Midazolam 1 & 5 mg/mL injections (Canada)<unk> s possess psycholeptic, sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant, and amnesic actions, which are useful in a variety of indications such as alcohol dependence, seizures, anxiety disorders, panic, agitation, and insomnia. Most are administered orally; however, they can also be given intravenously, intramuscularly, or rectally. In general,<unk> s are well tolerated and are safe and effective drugs in the short term for a wide range of conditions. Tolerance can develop to their effects and there is also a risk of dependence, and upon discontinuation a withdrawal syndrome may occur. These factors, combined with other possible secondary effects after prolonged use such as psychomotor, cognitive, or memory impairments, limit their long-term applicability. The effects of long-term use or misuse include the tendency to cause or worsen cognitive deficits, depression, and anxiety. The College of Physicians and Surgeons of British Columbia recommends discontinuing the usage of<unk> s in those on opioids and those who have used them long term.<unk> s can have serious adverse health outcomes, and these findings support clinical and regulatory efforts to reduce usage, especially in combination with non-benzodiazepine receptor agonists. Panic disorder Because of their effectiveness, tolerability, and rapid onset of anxiolytic action,<unk> s are frequently used for the treatment of anxiety associated with panic disorder. However, there is disagreement among expert bodies regarding the long-term use of<unk> s for panic disorder. The views range from those holding<unk> s are not effective long-term and should be reserved for treatment-resistant cases to those holding they are as effective in the long term as selective serotonin reuptake inhibitors (SSRIs). The American Psychiatric Association (APA) guidelines note that, in general,<unk> s are well tolerated, and their use for the initial treatment for panic disorder is strongly supported by numerous controlled trials. APA states that there is insufficient evidence to recommend any of the established panic disorder treatments over another. The choice of treatment between<unk> s, SSRIs, serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and psychotherapy should be based on the patient's history, preference, and other individual characteristics. Selective serotonin reuptake inhibitors are likely to be the best choice of pharmacotherapy for many patients with panic disorder, but<unk> s are also often used, and some studies suggest that these medications are still used with greater frequency than the SSRIs. One advantage of<unk> s is that they alleviate the anxiety symptoms much faster than antidepressants, and therefore may be preferred in patients for whom rapid symptom control is critical. However, this advantage is offset by the possibility of developing<unk>  dependence. APA does not recommend<unk> s for persons with depressive symptoms or a recent history of substance use disorder. The APA guidelines state that, in general, pharmacotherapy of panic disorder should be continued for at least a year, and that clinical experience supports continuing<unk>  treatment to prevent recurrence. Although major concerns about<unk>  tolerance and withdrawal have been raised, there is no evidence for significant dose escalation in patients using<unk> s long-term. For many such patients, stable doses of<unk> s retain their efficacy over several years. Guidelines issued by the UK-based National Institute for Health and Clinical Excellence (NICE), carried out a systematic review using different methodology and came to a different conclusion. They questioned the accuracy of studies that were not placebo-controlled. And, based on the findings of placebo-controlled studies, they do not recommend use of<unk> s beyond two to four weeks, as tolerance and physical dependence develop rapidly, with withdrawal symptoms including rebound anxiety occurring after six weeks or more of use. Nevertheless,<unk> s are still prescribed for long-term treatment of anxiety disorders, although specific antidepressants and psychological therapies are recommended as the first-line treatment options with the anticonvulsant drug pregabalin indicated as a second- or third-line treatment and suitable for long-term use. NICE stated that long-term use of<unk> s for panic disorder with or without agoraphobia is an unlicensed indication, does not have long-term efficacy, and is, therefore, not recommended by clinical guidelines. Psychological therapies such as cognitive behavioural therapy are recommended as a first-line therapy for panic disorder;<unk>  use has been found to interfere with therapeutic gains from these therapies.