Sedatives abuse

Substance-induced anxiety disorder, e.g. due to alcohol, opiate or sedative abuse. 

Roache, J.D. and Griffiths, R.R., Diazepam and triazolam self-administration in sedative abusers concordance of subject ratings, performance and drug self-administration, Psychopharmacology, 99, 309, 1989. 

No specific treatment programs have been developed for prescription sedative abusers. The problem is so often complicated by abuse of other drugs that it may be more expeditious to enroll the patient in a program designed for alcoholics or opiate-dependent persons. Patients with psychiatric disorders that can be defined, especially those with depression, may be treated with drug therapy specific for the underlying disorder. 

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. 

For example, tolerance develops rapidly to the euphoria produced by opioids such as heroin, and addicts tend to increase their dose in order to reexperience that elusive high. In contrast, tolerance to the gastrointestinal (GI) effects of opiates develops more slowly. The discrepancy between tolerance to euphorigenic effects (rapid) and tolerance to ejfects on vital functions (slow), such as respiration and blood pressure, can lead to potentially fatal accidents in sedative abusers. 

The hallucinogens are covered In chapter 4 of this volume. The literature of alcoholism Is so vast that no attempt can be made in this limited space to cover It. Furthermore there is a real question in our society whether we consider It to be a drug since, for example, its use Is not regulated by the Food and Drug Administration. Sedative abuse 0>ypnotlcs, tranquilizers) Is a serious, much studied problem. However, not even suggestions of a solution are at hand,so this class of drugs too will not be reviewed. 

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Educating the Patient and Family hi educating the patient and family about barbiturates and miscellaneous sedatives and hypnotics, several general points must be considered, as well as teaching about two common abuses of these drugp. 

CYP3A4, may contribute to methadone metabolism. Even with adequate methadone plasma levels, some patients continue to abuse drugs, such as sedatives, possibly because they are seeking some form of intoxication rather than relief of opioid hunger (Bell et al. 1990). Relapse to illicit drug use is also common during periods of high stress, even in patients with adequate plasma levels. 

Comparable findings for lifetime prevalence of psychiatric disorders were obtained in another study of 133 persons, which also found that 47% received a concurrent DSM-III diagnosis of substance abuse or dependence (Khantzian and Treece 1985). The most frequently abused substances were sedative-hypnotics (23%), alcohol (14%), and cannabis (13%). Similar rates of psychiatric disorders were found in other studies of drug abusers (Mirin et al. 1986 Woody et al. 1983). Although such diagnoses do not imply causality, and, in many cases, opioid dependence causes or exacerbates psychiatric problems, some causal link seems likely (Regier et al. 1990). 

Benzodiazepines and similar agents occupy a position of intermediate abuse potential, compared with most other sedative-hypnotics (Griffiths and Weerts 1997). Animal models of abuse habihty indicate that the reinforcing effects of benzodiazepines are less pronounced than are those of the barbiturates, opioids, and stimulants. Differences in abuse potential within the class have not been consistently demonstrated however, most chnicians agree that benzodiazepines with a rapid onset and short duration of action pose the greatest risk in susceptible individuals. 

Sporadic use (e.g., for the induction of sleep after a psychostimulant binge) does not require specific detoxification. Sustained use can be treated as described in the previous sections on detoxification from therapeutic or high dosages but with added caution. In mixed opioid and benzodiazepine abuse, the patient should be stabilized with methadone (some clinicians use other oral preparations of opioids) and a benzodiazepine. Buprenorphine should not be administered with benzodiazepines, because a pharmacodynamic interaction is possible (Ibrahim et al. 2000 Kilicarslan and Sellers 2000) and fatalities have been reported with the combination (Reynaud et al. 1998). Sedative-hypnotic withdrawal is the more medically serious procedure, and we usually... 

Glutethimide (3-ethyl-3-phenyl-2,6-piperidinedione) is a sedative-hypnotic drug that is now rarely used therapeutically because of wide variation in gastrointestinal absorption, fast development of pharmacodynamic tolerance, a fairly severe discontinuation syndrome, and potential for abuse. Reports of... 

Ibrahim RB, Wilson JG, Thorsby ME, et al Effect of buprenorphine on CYP3Aactivity in rat and human liver microsomes. Life Sci 66 1293—1298, 2000 Iguchi MY, Handelsman L, Bickel WK, et al Benzodiazepine and sedative use/abuse by methadone maintenance clients. Drug Alcohol Depend 32 257—266, 1993 Isbell H Manifestations and treatment of addiction to narcotic drugs and barbiturates. Med Clin North Am 34 423 38, 1950... 

Uni 1ke other drugs of abuse, the diagnosis of PCP intoxication is often difficult because of the wide spectrum of clinical findings that occurs with this drug. PCP toxicity sometimes can be mistaken for delirium tremens, acute psychiatric illness, sedative/ hypnotic overdosage, amphetamine intoxication, or sedative/ hypnotic withdrawal syndromes. 

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