Disorders due to use of sedatives, hypnotics or anxiolytics

ICD-10F13	Mental and behavioral disorders due to use of sedatives or hypnotics
DSM-5-TRF13.20	Sedative, Hypnotic, or Anxiolytic Use Disorder, Moderate or Severe

1. Definition and nosology

Disorders due to use of sedatives, hypnotics or anxiolytics (ICD-11: 6C44; DSM-5-TR: F13.20 Sedative, Hypnotic, or Anxiolytic Use Disorder) — impaired control over use of benzodiazepines, Z-drugs (zolpidem, zopiclone), barbiturates, and other anxiolytics. Often begins with a medical prescription in clinical practice; ‘iatrogenic dependence’ is common.

2. History

• 1960s — clinical introduction of benzodiazepines (chlordiazepoxide 1960, diazepam 1963).
• 1980s — recognition of the dependence potential of long-term use.
• NICE and APA — short-term use recommendation (2–4 weeks).

3. Epidemiology

• Long-term benzodiazepine use in the elderly: 10–20%; problem identification is low.
• Sex: higher prescription rates in women.
• Comorbidity: alcohol and opioid use (dangerous combination — overdose risk).

4. Etiology and pathogenesis

• Iatrogenesis — long-term prescriptions.
• Adaptation to the GABA-A receptor system — tolerance and discontinuation.
• Self-medication pattern in patients with anxiety, sleep disturbance.

5. Clinical features

• Dependence syndrome — loss of control, tolerance, withdrawal.
• Intoxication — sedation, ataxia, dysarthria, disinhibition, anterograde amnesia.
• Overdose — life-threatening respiratory depression with opioids.
• Withdrawal — may be life-threatening (like alcohol): tremor, anxiety, tachycardia, hypertension; severe cases: seizures and DT-like syndrome.

6. Diagnosis

6.1 Unified diagnostic criteria

DSM-5-TR — 11 criteria (AUD structure). Unlike DSM-5-TR, which uses a single severity scale, ICD-11 uses three separate categories: episode of harmful use, harmful pattern of use, and dependence. ICD-11 duration requirement: harmful pattern of use — at least 12 months if use is episodic, at least 1 month if continuous; dependence — at least 12 months, or at least 3 months if use is continuous (daily or almost daily).

6.2 Differences between sources

• NICE — benzodiazepine prescription 2–4 weeks; long-term use should be reassessed.
• Beers Criteria — avoid benzodiazepines in the elderly.

6.3 Diagnostic algorithm

1. Clinical interview + prescription history.
2. Toxicology screening.
3. Comorbid alcohol and opioid use (especially overdose risk).
4. Clinical examination — withdrawal signs.

6.4 Differential diagnosis

7. Examination and assessment

• Toxicology screening.
• Vital signs (discontinuation)

8. Treatment

1. Gradual discontinuation (taper) is the gold standard: conversion to equivalent dose of long-acting benzodiazepine (diazepam), then gradual reduction, usually by 10–25% every 2 weeks (Pottie 2018); with long-term use more slowly, by 5–10% every 2–4 weeks; total duration often lasts months. Rapid discontinuation can be life-threatening.
2. Hospitalization — severe withdrawal or comorbid substance use.
3. Psychosocial intervention — CBT for anxiety or sleep disorder; this reduces the need for pharmacotherapy.
4. Comorbid disorders treatment (anxiety, depression, sleep).
5. Prescription management — at the primary healthcare level.

8.1 Treatment methods

1. Ashton Manual Taper — Conversion to diazepam equivalent, then gradual reduction; family support.
2. CBT for Anxiety and Sleep — Alternative to benzodiazepine use; CBT-I for sleep.
3. Toxicological Monitoring — During the maintenance period.

8.2 Differences between sources

• NICE, BNF — taper protocols.
• Ashton Manual — practical clinical guide by Heather Ashton (C.H. Ashton); 2002 edition, revised 2011.

9. Prognosis

• Significant improvement with gradual taper and CBT.
• In older adults, discontinuation is both medically and psychologically difficult.

10. Myths and misconceptions

Myth 1: “Benzodiazepines can be taken safely for life”

Evidence: long-term use — tolerance, dependence, cognitive impairment, fall risk (in the elderly). NICE — short-term use.

Myth 2: “Rapid discontinuation is safe”

Evidence: Rapid discontinuation carries a risk of seizures and death; gradual taper is critical.

Myth 3: “Z-drugs (zolpidem) are not addictive”

Evidence: Z-drugs also cause dependence; AAFP and NICE recommend short-term use.

Myth 4: “Benzodiazepine + opioid is safe”

Evidence: FDA boxed warning — this combination significantly increases the risk of respiratory depression and death.

Myth 5: “Detoxification is sufficient”

Evidence: After discontinuation, alternative treatment (CBT, anxiety management) is required.

11. Sources

1. WHO. ICD-11. 6C44 Disorders due to use of sedatives, hypnotics or anxiolytics. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE Quick Reference Guide. Benzodiazepines.
4. Ashton C.H. Benzodiazepines: How They Work and How to Withdraw (Ashton Manual). 2002.
5. Pottie K., Thompson W., Davies S. et al. Deprescribing benzodiazepine receptor agonists: Evidence-based clinical practice guideline. Can Fam Physician 2018;64(5):339–351.
6. FDA Drug Safety Communication. Opioid pain or cough medicines combined with benzodiazepines: serious side effects. 2016.