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Tranquillizers and sleeping pills

Tranquillizers are depressant drugs that slow down the central nervous system (CNS), and thus are similar to such other CNS depressants as alcohol and barbiturates.

The term "major tranquillizer" was formerly applied to drugs used to treat severe mental illnesses, such as schizophrenia. However, these drugs are now more commonly called neuroleptics; their action specifically relieves the symptoms of mental illness, and they are rarely misused for other purposes. This paper therefore deals with the anti-anxiety agents, or anxiolytics (formerly called "minor" tranquillizers).

Anti-anxiety agents share many similiarities with barbiturates; both are classified as sedative/hypnotics. These newer agents were introduced under the term "tranquillizer" because, it was claimed, they provided a calming effect without sleepiness. Today, tranquillizers have largely replaced barbiturates in the treatment of both anxiety and insomnia because they are safer and more effective. The degree of sleepiness induced depends on the dosage. Tranquillizers are also used as sedatives before some surgical and medical procedures, and they are sometimes used medically during alcohol withdrawal.

Although tranquillizers do not exhibit the serious dependence characteristics of barbiturates, they nevertheless can produce tolerance and dependence. They may also be misused and abused.

The first drug to be labelled a tranquillizer was meprobamate - under the trade name Miltown - in 1954. Today, however, the most popular anti-anxiety agents are the benzodiazepines (e.g. Valium, Halcion, and Ativan). (NOTE that where a drug name is capitalized, it is a registered trade name of the manufacturer.) Since the early 1960s, the benzodiazepines have accounted for more than half the total world sales of tranquillizers. They are currently the most commonly prescribed class of psychotropic (mood-altering) drugs in Canada.

The first benzodiazepine developed was chlordiazepoxide, which is sold under such trade names as Librium and Novopoxide. The next was diazepam; it is marketed, among other brand names, as Valium, E-Pam, and Vivol. In the early 1970s diazepam was the most widely prescribed drug in North America. Now Halcion and Ativan - drugs from the same family as diazepam but eliminated more rapidly from the body - account for most benzodiazepine prescriptions. There are 14 different benzodiazepines currently available in Canada. Some are prescribed as anti-anxiety drugs (e.g. Valium, Librium); others are recommended as sleeping medications (e.g. Dalmane, Somnol, Novoflupam, and Halcion).

Effects

The effects of any drug depend on several factors he circumstances under which the drug is taken (the place, the user's psychological and emotional stability, the presence of other people, the simultaneous use of alcohol or other drugs, etc.).

With tranquillizers, a therapeutic dose (i.e. what is medically prescribed) relieves anxiety and may, in some people, induce a loss of inhibition and a feeling of well-being. Responses vary, however. Some people report lethargy, drowsiness, or dizziness. Tranquillizers, though, have very few side effects.

As the dose of a tranquillizer is increased, so is sedation and impairment of mental acuity and physical coordination. Lower doses are recommended for older people or for those with certain chronic diseases, since their bodies tend to metabolize these drugs more slowly.

Studies show that anti-anxiety agents, even at the usually recommended and prescribed doses, may disrupt the user's ability to perform certain physical, intellectual, and perceptual functions. For these reasons, users should not operate a motor vehicle or engage in tasks calling for concentration and coordination. Such activities are particularly hazardous if tranquillizers are used together with alcohol and/or barbiturates (i.e. other sedative/hypnotics) or antihistamines (in cold, cough, and allergy remedies). These effects occur early in therapy, however, and wane over time with increased tolerance (when more of the drug is needed to produce the same effect).

Because some tranquillizers (such as diazepam) are metabolized quite slowly, residue can accumulate in body tissues with long- term use and can heighten such effects as lethargy and

sluggishness.

Toxic effects

Tranquillizer overdose, particularly with benzodiazepines, has become increasingly common since the 1960s. While these drugs are usually safe even when an overdose is taken (death rarely results from benzodiazepine use alone), they can be fatal in combination with alcohol and other drugs that depress the central nervous system.

