Anti-Anxiety Drugs and Abuse
Anti-Anxiety Drugs and Abuse
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.
The drugs associated with this class of substance-related disorders are the benzodiazepines (e.g. diazepam [Valium], chlordiazepoxide [Librium], alprazolam [Xanax], triazolam [Halcion], and estazolam [ProSom]), the barbiturates (e.g., Seconal and pento-barbital [Nembutal]), and barbiturate-like substances including Quaalude, Equanil, and Doriden. Any of these drugs is capable of producing either wakeful relief from tension, or sleep, depending upon dosage. Some nonpsychiatric uses of anti-anxiety medications include treatment and prevention of seizures, or as 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, and when use is reduced or stopped 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)
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 dreamlike states and hallucinations. It has become particularly common in club and rave (large, all-night dance marathon) settings, and has also 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.
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 anti-anxiety drugs 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.
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.
According to the 2005 National Survey on Drug Use and Health, 20% of people 12 years of age and older have at some point in their life used prescription-type psychotherapeutic drugs (including anti-anxiety medications) for recreational purposes, although only 6.2% admitted to having done so in the month before the survey was taken. Of these, the highest rate of abuse occurred in people 18-25 (30.3%), followed by those in the 26 and older age bracket (19.3%). In general, males were more likely to abuse prescription-type drugs than females (21.9% versus 18.3%). By race, American Indians or Alaska natives were the most likely to engage in this form of drug abuse (29.0%), while African Americans were the least likely to do so (12.6%).
The manual used by mental health professionals to diagnose mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders, (the fourth edition, text revision or DSM-IV-TR, ) includes specific diagnostic criteria for four types of anti-anxiety medication abuse. These are:
Substance dependence, the more severe form of addiction, is a group of cognitive, behavioral, and physiological symptoms associated with the continued use of the substance, and includes both tolerance and withdrawal symptoms. Abuse is a less severe form of addiction that may also result in risky behavior, such as driving while under the influence. For example, an individual with an abuse disorder may miss work or school, or get into arguments with parents or spouse about substance use. Such problems 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 ante-rograde 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.
According to the National Institute on Drug Abuse (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.
The most typical course, according to the DSM-IV-TR 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 substance 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.
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 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.
Abuse —Substance abuse is a milder form of addiction than substance dependence. Generally, people who have been diagnosed with substance abuse do not experience the tolerance or withdrawal symptoms—the signs of physiological dependence—that people dependent on a substance experience.
Anxiolytic —A preparation or substance given to relieve anxiety; a tranquilizer. Barbiturates—A class of medications (including Seconal and Nembutal) that causes sedation and drowsiness. They may be prescribed legally, but may also be used as drugs of abuse.
Benzodiazepines —A group of central nervous system depressants used to relieve anxiety or to induce sleep.
Dependence —The adaptation of neurons and other physical processes to the use of a drug, followed by withdrawal symptoms when the drug is removed; physiological and/or psychological addiction.
GHB —GHB, or gamma hydroxybutyrate, is a central nervous system depressant that has been abused in the United States for euphoric, sedative, bodybuilding, and date-rape purposes.
Intoxication —The presence of significant problem behaviors or psychological changes following ingestion of a substance.
Ketamine —An anesthetic used predominately by veterinarians to treat animals that can be used as a date-rape drug.
Rohypnol —Rohypnol, or flunitrazepam, is a central nervous system depressant that is not legal in the United States, but is used as a date-rape drug.
Sedative —A medication that induces relaxation and sleep.
Tranquilizer —A medication that induces a feeling of calm and relaxation.
Withdrawal —Symptoms experienced by a person who has become physically dependent on a drug, experienced when the drug use is discontinued.
See alsoAddiction; Anxiety and anxiety disorders; Anxiety-reduction techniques; Barbiturates; Buspirone; Chlordiazepoxide; Clonazepam; Cloraza-pine; Cognitive-behavioral therapy; Diazepam; Disease concept of chemical dependency; Estazolam; Flurazepam; Fluvoxamine; Hypnotics and related disorders; Insomnia; Lorazepam; Sedatives and related drugs; Substance abuse and related disorders; Support groups; Triazolam; Zolpidem.
American Psychiatric Association. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.
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Mintzer, Miriam Z., and R. R. Griffiths. “An Abuse Liability Comparison of Flunitrazepam and Triazolam in Sedative Drug Abusers.” Behavioural Pharmacology 16.7 (November 2005): 579–84.
American Council for Drug Education, 136 E. 64th St., New York, NY 10021.
Narcotics Anonymous, P.O. Box 9999, Van Nuys, CA 91409. Telephone: (818) 780-3951.
National Institute on Drug Abuse (NIDA). U.S. Department of Health and Human Services. 5600 Fishers Lane, Rockville, MD 20857 <http://www.nida.nih.gov>.
U.S. Department of Health and Human Services, Office of Applied Statistics. 2005 National Survey on Drug Use and Health. <http://www.oas.samhsa.gov/nsduhLatest.htm>.
Barbara S. Sternberg, PhD
Ruth A. Wienclaw, PhD