22. Sedative-Hypnotic Use Disorders

8/12/2019 22. Sedative-Hypnotic Use Disorders

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Sedative-Hypnotic Use Disorder 109addiction, but relapse risk should be discussed with the patient, and a collaborative approach shouldbe used whenever possible.16. What is the role of naltrexone?

Naltrexone is n oral, long-acting opioid receptor antagonist that has been shown to be a success-ful, nonopioid treatment in certain populations. It works by blocking the opioid receptors; thus if aperson tries to get high, the effect is blocked. Naltrexone has been quite successful in treating healthprofessionals who may have easy access to opioids on the job, and it is often recommended for opioidaddicts who have been incarcerated and are returning to areas where opioids are again accessible.

Patients cannot have any opioids in their system when starting naltrexone; otherwise, the drugprecipitates an abstinence syndrome that may last over 24 hours. For many opioid addicts, this is thebiggest difficulty with starting naltrexone: they must abstain from short-acting opioids for 5 7 daysand from long-acting opioids for 10-14 days. Many patients withdraw from opioids using clonidineduring this period. They then are given an injection of naloxone before starting the oral, long-actingantagonist to be sure that opioids are no longer present.

BIBLIOGRAPHY1. Ball JC, Lange WR, Myers CP, Friedman SR: Reducing the risk of AIDS through methadone maintenance2. Gerstein DR: The effectiveness of drug treatment. Res Pub1 Assoc Res Nerv Ment Dis 70:253-273, 1988.3. McLellan AT, Arndt 10, Metger DS, et al: The effects of psychosocial services in substance abuse treatment.4. Novick DM, Pascarelli EF, Joseph H: Methadone maintenance patients in general medical practice.JAMA5 . Romac DR: Safety of prolonged, high-dose infusion of naloxone hydrochloride for severe methadone over-6. Wang DS, Sternbach G , Varon J: NaImefene: A long-acting opioid antagonist. Clinical applications in emer-

treatment. J Health SOCBehav 29:214-226, 1988.

JAMA 269: 1953-1959, 1993.259:3299-3302, 1988.dose. Clin Pharmacol5:251-254, 1986.gency medicine. Emer Med 16:471475, 1998.

22. SEDATIVE-HYPNOTIC USE DISORDERSlane A. Kennedy D.O.

1. What drugs are considered sedative-hypnotics?Sedative-hypnotic drugs include the barbiturates, barbiturate-like drugs, and benzodiazepines.

They are a diverse group of synthetic drugs with clear medical uses and may be prescribed as anxi-olytics (tranquilizers), hypnotics (to induce sleep), anticonvulsant medications, and muscle relax-ants. Short-acting and long-acting forms are available; all have the potential for abuse. Most aretaken orally, but some may also be injected intramuscularly or intravenously. Sedative-hypnotics areextensively prescribed in the United States. Barbiturates were introduced in 1903 but for the mostpart have been replaced by the benzodiazepines, which were introduced in 1960.

2. Who abuses sedative-hypnotics?Sedative-hypnotics are abused by both street addicts and patients who are receiving them byprescription. Street addicts may use them as adjuvants to boost the effect of drugs such as opioids, totake the edge off stimulants, or to help manage drug or alcohol withdrawal. Prescription addicts mayuse the drugs alone, seeking sedation or euphoria, but usually combine them with other substances.Community surveys estimate that about 5 of the general population have used sedative-hypnoticsfor nonmedical puiposes; prevalence is markedly greater in certain populations, such as patients onmethadone maintenance.


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I10 Sedative-Hypnotic Use Disorder3. How may the physician recognize sedative-hypnotic intoxication?Barbiturate and benz odiazepine intoxication appears sim ilar to alcohol intoxication without theodor of alcohol on the breath. Signs and sym ptoms are sedation, impa ired psychomo tor perfor-mance, slurred speech, ataxia, nystagmus, poo r mem ory and concentration, and labile emotions.4 Are sedative-hypnotics ethal in overdose?Benzodiazepines, when used alone, ar e remarkably safe in overdose, whereas barbiturates ar equite dangerous. Barbiturates or benzodiazepines in combination w ith other central nervous systemdepressants such as alcohol may cause death via respiratory dep ression or hypotensive shock.Profound and protracted coma may be seen with glutethimide (Doriden), a sedative som etimesabused in combination w ith Tylenol 4 (Dors and Fours).5. Does use of sedative-hypnotics result in physiologic dependence tolerance and/or with-

drawal?With regular use of high doses of sedatives, dependence occurs after about 1 month. However,development of dependence on benzodiazepines in lower, therapeutic doses is controversial. It isnow thought that depend ence may occu r with daily use of therapeutic doses, usually after 2 4months, but only in a subset of patients. Low -dose depen dence is primarily a withdrawal syndrom e;most patients taking a therapeutic regimen do not req uire increasing doses fo r continued efficacy.

