What is Benzodiazepine Toxicity?
Since the 1960s, with the creation of drugs like chlordiazepoxide and diazepam, benzodiazepines have become a popular choice of medication due to them being considerably safer than older sedatives, such as barbiturates, which were previously used for treating anxiety and insomnia. Benzodiazepines are a type of medication that have been developed and refined over several years.
Today, benzodiazepines are used to treat a range of conditions including anxiety, seizures, withdrawal symptoms, insomnia, and agitation, and are often used to sedate patients before procedures. Because of their many uses and the fact that they can be addictive, these drugs have been frequently prescribed and sometimes misused since they were first developed.
There are now more than 50 different types of benzodiazepines available globally. Because these drugs are so commonly used and easily accessible, overdoses are not uncommon and reflect just how prevalent their use is.
What Causes Benzodiazepine Toxicity?
Austrian scientist Leo Sternbach, who worked for Hoffmann-La Roche in Nutley, NJ, is known for his work in creating many drugs, particularly a group called benzodiazepines. In 1956, he unexpectedly developed a drug called chlordiazepoxide, which was given the green light for medical use in 1960. He later created a better and safer drug called diazepam in 1963.
Diazepam became incredibly popular. From 1969 to 1982, it was the most commonly prescribed drug in the United States, with the drug’s highest sales reaching over 2.3 billion doses in 1978.
Risk Factors and Frequency for Benzodiazepine Toxicity
Benzodiazepine use disorder, a condition where people misuse this type of drug, is believed to affect less than 1% of people during their whole lives. It’s challenging to get an accurate figure because benzodiazepines are often used alongside other drugs. However, we know that tranquillizer and sedative use, which includes benzodiazepines, affects around 1% and 1.1% of people in the US respectively over their lifetimes. In fact, in 2013, 2% of everyone in the US over 12 years old consumed benzodiazepines or similar drugs for non-medical purposes. Furthermore, the number of benzodiazepine prescriptions has been steadily rising annually since 1996. Because of this, they are some of the most frequently prescribed medicines worldwide. Over the ten years from 2003 to 2013, there has been a 109% increase in the number of people admitted to substance abuse treatment centers due to problems exclusively with benzodiazepine use.
Signs and Symptoms of Benzodiazepine Toxicity
Benzodiazepine toxicity, or overdose, primarily causes symptoms related to the slowing down of the central nervous system. Its effects range from mild sleepiness to a coma-like state. The typical person suffering from a benzodiazepine overdose will show signs of lowered brain activity but will have normal vital signs. Heart-related problems and deaths are uncommon if the overdose involves only benzodiazepines. Breathing problems, while more rare than in overdoses of another type of drug called barbiturates, are the most serious outcome and need immediate medical help. A severe decrease in breathing can happen with high amounts of benzodiazepines taken orally, with or without other drugs. Toxicity can also happen when benzodiazepines are used in combination with other drugs during medical procedures, especially with opioids like fentanyl.
In kids with benzodiazepine toxicity, symptoms usually appear within four hours of taking the drug. The most common symptom in kids is ataxia, a condition that affects balance and coordination, occurring in 90% of affected children. Less than 10% of kids will have breathing problems and low blood pressure has not been reported. Beaing problems are the most concerning symptoms and require immediate medical attention.
Testing for Benzodiazepine Toxicity
If a person is suspected of overdosing on a certain group of drugs called benzodiazepines, doctors usually base their diagnosis on the symptoms the person is showing. If the patient is conscious and responsive, they can often tell the doctor about the drugs they’ve taken, which could help with the diagnosis. When a patient can’t provide this information, for example, if they’re unresponsive, the priority is to stabilize the patient.
If the patient has breathing difficulties or noticeably irregular vital signs (like heart rate and blood pressure), these issues must be dealt with first, possibly including the use of a ventilator to assist with breathing or intravenous fluids to help maintain blood pressure.
Next, a series of tests can help establish what’s causing the patient’s symptoms. These include a rapid bedside blood sugar test (to identify if low blood sugar could be the cause of their symptoms), testing for the presence of certain drugs such as acetaminophen and aspirin, as well as alcohol. Doctors will also order an electrocardiogram or ECG, a test that checks for problems with the heart’s electrical activity. This can help identify if the patient has taken any specific drugs that could affect the heart. For any female patient who could potentially be pregnant, a pregnancy test would be done as well. Sometimes, a CT scan of the head is done to rule out brain-related abnormalities.
A urine test is usually done to identify the presence of drugs, but it has its limitations. The standard urine test can detect certain benzodiazepines, but not all. Some common benzodiazepines such as clonazepam, lorazepam, midazolam, and alprazolam may not show up on many urine drug tests. Even if a drug does show up in the test, it only means the person has used the drug recently; it doesn’t confirm that the drug caused the person’s current condition, nor does it identify exactly which drug the person took.
Treatment Options for Benzodiazepine Toxicity
When someone is experiencing acute benzodiazepine toxicity, which means they’ve had too much of a certain type of medication, the first thing doctors do is provide supportive care. It’s like giving the body what it needs to handle this medication overdose. Sometimes, the patient might even need a procedure called endotracheal intubation to help them breathe properly.
You might have heard of certain treatments like activated charcoal, hemodialysis, or whole bowel irrigation for poisoning or overdoses. However, they don’t work for benzodiazepine toxicity.
In certain cases, doctors might consider using an “antidote” for benzodiazepine toxicity. This antidote, called flumazenil, can reverse the effects of too much benzodiazepine in the body. However, using flumazenil usually comes with risks that outweigh the benefits. It can lead to seizures or irregular heart rhythms and can be life-threatening for people who regularly use benzodiazepines. If flumazenil were given to a person who has been using benzodiazepines for a long time, it could lead to severe seizures, putting their life at risk.
On the other hand, flumazenil can be used safely if the patient is not a regular user of benzodiazepines. This situation is usually common in children who have accidentally swallowed these medications. But even in these cases, the decision to use flumazenil is weighed carefully against the risks and benefits. Doctors consider it because, most of the time, people recover from a benzodiazepine overdose with time and supportive care alone.
What else can Benzodiazepine Toxicity be?
When a doctor is trying to figure out if someone has been poisoned by benzodiazepines, they consider a number of other conditions that have similar symptoms. These conditions include:
- Alcohol poisoning
- Low blood sugar (hypoglycemia)
- Abnormal levels of sodium in the blood (hyponatremia or hypernatremia)
- Stroke
- Opiate poisoning
What to expect with Benzodiazepine Toxicity
The outlook for recovery significantly depends on how fast the diagnosis is made and treatment started.
Possible Complications When Diagnosed with Benzodiazepine Toxicity
The negative effects of having too much benzodiazepine in your body can be severe. Many call these “complications,” and they can include:
- Respiratory arrest, or when you stop breathing
- Death
- Aspiration pneumonitis, an inflammation of the lungs caused by inhaling foreign matter
- Rhabdomyolysis, a condition where your muscle tissue breaks down and releases a harmful protein into your bloodstream
Preventing Benzodiazepine Toxicity
People who are using benzodiazepines for non-medical or recreational purposes should undergo therapy. Psychological counseling and appropriate treatments designed to manage and overcome addiction can be helpful in these situations.
