PAC 610 Module 5 Anxiolytics, Hypnotics and Stimulants Example

Calm, Sleep and Focus on Prescription: Benzodiazepines, Sleeping Pills and Stimulants in an Addiction Program

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 610: Psychopharmacology

Instructor Name

Month Day, Year

Calm, Sleep and Focus on Prescription: Benzodiazepines, Sleeping Pills and Stimulants in an Addiction Program

Carol and Devin, both clients of the fictional Ridgeview Recovery Center in Knoxville, raise the questions of this module. Carol, sixty-one, came to the program after a fall at home that led her daughter to notice how much wine she was drinking. During assessment she mentioned that she has taken alprazolam for "nerves" and sleep every night for nine years. Devin, twenty-three, has been free of cocaine for five months. He was diagnosed with ADHD as a child, stopped treatment as a teenager and now struggles to hold a job; he has asked whether he could take a stimulant. Both requests involve drugs that help some people and are misused by others.

Three Drug Groups

Benzodiazepines: Quick Relief, Slow Trap

Lader (2011) reviewed half a century of experience with benzodiazepines. They act quickly and are effective for acute anxiety and short-term insomnia. With regular use, however, tolerance develops, particularly to their sleep-promoting effects, and the body adapts so that stopping causes withdrawal. Lader described withdrawal symptoms ranging from rebound anxiety and insomnia to perceptual disturbances and, after high doses stopped abruptly, seizures. He noted that guidelines had for decades recommended limiting benzodiazepines to a few weeks, yet long-term prescribing remained common. Older adults face added risks of memory problems, confusion and falls. People with substance use disorders face a higher risk of misuse, and combining benzodiazepines with alcohol or opioids can dangerously slow breathing.

Sleeping Pills in Older Adults

Glass et al. (2005) pooled randomized trials of benzodiazepines and related sleeping pills in people aged sixty and older with insomnia. The drugs produced modest gains: on average about twenty-five minutes more sleep a night and fewer awakenings. Adverse effects were considerably more common: memory and thinking problems, daytime fatigue and psychomotor problems such as unsteadiness, which can lead to falls. The authors calculated that about thirteen older adults must take a sleeping pill for a single one of them to sleep better, while one in about six would experience an adverse event. They concluded that in this age group, the risks may not justify the benefits, especially for people with risk factors for falls or cognitive problems.

Stimulants and ADHD

Cortese et al. (2018) conducted a network meta-analysis of 133 randomized trials of ADHD medications, including more than 14,000 children, adolescents and adults. Most medications reduced ADHD symptoms more than placebo over about twelve weeks. Weighing effectiveness and tolerability together, the authors favored methylphenidate for younger patients and amphetamine-based drugs for grown-ups as the preferred starting points. Nonstimulant options such as atomoxetine were also effective, though generally less so in their analysis. The trials were short, so the authors cautioned that longer-term effects need more study.

For people with substance use histories, stimulants pose a known risk of misuse and diversion, particularly immediate-release forms. Yet untreated ADHD is itself associated with difficulties in work, relationships and recovery, so prescribers weigh both. Options include long-acting formulations that are harder to misuse, nonstimulant medications, close monitoring and coordination with addiction treatment.

Withdrawal and Tapering

Because the body adapts to long-term benzodiazepine use, stopping must be planned. Lader described slow tapering over weeks or months, sometimes after switching to a longer-acting drug such as diazepam, as the safer approach, with psychological support for the anxiety and insomnia that often return during and after withdrawal. Many people who taper slowly succeed, and some find their sleep and thinking improve once the drug is gone. Abrupt stopping after long use, by contrast, risks severe rebound symptoms and, at higher doses, seizures.

Alternatives That Carry Less Risk

For anxiety, antidepressants such as SSRIs and psychological treatments such as cognitive behavioral therapy are generally preferred for long-term use. For insomnia, cognitive behavioral therapy for insomnia, which works on sleep habits, timing and worry about sleep, is widely recommended as a first-line treatment and carries no risk of dependence. These options take longer to work than a pill, which is one reason clients and prescribers turn to benzodiazepines.

Applying the Evidence to Carol

Carol's case combines several warning signs: nine years of nightly benzodiazepine use, regular drinking, age over sixty and a recent fall. The counselor's first task is safety. With Carol's consent, the counselor should tell the program's prescriber and Carol's own physician about the combination of alprazolam and alcohol, which together increase sedation and the risk of falls and slowed breathing. The counselor should also make clear to Carol that she must not stop alprazolam suddenly, since after years of use that could cause serious withdrawal; any reduction should be a slow, supervised taper. In counseling, Carol can explore the anxiety and sleeplessness behind both habits, and she may be a good candidate for cognitive behavioral therapy for insomnia.

Applying the Evidence to Devin

Devin's request deserves a fair hearing rather than an automatic no. His counselor can acknowledge that ADHD is a real condition that may be undermining his recovery and job prospects, and that treatment options exist. The counselor can also be honest about the concern with stimulants given his history. With Devin's permission, the counselor can share his recovery history with the prescriber, who can consider a long-acting stimulant with monitoring, a nonstimulant such as atomoxetine or non-drug supports. The counselor can help Devin prepare for that appointment and continue working on skills, such as organization and time management, that help regardless.

Conclusion

Benzodiazepines, sleeping pills and stimulants all relieve real problems, and all carry misuse and safety risks that are sharper for people with addiction histories and for older adults. Lader's review explains why benzodiazepine dependence develops, Glass and colleagues show that sleeping pills in older adults often harm more people than they help and Cortese and colleagues show that ADHD medications work, with choices that depend on age and risk. Counselors can make these risks visible, support safer alternatives and keep clients connected to prescribers.

References

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S2215-0366(18)30269-4

Glass, J., Lanctôt, K. L., Herrmann, N., Sproule, B. A., & Busto, U. E. (2005). Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits. BMJ, 331(7526), 1169. https://doi.org/10.1136/bmj.38623.768588.47

Lader, M. (2011). Benzodiazepines revisited: Will we ever learn? Addiction, 106(12), 2086-2109. https://doi.org/10.1111/j.1360-0443.2011.03563.x