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Sedative-Hypnotics and Addiction Michelle Reynolds John Carroll University SEDATIVE-HYPNOTICS AND ADDICTION 2

Abstract

This study examined the history and effects sedative-hypnotics have, both physically and psychologically, as well as the effect on society. Sedative-hypnotics are one of the oldest classifications of drugs, and as such, one of the most commonly abused drugs. They depress the central , many times inducing a feeling of relaxation and pleasure. There are many reasons a person might become addicted to sedative-hypnotics, but the most common issue is (sometimes self-medication) for insomnia, , and/ or pain relief. Many sedative- addicts are also addicted to other substances, usually . Polydrug use is common with sedative-hypnotics, which is usually where the danger lies for users. Treatment for sedative-hypnotic addicts is a process of weaning the addict off the substance, in combination with intensive psychological counseling to reinforce healthy thoughts and behaviors. Due to the legality of many sedative-hypnotics, this large social issue will most likely continue to be a problem for many years to come.

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History of sedative-hypnotics

Sedative-hypnotics are one of the most commonly used and abused drugs in the United

States today (Kane, 2013). In the broadest sense of the definition of sedative-hypnotics, this classification of drugs includes anything that depresses the , including ethanol and marijuana. These drugs might be used to calm an anxious person, promote sleep, relieve pain, and even anesthetize for a medical procedure. However, when many of these drugs are used, fine and gross motor activities are affected and consciousness can become a struggle to maintain; in more severe cases with higher dosages, unconsciousness, paralysis, and even death can occur. Sedative-hypnotics can also severely affect an unborn fetus, causing birth defects and behavioral problems for the babies.

The focus of this paper will be mainly on the sedative-hypnotic pills that are commonly illicitly used, including the two major categories of and ; however, methaqualone, ethchlorvynol, chloral hydrate, and mebrobamate are also members of the sedative-hypnotic study. The brand names for the most common names of sedative-hypnotics include Seconal, Valium, Ativan, Nembutal, Quaaludes, and Xanax (Division of Alcohol and

Drug Abuse, 1993). Methaqualone (brand names: Quaaludes, Sopors), originally prescribed to treat anxiety and to promote sleep, was “one of the most commonly abused drugs and [could] cause both physical and ” (Division of Alcohol and Drug Abuse,

1993).

There are also legal, over-the-counter types of sedative-hypnotics that are readily available to the general public (Kane, 2013). , decongestants, and sleep aids are SEDATIVE-HYPNOTICS AND ADDICTION 4 considered sedative-hypnotics because of the general drowsiness caused by many of the products.

The use of sedative-hypnotics throughout history is long and for drugs like alcohol and marijuana, celebrated. Early societies used synthetic sedative-hypnotics, such as ethanol analogues, piperidinedione derivitives, and potassium bromide, which commonly caused , a disease characterized by excessive sedation and (National Institute on Drug

Abuse, 2012). Barbiturates were also a popular method of pain and anxiety relief. Ciraulo &

Knapp (2011) noted that “barbiturates have been clinically available since the 1900s and were widely the most prescribed agents for anxiety until the introduction of meprobamate in 1955 and, subsequently, the advent of benzodiazepines with in 1957” (Ciraulo & Knapp,

2011). Benzodiazepines became the preferred sedative-hypnotic of choice for many people because the risk of overdose and toxic effects of barbiturates was so high.

Today, sedative-hypnotics are used in many capacities, both legally and illegally. Some are used to treat anxiety and relieve pain. Others are used medically to prepare for surgery

(Kane, 2013). Barbiturates seem to produce greater mood enhancement and self-administration than benzodiazepines, in recent studies. The toxic threshold, however, is so high for barbiturates that unacceptable side effects are commonly seen among barbiturates (Longo & Johnson, 2000).

As with many substances that are intended to be , many sedative-hypnotics that are prescribed are used illicitly, which can cause addiction and adverse effects on the user (Longo &

Johnson, 2000).

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Effects on society

Because of the legality of many sedative-hypnotics, they are very commonly abused and misused. A 1990 study for the American Psychiatric Association found that “11 to 15 percent of the adult population has taken a one or more times during the preceding year”

(Salzman, 1990). The and Mental Health Services Administration also found that an estimated 2.6% of the U.S. population 12 years of age or older used tranquilizers or illicitly, compared with a total of 15.3% of the population who used any substance illegally” (SAMHSA, 2010). However, good news has been found, despite increased media reports of deaths due to sedative-hypnotics. SAMHSA also found that in 2010, of the 2.8% of the total U.S. population diagnosed with substance abuse or dependence, less than half a percent were diagnosed for drug use/abuse related to sedatives or tranquilizers (SAMHSA, 2010).

