Frequently asked Questions

Health Professionals FAQ

What are benzodiazepines, sedatives, and hypnotics?

Benzodiazepines are psychotropic drugs, that is, drugs that affect the mind and are mood-altering. They are also known as minor tranquilizers, anti-anxiety medication, sedatives, and hypnotics and are prescribed predominantly for anxiety and sleeping problems. According to evidence, there exists a significant risk of dependence on benzodiazepines when taken regularly, and the recommended length of use is no longer than four weeks of daily use. This recommendation is valid also for non-benzodiazepine hypnotics: zolpidem, zopiclone and eszopiclone, and zaleplon.

How benzodiazepines work?

Benzodiazepines are:

• Absorbed in the stomach and small intestine and metabolised by the liver (when taken orally)
• Highly fat-soluble and accumulate in fatty tissue
• Excreted through sweating, saliva, urine, faeces, and breast milk.

Benzodiazepines exert their influence widely across the brain, emotional reactions, memory, thinking, and the control of consciousness, as well as muscle tone and coordination.

Benzodiazepines and non-benzodiazepine hypnotics are central nervous system (CNS) depressants that work by increasing the efficacy of our brain's natural calming chemical, gamma-aminobutyric acid (GABA). GABA is one of the main neurotransmitters of the CNS, the chemicals responsible for communicating messages between our brain cells (neurons), and GABA’s message is inhibitory.

Almost 40% of the brain’s neurons have GABA receptors, which is the specialized site where GABA binds. It produces its inhibitory effect by changing the chemistry of that neuron so that it either slows down or stops firing. Benzodiazepines work by binding to a specific site on the GABA receptor and enhance the action of GABA. This results in greater inhibition, or an increased likelihood that the neuron will stop firing altogether. Benzodiazepine binding sites are most found in the areas of the brain controlling our consciousness, coordination, emotions, memory, muscle tone, and thinking. The location of the binding sites may explain the significant effects of benzodiazepines in these areas and why these functions are often severely affected during withdrawal.

3. What are the effects of benzodiazepines?

Although benzodiazepines are often categorised as either sleeping pills or anti-anxiety agents, they all have the same basic effects – in the short term, their sedative action relieves anxiety and promotes sleep. They also have amnesic effects, are muscle relaxants, and have anticonvulsant properties. The main difference between the drugs is their strength and length of action in the body.

What is the length of action?

Benzodiazepines have a complex metabolic structure. They are short, medium, and long-acting – depending upon the metabolic structure of each drug. Table 2 identifies long, medium, and short-acting benzodiazepines. Length of action is also influenced by other factors such as the health of the liver, age and weight, and short-acting benzodiazepines may last as long as the long-acting drugs in some people.

 

What type of benzodiazepines are usually prescribed?

In prescribing practice, the shorter-acting benzodiazepines are usually prescribed as sleeping pills and the longer-acting ones for the alleviation of anxiety. This is because the longer-acting benzodiazepines have a generalised effect on anxiety, whereas short-acting benzodiazepines help promote sleep without giving a ‘hangover’ effect the next day. Other factors such as the age of the patient and common usage of a particular brand may also influence which benzodiazepine a doctor will prescribe.

What are the medical uses of benzodiazepines?

Benzodiazepines have several common medical uses, including being used:

• As a muscle relaxant
• For endoscopy procedures
• As an anesthetic or a pre-med before surgery or chemotherapy
• To assist with acute alcohol or drug withdrawal (in residential care under medical supervision)
• To treat epilepsy (usually where other medications have not been effective)
• In palliative care

In psychiatry to treat patients with severe psychomotor agitation or high suicide risk

Appropriate benzodiazepine use could include:

• One- or two-nights’ use for prolonged sleeplessness when all other methods have failed and provided that the insomnia is not due to circadian rhythm disturbance or a chronic sleep problem (appropriate use could be for recent grief or acute stress)
• Insomnia due to jet lag
• Severe and acute muscle spasms where conventional methods like massage have not eased the spasm
• Severe and acute recent anxiety if no other appropriate support is available or while counselling support is arranged.

 

How health providers can make a safe and appropriate use of benzodiazepines?

If benzodiazepines are necessary, a prescription should be for:

• A limited length of time – a few days only and not exceeding two weeks
• Intermittent use – if used occasionally there is no risk of dependency.

 

If a prescription is warranted, information should be provided about:

• The potential risk of dependency and withdrawal if used for longer than a few weeks
• Effects on the emotions and the possible impairment of concentration and memory
• The possibility of rebound insomnia and anxiety when ceasing to use benzodiazepines
• Effects when used with other drugs
• Risks associated with driving or working with heavy machinery. Benzodiazepines should not be prescribed for people currently using excessive amounts of alcohol or illicit drugs.

