Anti-anxiety drugs and abuse

Definition

Anti-anxiety drugs, or "anxiolytics," are powerful central nervous system (CNS) depressants that can slow normal brain function. They are often prescribed to reduce feelings of tension and anxiety, and/or to bring about sleep. Anti-anxiety medications are among the most abused drugs in the United States, obtained both legally, via prescription, and illegally, through the black market. These drugs are also known as sedatives.

Description

The drugs associated with this class of substancerelated disorders are the benzodiazepines [such as diazepam (Valium), chlordiazepoxide (Librium), alprazolam (Xanax), triazolam (Halcion), and estazolam (ProSom)], the barbiturates [such as Seconal and pentobarbital (Nembutal)], and barbiturate-like substances including Quaalude, Equanil, and Doriden. Any of these drugs is capable of producing wakeful relief from tension, or sleep, depending upon dosage. Some non-psychiatric uses of anti-anxiety medications include treatment and prevention of seizures , muscle relaxants, anesthetics, and drugs to make other anesthetics work more effectively (known as "adjuvants").

Although the types of central nervous system depressants work differently, they all produce a pleasant drowsy or calming effect. If used over a long period of time, tolerance develops, and larger doses are needed to achieve the initial effects. Continued use can lead both to physical dependence when use is reduced or stopped, and to withdrawal symptoms. When combined with each other or other CNS depressants, such as alcohol, the effects are additive.

In addition to the drugs available in the United States by prescription, there are three other drugs that are predominantly central nervous system depressants with significant potential for abuse. These are:

• gamma hydroxybutyrate (GHB)
• flunitrazepam (Rohypnol)
• Ketamine

GHB has been abused in the United States since about 1990, for its euphoric, sedative, and anabolic (bodybuilding) effects. It was widely available over the counter in health food stores until 1992. Bodybuilders used it to aid in reducing percentage of body fat, and to build muscle. Street names for GHB include "Liquid ecstasy," "soap," "Easy lay," and "Georgia home boy."

Rohypnol has been of particular concern during the last few years because of its abuse in date rape. When mixed with alcohol, Rohypnol can incapacitate its victims and prevent them from resisting sexual assault. It can also lead to anterograde amnesia , in which individuals cannot remember what they experienced while under the influence. Rohypnol can be lethal when mixed with alcohol and/or other depressants. Rohypnol is not available by prescription in the United States, and it is illegal to import it. Even so, illegal use of Rohypnol started appearing in the United States in the early 1990s, where it became known as "rophies," "roofies," "roach," and "rope."

Ketamine is an anesthetic used predominately by veterinarians to treat animals. It can be injected or snorted. Ketamine goes by the street names of "Special K," or "Vitamin K." At certain doses, ketamine can cause dream-like states and hallucinations . It has become particularly common in club and rave (large, all-night dance marathon) settings, and has been used as a date rape drug. At high doses, it can cause delirium , amnesia, impaired motor functioning, high blood pressure, and depression. It can also cause potentially fatal respiratory problems.

Causes and symptoms

Causes

Anti-anxiety drugs can be taken orally to bring about a general calming or drowsy effect, usually experienced as pleasant. Abuse of anti-anxiety medication can develop with prolonged use, as tolerance grows relatively quickly. Increasing amounts of the drug are then needed to produce the initial effect. It is possible to become addicted to anti-anxiety drugs even when they are medically prescribed.

A second cause of anti-anxiety drug abuse is the use of these drugs, especially when combined with other drugs, such as cocaine. It is not uncommon for an addict to pair the use of a stimulant, such as cocaine or methamphetamine, with a CNS depressant. This allows the user to feel alert for an extended period of time, and then be able to "come down" from the high, and even fall asleep.

Symptoms

Even when prescribed for medical reasons, an individual taking central nervous system depressants usually feels sleepy and uncoordinated during the first few days of treatment. As the body adjusts to the effects of the drug, these feelings begin to disappear. If the drug is used long term, the body develops tolerance, and increasing doses are needed to obtain the desired effect of general calming or drowsiness.

The use of anti-anxiety drugs can pose extreme danger when taken along with other medications that cause CNS depression, such as prescription pain medicines, some over-the-counter cold and allergy medications, or

alcohol. Use of additional depressants can slow breathing and respiration, and can even lead to death.

