Back More
Salem Press

Table of Contents

Principles of Health: Pain Management

Sedative-hypnotic misuse

by Katia Marazova, , MD, PhD,, Mihaela Avramut, , MD, PhD

CATEGORY: Addiction

ALSO KNOWN AS: Depressant misuse

History of Use

Bromide, the first sedative-hypnotic, originated in 1838 and was followed by chloral hydrate, paraldehyde, and barbiturates. Bromide compounds were frequently used as sedatives and anticonvulsants in the nineteenth and early twentieth century.

Barbiturates were first introduced for medical use in the early twentieth century. Since then, approximately fifty barbiturates were marketed but less than fifteen remain in medical use. Barbiturates became popular in the 1960s as treatment for anxiety, insomnia, and seizure disorders, but the dependence-producing potential and the dangers of overdose restricted their use significantly. Since the 1970s, barbiturates were largely replaced by the safer BDZ group.

The first BDZs, chlordiazepoxide and diazepam, were introduced in clinical practice in the early 1960s. Although more than two thousand different BDZs have been synthesized, less than twenty are currently approved in the United States. BDZ usage increased dramatically in the 1970s, with total sales accounting for about 10 percent of all prescriptions in many Western countries. The perceived desirable properties of anxiety alleviation, euphoria, disinhibition, and sleep promotion have led to the compulsive misuse of virtually all of the drugs classed as sedative-hypnotics.

Causes

Depressant misuse is on the rise because of the wide availability of drugs by prescription or through the illicit marketplace. Examples of illegal depressants of misuse include the date rape drugs flunitrazepam (Rohypnol) and gamma-hydroxybutyric acid (GHB, a natural depressant).

Overall, short-acting agents are more likely to be used nonmedically than those with long-lasting effects. Because of their wider margin of safety, benzodiazepines have largely replaced barbiturates. They now constitute the most prescribed central nervous system (CNS) depressants—and the most frequently misused, usually to achieve a general feeling of relaxation. However, barbiturates and barbiturate-like drugs still pose clinical problems, as many young people underestimate the risks these drugs carry. Non-benzodiazepine sedatives, such as zolpidem (Ambien), also can generate misuse and dependence.

Most sedative-hypnotic drugs work by enhancing the inhibitory activity of the neurotransmitter gamma-aminobutyric acid, thus reducing CNS activity and promoting relaxation and sleep. They are usually prescribed to treat sleep disorders, anxiety, acute stress reactions, panic attacks, and seizures. In higher doses, some agents become general anesthetics. Chronic use results in tolerance and dependence (both psychological and physical).

Risk Factors

Barbiturate misuse occurs most commonly in mature adults with a long history of use, while benzodiazepines are favored by younger persons (those younger than forty years of age). Two main categories of people misuse depressant drugs. The first category comprises people who receive depressant prescriptions for psychiatric disorders or who obtain them illicitly to cope with stressful life situations. These persons have a high risk of becoming dependent, especially if they receive high doses, take the drug for longer than one month, and have a history of substance misuse or a family history of alcoholism. However, if dose escalation is not evident and drugs are not used to achieve a state of intoxication, chronic benzodiazepine users should not be considered misusers.

A second important category comprises people who use sedative drugs in the context of alcohol or multiple-drug misuse. These people may take benzodiazepines to alleviate insomnia and anxiety (sometimes induced by stimulants), to increase the euphoric effects of opioids, and to diminish cocaine (or alcohol) withdrawal symptoms.

Abuse of hypnotics or sleeping pills often corresponds to misuse of alcohol, which is also a depressant. (rustycanuck via iStock)

POHPain_p0326_1.jpg

Other Uses of Sedative-Hypnotics

Some of the sedative-hypnotics are used to commit sexual assaults. Because these drugs are sedating and induce a temporary amnesia, they are sometimes added to alcoholic beverages and soft drinks to incapacitate the intended victim of a rape. Flunitrazepam (Rohypnol), also known with the street names rophies, roofies, and roach, is a long-acting BDZ used as a favored sedative of misuse among adolescents and adults, and it is typically used in combination with alcohol as a party drug and a date rape drug.

