Review Question - QID 105618

The patient in the vignette above is exhibiting signs of intoxication with a depressant. Given her history of panic disorder and normal HEENT exam, the correct answer is alprazolam.

Alprazolam is a short acting benzodiazepine often prescribed for rapid relief from panic attacks. Benzodiazepines produce their anxiolytic effects by potentiating the actions of GABA, and at high doses can cause CNS depression. This patient is exhibiting the signs of benzodiazepine overdose which include ataxia, stupor, somnolence, and minor respiratory depression. The treatment for benzodiazepine overdose is supportive care. Flumazenil (a competitive GABA antagonist) should be avoided, in general, as it can precipitate withdrawal and seizures. It could potentially be used in severe cases if you fear the patient will lose their airway, but this is rare.

Longo et al. review the chronic use of benzodiazepines, noting that overdose can happen, but that overdose on benzodiazepines alone rarely results in death. However, the cumulative effect on respiratory depression that occurs when benzodiazepines are used in addition to other drugs of abuse can be very dangerous. Therefore, the authors recommend the use of antidepressants, buspirone, and anticonvulsants for patients with panic disorder and a history of substance abuse.

Jann et al. also describe the dangers of benzodiazepines in an article detailing the risks of unintentional prescription drug overdose. The authors note that between 2003 and 2009, the 2 prescription drugs with the highest increase in death rates were oxycodone at 264.6% and alprazolam at 233.8%. They describe the pharmacokinetic interactions of opioids and benzodiazepines and recommend exercising extreme caution when prescribing both benzodiazepines and opioids to the same patient.

Illustration A is a table detailing the adverse effects of benzodiazepines

Incorrect Answers:
Answer 1: Fluoxetine is an SSRI commonly prescribed for panic disorder, however an overdose of fluoxetine could lead to serotonin syndrome (tachycardia, sweating, mydriasis).
Answer 2: MDMA is a stimulant similar to methamphetamines and overdose would cause tachycardia, tachypnea, and pupillary dilation.
Answer 4: Marijuana commonly causes euphoria, anxiety, increased appetite, dry mouth, conjunctival injection and tachycardia.
Answer 5: Oxycodone overdose will cause CNS depression, however opioid overdose would likely cause miosis, and additionally the history of panic disorder make alprazolam more likely.