiazepines, barbiturates and meprobamate were often used to alleviate anxiety and distress. However, these medications were associated with dependence, and barbiturates were lethal in overdose. Being much safer than barbiturates and meprobamate, benzodiazepines were described as one of the twentieth centurys greatest inventions . Small wonder, then, that in the mid-1970s they became the most widely prescribed group of psychotropic medications in the world .
What caused the subsequent fall in enthusiasm for benzodiazepines? It is undoubtedly the fact that they are associated with pharmacological dependence and that difficulties in ceasing the drugs after long-term use are common. One inquiry into this matter concluded that addiction should be differentiated from non-addictive or therapeutic dependence, and that benzodiazepines were more associated with the latter, not the former . Unfortunately, this nuanced approach to benzodiazepine-induced dependence was quickly lost in the noise produced by the more vocal and influential benzodiazepine opponents.
BOX 1 Reasons for benzodiazepine use in anxiety disorders
What Is The Likelihood Of Withdrawal And Misuse
The properties of each drug play a role in how common and severe the withdrawal symptoms are and the drugsâ potential for misuse.
In general, Ativan causes fewer withdrawal symptoms and has less potential for misuse than Xanax. This is likely because Ativan has a more prolonged effect and slower elimination rate than Xanax.
It is more likely that missed doses or abruptly stopping Xanax can cause rapid withdrawal effects, including anxiety, insomnia, and panic attacks.
Benzodiazepine withdrawal symptoms include:
- tingling in the arms and legs
- cognitive deficits
- mood swings
The severity of the withdrawal symptoms depends on the length of treatment, type of drug, dosage, underlying medical conditions, and use of other drugs or alcohol.
People taking benzodiazepines may develop dependence at low dosages as well as high dosages, and this can develop within several weeks .
If a person takes Xanax or Ativan for a month or longer, they should slowly reduce the drug to minimize withdrawal symptoms. Even when decreased over several weeks, people may still experience withdrawal symptoms for 1 week to several weeks, which may make it difficult to stop the medication.
A person should never change their dose or stop taking the medication without speaking with their doctor. Their doctor will put together a plan with them.
Rare, severe withdrawal symptoms include seizures, psychosis, and confusion.
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Efficacy And Tolerability Of High
Alprazolam and clonazepam are approved for the treatment of panic disorder by the U.S. Food and Drug Administration and were found to be effective in double-blind, placebo-controlled studies.
Alprazolam has been studied extensively in the treatment of panic disorder, with 3 placebo-controlled studies of up to 10 weeks’ duration. Alprazolam is the only high-potency benzodiazepine developed in an XR formulation.
The efficacy of alprazolam XR 1 to 10 mg using a flexible-dose study design once daily in the treatment of panic disorder was established in two 6-week placebo-controlled studies. The studies had similar designs, with a placebo run-in, 3-week titration, and 3-week maintenance period, and they achieved a mean daily dosage of less than 5 mg. The studies also included a complex discontinuation design to examine and compare various aspects of withdrawal-related symptoms. Two additional 8-week fixed-dose placebo-controlled studies involving final doses of 4 mg and 6 mg once daily did not show a benefit for either dose. These findings suggest the importance of flexible dosing to meet the patient’s personal needs.
In the Pecknold et al. study, alprazolam XR and IR were equally efficacious and superior to placebo on the Hamilton Rating Scale for Anxiety phobia and work disability measures. In the Schweizer et al. study, the mean weekly frequency of panic attacks decreased significantly and abruptly from week 1 onward throughout the whole study period .
Do I Need This Treatment
A certain amount of anxiety or insomnia is a normal reaction to what is happening in your life. You may worry or feel stressed, and sometimes these feelings can keep you up at night. Most often, these feelings pass and are not a problem. However, these feelings can become a problem when they continue over a longer term, cause severe distress, make you feel physically ill and affect your behaviour. This kind of anxiety may be triggered by a challenging life event. It can also be a symptom of a mental health problem.
The ability to fall asleep and to sleep through the night can be affected by many types of health problems. These include physical conditions that cause pain or trouble breathing, as well as mental health problems. When sleep is disrupted, health can be further affected.
While each situation is unique and different treatment approaches may be called for, benzodiazepines can help to provide relief.
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Natrol Melatonin Fast Dissolve Tablets
A lack of melatonin can cause major disruptions to your sleep cycle. That, in turn, can cause you to feel anxious. Natrol Melatonin Fast Dissolve Tablets get right to work filling the melatonin gap and restoring your natural circadian rhythms.
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Flaws: Contains the sweetener xylitol. Must be kept in a cool dry place.
Drugs To Treat Anxiety Disorder
Xanax has boxed warnings. These are the most serious warnings from the Food and Drug Administration . Boxed warnings alert doctors and patients about drug effects that may be dangerous.
Using benzodiazepines, even as prescribed, can lead to physical dependence and withdrawal if you stop taking the drug suddenly. Withdrawal can be life threatening.
Using benzodiazepines can also lead to misuse and addiction. Misuse of benzodiazepines increases your risk of overdose and death.
Only take these drugs as your doctor prescribes. Talk with your healthcare professional if you have any concerns about safely taking a benzodiazepine.
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What Is The Best Benzodiazepine For Performance Anxiety
I have anxiety giving presentations to an audience. What is the best benzodiazepine for this?
Benzodiazepines are not actually a preferred medication for performance anxiety, or stage fright. The preferred medication for performance anxiety are beta blockers, like propranolol. The main reasons why beta blockers are preferred over benzodiazepines are that propranolol is effective at reducing the physical symptoms of anxiety by blocking the adrenaline receptors, and propranolol is not an addictive drug, while benzodiazepines have side effects like sedation and tremors, and benzodiazepines are potentially addictive.
