Abstract

Benzodiazepines and benzodiazepine-related drugs (BDZs) are a class of drugs that enhance the effect of gamma-aminobutyric acid (GABA) at GABA-A receptors. The basic properties of benzodiazepines as an anxiolytic, sedative, hypnotic, anticonvulsant, and muscle relaxant have given rise to their clinical use. Benzodiazepine-related drugs act more selectively, exerting hypnotic and some anxiolytic effects.

Tolerance develops over time due to neuroadaptive processes, causing many chronic users to need increasingly large dosages for similar effects. BDZs are known to have high potential for dependence and addiction. In addition, their use has been associated with a range of adverse effects, including sedation and cognitive and psychomotor
impairment, leading to traffic accidents, falls and fractures, especially in the elderly.

Due to their fast onset of action, BDZs are very effective in alleviating troublesome symptoms. Guidelines
emphasise that BZDs are not drugs of first choice and should only be used for short-term relief (up to 4 weeks) for anxiety or insomnia that is severe, disabling or subjecting individuals to extreme distress. Benzodiazepines are also useful for status epilepticus or as a rescue for repeated seizures and in reducing alcohol withdrawal.

In 2023, Estonia’s restrictions for prescribing BDZ were amended. At treatment initiation, the product with the lowest strength should be prescribed, with quantity limit of 30 tablets, 25ml oral drops, 20 ampoules, 20 suppositories, or 10 rectal tubes. In continued treatment, a further 60 tablets, 25ml oral drops, 20 ampoules, 20 suppositories, or 10 rectal tubes of BDZs can be prescribed within 30 days. A treatment scheme with larger amounts can only be used on the recommendation of a psychiatrist.

In recent years, the prescription of BDZs has slightly decreased in Estonia. However, there is some evidence of worrying trends, such as the increase in BDZ use among young people and an increase in the number of long-term or high-dose users, and use of BDZ in combination with other medicines with addictive potential, which requires attention and appropriate management.

Good clinical governance and an evidence-based approach are key to safe and appropriate prescribing. This encompasses better awareness of the advantages and disadvantages associated with BDZ use, and better access to mental health services, including alternative treatment options.