Among the chemical dependency groups, substances whose primary mode of action is a depressant effect have been gathered under the heading of Sedative-Hypnotics. Alcohol, benzodiazepines and barbiturates all belong to this category. Nonbarbiturate nonbenzodiazepine sedative-hypnotics are also included, such as buspirone, chloral hydrate, carisoprodol, and gamma-hydroxybutyrate (GHB).
Sedative-hypnotic use is common. Benzodiazepines for therapeutic use are one of the most frequently prescribed pharmaceuticals in the world. The wide availability by prescription for legitimate use creates ample opportunity to maintain an established long-duration chemical dependence.
The use of sedative-hypnotics also tends to accompany chemical dependency to both stimulants and opioids. Frequently in these individuals no dependency is present to a sedative-hypnotic, the depressant chemical is simply a tool used to help offset side-effects or withdrawal symptoms created by the substance they are dependent on (Cooper, 2009).
Chief amongst the sedative-hypnotic chemicals of dependence is alcohol, which is licit (socially accepted), and possesses predictable central nervous system depressant effects. Roughly two-thirds of Americans drink alcohol with around one in ten using it to significant abuse. Excessive alcohol use has been identified as the third leading preventable cause of death amongst Americans and comprises of a large number of emergency room visits each year (Gold & Aronson, 2009).
|Alcohol Use Prevalence in the United States in 2004|
- Alcohol dependence = 2 to 9 percent of population
- Risky drinking = 4 to 29 percent of population
- Harmful drinking = 0.3 to 10 percent of population
|(Gold, & Aronson, 2009)|
Acute indicators, which may signal the presence of an alcohol or other depressant chemical dependence, range from suspicious circumstances in an accident to obvious disinhibition from the CNS depressant effect. Blood levels for acute use symptoms may be an effective tool to aid a person to realize that they have a problem that requires treatment.
Chronic physical symptoms specific to alcohol dependence range widely and are dependent to areas of physiologic vulnerability specific to each individual. They may include effects of chronic use such as the following (Cohagan, & Worthington, 2007);
Neurologic - Korsakoff psychosis, Wernicke encephalopathy, peripheral neuropathy, dementia resulting to structural changes in the brain
Psychiatric - Anxiety or depressive disorders
Immunologic - Neutrophil function suppression
Gastrointestinal - Liver cirrhosis, peptic ulcer disease, pancreatitis
Obstetric - Fetal alcohol syndrome, mental retardation, fetal deformities
Endocrine - Male testicular atrophy, impotence, gynecomastia
Assessment for alcohol or other depressant dependence requires personal history information in order to determine the presence of chemical use patterns and any negative consequences that may be related to use. Information either from the client or from family members is helpful, and often clients are very forthcoming concerning substance use as long as questions are framed in an open and nonjudgmental manner.
Even when being fully cooperative, clients frequently underestimate their own substance use. Tools such as the CAGE alcohol-screening questionnaire can help the health provider to gain the clearest understanding possible. A single positive response for any of the CAGE four questions is considered as suggestive of an alcohol dependence problem. Two or more positive responses increase probability of a dependence problem to around 90-percent. Please remember when using the CAGE tool that it is best utilized when not preceded by questions concerning types or numbers of drinks consumed.
|CAGE Questionnaire for Alcohol Use Screening|
|C-||Has anyone ever felt you should Cut down on your drinking?|
|A -||Have people Annoyed you by criticizing your drinking?|
|G -||Have you ever felt Guilty about your drinking?|
|E -||Have you ever had a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?|
|(Cohagan, & Worthington, (2007)|
Making a dependency diagnosis with any of the sedative-hypnotics only requires meeting the criteria discussed earlier: tolerance, avoidance of withdrawal, consumption greater than intended and negative consequences of use. Health practitioners do not actually need to quantify consumption amounts to detail; however, learning amount of typical intake during both "normal" and "binge" episodes can be very helpful in both risk assessment for chronic health concerns and later in counseling for dependency.