<unk> s are usually administered orally; however, very occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. Generalized anxiety disorder<unk> s have robust efficacy in the short-term management of generalized anxiety disorder (GAD), but were not shown effective in producing long-term improvement overall. According to National Institute for Health and Clinical Excellence (NICE),<unk> s can be used in the immediate management of GAD, if necessary. However, they should not usually be given for longer than 2–4 weeks. The only medications NICE recommends for the longer term management of GAD are antidepressants. Likewise, Canadian Psychiatric Association (CPA) recommends<unk> s alprazolam, bromazepam, lorazepam, and diazepam only as a second-line choice, if the treatment with two different antidepressants was unsuccessful. Although they are second-line agents,<unk> s can be used for a limited time to relieve severe anxiety and agitation. CPA guidelines note that after 4–6 weeks the effect of<unk> s may decrease to the level of placebo, and that<unk> s are less effective than antidepressants in alleviating ruminative worry, the core symptom of GAD. However, in some cases, a prolonged treatment with<unk> s as the add-on to an antidepressant may be justified. A 2015 review found a larger effect with medications than talk therapy. Medications with benefit include serotonin-noradrenaline reuptake inhibitors,<unk> s, and selective serotonin reuptake inhibitors. Anxiety<unk> s are sometimes used in the treatment of acute anxiety, as they bring about rapid and marked relief of symptoms in most individuals; however, they are not recommended beyond 2–4 weeks of use due to risks of tolerance and dependence and a lack of long-term effectiveness. As for insomnia, they may also be used on an irregular/"as-needed" basis, such as in cases where said anxiety is at its worst. Compared to other pharmacological treatments,<unk> s are twice as likely to lead to a relapse of the underlying condition upon discontinuation. Psychological therapies and other pharmacological therapies are recommended for the long-term treatment of generalized anxiety disorder. Antidepressants have higher remission rates and are, in general, safe and effective in the short and long term. Insomnia Temazepam (Normison) 10 mg tablets<unk> s can be useful for short-term treatment of insomnia. Their use beyond 2 to 4 weeks is not recommended due to the risk of dependence. The Committee on Safety of Medicines report recommended that where long-term use of<unk> s for insomnia is indicated then treatment should be intermittent wherever possible. It is preferred that<unk> s be taken intermittently and at the lowest effective dose. They improve sleep-related problems by shortening the time spent in bed before falling asleep, prolonging the sleep time, and, in general, reducing wakefulness. However, they worsen sleep quality by increasing light sleep and decreasing deep sleep. Other drawbacks of hypnotics, including<unk> s, are possible tolerance to their effects, rebound insomnia, and reduced slow-wave sleep and a withdrawal period typified by rebound insomnia and a prolonged period of anxiety and agitation. The list of<unk> s approved for the treatment of insomnia is fairly similar among most countries, but which<unk> s are officially designated as first-line hypnotics prescribed for the treatment of insomnia varies between countries. Longer-acting<unk> s such as nitrazepam and diazepam have residual effects that may persist into the next day and are, in general, not recommended. Since the release of non<unk> s in 1992 in response to safety concerns, individuals with insomnia and other sleep disorders have increasingly been prescribed nonbenzodiazepines (2.3% in 1993 to 13.7% of Americans in 2010), less often prescribed<unk> s (23.5% in 1993 to 10.8% in 2010). It is not clear as to whether the new non<unk>  hypnotics (Z-drugs) are better than the short-acting<unk> s. The efficacy of these two groups of medications is similar. According to the US Agency for Healthcare Research and Quality, indirect comparison indicates that side-effects from<unk> s may be about twice as frequent as from nonbenzodiazepines. Some experts suggest using nonbenzodiazepines preferentially as a first-line long-term treatment of insomnia. However, the UK National Institute for Health and Clinical Excellence did not find any convincing evidence in favor of Z-drugs. NICE review pointed out that short-acting Z-drugs were inappropriately compared in clinical trials with long-acting<unk> s. There have been no trials comparing short-acting Z-drugs with appropriate doses of short-acting<unk> s. Based on this, NICE recommended choosing the hypnotic based on cost and the patient's preference. Older adults should not use<unk> s to treat insomnia unless other treatments have failed. When<unk> s are used, patients, their caretakers, and their physician should discuss the increased risk of harms, including evidence that shows twice the incidence of traffic collisions among driving patients, and falls and hip fracture for older patients. Seizures Prolonged convulsive epileptic seizures are a medical emergency that can usually be dealt with effectively by administering fast-acting<unk> s, which are potent anticonvulsants. In a hospital environment, intravenous clonazepam, lorazepam, and diazepam are first-line choices. In the community, intravenous administration
Benzodiazepine
Synthetic cannabinoids
Antidepressant
Alcohol 
Gabapentinoid
Substituted amphetamine
Methamphetamine
Antipsychotic