Benzodiazepines

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Benzodiazepines are in the class of drugs known as depressants, and are used to produce sedation, induce sleep, alleviate anxiety,  relieve muscle spasms, and prevent seizures. They act on the body by affecting the functioning of the central nervous system (brain and spine). At high doses, benzodiazepines act as hypnotics. When taken in moderate doses, they exhibit anti-anxiety effects, and at low doses, they produce sedation. Benzodiazepines are widely prescribed and at present, 15 different drugs are available in the United States. An additional 20 drugs in the benzodiazepine family are sold in other countries. 

 Benzodiazepines that act for short periods are typically used to help individuals who have difficulty falling asleep and who do not have anxiety during the daytime. Examples of such drugs include estazolam (ProSom), flurazepam (Dalmane), temazepam (Restoril), and triazolam (Halcion). In addition, zolpidem (Ambien) and zaleplon (Sonata) are also drugs  approved to treat insomnia. Although not technically considered benzodiazepines, they share many of the same properties. Short-acting benzodiazepines can also be used to relieve anxiety and promote sedation prior to anesthesia or certain medical procedures, such as an MRI (magnetic resonance imaging). Midazolam (Versed) is an example of one such drug.

 For individuals who have difficulty falling asleep and who also experience daytime anxiety, longer-acting benzodiazepines are the most appropriate choice. Examples of these medications include alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), halazepam (Paxipam), lorazepam (Ativan), oxazepam (Serax), prazepam (Centrax), and quazepam). Long-acting benzodiazepines used to prevent seizures include clonazepam (Klonopin), Valium, and Tranxene.

 Section 812 of the Controlled Substances Act (CSA) classifies various drugs and other substances according to their potential for abuse, therapeutic usefulness, and safety profiles. Of the five schedules, Schedule I has the highest potential for abuse and Schedule V has the lowest. Benzodiazepines, as well as Ambien and Sonata, are classified as Schedule IV drugs. Apart from their modest potential for abuse, the repeated use of benzodiazepines in large doses (and for some people, the daily use at standard therapeutic levels) may result in amnesia, hostility, irritability, and vivid dreams. In addition, some individuals may become tolerant to the effects of benzodiazepines. Concurrent use of alcohol and benzodiazepines can be life threatening. Addiction is also possible, and those who do develop a physical dependence to benzodiazepines experience withdrawal symptoms similar to those of alcohol, and may require hospitalization.

 Benzodiazepines and Fibromyalgia

Benzodiazepines can be of therapeutic value to fibromyalgia patients due to their ability to treat both anxiety and insomnia, both of which are frequent comorbid conditions experienced by fibromyalgia patients. In fact, an estimated 20% of fibromyalgia patients suffer from generalized anxiety disorder, and close to 90% of all fibromyalgia patients experience some type of sleep disturbance, including insomnia. Despite the availability of other therapies, benzodiazepines are considered the standard course of therapy for individuals with insomnia (Ioachimescu & El-Solh, 2012) and are the most widely prescribed class of drugs for the treatment of anxiety (Hadley et al., 2012). In addition, benzodiazepines may also be useful to help treat restless leg syndrome (Miletic & Relja, 2011), which can also be experienced by a disproportionate number of fibromyalgia patients.

 The scientific literature regarding the use of benzodiazepines in fibromyalgia patients specifically is mostly limited to a handful of observational studies that have evaluated drug therapy and healthcare resource use among fibromyalgia. White et al. (2009) demonstrated that fibromyalgia patients tend to increase their use of medication, including use of benzodiazepines, with increasing time since diagnosis. For example, prior to receiving a diagnosis of fibromyalgia, approximately 19% of patients studied by White and colleagues used benzodiazepines. Following diagnosis, that percentage increased to 24%. Another study also found an increased use of benzodiazepines in patients who were newly prescribed gabapentin (Neurontin) (Gore et al., 2009). A survey of 434 fibromyalgia patients found that 21% reported using benzodiazepines (Shaver et al., 2009). 

With regard to the specific treatment of fibromyalgia, one study from 1991 investigated the use of ibuprofen and alprazolam (Xanaz) to treat fibromyalgia. Following an eight week study of 52 patients, the researchers found that combined therapy with ibuprofen and alprazolam was beneficial at improving patients’ rating of their disease severity and tender point severity (Russell et al., 1991).

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References

1.        Benzodiazepines. United States Drug Enforcement Agency.No date; Accessed May 23, 2012.

2.        Controlled Substance Schedules. U.S. Department of Justice, Drug Enforcement Agency, Office of Diversion Control.No date; Accessed May 23, 2012.

3.        White LA, Robinson RL, Yu AP, Kaltenboeck A, Samuels S, Mallett D, Birnbaum HG. Comparison of health care use and costs in newly diagnosed and established patients with fibromyalgia. J Pain. 2009;10(9):976-93.

4.        Gore M, Sadosky AB, Zlateva G, Clauw DJ. Clinical characteristics, pharmacotherapy and healthcare resource use among patients with fibromyalgia newly prescribed gabapentin or pregabalin. Pain Pract. 2009;9(5):363-374.

5.        Shaver JL, Wilbur J, Lee H, Robinson FP, Wang E. Self-reported medication and herb/supplement use by women with and without fibromyalgia. J Womens Health (Larchmt). 2009;18(5):709-716.

6.        Russell IJ, Fletcher EM, Michalek JE, McBroom PC, Hester GG. Treatment of primary fibrositis/fibromyalgia syndrome with ibuprofen and alprazolam. A double-blind, placebo-controlled study. Arthritis Rheum. 1991;34(5):552-560.

7.        Miletić V, Relja M. Restless legs syndrome. Coll Antropol. 2011;35(4):1339-1347.

8.        Ioachimescu OC, El-Solh AA. Pharmacotherapy of insomnia. Expert Opin Pharmacother. 2012;13(9):1243-1260.

Hadley SJ, Mandel FS, Schweizer E. J Switching from long-term benzodiazepine therapy to pregabalin in patients with generalized anxiety disorder: a double-blind, placebo-controlled trial. Psychopharmacol. 2012;26(4):461-470.

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