Polydrug use is also common among users of benzodiazepines. Longo and Johnson

(2000) found that “an estimated 80 percent of benzodiazepine abuse is part of polydrug use, most commonly with opioids… Studies indicate that 3 to 41 percent of alcoholic persons report that they abused benzodiazepines at some time, often to modulate intoxication or withdrawal effects”

(Longo & Johnson, 2000). Sedative-hypnotics and benzodiazepine overdoses tend not to be fatal; however, when another drug is coingested with a sedative-hypnotic, the risk of death is increased exponentially. Combinations of sedative-hypnotics and opioids or alcohol commonly depress the respiratory system, leading to fatal effects (Ciraulo & Oldham, 2013).

A major effect that sedative-hypnotics have had on society in general is facilitation of date rape. A study by the Canadian Sexual Assault Centre found that of the 1,400 women who reported that they were raped, almost 25% of them were facilitated through surreptitious drug SEDATIVE-HYPNOTICS AND ADDICTION 6 administration, usually benzodiazepines, such as (Rohypnol) or gamma hydroxybutyrate acid (GHB) (Weir, 2001). However, alcohol and marijuana are also sedative- hypnotics and are commonly used to “lower sexual inhibition and enhance the possibility of unwanted sexual intercourse” (Weir, 2001). Rape treatment centers in the U.S. found that 69% of urine samples submitted by victims of suspected drug-facilitated rapes showed the presence of alcohol and marijuana was found in another 18% of samples, as compared to only 4% for GHB and flunitrazepam (Weir, 2001). Nevertheless, in today’s society, women are being strongly cautioned to watch their drinks and never leave their drinks unattended, to prevent unwanted drug administration.

Physiological effects of sedative-hypnotics

Sedative-hypnotics can cause both physical and psychological dependence. The Missouri

Department of Mental Health notes “When regular users stop using large doses of these drugs suddenly, they may develop physical withdrawal symptoms ranging from restlessness, insomnia and anxiety, to convulsions and death. When users become psychologically dependent, they feel as if they need the drug to function. Finding and using the drug becomes the main focus in life”

(Missouri Department of Mental Health, 1993).

Geoff Kane notes that sedative-hypnotics work “by augmenting the effects of gamma- aminobutyric acid (GABA)… Boosting GABA both calms the brain and increases in the nucleus accumbens” (Kane, 2013). This reward of increased dopamine means that the user is more likely to have pleasurable effects from the drug and thus, repeat the experience. Studies show that sedative-hypnotics are addictive and long-term use of the medication can cause SEDATIVE-HYPNOTICS AND ADDICTION 7 tolerance levels to rise and withdrawal symptoms to occur if the user suddenly stops the medication (Kane, 2013; Scher, 2014).

Babies born to mothers who abuse sedatives during pregnancy may be physically dependent on drugs and show symptoms of withdrawal after birth. Their symptoms “may include breathing problems, feeding difficulties, disturbed sleep, sweating, irritability, and fever”

(UnityPoint Health). Benzodiazepines can also be found in a using mother’s breast milk, and so are usually inappropriate for breast-feeding mothers to use. It is also noted that newborns who have been exposed to sedative-hypnotics may demonstrate floppy baby syndrome and withdrawal symptoms. Using sedative-hypnotics during pregnancy also carry an increased risk of cleft lip and other malformations to the fetus (Ciraulo & Oldham, 2013).

Sedative-hypnotics have a profound effect on the psychomotor skills of the user. Both quantitative and qualitative studies have found delayed reaction times among sedative-hypnotic users, especially the elderly, who generally have lower metabolisms and greater susceptibility to central nervous system depression. Other psychomotor symptoms can include “drowsiness, poor concentration, [loss of full control of bodily movements], dysarthria [difficult or unclear speech] , motor incoordination, [double vision], muscle weakness, vertigo, and mental confusion” (Longo & Johnson, 2000). Some benzodiazepines in large doses can cause , making them extremely suitable for pre-surgical medication. Also,

“specific deficits in visuospatial ability and sustained attention have also been described in patients who have taken therapeutic doses of benzodiazepines regularly for longer than one year”

(Longo & Johnson, 2000). SEDATIVE-HYPNOTICS AND ADDICTION 8

However, some users do not experience the normal effects of benzodiazepines and sedative-hypnotics. These abnormal effects, termed paradoxical disinhibition, can be characterized as “increased excitement, irritability, aggression, hostility, and impulsivity may occur in some patients who take benzodiazepines” (Longo & Johnson, 2000). Attacks of extreme anger or violence can result, as can other antisocial or indiscretionary behaviors. These reactions are most commonly observed in children, elderly, and those with developmental disabilities.

