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Sedatives and hypnotics: Pharmacology and epidemiology

INTRODUCTION

The term "sedative-hypnotics" refers to a heterogeneous class of drugs that includes benzodiazepines, barbiturates, and various other hypnotics. A sedative lowers excitement and calms the awake patient, whereas a hypnotic produces drowsiness and promotes sleep. By tradition, they are categorized into a single class because of their common ability to induce sedation and sleep.

Significant variation in safety, and in the circumstances for which use is clinically appropriate, exists within the class of sedative- hypnotics. Barbiturates are now largely limited to induction of anesthesia, while benzodiazepines are widely used for purposes other than sedation, including the treatment of anxiety, insomnia, and epilepsy [1].

Several properties distinguish the benzodiazepines from the other sedatives. Although the clinical effects of the benzodiazepines resemble and overlap with other sedative-hypnotics, benzodiazepines are more specifically anxiolytic. They do not produce surgical anesthesia, coma, or death, even at high doses, except when co-administered with other agents that suppress respiration.

The relative safety and effectiveness of the benzodiazepines create a significant margin of safety that has led to their widespread use [2]. Several of the benzodiazepines, including alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and clonazepam (Klonopin) are among the most frequently prescribed psychotropic medicines worldwide. The World Health Organization [3] labeled them "essential drugs" that should be available in all countries for medical purposes.

Despite their relative safety, issues related to potential abuse, withdrawal, and side effects of benzodiazepines remain. In March of 2007, the United States Food and Drug Administration advised that the manufacturers of sedative-hypnotic medications strengthen their labeling to include stronger language about rare cases of severe allergic reactions and complex sleep-related behaviors [4,5].
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