But if you and your doctor decide on taking a benzodiazepine for performance anxiety, then the best benzodiazepines are lorazepam and clonazepam . Lorazepam and clonazepam have less addictive potential than diazepam and alprazolam , as diazepam and alprazolam give a person a euphoric feeling , thereby increasing the risk of addiction. Lorazepam and clonazepam have less euphoric effects.
If you want anxiety relief for just a couple of hours, then lorazapam is your best choice. For longer anxiety relief, your best choice is clonazepam. But hopefully, you and your doctor will agree that beta blockers are the best choice overall for performance anxiety.
The Development Of Bdz Ligands Selective For Certain Receptor Subtypes
Diazepam, synthesized in 1963, for many years represented a synonym for BDZ group of drugs, and only later a huge number of BDZ ligands were synthesized. Diazepam has a wide spectrum of indications and shows anxiolytic, hypnotic, myorelaxant, anticonvulsant and other effects. Moreover, the examination of diazepam, as a reference BDZ, on genetically modified animals provided linkage of certain effects with specific receptor subtype and enabled further development of selective drugs with new, narrow profiles of action . The past decade of research has led to an increased understanding of the specific GABAA receptor subtypes responsible for various pharmacological effects of BDZs .
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I Need Relief And I Need It Now
So where does that leave you if youre suffering? Even when anxiety relief comes with side effects and dangers, that can still sound like a fair trade when panic and fear are ruling your life.
The bottom line is that theres a time and place for anxiety medication. If you have severe anxiety thats interfering with your ability to function, medication may be helpfulespecially as a short-term treatment. However, many people use anti-anxiety medication when therapy, exercise, or other self-help strategies would work just as well or better, minus the drawbacks.
Anxiety medications can ease symptoms, but theyre not right for everyone and theyre not the only answer. Its up to you to evaluate your options and decide whats best for you.
Drug Dependence And Withdrawal
When taken regularly, benzodiazepines lead to physical dependence and tolerance, with increasingly larger doses needed to get the same anxiety relief as before. This happens quicklyusually within a couple of months, but sometimes in as little as a few weeks.
If you abruptly stop taking your medication, you may experience severe withdrawal symptoms such as:
- Increased anxiety, restlessness, shaking.
- Depression, confusion, panic attacks.
- Pounding heart, sweating, and in severe cases, seizure.
Many people mistake withdrawal symptoms for a return of their original anxiety condition, making them think they need to restart the medication. Gradually tapering off the drug will help minimize the withdrawal reaction.
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Are Benzodiazepines For Anxiety Safe
Some of the most popular anti-anxiety medications are benzodiazepines, including Xanax, Ativan, Valium, and Tranxene, to name a few. And in many cases, they work well and can help people better manage their anxiety when taken alongside mental health treatment. But in some cases, they may do more harm than good.
Part of what makes benzodiazepines so effective at treating anxiety is that they are sedatives, meaning they make it easier to relax. When taken as prescribed, their sedative properties can help counter many anxiety symptoms. But when taken in excessive quantities, especially with the intent being to enjoy the effects rather than treat anxiety symptoms, these medications can be habit-forming and easily abused.
This is why, when an individual with anxiety has a history of addiction, they are typically prescribed a non-addictive anxiety medication. Lets take a look at what some of those options look like.
Why Are Benzodiazepines Dangerous
While benzos can be very useful drugs when taken strictly as directed, they are dangerous to the point that even misuse can have severe consequences, including a rapid escalation to addiction.
Benzos are not meant to be taken long-term. They are usually prescribed either as a low dose to be taken as needed in the case of a panic attack or for a period of about seven-to-10 days if treating insomnia. Users will quickly build up a tolerance for the medications if they are taken regularly for more than that time.
- Impaired coordination
- Hangover drowsiness
Hangover drowsiness, which are strong feelings of sedation that can continue into the next day if a benzo has been taken the night before, can be extremely dangerous and often leads to car accidents or other risky situations that require alertness.
Other dangers of benzodiazepines include something called the rebound effect, when someone has grown tolerant to the point of paradoxical reactions, namely, their symptoms of anxiety or insomnia return, usually with much more intensity. This can manifest as hyperactivity, vivid nightmares, extreme aggression and hostility, panic attacks, paranoia, and sleep deprivation.
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Selective Norepinephrine Reuptake Inhibitors For Anxiety
SNRIs work the same way as SSRIs, but they block the reuptake of both serotonin norepinephrine. While these are typically prescribed for depressive disorders, they may also be used to treat anxiety in some cases, although SSRIs are usually the first choice for health care providers. For this reason, SNRIs are typically prescribed after SSRIs have been proven ineffective for an individual.
Common types of SNRIs for anxiety include:
What Are Safer Alternatives For Treating Anxiety
The main alternative to treating anxiety that is considered safer than benzodiazepines is a class of medications called selective serotonin reuptake inhibitors . These are primarily prescribed as antidepressants, but they can also be used to help with anxiety disorders.
The main benefit of using antidepressants is that they are not addictive and, therefore, have an extremely low abuse potential. However, unlike benzos, they are not fast-acting and can take as long as six weeks to become effective, and in the meantime, they can actually make someones anxiety worse before starting to improve it.
Antihistamines, while typically used as over-the-counter allergy medications, are also often recommended as a safer treatment for anxiety. Like SSRIs, they are not considered to have addictive qualities and, like benzodiazepines, they work very quickly, typically within 30 minutes. The most significant disadvantage of treating anxiety with antihistamines is that their main side effect is sedation, which can lead to the same unsafe conditions as the drowsiness caused by benzodiazepines.
Many medical professionals also recommend a non-medication approach to safely treating anxiety through the use of cognitive behavioral therapy to help someone address the potential underlying issues behind their anxiety.
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