Benzodiazepines are a versatile class of medications with several medical uses in the United States. They are primarily used to treat anxiety and sleep disorders. Because these are two of the most common health issues in the United States, benzodiazepines are widely prescribed and used. They were first introduced in the 1960s as a safer alternative to barbiturates, which are a similar kind of drug with more dangerous side effects. Benzodiazepines were so popular that they became the most commonly prescribed drug in the world by the 1970s. Today, there are dozens of benzodiazepine medications used all over the world.

Benzodiazepines are in a class of drugs called central nervous system depressants, along with alcohol and barbiturates. The drugs in this category work similarly in the brain and body. Because they are so similar, is there a difference between different benzodiazepine options? How do you know which benzodiazepine is right for your needs? There are some important differences between each prescription medication, and it’s important to work with your doctor to find the one that is best for you. 

Here’s a brief overview of the different types of benzos and how they compare.

What Are Benzodiazepines?

What Are Benzodiazepines?

Benzodiazepines are some of the most widely prescribed sedative drugs in the United States. This class of drugs works on the gamma-aminobutyric acid (GABA) receptors in the brain to slow down how fast neurons fire.
There are about 15 different types of benzodiazepine drugs in the world. Only a few have been approved for any medical use, and even fewer of those are legal to prescribe in the U.S.

While some benzodiazepines have been approved by the U.S. Food and Drug Administration (FDA), they are still Schedule IV per the Controlled Substances Act (CSA), so they require a prescription from a medical professional. Taking any benzodiazepine without a prescription is an abuse of the drug.

How Benzodiazepines Work in the Brain

How Benzodiazepines Work in the Brain

GABA is an important neurotransmitter that regulates communication between brain cells. Without enough GABA in the brain, you may feel anxious, experience a panic attack, or have a seizure in the most extreme cases.

Benzodiazepines act on the GABA-A receptors specifically, so your brain’s naturally produced GABA can remain bioavailable and slow down signaling. For people with seizure disorders, this prevents or stops many seizures.

More often, for people who experience anxiety or panic, short-acting benzodiazepines will stop mania, psychosis, and panic attacks. They will also manage insomnia or reduce anxiety about specific situations like surgery or social engagements.

This class of central nervous system (CNS) depressants was developed as a replacement for barbiturates, other sedative-classified drugs with an adverse action on the brain. Barbiturates were found to be addictive and dangerous.

Benzodiazepine Onset of Action

Benzodiazepine Onset of Action

The term onset of action refers to the amount of time a drug takes to begin working. The onset of action can vary widely depending on the drug and the way you take it. If you’re in a hospital setting and you’re given a drug intravenously, the onset of action may be extremely quick. Drugs taken by mouth need to make their way through your digestive system before they are absorbed into your bloodstream, so tablets and pills usually take longer to work. If you’re given a prescription for a benzodiazepine, you’ll probably be taking a tablet. Here’s a quick benzodiazepine comparison. How long do different benzos take to begin working?

Diazepam (Valium) and clorazepate (Tranxene) begin working quickly. They could have an onset of action as short as 20 to 30 minutes. Quick onsets of action may be ideal for people who need fast relief. For instance, clorazepate is sometimes used to treat partial seizures. Since seizures can come on suddenly, fast relief is important. Panic disorders also need quick relief. 

The popular drug alprazolam (Xanax) has an intermediate onset of action, along with oxazepam lorazepam (Ativan) and clonazepam (Klonopin), while (Serax) has a slow onset. Xanax may take one to two hours before you feel its effects. Benzos that take a long time to work may still be useful as long as you have time to prepare. They may be used to treat insomnia by taking it just before they wind down for the night. 

Benzodiazepine Duration of Action

The duration of action refers to the length of time a drug works.

Benzodiazepines fall into different categories, including short-acting, intermediate-acting, and long-acting benzodiazepines.

Benzodiazepines with a short duration of action may be useful for people who have trouble falling asleep but can usually stay asleep through the night. Short-acting benzodiazepines may be available in extended-release forms. Extended-release tablets are formulated to release a large dose of the drug over time, extending the length of time they are effective. 

Benzos that last for long periods are useful for short-term therapeutic use. If you have an anxiety disorder, you may take a long-acting benzodiazepine consistently for a few days or weeks to help relieve symptoms. Then you may taper off the medication. 

The Many Types of Benzodiazepines

The Many Types of Benzodiazepines

Different types of benzodiazepines have different lengths of action. For instance, short-acting benzodiazepines bind to the brain quickly, have a short half-life, and are metabolized out of the body rapidly.

Benzodiazepines fall into the following categories: 

  • Short-acting: alprazolam, diazepam, estazolam
  • Intermediate-acting: chlordiazepoxide, lorazepam
  • Long-acting: clonazepam, oxazepam, prazepam, temazepam

The following are the most commonly prescribed benzodiazepines in the U.S.