What is the effectiveness of benzodiazepines on insomnia?

There is inadequate evidence for the efficacy of benzodiazepines and non-benzodiazepine hypnotics to treat chronic insomnia (primary or due to another psychiatric or medical condition), with studies that do exist showing only short-term efficacy (American Psychiatric Association).

In the short term, benzodiazepines and non-benzodiazepine hypnotics induce sleep in approximately 50 percent of cases. The therapeutic effects of the sleep-inducing action of benzodiazepines and non-benzodiazepine hypnotics are short-lived, however – about one to two weeks. As there is a risk of dependency associated with the long-term use of benzodiazepines and non-benzodiazepine hypnotics, chronic insomnia should be viewed as a disorder requiring further investigation and treatment.

Research into the causes of insomnia concludes that benzodiazepines and non-benzodiazepine hypnotics have limited value in the treatment of sleep disturbances and that long-term benzodiazepine non-benzodiazepine hypnotics use worsens the quality of sleep. Long-term benzodiazepine and non-benzodiazepine hypnotics use (over a few months or years) results in less time in the deep sleep stage, less REM sleep, and more frequent waking during the night.

Why benzodiazepines and non-benzodiazepine hypnotics are not the best first election to treat insomnia in older adults?

In older adults, changes in circadian rhythm may mean a tendency to wake up earlier and feel sleepy earlier in the evening. Older adults in general tend to have more fragmented sleep, with less time in the deep sleep phase. Although frequently prescribed to older adults, benzodiazepines and non-benzodiazepine hypnotics don’t correct these physiological changes.

What are the harmful effects of benzodiazepines?

Although benzodiazepines relieve the symptoms of anxiety and insomnia in the short-term, they don’t cure the problem and have several unwanted and potentially harmful effects. Benzodiazepines and non-benzodiazepine hypnotics, even in small doses taken regularly for only a few weeks, can produce tolerance and dependence. For people using benzodiazepines and non-benzodiazepine hypnotics for months or years, the risk of drug withdrawal is significant, and the withdrawal syndrome can be painful and prolonged.

How to know when a person has benzodiazepine dependency?

Drug dependence usually has physical and psychological elements. People who are dependent on benzodiazepines and non-benzodiazepine hypnotics may:

• Feel unable to cope without the drug:
• Find it extremely difficult to stop taking the drug
• Find the drug no longer has the same effect, so may increase the dose or drink alcohol to achieve the same effect
• Perceive that they need the drug to function normally
• Have withdrawal symptoms if the drug is cut down or stopped
• Crave the drug
• Feel unable to leave the house without the drug
• Take relief knowing they have access/enough of the drug.

How long does it take to reduce benzodiazepine use?

During the withdrawal period, many people may experience acute and prolonged physical, emotional, or psychological discomfort. Given that recovery from withdrawal symptoms can take a long time, it is important that health professionals support and provide counselling and support during the time it takes for the person to recover.

People who initiate the process of reducing benzodiazepine or non-benzodiazepine hypnotics use need to resolve other problems before they begin the withdrawal. Because of this, it is important to offer them detailed information about the steps and alternative strategies. Providing information usually allows people to make informed decisions and cope with the process of reduction.

What alternative treatments are available to meet the challenge of reducing benzodiazepine use?

Cognitive-behavioral therapy for insomnia (CBT-I) involves a combination of behavioral modification, such as stimulus control and sleep restriction, and cognitive strategies, such as the replacement of fears about sleep with more positive expectations. Clinical trials show that CBT-I can be equally or more effective than hypnotics over an extended period without associated side effects. Medication alone or in combination with CBT-I may be necessary for some patients, after considering prior treatment responses, the availability of CBT-I resources, and patient preferences.

Sources:

Ree, L. Beyond Benzodiazepines toolkit. (2018) Reconnexion. Available: https://uploads-ssl.webflow.com/5aced27ea8e8388044acab17/5ca5aa7876bfccbcc79cba1d_Benzo%20Toolkit%20Booklet%20web4.pdf

Guideline on deprescription of benzodiazepine and sedative hypnotics (BSHs) in insomnia disorder: Trustworthy guidelines to reduce BSHs published on MAGICapp website and BE-SAFE portal - Published: August 31st, 2023. Available: https://besafe-horizon.eu/files/be-safe/content/en/Documents/BE-SAFE- Deprescription of benzodiazepine and sedative hypnotics %28BSHs%29_corrected.pdf