Benzodiazepines: Uses, common brands, and safety info

Benzodiazepines are a class of drugs utilized for the acute treatment of anxiety symptoms, sedation, and other mental health-related disorders. The goals for treating anxiety are to shorten the frequency, severity, and duration of symptoms. There are a variety of benzodiazepines available for the treatment of anxiety and insomnia, and all are effective, but each may vary in terms of onset or duration of action as well as their potential for side effects. We will discuss the various properties of benzodiazepines, their common brand names, and their safety and indications.

Other benzodiazepines:

• Byfavo (remimazolam)

What are benzodiazepines?

Benzodiazepines (or “benzos,” as some people refer to them) are a group of drugs most commonly used for the treatment of acute anxiety symptoms. While all benzodiazepines have anxiolytic properties, some are only marketed for use as sedative-hypnotics. Benzodiazepines are considered first-line treatment for acute anxiety symptoms. Due to their potential for abuse and misuse, all benzodiazepines are classified as controlled substances by the Drug Enforcement Agency (DEA).

How do benzodiazepines work?

Benzodiazepines work by enhancing the effects of a neurotransmitter, gamma-aminobutyric acid (GABA), in the brain. There is a signal pathway in your brain that is responsible for your levels of consciousness and anxiousness. This is known as the reticular pathway. When GABA interacts with its receptors in the brain, it inhibits or slows the activity of this pathway, increasing sedation and decreasing anxiousness. Benzodiazepines enhance the effects of GABA, making these effects even stronger. This is why benzodiazepines are known as central nervous system (CNS) depressants (also sometimes referred to as “downers”) because they are depressing the body’s natural level of CNS activity.

What are benzodiazepines used for?

• Acute or generalized anxiety disorder

• Panic disorder

• Short-term treatment of insomnia

• Seizure disorder

The properties of each benzodiazepine vary and make each useful for different purposes. Benzodiazepines tend to be used for one purpose, though some have multiple uses. The following chart provides a general overview of the most common uses for the benzodiazepine drug class. At times, a benzodiazepine may be used “off-label” to treat disorders it may not be approved to treat by the Food and Drug Administration (FDA). One such example is the use of benzodiazepines as a treatment for muscle spasms. The use of a benzodiazepine to treat any disorder is at the discretion of your physician.

Indications and benzodiazepines approved for use

• Anxiety: Alprazolam, chlordiazepoxide, clorazepate, diazepam, flurazepam, midazolam, oxazepam

• Panic attacks: Alprazolam, clonazepam

• Insomnia: Estazolam, flurazepam, lorazepam, quazepam, temazepam, triazolam

• Seizures/anticonvulsant agents: Seizures/anticonvulsant agents

This list is not intended to be all-inclusive of approved indications for benzodiazepines. There are other indications for these drugs, such as the treatment of alcohol withdrawal syndrome, not listed here. 

It is also important to note that within each indication, some benzodiazepines are “preferred” for a specific sub-type. For instance, clobazam is indicated only for seizures associated with Lennox-Gastaut syndrome. All benzodiazepines possess sedative effects, but some are more appropriate for the specific treatment of different components of insomnia. Lorazepam has a relatively short onset of action and is used specifically to induce sedation or sleep because it is short-acting. Temazepam’s onset of action is more delayed, but its effects last six to eight hours, making it a more long-acting and effective tool against maintaining sleep when treating insomnia. Your healthcare professional can help determine which benzodiazepine is most appropriate for your specific condition or symptomatology.

Who can take benzodiazepines?

Infants, children, and adolescents

Safety and efficacy have not been established in these populations. The use of benzodiazepines in this population is strictly limited to the treatment of status epilepticus. The use of benzodiazepines in infants, children, and adolescents is generally not recommended.

Adults

Benzodiazepines are safe to be used in adults. The most common side effects are the result of central nervous system (CNS) depression, which include drowsiness, sedation, and psychomotor impairment. Some patients may experience memory impairment. 

Seniors 

Benzodiazepines should be used only when necessary in seniors. Benzodiazepines may be metabolized more slowly and therefore drug accumulation could occur. Enhanced CNS depression puts older patients at risk for falls and injuries.

Patients with liver impairment

Similar to older patients, patients with liver disease or impaired liver function are likely to experience an accumulation of the drug and be at an increased risk for CNS depression. Your physician may lower your dose or divide your dose into multiple doses.

