Epidemiology. All hypnotics and sedatives potentiate the action of each other and alcohol. Abuse has different stereotypes. One of them is for persons of predominantly middle-aged persons to receive constant access to drugs through doctors as part of anxiety and insomnia therapy. They can prescribe medications from several doctors at the same time, drug dependence often remains unnoticed by others until the appearance of physical signs of abuse. Drugs can be used occasionally by adolescents to obtain a sedative or euphoric effect. They are used by experienced drug addicts for intravenous administration due to their greater cheapness compared to heroin or to potentiate the effect of weak opiates. Alcoholics use them to increase intoxication or alleviate the syndrome. Abusive stimulants use them to relieve excessive arousal. Diazepam is used by cocaine addicts to alleviate the withdrawal syndrome.
Clinic. Intoxication is subjectively perceived as a feeling of pleasant, warm drowsiness, its small degrees resemble alcohol intoxication. In addition to the main ones (see below), symptoms include a decrease in the focus of thinking and memory, a slowdown in speech and understanding, episodes of sexual disinhibition, and an accentuation of the main personality traits. General inhibition disappears in a few hours, but violations of fine motor skills, thinking and affect can last 10-20 hours. Against the background of dysphoria, transient paranoid perceptions and suicidal tendencies can occur.
Physical signs, besides the main ones (see below), may include diplopia, strabismus, decrease in blood pressure and height of tendon reflexes. Death can occur as a result of suicide, an accident, or an unintentional overdose (the lethal dose for an experienced drug addict can be, under certain conditions, not higher than for a novice). These drugs are most often used in the implementation of suicidal tendencies. Death comes on the background of deep coma, respiratory arrest and cardiac activity.
With regular admission, increased tolerance is produced. The dose of an experienced drug addict is 1.5-2 g per day. Physical dependence develops as a result of taking low doses (10-40 mg per day) for several years or high doses in just a few weeks or months. Receiving doses higher than therapeutic for several weeks or more becomes a prerequisite for the onset of withdrawal syndrome, characterized, in addition to the main symptoms (see below), anxiety, sweating, loss of appetite, fever, up to delirium (clinically indistinguishable from alcohol), amnestic syndrome and coma. The syndrome reaches its highest intensity on day 2–3 of abstinence. Convulsive manifestations always precede delirious. Symptoms last 2–3 days, rarely up to 2 weeks.
Unlike barbiturates, benzodiazepines have a higher safety threshold. They suppress the respiratory center to a lesser extent, the lethal dose correlates with the narcotic effective as 200: 1. High doses (more than 2 g) taken with a suicidal purpose cause drowsiness, ataxia, and sometimes confusion, leaving no residual marks. In individuals with low frustration tolerance, benzodiazepines can have a disinhibitive effect with aggressive behavior. Due to the lower level of euphoria attained, the risk of addiction is relatively lower, which does not exclude the possibility of increasing tolerance and the appearance of withdrawal syndrome.
The daily dose of an experienced drug addict can be 1–1.5 g of diazepam. Withdrawal syndrome develops on the background of a daily dose of about 40 mg, but can also be observed at therapeutic doses (10-20 mg) if the drug has been taken for more than a month. Longer-acting drugs (diazepam) give a more delayed withdrawal (5-7 days). Convulsive manifestations may be the first sign of not expected benzodiazepine withdrawal syndrome. Symptoms of withdrawal include anxiety, numbness of the limbs, dysphoria, increased sensitivity to light and sound, nausea, sweating, muscle twitching. Withdrawal syndrome is not necessarily accompanied by a desire to resume taking the drug. Due to the slow release of benzodiazepines from the body, signs of withdrawal can last up to several weeks.
The diagnosis of acute intoxication is made on the basis of common for measure:
1) the presence of at least one of the following mental symptoms:
a) euphoria and disinhibition,
b) apathy, sedation,
c) conflict, aggressive behavior,
d) affective instability,
e) decrease in concentration,
f) anterograde amnesia,
g) psychomotor disturbances, and a decrease in mental productivity;
2) at least one of the following somatoneurological signs:
a) uncertainty of gait,
b) Romberg negative test,
c) blurred speech,
d) nystagmus, and impairment of consciousness (stupor, coma),
e) skin erythema, pustules.
The diagnosis of withdrawal syndrome is made on the basis of common criteria for as well as the presence of at least three of the following symptoms:
1) tremor of the fingers of the outstretched hands, the tip of the tongue or eyelids,
2) nausea, vomiting,
4) orthostatic hypotension,
5) psychomotor anxiety,
8) weakness, malaise,
9) transient visual, tactile or auditory hallucinations or illusions,
10) paranoid perceptions,
11) large convulsive seizure.
The diagnosis is further confirmed by specific laboratory methods.
Treatment. It is more expedient to start the removal from the cancellation state in stationary conditions. In a state of coma or with marked signs of intoxication, the appointment of barbiturates is not recommended. When removing the moderate withdrawal syndrome method of sampling is selected dose of the drug, allowing to achieve a mild sedation. After keeping it for 1-2 days, the dose gradually decreases (not less than 10% per day, the last 10% is brought to zero within 3-4 days). When signs of withdrawal are resumed, dose reduction should be even more gradual. Short-term barbiturates should be replaced with drugs with a longer-term effect (phenobarbital). Replacing barbiturates with benzodiazepines is not advisable due to the risk of replacing one dependency with another.
With a psychological deficit of problem-solving behavior, a drug certainly helps to cope with internal stress, anxiety, a sense of its own low value. Therefore, at the exit to the full abstinence of the patient must be accompanied by appropriate psychosocial activities, otherwise he will be doomed to again turn to the use of the drug. Prevention of abuse requires the orientation of the doctor on the appointment of drugs in a short time in the presence of a specific therapeutic target. The doctor should be wary of such indirect signs of abuse as visits to other doctors, requests for higher doses, for issuing new prescriptions to replace lost ones.