Flunitrazepam has never been approved for medical use in the United States. Gamma-hydroxy butyrate (GHB), a natural CNS depressant resulting from the metabolism of the inhibitory neurotransmitter GABA, has emerged as a significant drug of misuse. It gained popularity for recreational use because of its pleasant, alcohol-like, hangover-free high with aphrodisiac properties.

Body-builders misuse GHB for its alleged utility as an anabolic agent. GHB is often taken by young polydrug misusers (who are called clubbers and ravers) in combination with amphetamines to produce euphoria and a hallucinatory state. Because of concerns about GHB misuse and date rape usage, in 2000 this drug was made a schedule I controlled substance. Because flunitrazepam and GHB are illegal in the United States, they are available only through the underground market.

Those who chronically misuse sedative-hypnotics prefer the short-acting barbiturates, the barbiturate-like depressants glutethimide and methaqualone, and the faster-acting BDZs diazepam, alprazolam, and lorazepam. Persons who misuse sedative-hypnotics are most likely to be those who use drugs to relieve stress; who use drugs to counteract unpleasant effects of other drugs of misuse; and who combine CNS depressants with alcohol or opiates to potentiate their effects.

Significant safety concerns with sedative-hypnotics include important drug interactions (for example, the inhibitors of drug metabolism such as antifungals, erythromycin, clarithromycin, or cimetidine significantly prolong their effect and increase their toxicity) and their appropriate use in special populations (elderly people, pregnant women, and persons with a history of substance misuse). Overdosing on sedative-hypnotics is among the most common methods for attempting suicide.

Symptoms

People who misuse depressants often engage in drug-seeking behaviors that include frequently requesting, borrowing, stealing, or forging prescriptions; ordering and purchasing medication online; and visiting several doctors to obtain prescriptions. These behaviors often accompany changes in sleep patterns and irritable mood and increased alcohol consumption. Recreational use and self-medication with depressants may lead to accidental overdoses and suicide attempts. Many persons use a “cocktail” of alcohol and depressant medications for enhanced relaxation and euphoria. This practice is dangerous, as it carries a high risk of overdose.

Sedative-hypnotic drug intoxication resembles alcohol, painkillers, and antihistamine intoxication. It presents with impaired judgment, confusion, drowsiness, dizziness, unsteady movements, slurred speech, and visual disturbances. Young adults attempting to get high may show excitement, loss of inhibition, and even aggressive behavior. Acute GHB intoxication leads to sleep and memory loss. These manifestations occur without alcohol odor on the breath, unless the misuser combined the drug with alcohol. In the case of barbiturates, the behavioral effects of intoxication can vary depending on the time of day, the surroundings, and even the user’s expectations.

Tolerance to barbiturates is not accompanied by an increase in lethal dose, as it is with opiates. For this reason, an overdose can be fatal. Signs and symptoms of barbiturate overdose vary, and they include lethargy, decreased heart rate, diminished reflexes, respiratory depression, and cardiovascular collapse.

All sedative-hypnotics can induce physical dependence if taken in sufficient dosage over a long time. Withdrawal from depressant medication results in a “rebound” of nervous system activity. In a mild form, this leads to anxiety and insomnia. In cases of more severe dependence, withdrawal manifests with nausea, vomiting, tremors, seizures, delirium, and ultimately, death. Therefore, discontinuation of prescription drugs necessitates close medical supervision.

Screening and Diagnosis

To evaluate a person who might misuse depressant medication, a doctor will obtain a thorough medical history, ask questions about current and previous drug and alcohol use, and perform a physical examination. A psychiatric evaluation may also be required. The diagnosis of depressant drug misuse relies on evidence of dose escalation, on obtaining multiple prescriptions, and on taking the drug for purposes other than those stated in the prescription.

