Sedative medications dependence

The safety and efficacy of zolpidem for insomnia is similar to that of the benzodiazepines. As with other sedative medications, treatment optimally should not exceed 4 weeks to minimize tolerance and dependence. Zolpidem is less disruptive of sleep stages than benzodiazepines. The most common adverse effects include drowsiness, amnesia, dizziness, headache, and gastrointestinal complaints. Several cases of brief psychotic reactions have been reported in women. ... 

The question arises whether anxiolytic activity must always be accompanied by concomitant skeletal muscle relaxant and anticonvulsant activity as well as strong sedation. Can an anxioselective drug exist that will not interact significantly and additively with CNS depressant compounds, particularly alcohol More significantly, both from a medical and sociologic viewpoint, will it be possible to treat anxiety and stress without the added complication of potent sedative effects, dependency, and abuse ... 

Chronic insomnia calls for careful assessment for a medical cause, non-pharmacologic treatment, and careful use of sedative-hypnotics (intermittently to prevent tolerance and dependence). 

Most sedative drugs, including narcotics and alcohol, potentiate the sedative effects of benzodiazepines. In addition, medications that inhibit hepatic cytochrome P450 (CYP) 3A3/4 increase blood levels and hence side effects of clonazepam, alprazolam, midazolam, and triazolam. Lorazepam, oxazepam, and temazepam are not dependent on hepatic enzymes for metabolism. Therefore, they are not affected by hepatic disease or the inhibition of hepatic enzymes. 

Schedule IV - This class represents medications considered to be of low abuse potential with the possibility of limited dependence especially when compared to the previous schedules. Examples are phenobarbital, chloral hydrate, the benzodiazepine tranquilizers, propoxyphene and meprobamate (all are sedatives). 

Long term or excessive use of these medications may also cause tolerance and physical dependence.14,31 In particular, carisoprodol should be used cautiously because this drug is metabolized in the body to form meprobamate, which is a controlled substance (see Chapter 1) that has sedative/anxiolytic properties but is not used extensively because it has strong potential for abuse.13,73 Hence, use of cariso-... 

Adverse effects. Use of diazepam as an antispasticity agent is limited by the sedative effects of this medication that is, patients with spasticity who do not want a decrease in mental alertness will not tolerate diazepam therapy very well. Extended use of the drug can cause tolerance and physical dependence, and use of diazepam for the long-term treatment of spasticity should be avoided whenever possible.102... 

Nonbenzodiazepine anxiolytic. Busprione (Bu-Spar) is the first in a class of drugs that specifically work as anxiolytics. In addition to exerting no sedative effect, this medication poses few of the disadvantages associated with the benzodiazepines—such as physical or psychological dependency—and does not significantly interact with most other compounds. 

Other substances of abuse—including caffeine, cannabis, inhalants, and nicotine—are not covered here since they are less important clinically. Caffeine intoxication can lead to anxiety or confusion. Inhalants can cause an organic psychosis and are very neurotoxic—leading to permanent neurological deficit. Nicotine dependence can be treated with a nicotine gum or patch (in conjundion with cognitive-behavioral treatment). Sedative abuse and dependence is discussed in chapter 16, on antianxiety medications. 

Minor tranquilizers and sedative-hypnotics are widely used in general medical practice and psychiatry. Although the benzodiazepines as a class are much safer than earlier medications (there is less risk of dependency and abuse, and withdrawal symptoms are generally much less dangerous than with barbiturates), problems do exist when patients begin to reduce doses, especially if they discontinue rapidly or "cold turkey." Benzodiazepine withdrawal sjmdromes are encoimtered frequently. They cause considerable patient distress, can be dangerous at times, and are almost always avoidable if the clinician follows the discontinuation guidelines carefully. 

Sedative-hypnotics are prescribed for short-term use because the patient can develop a tolerance of and dependency on the medication. Avoid chronic use of sedative-hypnotics. Nonpharmacological methods that promote sleep should be tried before prescribing sedative-hypnotics to aid with sleep. 

Older medications, such as the barbiturates, are used as sedative-hypnotics, but toxicity limits their widespread use. For example, they can cause significant central nervous system (CNS) depression, physical dependence, and tolerance. Additionally, they are potent inducers of liver enzymes, which can lead to clinically significant drug interactions when these medications are administered with other drugs extensively metabolized by the liver. 

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