Tolerance to the sedation and the mood effects of sedative-hypnotics may lead to ingestion oflarger and more frequent doses to achieve the desired psychoactive effects. However, overdoses ofbarbiturates can be lethal, because tolerance of respiratory d epression does not occur. When benzo-diazepines are taken a lone, remark ably high dos es are tolerated , but toxicity is significantly en-hanced when other depressants are added. Most addicts are aware of the relative safety ofbenzodiazepines compared with barbiturates; thus, barbiturate depend ence is infrequent.Withdrawal syndromes m ay b e severe and life-threatening. The onset varies from hours to days,according to the half-life of the drug. Signs and sym ptom s include tachycardia, tremor, restlessnessand insomnia, diap hor esis, nau sea, vomiting, anxiety and ag itation, transient hallucinations, andgrand ma1 seizure. Th e clinical symptom s of withdrawal from either high-dose barbiturates or ben-zodiazepines are similar. Less severe withdrawal may be seen with discontinuation of lower (thera-peutic) doses of benzodiazepines, but the severity may be increased with the shorter-acting, morepotent benzodiazepines.

6. Does regular use of sedative-hypnotics cause medical problems?Unlike alcohol, sedative-hypnotics rarely cause direct organ toxicity. Paraldehyde and chloralhydrate, rapid-acting hypno tics, may be irritating to the throat a nd gastric mucosa, when takenorally, or cause necros is if injected intram uscularly.7. Are Quaaludes still abused?Methaqualone was removed from the market in the U.S. around 1980,but it is still available onthe street in certain regions. Marketed originally as a nonaddictive sedative, it was widely abused,produced dependence, and was associated with lethal overdose as well as serious withdrawal syn-dromes. U nusual overdose symptoms include muscular h ypertonicity, shivering, myoclonus, seizures,and excessive salivation and b ronchial secretions, which may comprom ise the airway. Methaqualonewas falsely rumored to be an aphrodisiac; abusers felt a pleasant high along with contentment.8. Are muscle relaxants addictive?Muscle relaxants may be abused, usually for their sedative properties. Grand ma1 seizures havebeen seen in patients wh o abruptly discontinue carisoprod ol (Soma ), because a metabo lite of Som ais meprobamate, a barbiturate-like drug.9. What is the treatment for sedative-hypnotic withdrawal?Som e patients wh o take prescribed lower doses become physiologically dependent even withoutabusing the drug fo r psychoactive effects. This problem is ot considered an addiction, and the drug


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Cocaine and Amphe tamine Use Disorderscan be tapered over several weeks on an outpatient basis, with careful monitoring and patient-physi-cian com munication.Patients who abuse a sedative-hypnotic should be stabilized on an oral, long-acting barbiturate,such as phen obarbital, or benzodiazepine, such as chlorazepate (Tranxene). After stabilization, thedose is tapered. Optimally, the initial period of withdrawal should occur in the hospital. This ap-proach allow s supervision of the patient in case of intoxication o r severe withdrawal sym ptoms, suchas seizure, and prevents the patient from using other drugs or alcohol during withdrawal. Use of val-proic acid or carbamazepine may allow a more rapid taper without fear of withdrawal seizures, andopen trials appear promising.Hospitalization is not always possible, and som etimes benzodiazepine detoxification is accom-plished on an outpatient basis with strict monitoring. Patients must be well-motivated or have strongcontingent consequences; they shou ld be seen o n a daily basis and receive med ication daily. Wheneverpossible, avoid using the abused substance for the taper, because craving and other conditioned behav -iors may create difficulties.

BIBLIOGRAPHY1. Pages KP, Ries RK: Use of anticonvulsants in benzodiazepine w ithdrawal. Am J Addict 7(3):198-204, 199 8.2. Perry PJ , Alexander B: Sed ativeh ypno tic dependence: Patient stabilization, tolerance testing, and withdrawal.3. Seivewnght N, Dougal W: Withdrawal symptoms from high dos e benzodiazepines in poly drug abusers. DrugDrug Intell Clin Pharm 20532-537, 1986.Alcohol Depend 32:15-23, 1993.

23. COCAINE A ND AMPHETAMINEUSE DISORDERS

Ja ne A. Kennedy, D . 0

1. Who uses cocaine and amphetamine?Cocaine use in the United States has escalated dramatically since the early 1970s, when about 5million had tried the drug at least once-in the late 1980s,about 40 million had tried it. Cocain e typ-ically is used by persons aged 18-30. In the 1990s, indicators suggested a drop in cocaine use am ongcasual, recreational users, but sustained or increased prevalence among hard-core users.Amphetamine use is highest among 18-25 year olds; in som e parts of the country it is stronglyassociated w ith motorcycle gang memb ers. Since tightened regulation of prescription amphetaminein the late 1970s,only about 25 of abused amph etamine is prescription drug; the other 75 is il-licitly manufactured.2. Do cocaine and amphetamine have the same effect?In recent years attention has focused on cocaine dependence, because its use is more widespreadthan use of am phetam ines. Both drugs, however, increase the central action of dopamine and both thecentral and peripheral action of norepinephrine. In theory, they shou ld be quite sim ilar in effect, but

most users have a distinct preference for either coc aine or amphetamine. Both drugs are quite rein-forcing. Animals w ill self-administer stimulants continuously until they die, forsaking food and waterand suffering repeated seizures and exhaustion; for m any hum ans, similar effects have been seen.3. What forms are available? What are the routesof administration?Amp hetamine is available in oral prescription medication as dextroamphetamine and metham-phetamine; it also is manufactured ill icitly as powder or crystallized (ice) m ethamp hetamine.Cocaine hydrochloride is obtainable pharmaceutically for use as a local anesthetic; it is availableillicitly in either powder or crystallized (rock or crack) forms.

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22. Sedative-Hypnotic Use Disorders