Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, M.D.
 9 March 2005

WHAT IS A BENZODIAZEPINE?

            A patient recently returned from a clinic in Minneapolis where her family had taken her to a “Sleep Clinic”.  The family’s problem was that grandmother lived with her daughter’s family which included three teenage children.  The elderly grandmother had chronic lung disease which left her SOB when she tried to lie down to sleep. Thus, the patient was sitting up in a chair sleeping during the day and wandering about the house at night sometimes confused and waking up other family members.  The daughter felt that grandmother needed specialty help and thus the trip to Minneapolis.  On their return, the grandmother had received instructions to try a medication called lorazepam (Ativan) at a half milligram dose at bedtime.  Grandmother was instructed that the dose could be increased to a milligram if necessary to help reverse the sleep cycle in which the patient had been sleeping during the day but up all night.  The daughter was very disappointed that after a $13,000 dollar evaluation all that was given was a “sleeping pill”.  She looked up the drug on the internet and found that it was a “benzodiazepine”.  The daughter wanted to know what a benzodiazepine was and how it worked.  She wanted to know if it was safe because there were so many warnings  and side effects mentioned on the internet.

            The above problem is not atypical.  As age progresses adults need less and less sleep.  Children classically need at least 8 hours sleep.  As a person passes age 30, the need for sleep diminishes and by the time a person is 80 years of age, it seems that only 4-6 hours of sleep are necessary for adequate rest.  The reason for this normal change with aging is not understood, but elderly individuals often complain that they can only sleep four hours a night not knowing that this is really perfectly normal.

            The story of benzodiazepines begins in the 1950’s when the first drug of its kind called Librium (chlordiazepoxide) was developed.  This came on the market in 1961.  There was a time when Librium was the most prescribed sedative and sleeping preparation on the market but it has been superseded over the years by more effective medications.  The textbook of pharmacology now lists 21 different benzodiazepines that are commercially available.  These include Valium Ativan, Klonopin, Xanax and Tranxene to name a few.  All of the products on this list of 21 drugs have more or less the same properties.

             Specifically, this family of drugs:  1. provide a sleeping preparation; 2. provides a relief from anxiety; 3.  are excellent anti-seizure medications;  4.  are still the backbone of treatment for alcohol withdrawal problems;  5.  are often touted as “muscle relaxants” although in fact, there is no such thing.

            As mentioned above, the first of these products came on the market in 1961.  Now 44 years later, we know the side effects relatively well. These include abuse problems in which the person likes the effect of the drug and uses it excessively.  True physical addiction to the benzodiazepines is not an expectation but psychological dependence, especially to a drug called Xanax, can sometimes be a problem.  If these drugs are used in a person who has sleep apnea, they can be dangerous because, they suppress the drive to awaken when the person stops breathing from the sleep apnea.  They are best avoided in individuals who have problems with snoring and sleep apnea.  Occasionally, individuals will have unexpected and unpredictable responses in which the drug seems to excite the person more than sedate them.  Lastly, if the drug does not keep the person asleep, falls with a hip fracture can occur when the person wanders at night under the influence of the drug.  But other than these four considerations, the benzodiazepine group of drugs is remarkably safe.

            The daughter then brought forth a printout from her computer stating that the drugs are recommended only to be used for 10 days or less for temporary relief of sleep disorders.  It stated that the person could have adverse affects if they  are used on a longer term basis. I agree that dependence upon a sleeping medication is probably not as favorable as being able to sleep without such.  There are a large number of people who use a benzodiazepine preparation at bedtime periodically over a long term basis in order to facilitate sleep.  Speaking for myself, I have never seen anything bad happen to these people because they use a sleeping pill.  A sleeping pill is a tool like a spoon or a knife or a key.  A knife used to put butter on bread is o.k.  A knife used to stab another person is probably not o.k. But it isn’t the knife that is bad; it is how and why the knife was used.  If a person uses a sleeping pill in order to improve quality of sleep, I think that is a constructive, useful application of the medication.  For those few individuals who tend to accelerate the dose and remain tired all day too, the drug is not a useful step.  But the idea of limiting use of the medication for 10 days only, strikes me as a cockamamie idea impinging on the freedom of those who want and need assistance to sleep well.

            So I saw the daughter and grandmother about a week after they had returned from Minneapolis.  I asked how the lorazepam was working to help the grandmother sleep and the daughter volunteered that things seemed to be much better.  I reassured her that there is no “downside” to the use the lorazepam  to achieve adequate sleep for her mother and its long term use would be acceptable.  If her mother were to demonstrate increased drowsiness during the day in addition to sleeping all night, the use of the medication might be excessive and cut back,  but the daughter volunteered grandmother was much more awake during the day now but she was sleeping at night.

            As a last comment, I did point out to the daughter that she could have gotten lorazepam through her local clinic at the simple cost of one clinic visit along with local follow up care.  I pointed out to her that she could have had that for a lot less than $13,000 dollars.  Your local clinics are well aware of this type of problem and with certain exceptions can be dealt with very effectively with sleep problems.  On occasion “a sleep study” may be useful in designing a program to help an individual sleep but you don’t have to go Minneapolis to get that done.