Sedative

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

A sedative is a substance that depresses the central nervous system (CNS), resulting in calmness, relaxation, reduction of anxiety, sleepiness, and slowed breathing, as well as slurred speech, staggering gait, poor judgment, and slow, uncertain reflexes. Sedatives may be referred to as tranquilizers, depressants, anxiolytics, soporifics, sleeping pills, or sedative-hypnotics. This, however, may be inaccurate as sedatives are a type of depressant as are tranquilizers which are mild in their action compared to that of sedatives. Also, sedatives only act as hypnotics (sleep-inducing drugs)in relatively high doses. Sedatives can be abused to produce an overly-calming effect (alcohol being the classic and most common sedating drug). At high doses or when they are abused, many of these drugs can cause unconsciousness (see hypnotic) and even death.

Types of Sedatives

Therapeutic Use

Doctors and nurses often administer sedatives to patients in order to dull the patient's anxiety related to painful or anxiety-provoking procedures. Although sedatives do not relieve pain in themselves, they can be a useful adjunct to analgesics in preparing patients for surgery, and are commonly given to patients before they are anaesthetized, or before other highly uncomfortable and invasive procedures like cardiac catheterization , colonoscopy or MRI. They increase tractability and compliance of children or troublesome or demanding patients.

Patients in intensive care units are almost always sedated (unless they are unconscious from their condition anyway)

Sedative Dependence

All sedatives can cause physiological and psychological dependence when taken regularly over a period of time, even at therapeutic doses. Dependent users may get symptoms ranging from restlessness, insomnia to convulsions and death. When users become psychologically dependent, they feel as if they need the drug to function, although there is no physical dependence. In both types of dependences, finding and using the sedative becomes the focus in life. Both physical and psychological dependence can be treated with therapy. (see Sedative Dependence).

Abuse and Overdoses

All sedatives can be abused, but barbiturates and benzodiazepines are responsible for most of the problems with sedative abuse due to their widespread "recreational" or non-medical use. People who have difficulty dealing with stress, anxiety or sleeplessness may overuse or become dependent on sedatives. Heroin users take them either to supplement their drug or to substitute for it. Stimulant users frequently take sedatives to calm excessive jitteriness. Others take sedatives recreationally to relax and forget their worries. Barbiturate overdose is a factor in nearly one-third of all reported drug-related deaths. These include suicides and accidental drug poisonings. Accidental deaths sometimes occur when a drowsy, confused user repeats doses, or when sedatives are taken with alcohol. In the U.S., in 1998, a total of 70,982 sedative exposures were reported to U.S. poison control centers, of which 2310 (3.2%) resulted in major toxicity and 89 (0.1%) resulted in death. About half of all the people admitted to emergency rooms in the U.S. as a result of nonmedical use of sedatives have a legitimate prescription for the drug, but have taken an excessive dose or combined it with alcohol or other drugs.

See also Other non-therapeutic use.

Sedatives and Alcohol

Sedatives and alcohol are sometimes combined recreationally or carelessly. Since alcohol is a strong depressant that slows brain function and depresses respiration, the two substances compound each other's actions synergistically and this combination can prove fatal.

Lookalikes

Lookalikes, or pills made to mimic the appearance and the effects of authentic sedatives, are sold on the street. Lookalikes may contain over-the-counter drugs, such as antihistamines, that cause drowsiness. Since the actual composition is unknown, neither the intensity of the primary effect nor the range of side effects can be predicted.

Sedatives and Amnesia

Sedation can sometimes leave the patient with long-term or short-term amnesia. Lorazepam is one such pharmacological agent that can cause anterograde amnesia. Intensive care unit patients who receive higher doses over longer periods of time, typically via IV drip, are more likely to experience such side effects.

Sedative Drugs and Crime

The sedatives GHB, Flunitrazepam (Rohypnol), and to a lesser extent, temazepam (Restoril), and midazolam (Versed)[1] are known for their use as date rape drugs (also called a Mickey), administered to unsuspecting patrons in bars or guests at parties to reduce the intended victims' defenses. These drugs are also used for robbing people, indeed statistical overviews suggest that the use of sedative-spiked drinks for robbing people is actually much more common than their use for rape.[2]

Cases of criminals taking rohypnol themselves before they commit crimes have also been reported, as the loss of inhibitions from the drug may increase their confidence to commit the offence, and the amnesia produced by the drug makes it difficult for police to interrogate them if they are caught.

Sedative Withdrawal

Differential Diagnosis

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Withdrawal[3]

“
  • A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been prolonged.

AND

  • B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A:
  • 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
  • 3. Insomnia.
  • 4. Nausea or vomiting.
  • 6. Psychomotor agitation.
  • 7. Anxiety.

AND

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specify if:

  • With perceptual disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium.
 ”

Sedative Intoxication

Differential Diagnosis

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Intoxication[3]

“
  • A. Recent use of a sedative, hypnotic, or anxiolytic.

AND

  • B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use.

AND

  • C. One (or more) of the following signs or symptoms developing during, or shortly after,sedative, hypnotic, or anxiolytic use:

1. Slurred speech.

2. Incoordination.

3. Unsteady gait.

4. Nystagmus.

5. Impairment in cognition (e.g., attention, memory).

6. Stupor or coma.

AND

  • D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.
 ”

Sedative Use Disorder

Differential Diagnosis

Risk Factors

  • Availability of the substances
  • Alcohol use disorder
  • Environmental factors
  • Early onset of use
  • Genetic predisposition
  • Peer use of the substance[3]

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Use Disorder[3]

“
  • A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • 1. Sedatives, hypnotics, or anxiolytics are often taken in larger amounts or over a longer period than was intended.
  • 2. There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.
  • 3. A great deal of time is spent in activities necessary to obtain the sedative, hypnotic,or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.
  • 4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
  • 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to sedative, hypnotic, or anxiolytic use; sedative-,hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school;neglect of children or household).
  • 6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).
  • 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.
  • 8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).
  • 9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.
  • 10. Tolerance, as defined by either of the following;
  • a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect.
  • b. A markedly diminished effect with continued use of the same amount of the sedative,hypnotic, or anxiolytic.

Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.

  • 11. Withdrawal, as manifested by either of the following:
  • a. The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics.
  • b. Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol)are taken to relieve or avoid withdrawal symptoms.

Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.


Specify if:

  • In early remission: After full criteria for sedative, hypnotic, or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic, or anxiolytic use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic,” may be met).
  • In sustained remission: After full criteria for sedative, hypnotic, or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic, or anxiolytic use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic,” may be met).

Specify if:

  • In a controlled environment: This additional specifier is used if the individual is in an environment where access to sedatives, hypnotics, or anxiolytics is restricted.
 ”

References

  1. ↑ Negrusz A (2003). "Analytical developments in toxicological investigation of drug-facilitated sexual assault". Analytical and bioanalytical chemistry. 376 (8): 1192–7. doi:10.1007/s00216-003-1896-z. PMID 12682705. Unknown parameter |coauthors= ignored (help); Unknown parameter |month= ignored (help)
  2. ↑ Thompson, Tony (19 December, 2004). "'Rape drug' used to rob thousands". The Observer. Retrieved 2008-05-08. Check date values in: |date= (help)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.

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