Withdrawal from anti-anxiety medications can be dangerous if not done under medical supervision. The safest method of withdrawal involves a gradual reduction of dosage. Abrupt withdrawal from these medications can lead to seizures due to sudden increase in brain activity.

Demographics

Several studies conducted by the National Institute of Drug Abuse, or NIDA, suggest that prescription drug abuse is on the rise in the United States. According to the 1999 National Household Survey on Drug Abuse , an estimated 1.6 million Americans first tried prescription pain relievers for non-medical purposes in 1998. Between 1990 and 1998, the number of people who used tranquilizers increased by 132%, and the number of new sedative users increased by 90%. In 1999, an estimated four million people —almost 2% of the population aged 12 and older— by 2001 were using prescription drugs for nonmedical purposes. Sedatives and tranquilizers were used by 1.3 million of these people.

In 1999, an estimated four million Americans, about 2% of the population age 12 and older, had used prescription drugs non-medically within the past month. Of these, 1.3 million misused sedatives and tranquilizers. Of particular concern is the growing abuse among older adults, adolescents, and women.

Misuse of prescribed medications may be the most common form of drug abuse among the elderly, according to the NIDA. Older people are given prescriptions approximately three times more often than the general population, and have poorer compliance with directions for use.

The National Household Survey on Drug Abuse indicates the steepest increase in new users of prescription drugs for non-medical purposes occur in 12- to 17- and 18- to 25-year-olds. Among 12- to 14-year-olds, psychoactive medications, including anti-anxiety drugs, were reportedly among the primary drugs used.

The 1999 Monitoring the Future Survey , a yearly survey of drug use and related attitudes conducted among eighth, 10th and 12th graders nationwide, found that for barbiturates, tranquilizers, and narcotics other than heroin, long-term declines in use during the 1980s leveled off in the early 1990s, with modest increases in use starting again in the mid-1990s.

Overall, men and women have approximately equal rates of non-medical use of prescription drugs, with the exception of 12- to 17-year-olds. In this age category, young women are more likely to use psychoactive drugs non-medically. Also, among women and men who use anti-anxiety drugs non-medically, women are almost twice as likely to become addicted.

GHB-related emergency room visits increased from 55 in 1994 to 2,973 in 1999, according to the NIDA. There were 13 reported Rohypnol-related emergency room visits in 1994, versus 634 in 1998. The number decreased to 540 in 1999. Ketamine-related emergency room visits rose from a reported 19 in 1994 to 396 in 1999. Recent use have been reported more frequently among white youth in many major metropolitan areas.

Diagnosis

The manual used by mental health professionals to diagnose mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders , also known as the DSM-IV-TR , includes specific diagnostic criteria for four types of anti-anxiety medication abuse. These are:

• dependence
• abuse
• intoxication
• withdrawal

Dependence, the more severe form of addiction , refers to very significant levels of physiological dependence, with both tolerance and withdrawal symptoms. Abuse, the less severe form of addiction, may still result in risky behavior, such as driving while under the influence. An individual with an abuse disorder may miss work or school, or get into arguments with parents or spouse about substance use. The problem can easily escalate into full-blown dependence.

Intoxication refers to the presence of clinically significant problem behaviors or psychological changes, such as inappropriate sexual or aggressive behavior, mood swings, impaired judgment, or impaired social or work functioning that develop during or shortly after use of an anti-anxiety medication. As with other CNS depressants such as alcohol, these behaviors may be accompanied by slurred speech, unsteady gait, memory or attention problems, poor coordination, and eventually, stupor or coma. Memory impairment is relatively common, especially a kind known as anterograde amnesia that resembles alcoholic blackouts.

Withdrawal is a characteristic syndrome that develops when use of anti-anxiety medication is severely reduced or stopped abruptly. It is similar to abrupt cessation of heavy alcohol use. Symptoms may include increases in heart rate, respiratory rate, blood pressure or body temperature, sweating, hand tremor, insomnia , anxiety, nausea, and restlessness. Seizures may occur in perhaps as many as 20-30% of individuals undergoing untreated withdrawal. In the more severe forms of withdrawal, hallucinations and delirium can occur. Withdrawal symptoms are generally the opposite of the acute effects experience by first-time users of the drugs. Length of withdrawal varies depending upon the drug, and may last as few as 10 hours, or as long as three to four weeks. The longer the substance has been taken, and the higher the dosages used, the more likely that withdrawal will be severe.

