Anxiolytics or tranquilizers (chemically, benzodiazepines or similar drugs) are medications used to produce rapid effects on anxiety, sleep, agitation, and a variety of “bodily” symptoms associated with anxious and depressive states. One improper use of these drugs, given their alcohol-like effects, is to produce intoxication or euphoria. Although they are intended for occasional use or for short periods, people who take them often find themselves using them for long periods, with two types of problems.
The first is difficulty discontinuing the medication, both because of withdrawal symptoms—including worsening anxiety that not everyone can tolerate—and because of the usually illusory belief that anxiety is being kept under control thanks to regular use of the drug, and that it would not be possible to sleep or remain calm without taking it. This represents a “benign” attachment to the anxiolytic, which can be resolved by establishing appropriate treatment for the underlying disorder and then gradually discontinuing the anxiolytic or sleeping medication.
The second problem is actual dependence, which consists of being “drawn” toward using the medication not so much because of a therapeutic effect, but because of an impulse to take it. This second form often involves progressively increasing doses, episodes of intoxication caused by repeated or massive doses, and above all a loss of control over use—that is, consumption that begins with the intention of producing well-being but actually produces toxic effects or develops into an “anxiolytic binge” with unpredictable effects.
The treatments for which information is available include more or less complex techniques for tapering and discontinuing the anxiolytic to which the person has become accustomed. However, this is not easily achieved when an anxiety disorder or depression remains untreated, and it is even more difficult when there is benzodiazepine dependence.
In the latter case in particular, the person is exposed to greater risks because they abuse irregular doses. As a result, they may often take doses greater than those to which they are accustomed and may also experience unpredictable withdrawal episodes.
Withdrawal from tranquilizers is not only unpleasant but also dangerous, since seizures, loss of consciousness, and major psychiatric disturbances may occur.
More recently, data have accumulated on the effectiveness of an approach to anxiolytic dependence, specifically in its form of recurrent or persistent “abuse.” This involves using a molecule (clonazepam) that produces a “switching-off” signal in the brain for the urge to use the drug, acting on the same receptor system targeted by anxiolytics but in a different way—namely, tonically, through a slow increase in blood concentrations followed by maintenance of a stable concentration.
The receptors occupied by the medication are no longer readily available to be stimulated by the drug being abused, so the effects of the abused psychotropic medication are hindered or blocked. At the same time, the desire to take it is reduced. Over the course of several weeks, the person loses desire and impulse toward the medication they had been abusing and reduces or stops its use. There is no risk of withdrawal because the medication used to treat the dependence counterbalances the possible abrupt discontinuation of the substance itself.
Treatment is initiated without requiring the person to stop using the substance, and indeed part of its mechanism specifically relies on interfering with the ongoing desire and impulse to use the anxiolytic.
Once the desired result has been achieved, a maintenance phase is necessary. Discontinuing treatment during the first few months carries a significant risk of renewed tranquilizer abuse several weeks later. The initial studies were conducted on heroin-dependent individuals who, despite stopping heroin use, continued to abuse tranquilizers or switched to them.
More recently, results have also been described in people who abuse tranquilizers but do not use illicit drugs.
The method consists of introducing clonazepam, which has a threefold action. It occupies the sites of action of the tranquilizer and produces an effect that prevents withdrawal, but, above a certain dose, it also prevents the tranquilizer from acting on those receptors. The difference lies in the way the receptors are stimulated by clonazepam—slowly and tonically—compared with the way they are stimulated by the abused tranquilizer, which acts rapidly and in waves.
During the introduction phase, the technical challenge is naturally to identify the effective dose, which on average is around 6 mg (a level at which clonazepam can also interfere with medium-to-high doses of the abused tranquilizer).
The relative difficulty lies in the fact that, at least initially, the person remains attached to the idea that the tranquilizer they were accustomed to, or that they crave, is “useful,” perhaps as long as they do not take too much of it, or that it is necessary to manage anxiety. In reality, however, it worsens anxiety control—that is, the behavior the person displays when anxious, which becomes impulsive and aggressive.
The initiation of treatment often requires a brief hospitalization because people who abuse high doses of tranquilizers usually have problems with both memory and medication management.
Once the desired result has been achieved—that is, control over the impulse to abuse anxiolytics—treatment continues because control does not mean biological recovery. As with other addictions, the desire must remain suppressed for a long time so that the brain can subsequently remain stable without relapses.
The maintenance phase is therefore the period during which the person, without the desire that previously compelled them to abuse the medication and without the state of intoxication, can return to normal functioning.