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Lorazepam, also known under the brand name Ativan, is a prescription-only drug available to treat conditions including anxiety, insomnia, and alcohol withdrawal symptoms. It is one medication of the benzodiazepine class of drugs.[1]
Controlled substances are prescription-only or banned drugs that are psychoactive and are open to abuse. They are listed in different schedules based on the risk they pose under the Controlled Substances Act.[2] Lorazepam is classified as a Schedule IV drug, meaning that it has less strict controls than potentially more harmful medications.[1]
Here’s how and why lorazepam is classified as a Schedule IV drug.
- Lorazepam is a benzodiazepine most often used as a short-term treatment for anxiety and panic disorders.
- It is a Schedule IV drug under the Controlled Substances Act, meaning that it is only available on a prescription from a doctor.
- The main risks associated with taking lorazepam are abuse and withdrawal symptoms.
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Is Ativan (Lorazepam) a controlled substance?
The Controlled Substances Act lists five schedules (levels) of classification, with Schedule I drugs being illegal substances and non-prescription medications, while Schedule V drugs are easily available with a refillable prescription.[3] Benzodiazepines, including lorazepam, are considered Schedule 4 drugs.[4]
Lorazepam and its medical uses
Lorazepam is a benzodiazepine, a category of drug commonly used to treat acute anxiety disorders. It enhances the effect of a neurotransmitter called GABA, which reduces activity in nearby neurons. This inhibitory action has a calming, depressant, and anti-anxiety effect.[5]
Lorazepam is licensed by the FDA for the treatment of anxiety disorders, convulsive status epilepticus, and as premedication before anesthesia.[11]
Lorazepam taken orally is slower to take effect than some other benzodiazepines and remains in the bloodstream for slightly longer. This may make it preferable for patients who have anxiety throughout the day, for example, those with generalized anxiety disorder (GAD) and social anxiety disorder (SAD).[6][7]
Lorazepam is used off-label to treat other conditions, including symptoms associated with alcohol withdrawal, panic disorder, and vertigo.
Implications: Prescribing guidelines and misuse potential
The Controlled Substances Act sets out guidelines for how drugs are assigned to each schedule and rules for how they may be prescribed.
Use and misuse of lorazepam
The guidelines for Schedule 4 drugs have three parts:
- Risk of abuse: As a Schedule IV drug, lorazepam is considered to be a lower risk for abuse than Schedule III drugs, such as ketamine and anabolic steroids.
- Medical uses: Lorazepam has accepted medical uses within the US - it is used to treat anxiety and seizures.
- Dependence potential: Lorazepam use can lead to physical and/or psychological dependence and withdrawal symptoms, including headache and seizures. This risk of dependence is less severe than for Schedule III drugs.
Prescribing guidelines for lorazepam
Doctors are allowed to prescribe lorazepam, both for FDA-approved purposes and off-label. The prescriptions may be refilled up to five times, and they expire after 6 months. [3]
Unlike Schedule II drugs, lorazepam prescriptions do not need to be written down or sent electronically. An oral prescription is permissible.
Alternatives to lorazepam
There are multiple alternatives to lorazepam for treating anxiety and panic disorders. Other benzodiazepines, such as alprazolam (Xanax), may be used in a similar way to lorazepam. Benzodiazepines are generally recommended for short-term use. Other alternatives may be preferred for the treatment of anxiety long-term, whereas benzodiazepines are often used for anxiety or panic that comes on suddenly and/or is short-lived.[8]
Most doctors will prescribe antidepressants for anxiety before suggesting lorazepam. These carry less risk of withdrawal effects and can be prescribed safely for longer periods of time without the risk of dependence.[9]
For patients with panic disorders or phobias, beta-blockers can be prescribed off-label to help reduce the symptoms of an acute attack. Drugs (such as propranolol) can help slow the heart rate and reduce nervous sweating and shaking.[10]
In addition to pharmacological treatments, psychological therapies can address the underlying causes of anxiety and panic disorders, leading to long-term improvements.
Lorazepam is also used to treat convulsive status epilepticus through intravenous administration, which can be difficult during seizures. Diazepam appears to be an equally effective first-line treatment and can be administered rectally. Convulsive status epilepticus is an emergency, and prompt treatment is necessary. Benzodiazepines are the main type of medications effective for stopping seizures.
How to use lorazepam safely
Lorazepam should only be taken on the advice of your doctor or medical practitioner and always taken as directed. Special care should be taken if lorazepam is being prescribed for more than 4 weeks at a time.
Lorazepam may not be appropriate for people with a history of substance use disorder (SUD). It should also be avoided by anyone who is pregnant, planning to become pregnant, or breastfeeding. People over the age of 65 need to be aware that there is an increased risk of dizziness and drowsiness.
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