Multiple tests detect the presence of drugs and also potential medical complications. These include drug screening (urine and blood), electrolyte and liver profiles, an electrocardiogram, and X-ray and magnetic resonance imaging.

Treatment and Therapy

Therapeutic strategies for depressants misuse vary according to the drug used, the severity of the manifestations, and the duration of drug action. Common therapies include detoxification, which involves the use of agents that reverse the effects of the drug (for example, using Flumazenil for benzodiazepine misuse and using Naloxone for narcotics misuse). Other common therapies include the use of medications that mitigate withdrawal symptoms, counseling in inpatient or outpatient settings, support groups, and relaxation training. When a person receiving treatment has combined a CNS depressant with alcohol or other drugs, all aspects of this addiction have to be addressed and treated.

Prevention

Sedative-hypnotic medication should be used only as prescribed. Combinations of CNS depressants (such as alcohol/drug or over-the-counter drug/prescription medication) pose high risks and should be avoided.

People who are unsure of a drug’s effects, or who suspect dependence, should consult a pharmacist or a doctor. Those people who are contemplating the discontinuation of a CNS depressant or who are experiencing withdrawal symptoms should seek medical care immediately.

A careful assessment is necessary before prescribing depressant medication in persons with a history of drug misuse. These individuals require close monitoring. Also, caregivers and health care providers should verify that there are no alternative sources for obtaining the drug of misuse.

References

1 

Cooper, Jeffrey S. “Sedative-Hypnotic Toxicity.” Medscape, 9 Nov. 2019, emedicine.medscape.com/article/818430-overview.

2 

Erlach, Stephen P. “Sedative, Hypnotic, Anxiolytic Use Disorders Treatment & Management.” Medscape, 9 Nov. 2019, emedicine.medscape.com/article/290585-treatment.

3 

Ford, Jason A. “The Prescription Drug Problem We Are Missing: Risks Associated with the Misuse of Tranquilizers and Sedatives.” Journal of Adolescent Health, vol. 63, no. 6, 2018, pp. 665–666., doi:10.1016/j.jadohealth.2018.09.007.

4 

Hanson, Glen R., Peter J. Venturelli, and Annette E. Fleckenstein. Drugs and Society. 11th ed. Sudbury, MA: Jones, 2012.

5 

Hasan, Aliya, and Valmiki Sharma. “Substance Abuse and Conscious Sedation: Theoretical and Practical Considerations.” British Dental Journal, vol. 227, no. 10, 2019, pp. 923–927., doi:10.1038/s41415-019-0897-z.

6 

Heller, Jacob L. “Barbiturate Intoxication and Overdose.” MedlinePlus. National Library of Medicine, 15 Jan. 2014.

7 

“Sedative, Hypnotic or Anxiolytic Drug Use Disorder.” Harvard Health Publishing, Harvard Medical School, Dec. 2018, www.health.harvard.edu/a_to_z/sedative-hypnotic-or-anxiolytic-drug-use-disorder-a-to-z.

8 

Weaver, Michael F. “Prescription Sedative Misuse and Abuse.” The Yale Journal of Biology and Medicine, vol. 88, no. 3, Sept. 2015, pp. 247–256.

Citation Types

Type
Format
MLA 9th
Marazova, Katia, and Mihaela Avramut. "Sedative-hypnotic Misuse." Principles of Health: Pain Management, edited by Michael A. Buratovich, Salem Press, 2020. Salem Online, online.salempress.com/articleDetails.do?articleName=POHPain_0128.
APA 7th
Marazova, K., & Avramut, M. (2020). Sedative-hypnotic misuse. In M. A. Buratovich (Ed.), Principles of Health: Pain Management. Salem Press.
CMOS 17th
Marazova, Katia and Avramut, Mihaela. "Sedative-hypnotic Misuse." Edited by Michael A. Buratovich. Principles of Health: Pain Management. Hackensack: Salem Press, 2020. Accessed September 19, 2025. online.salempress.com.