Scope & clinical importance

Sedative misuse spans prescribed overuse, self‑medication, diversion and illicit use. Long‑term benzodiazepine use carries risks of cognitive decline, falls in older adults, dependence and dangerous interactions with opioids or alcohol. Early recognition enables safer prescribing, withdrawal planning and referral to specialist care where needed.

Patterns of misuse

• Prescribed long‑term use beyond guideline recommendations.
• Dose escalation (tolerance) and seeking multiple prescribers.
• Recreational use combined with alcohol or opioids to enhance effects.
• Use of non‑prescribed agents (internet, friends) and polydrug use.

Recognition — history, exam & screening

1. Ask directly about sedative/hypnotic use and source; document duration, dose, frequency, last use and attempts to stop.
2. Screen for dependence features: craving, inability to cut down, time spent obtaining/using, continued use despite harm.
3. Examine for sedation, ataxia, cognitive impairment, injection marks (if IV use) and signs of co‑ingestion (alcohol smell, opioid miosis).
4. Use prescription monitoring programs and pharmacy checks to detect doctor‑shopping where available.

Risks & harms

• Overdose risk, especially when combined with opioids or alcohol — respiratory depression and death.
• Cognitive impairment, sedation and increased fall risk in older adults.
• Dependence and protracted withdrawal with anxiety, insomnia, tremor and seizures.
• Social, occupational and legal harms from misuse and associated behaviours.

Management principles — prescribing & de‑prescribing

• Avoid initiating long‑term benzodiazepine therapy where possible; prefer non‑pharmacological options for anxiety and insomnia (CBT‑I, CBT for anxiety).
• Where long‑term use exists, assess dependence and consider a structured, patient‑centred taper rather than abrupt cessation.
• Coordinate with the patient — explain risks, set goals, and provide written taper plans with regular follow-up and support.
• Consider switching short‑acting agents to a single long‑acting benzodiazepine (diazepam) to stabilise and then perform gradual dose reduction under supervision.

Withdrawal management

• Design tapers over weeks‑to‑months depending on dose and duration—typical reductions ~10% every 1–2 weeks, slower if needed for severe dependence.
• Provide psychological support, CBT for anxiety/insomnia, and symptomatic medications for insomnia or autonomic symptoms where appropriate.
• In cases of severe dependence or prior withdrawal seizures, consider inpatient detoxification with benzodiazepine substitution and monitoring.
• Avoid abrupt switch to flumazenil; flumazenil is rarely indicated for chronic users due to seizure risk and should only be used in selected acute overdose settings by experienced teams.

Managing acute overdose

• Assess and secure airway, breathing and circulation. Provide oxygen and ventilatory support if respiratory depression present.
• Use naloxone if opioid co‑ingestion suspected; naloxone will not reverse benzodiazepine effects.
• Flumazenil is rarely used—reserve for suspected isolated benzodiazepine overdose in non‑dependent patients and where risk of seizure is low; avoid in mixed overdose or chronic benzodiazepine users.
• Observation and supportive care often sufficient; monitor for re‑sedation if flumazenil given.

Treatment pathways & referral

• Primary care: brief intervention, develop taper plan, provide psychological therapies and coordinate follow‑up.
• Specialist addiction services: complex dependence, polydrug use, repeated overdoses, or when inpatient detox required.
• Mental health services: comorbid anxiety disorders, insomnia, depression or psychosis—integrated care improves outcomes.

Harm reduction strategies

• Educate about dangers of mixing with opioids/alcohol; provide naloxone to people who use sedatives alongside opioids.
• Reduce supply risk: single prescriber, limited quantity prescriptions, avoid refills without review and use pill counts where appropriate.
• Promote safer alternatives: CBT for insomnia, sleep hygiene, and evidence‑based anxiety treatments (SSRIs, psychotherapy) instead of long‑term benzodiazepines.

Key takeaways

• Identify sedative misuse early—assess for dependence, co‑ingestants and overdose risk.
• Prefer non‑pharmacological treatments for insomnia/anxiety; when deprescribing benzodiazepines, use slow, patient‑centred tapers.
• Reserve flumazenil for selected acute overdose situations; avoid in chronic users or mixed overdoses due to seizure risk.
• Refer complex cases to specialist addiction or psychiatric services and provide harm reduction (naloxone, single prescriber, education).