Medical treatment of an overdose of sedative-hypnotics is similar to treatment for other drug overdoses. Scher recommends “inducing emesis (vomiting), performing lavage (stomach pumping), and administering activated charcoal to a patient who has orally ingested the drug, depending on the time of ingestion and level of consciousness…Laxatives may also be used to induce catharsis” (Scher, 2014). In severe cases of benzodiazepine overdose, the antagonist can be administered intravenously, though patients with a history of seizures or recent head trauma may not have flumazenil administered due to an increased risk of seizures caused by flumazenil. For overdoses, sodium bicarbonate can be administered intravenously to alkalinize the urine, thereby increasing the rate of barbiturate excretion.

Clients who are mildly to moderately addicted to benzodiazepines are tapered off the addiction slowly in an outpatient setting (Scher, 2014). Mild withdrawal effects may be felt and the client must be able to cope with the withdrawal in order for the tapering to be effective. The tapering usually lasts a period of approximately six weeks to three months with a decrease happening every two weeks (Scher, 2014). For clients who are severely addicted to benzodiazepines, advanced withdrawal is likely and so, must be managed in an intensive care SEDATIVE-HYPNOTICS AND ADDICTION 9 environment with medication available in doses sufficient to suppress withdrawal symptoms

(Scher, 2014).

Psychological effects of sedative-hypnotics

A strong connection has been found between benzodiazepine use and depressive symptoms and the emergence of suicidal ideation. There is also some evidence to suggest that higher benzodiazepine usage is correlated with an increased risk of depression; however, reducing the dosage resolved the depressive symptoms, in some cases (Longo & Johnson, 2000).

It is also common to note an “emotional anesthesia” in sedative-hypnotic users, in which the user’s affect is blunted and they become progressively more incapable of dealing with stressors and emotions (Longo & Johnson, 2000).

A 2000 longitudinal study analyzed the efficacy of detoxification treatment for sedative- hypnotic dependence, compared the results to detoxification treatment for alcohol dependency.

Researchers found that the detoxification treatment for sedative-hypnotic dependence, while being exactly the same treatment protocols, was less effective for dependents of sedative- hypnotics. Charney reports “…at 3 months, benzodiazepine-dependent patients fared worse than alcohol-dependent patients in terms of several outcome measures: they reported a lower rate of achieving abstinence, shorter periods of continuous abstinence, and more frequent drug use”

(Charney et al., 2000). However, at 6 months, the differences were much less and benzodiazepine-dependent patients reported significant decreases in anxiety and increases in abstinence.

Scher points out the increased anxiety many long-term users may feel regarding the discontinuation of the sedative-hypnotic. He notes “it is important to understand why patients SEDATIVE-HYPNOTICS AND ADDICTION 10 are taking these medications and to offer a number of alternative therapies” (Scher, 2014).

Anxiety and sleeping problems are the two major reasons that patients seem to use sedative- hypnotics and there are several other, non-addictive medicines and therapies are available for each, which might help to reduce the anxiety a long-term user may feel.

Mental health treatment is essential to effective treatment of an addiction, in addition to medical attention. The National Institute on Drug Abuse notes that “behavioral approaches help engage people in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse” (National Institute on Drug Abuse, 2012). Several theories of counseling have been shown to be effective with sedative-hypnotic . Cognitive- behavioral therapy, motivational interviewing, and 12-step facilitation therapy are all noted by the Institute to be particularly helpful for sedative-hypnotic addictions.

Summary

Sedative-hypnotic use and addiction, specifically benzodiazepine usage, is unfortunately common in today’s society (Kane, 2013). These drugs are commonly used and in many cases, completely legal, but used illicitly or improperly. Media attention to the use of sedative-hypnotic drugs, especially among teens and adolescents, has increased, despite the fact that the usage of sedative-hypnotics is actually on the decline (SAMHSA, 2010). Sedative-hypnotics can have profound effects on the central nervous system, depressing reaction times, psychomotor skills, and in some cases, causing depression and suicidal ideation (Longo & Johnson, 2000).

Treatment for sedative-hypnotic addiction is usually focused on the behavioral therapies, namely SEDATIVE-HYPNOTICS AND ADDICTION 11 cognitive behavioral therapy and motivational interviewing (National Institute on Drug Abuse,

2012). However, medical attention is required in addition to mental health treatment, in order to safely wean the person off sedative-hypnotics. If left to deal with the symptoms of withdrawal on his/her own, a person could experience severe effects, such as grand mal seizures or even death

(Scher, 2014). It is important that medical and mental health providers understand sedative- hypnotics and be prepared to educate clients and patients about the effects of the drugs if the downward usage trend is to continue in the future.

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