Over the past two decades, benzodiazepine prescriptions have increased by almost 70%. Not surprisingly, overdose deaths involving benzodiazepines have increased 10 fold. How can we use these medications to aid our patients, while curbing the current opioid epidemic?
Background
Benzodiazepines are inherently one of the safest drugs available. In the 1970s, diazepam (Valium) was by far the most prescribed drug in the US. Along with Lorazepam (Ativan) and Triazolam (Halcion), benzodiazepines work on the central nervous system as a depressant. By heightening the effect of gamma-aminobutyric acid, GABA(A) receptors are inhibited. This results in anti-anxiety, sleep induction and muscle relaxing properties. Furthermore, a hallmark of this class of drug is anterograde amnesia – the inability to form new memories.
Use in Dentistry
Considering the vast number of people that avoid the dentist due to fear and anxiety, benzodiazepines are a great tool in the dentist’s tool kit. Also, these drugs can be used to treat TMJ dysfunction, due to their muscle relaxing properties. For dentistry, the most commonly prescribed form is Triazolam (Halcion), as it has a shorter half-life, it starts working in about 15 minutes and wears off quickly. For the highly anxious adult patient, usually 2.5mg to 5mg of Valium is given, where effects are expected in 30-45 minutes.
Dangers of Benzodiazepines
As mentioned, benzodiazepines themselves have a high margin of safety. The hazard comes into play where these drugs are combined with other central nervous system depressants – such as opioids and alcohol. In fact, it is this combination of drugs that has seen significantly higher rates of fatality – 10 times higher compared to patients only receiving opioids.
Safety Considerations
- Always practice conservative dosing. A one-time dose prior to an appointment is always recommended.
- By completing a medical and medication history, benzodiazepines should never be prescribed when the patient is also being treated with opioids.
- Flumazenil is the reversal agent for benzodiazepines overdose. Naloxone is reversal agent for opioid overdose. These drugs should also be added to the dentist’s emergency kit – especially when practicing sedation dentistry.
- When a patient’s medication history shows that they are already taking benzodiazepines, anti-anxiety should only be achieved with nitrous oxide. Nitrous oxide does not partake in any metabolic process, and almost all of the nitrous oxide that is taken in by the patient is also expelled.