  • Valium (diazepam)
  • Xanax (alprazolam)
  • Ativan (lorazepam)
  • Klonopin (clonazepam)
  • Halcion (triazolam)
  • Versed (midazolam) 

Benzodiazepines are often prescribed as a short-term treatment for insomnia. The most popular short-acting benzodiazepines to treat insomnia in the U.S. include: 

  • Triazolam (Halcion)
  • Estazolam (ProSom)
  • Flurazepam (Dalmane)
  • Temazepam (Restoril)

Sometimes, a person with chronic insomnia associated with an anxiety disorder will benefit from a higher level of sedation, which can help them sleep and keep them calm during the day. Benzodiazepines with a longer duration of action work best in this case. These medications include: 

  • Alprazolam
  • Chlordiazepoxide (Librium)
  • Clorazepate (Tranxene)
  • Oxazepam (Serax)
  • Prazepam (Centrax)
  • Quazepam (Doral)

Valium, Klonopin, and Tranxene are sometimes also used as anticonvulsants since their action is longer than that of other benzodiazepines. Librium is sometimes administered off-label to manage alcohol withdrawal. Other short-acting benzodiazepines may treat panic attacks or general anxiety that is triggered in specific situations.

Intended for Short-Term Use

Intended for Short-Term Use

No benzodiazepines are intended to be taken for more than two weeks except in some instances of seizure disorders. Many chronic seizure conditions like epilepsy have more targeted medications for treatment, and benzodiazepines are still intended for short-term use for these conditions.

When prescribed by an overseeing physician, benzodiazepines are safe to take in specific doses. However, the body begins to develop a tolerance to this type of sedative very quickly. After two to four weeks of use, the original dose of any benzodiazepine will be much less effective.

People with anxiety and insomnia are encouraged to seek therapy to manage the symptoms of their chronic condition, and they may receive other, more specific prescription drug interventions. Those with epilepsy should take other medications that are better for long-term symptom management.

People going through alcohol withdrawal should work with a detox and rehabilitation program. They may take benzodiazepines to taper off alcohol abuse, but this is a short-term treatment.

Benzodiazepine Abuse

Benzodiazepine Abuse

Unfortunately, because benzodiazepines are widely prescribed, they are also widely abused. This has led to an epidemic alongside opioid abuse in the U.S.
According to a 2018 survey, about one in eight American adults used benzodiazepines in the prior year; this represents about 12.8 percent of the population, which rose from previous survey years, suggesting that there are more benzodiazepines in medicine cabinets all over the country.

Misuse of these drugs accounted for about 17 percent of benzodiazepine use, according to the new survey. Misuse was highest among young adults, 18 to 25 years old. The study also found significant benzodiazepine use among older adults, ages 50 to 64.

People who abuse benzodiazepines without a prescription were most likely to get them from a friend or relative — either by asking for them or stealing the drugs.

The National Institute on Drug Abuse (NIDA) reports that about 30 percent of opioid overdoses in the U.S. involve benzodiazepines. Benzodiazepines can increase the effects of opioids on dangerous levels that lead to physical harm.

Dangerous Versions

Dangerous Versions

One of the most dangerous benzodiazepines is flunitrazepam, known by the brand name Rohypnol. This benzodiazepine is still prescribed for limited uses, such as part of a larger narcolepsy treatment plan. However, it is more notorious as a date rape drug. When slipped into a drink, especially alcohol, a dose of Rohypnol can cause someone to blackout. If they remain awake or pass out, one thing for sure is that they will not remember anything from that time.

Under the Date Rape Prevention Act, there are federal penalties for using flunitrazepam without a prescription, obtaining a false prescription, or abusing the drug outside of the prescription, especially by administering it to others. This benzodiazepine is 10 times more potent than Valium, which is already a long-acting benzodiazepine.

Another harmful benzodiazepine that is increasingly abused in the U.S. is etizolam. This sedative is not regulated under the Controlled Substances Act, and it is not legal to use in the U.S. because as the U.S. Food and Drug Administration (FDA) has not approved it. This potent medication is only legal for prescription use in Japan, Italy, and India; no other country uses it for prescription treatments. With more online sales of drugs all over the world, etizolam is increasingly found in the U.S. because it is purchased from illicit distributors.

Etizolam may be found in tablet form, marked 0.25 mg, 0.5 mg, or 1 mg. If these drugs are purchased online, there is no way to know how much etizolam is actually in any tablet, if the substance has been mixed with other harmful chemicals like laundry detergent, or if the drug contains other intoxicating drugs like fentanyl, which can cause an overdose or death.

Powdered versions of etizolam are also available online for illegal sale. Powders are even more likely to contain adulterants or diluents.

Overcoming Abuse and Addiction

Overcoming Abuse and Addiction

If you take benzodiazepines as prescribed by your doctor and want to stop, you should work with them to safely taper your prescription down until your body is no longer dependent on the drug. Benzodiazepines quickly lead to physical dependence if you take them consistently, even if you do so as prescribed. Withdrawal symptoms will occur if you try to quit taking this medication suddenly, without help or oversight, and withdrawal from benzodiazepines can be dangerous.

If you abuse benzodiazepines, you will need medical supervision to detox safely from them.  If you follow medical detox with a rehabilitation program, such as behavioral therapy, it will help you manage the cravings and triggers to help prevent relapse in the future. 

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