Treatments

According to the NIDA, successful treatment for anti-anxiety medication addiction needs to incorporate several components. Counseling, particularly cognitive-behavior counseling, focuses on helping addicted individuals identify and change behaviors, attitudes, and beliefs that contributed to their drug usage. Combined with prescribed medications to make withdrawal safer and easier, counseling can help the addicted individual eventually make a full recovery. Often, it takes multiple courses of treatment before full recovery can be achieved. Various levels of care, from outpatient to residential care for up to 18 months, are available, depending upon need. Narcotics Anonymous also offers ongoing recovery support.

Prognosis

The most typical course, according to the DSM-IVTR involves teens or young people in their early 20s who may escalate occasional use of anti-anxiety medications to the point at which they develop problems such as abuse or dependence. This is particularly likely for individuals who also abuse other substances. An initial pattern of use at parties can eventually lead to daily use and high degrees of tolerance.

A second course, observed somewhat less frequently, involves individuals who initially obtain medications by prescription, usually for treatment of anxiety or insomnia. Though the vast majority of people who use medications as prescribed do not go on to develop subtance abuse problems, a small minority do. Again, tolerance develops and the need for higher dosages to reach the initial effects occurs. Individuals may justify their continued use on the basis of the original symptoms, but active substance-seeking becomes increasingly part of the picture. Others at higher risk are those with alcohol dependence who might be given prescription anti-anxiety medications to reduce their anxiety or insomnia.

Prevention

Health care professionals play a very important role in preventing and detecting abuse of prescription drugs. Primary care physicians, nurse practitioners and pharmacists can all play a role.

It is estimated by the NIDA that approximately 70% of all Americans visit a health care provider, at least once every two years. Thus, health care providers are in a unique position not only to prescribe medications as appropriate, but also to identify prescription drug abuse when it exists and recommend appropriate treatment for recovery. Screening for substance abuse should be incorporated into routine history taking, or if a patient presents with symptoms associated with problem drug use.

Over time, providers should be alert to any increases in the amount of medication being used, which may be a sign of tolerance. They should also be aware that individuals addicted to prescription medications may engage in "doctor shopping," that is, going from provider to provider in an effort to obtain multiple prescriptions of their abused drug.

Pharmacists can play a role in preventing prescription drug abuse as well. They should provide information and advice about the correct way to take prescribed medications, and be alert to drug interactions. They can also play a role in detecting prescription fraud by noticing suspicious-looking prescription forms.

See also Addiction ; Anxiety and anxiety disorders ; ; Barbiturates ; Buspirone ; Chlordiazepoxide ; Clonazepam ; ; Cognitive-behavioral therapy ; Diazepam ; Disease concept of chemical dependency ; Estazolam ; Flurazepam ; Fluvoxamine ; Insomnia ; Lorazepam ; Sedatives and related disorders ; Substance abuse and related disorders ; Support groups ; Triazolam ; Zolpidem

Resources

BOOKS

American Psychiatric Association. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Kaplan, Harold I., M.D. and Benjamin J. Sadock, M.D. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition, Baltimore, MD, Lippincott Williams and Wilkins, 1998.

PERIODICALS

NIDA Notes 16, no. 3 (August 2001).

NIDA Infofax: Pain Medications and Other Prescription Drugs #13553.

NIDA Infofax: Club Drugs #13674.

NIDA Infofax:Rohypnol and GHB #13556.

NIDA Infofax:Treatment Methods #13559.

NIDA. NIDA Research Report Series: Prescription Drugs: Abuse and Addiction. 2001.

ORGANIZATIONS

American Council for Drug Education. 136 E. 64th St., NY, NY 10021.

Narcotics Anonymous. PO Box 9999, Van Nuys, CA 91409. (818) 780-3951.

National Institute on Drug Abuse (NIDA). US Department of Health and Human Services, 5600 Fishers Ln., Rockville, MD 20857 <http://www.nida.nih.gov> .

Barbara S. Sternberg, Ph.D.