|CDC Excessive Alcohol Use Definitions|
- Heavy Drinking = More than two drinks per day for men, more than one drink per day for women
- Binge Drinking = Five or more drinks during a single occasion for men, four or more drinks during a single occasion for women
- Excessive Drinking = Includes BOTH heavy and binge drinking
- A standard drink is defined as;
- 0.5 ounces of pure alcohol (1.2 tablespoons or 13.7 grams)
- 1.5 ounces of distilled (80 proof) spirits or distilled liquor (e.g. rum, vodka, gin, whiskey)
- 5 ounces of wine
- 8 ounces of malt liquor
- 12 ounces of regular beer or wine cooler
|(CDC, Alcohol and Public Health, 2008)|
Withdrawal symptoms are a red flag for any health professional that chemical dependency is an issue. An awareness of some key aspects of alcohol withdrawal is therefore essential in order to recognize and supply the best support and treatment.
|Alcohol Withdrawal Characteristics|
- "The Shakes" 12 to 24 hours (times are approx., i.e., can begin manifesting within 6 hours) after the last drink. Tremor may be accompanied by anxiety, headache, tachycardia, diaphoresis, insomnia, or anorexia, and reflect an over-excitation of the CNS.
| || |
- "Rum Fits" 24 to 72 hours after last drink. Generalized seizures may manifest, as may alcoholic hallucinations. Untreated alcohol withdrawal seizures progress to delirium tremens in about one-third of clients.
- "DT's" 3 to 5 days after last drink. Delirium tremens (DT) is a condition characterized by fever, disorientation, and visual hallucinations. DT's are regarded as a medical emergency and warrant inpatient treatment.
|(Cohagan, & Worthington, 2007), (Hoffman, & Weinhouse, 2009)|
In our focus on alcohol as the most prevalent of the sedative-hypnotic chemicals of the dependence group please be aware that one of the commonly observed characteristics of alcohol dependence is a loss of control by the user concerning behaviors associated with alcohol use. This can be manifested in such things as drinking their alcohol more quickly than circumstances might dictate, or gulping their very first drink. Other indicators might include showing concern or worry when events interfere with planned drinking opportunities, or using alcohol as a primary mechanism to release stress. Frequent thoughts or talk about drinking and when they will be able to engage in their next drink can also be an indication of need to assess for dependence.
Blood alcohol levels may not be of great assistance in determining a diagnosis of alcohol dependence. The presence of detectable alcohol by breath test or in the bloodstream does not present the requisite information to determine the pattern of use present. Other laboratory tests may supply a clearer picture of use patterns (Gold, & Aronson, 2009).
- MCV or Mean Corpuscular Volume - Macrocytosis (MCV of between 100 and 110 fL in the complete blood count) is frequently associated with a pattern of alcohol use indicative of dependence. Regular ingestion of 80 grams of alcohol each day (equivalent to one bottle of wine) leads to this change in around 90-percent of individuals. Abstaining from alcohol allows the body to resolve macrocytosis within two to four months.
- Liver studies - A number of characteristic liver changes accompany consistent and extended alcohol use. Abnormalities in serum aspartate and alanine aminotransferases as well as gammaglutamyl transferase (GGT) are commonly associated with alcohol dependence or abuse.
- Serum Carbohydrate-deficient Transferrin (CDT) - is an intriguing blood assay that can be of great use identifying chronic heavy alcohol use. This test is actually a better biomarker for alcohol consumption than either MCV or GGT as its sensitivity for significant alcohol intake is between 60 to 70-percent while its specificity is between 80 to 90-percent. A rising CDT concentration can be an indication of relapse during treatment.
It is important for the health professional to remember that the presence of other chemicals in the sedative-hypnotic group will also tend to resemble alcohol intoxication. The use of both laboratory screening tools and interview skills are important. In cases of severe impairment, the following studies are recommended (Cooper, 2009):
- Complete blood count (CBC)
- Arterial blood gas (ABG)
- Chemistry profile with glucose
- Toxicology screen
- Suspected intentional exposures should always include; Alcohol, Salicylate, and Acetaminophen
- Quantitative serum drug concentration levels are recommended for clients with serious toxicity symptoms