In Canada, as elsewhere, tranquillizer-related poisonings and overdoses have kept pace with the drug's availability. It is a fact that the drugs used in suicide attempts are those most widely prescribed and available. (The majority of these drug-related suicide attempts are by women under 30.) 

Tolerance and dependence

Because tolerance to the mood-altering effects of tranquillizers can develop with regular use, higher daily doses become necessary to maintain the desired effects. Tolerance may occur even at prescribed doses.

Chronic users may become both psychologically and physically dependent on tranquillizers.

Psychological dependence exists when a drug is so central to a person's thoughts, emotions, and activities that the need to continue its use becomes a craving or compulsion.

With chronic use, especially at higher doses, physical dependence can also occur. The user's body has adapted to the presence of the drug and suffers withdrawal symptoms when use is stopped. The frequency and severity of the withdrawal syndrome depends on the dose, duration of use, and whether use is stopped abruptly or tapered off. Symptoms range in intensity from progressive anxiety, restlessness, insomnia, and irritability in mild cases to delirium and convulsions in severe cases.

Dependence may also occur following long-term therapeutic use, but withdrawal symptoms in such cases are mild. Patients complain of gastrointestinal problems, loss of appetite, sleep disturbances, sweating, trembling, weakness, anxiety, and changes in perception (e.g. increased sensitivity to light, sound, and smells).

Risk of dependency increases if tranquillizers are taken regularly for more than a few months, although problems have been reported within shorter periods. The onset and severity of withdrawal differ between the benzodiazepines that are rapidly eliminated from the body (e.g. Halcion) and those that are slowly eliminated (e.g. Valium). In the former case, symptoms appear within a few hours after stopping the drug and may be more severe. In the latter case, symptoms usually take a few days to appear.

Tranquillizers and pregnancy

If a woman uses tranquillizers regularly, the drug can affect the baby for up to 10 days after birth. Babies may exhibit the withdrawal symptoms common to such other depressant drugs as alcohol and barbiturates. These symptoms include feeding difficulties, disturbed sleep, sweating, irritability, and fever. Symptoms will be more severe if the doses the mother took are higher.

Administration of diazepam during labor has been linked to decreased responsiveness and respiratory problems in some newborns.

Who uses tranquillizers

A 1989 Addiction Research Foundation survey of Ontario adults aged 18 years and over indicated that 6.5% had used tranquillizers in the previous 12 months - roughly half the percentage of users reported in 1977.

The survey showed that women, as a group, use tranquillizers most frequently. A 1990 study done at the Foundation found that women who were abused as girls, or who saw their mothers abused by a male partner, were more likely, as adults, to use tranquillizers and also illegal drugs. The study found too that women who are abused by their partners use more tranquillizers - as well as more sedatives, sleeping pills, and alcohol - than other women.

Other frequent tranquillizer users are people over 50 (with those over 65 being the highest users); those with only elementary school education; people in the lowest income group; and those who marked their occupation category as "other" (which included people who are housewives and students, and those who are disabled, retired, or unemployed).

The study also showed that tranquillizer use by people 50 years and more remained at virtually a constant level from 1977 to 1984, but declined in 1987. For those between 18 and 29, use decreased steadily from 1977 to 1987.

In a separate Foundation study done in 1987, Ontario students in grades 7 to 13 were polled. The findings showed that 4.9% reported using prescribed tranquillizers, and 3% non-prescribed tranquillizers, at least once in the preceding year. The self reported rate of use was highest among 16- and 17-year-old students (6.3% for prescribed tranquillizers, and 4.5% for nonprescribed ones).

People dependent on alcohol or other drugs are at higher risk than others for tranquillizer abuse and dependence. Alcohol treatment and methadone maintenance programs report that their clients often abuse or are dependent on tranquillizers.

Amphetamine and cocaine users frequently take tranquillizers to relax or sleep after over-stimulation by the former drugs. Prescribing tranquillizers to users of other drugs, or to people undergoing withdrawal, carries a risk of transferring their dependence to tranquillizers. Dose and duration of treatment should be closely monitored.

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Copyright (c) 1980 Revised January 1991 Alcoholism and Drug Addiction Research Foundation, Toronto Canada
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