Are benzodiazepines safe?

Benzodiazepines recalls

The following is a list of current recalls involving benzodiazepines. This list may not be all-inclusive. Your pharmacist can help with any concerns you have about recalled products.

• RXQ Compounding, LLC voluntary recall, and cessation of production due to lack of sterility process (June 2019)

• PharMEDium Services, LLC voluntary recall of certain compounded sterile products due to lack of sterility (June 2018)

• Amneal Pharmaceuticals voluntary recall of lorazepam oral concentrate, USP 2 mg/mL due to misprinted dosing droppers (June 2017)

Benzodiazepines restrictions

Do not take benzodiazepines if you have a history of a hypersensitivity reaction to any benzodiazepine. 

Benzodiazepines should be avoided in patients with a history of substance or prescription drug abuse as they have the potential to be habit-forming. For this reason, long-term use of benzodiazepines is generally not recommended. 

Benzodiazepines should be avoided in patients with pulmonary disease as respiratory depression may be worsened by benzodiazepines. 

Benzodiazepine use should also be avoided in the geriatric population as well as in pediatric patients, with the exception of its use in status epilepticus. 

Patients with liver or kidney disease should be monitored closely while on benzodiazepines. Their dosages may need to be adjusted to avoid dangerous levels of CNS depression.

Can you take benzodiazepines while pregnant or breastfeeding?

Some benzodiazepines have been associated with teratogenesis, or birth defects, and therefore use in pregnancy is generally discouraged. If necessary, use benzodiazepines with the shortest duration of action for as little of a duration as possible. Avoid use in the first trimester. Estazolam, flurazepam, and temazepam are contraindicated in pregnancy. Because benzodiazepines are known to cross into the breastmilk, you should not take them while breastfeeding.

Are benzodiazepines controlled substances?

Benzodiazepines are considered schedule IV controlled substances by the DEA due to their potential for abuse and misuse. Each state may have specific conditions or requirements for the prescribing of controlled substances in addition to the federal regulations put forth by the DEA. Benzodiazepines should be avoided in patients with a history of substance abuse. If you have been taking a benzodiazepine regularly for an extended period of time, you should not stop suddenly as you may experience withdrawal symptoms. Your physician should guide a slow titration to discontinue the drug safely.

Common benzodiazepine side effects

The adverse effects of benzodiazepines are mostly the result of the CNS depression caused by this class of drugs. Dizziness, drowsiness, and slowed respiratory rate occur with each benzodiazepine to some degree. Some patients report a loss of control of body movements as well as impaired cognition, or a “foggy” feeling. Low blood pressure and memory loss have also been reported. These side effects may decrease with continued usage but should be monitored closely. These side effects make it unsafe to take benzodiazepines and perform activities such as driving or operating heavy machinery. These side effects can be increased by other substances which also cause CNS depression, such as alcohol, opioids, and barbiturates. Therefore, benzodiazepines should be avoided with other CNS depressants.

The most common benzodiazepine side effects are: 

• Loss of control of body movements

• Drowsiness

• Decreased respiratory function

• Memory impairment

• Dizziness

• Irritability

• Fatigue

• Constipation

• Hypotension

• Decreased sex drive

• Menstrual irregularity

• Increased appetite

• Weight gain

• Impaired cognition

How much do benzodiazepines cost?

Most benzodiazepines are available generically and are usually very cost-effective, typically less than $20 with a SingleCare coupon. There are some exceptions to this, however. Doral averages $432 for a 15-tablet prescription of the brand name. The generic version of Doral, quazepam, is available with a SingleCare coupon for $333. This is significantly more expensive than some other more commonly used benzodiazepines. For example, the generic formulation of Xanax, alprazolam, is available for as little as $16 for a one-month supply of the 1 mg through SingleCare’s coupon. Valium is another more commonly utilized benzodiazepine. Diazepam, the generic form of Valium, is available for a price as low as $3 with a SingleCare coupon. 

Some commercial insurance plans may have limitations or conditions for their coverage of benzodiazepines. Medicare drug plans generally do not cover benzodiazepines as there are safety concerns regarding their use in the older population. Before you fill your benzodiazepine prescription, check with SingleCare to make sure you are paying the lowest possible price.