More common More common side effects may include: Central nervous system depression, including somnolence, dizziness, depressed mood, fatigue, ataxia, headache, vertigo, impairment of memory, impairment of motor functions, hangover feeling in the morning, slurred speech, decreased physical performance, numbed emotions, reduced alertness, muscle weakness, double vision, and inattention have been reported. Unpleasant dreams and rebound insomnia have also been reported.<unk>  is a long-acting benzodiazepine with an elimination half-life of 15–38 hours (mean elimination half-life 26 hours). Residual "hangover" effects after nighttime administration of<unk>  such as sleepiness, impaired psychomotor and cognitive functions may persist into the next day, which may impair the ability of users to drive safely and increases the risk of falls and hip fractures. Less common Less common side effects may include: Hypotension, faintness, palpitation, rash or pruritus, gastrointestinal disturbances, and changes in libido are less common. Very infrequently, paradoxical reactions may occur, for example, excitement, stimulation, hallucinations, hyperactivity, and insomnia. Also, depressed or increased dreaming, disorientation, severe sedation, retrograde amnesia, headache, hypothermia, and delirium tremens are reported. Severe liver toxicity has also been reported. Cancer Benzodiazepine use is associated with an increased risk of developing cancer. However, conflicting evidence implies that further research is needed in order to conclude that products of this class really do induce cancer. Mortality<unk>  therapy, compared with other drug therapies, increases risk of death when used for intractable epilepsy in an analysis of 302 patients. The risk of death from<unk>  therapy may be greater in younger patients (children below 3.4 years in the study) with intractable epilepsy. In older children (above 3.4 years), the tendency appears to be reversed in this study.<unk>  may cause sudden death in children. It can cause swallowing incoordination, high-peaked esophageal peristalsis, bronchospasm, delayed cricopharyngeal relaxation, and severe respiratory distress necessitating ventilatory support in children.<unk>  may promote the development of parasympathetic overactivity or vagotonia, leading to potentially fatal respiratory distress in children. Liver<unk>  has been associated with severe hepatic disorders, similar to other nitrobenzodiazepines. Nitrobenzodiazepines such as<unk> , nimetazepam, flunitrazepam, and clonazepam are more toxic to the liver than other benzodiazepines as they are metabolically activated by CYP3A4 which can result in cytotoxicity. This activation can lead to the generation of free radicals and oxidation of thiol, as well as covalent binding with endogenous macromolecules; this results, then, in oxidation of cellular components or inhibition of normal cellular function. Metabolism of a nontoxic drug to reactive metabolites has been causally connected with a variety of adverse reactions. Other long-term effects Long-term use of<unk>  may carry mental and physical health risks, such as the development of cognitive deficits. These adverse effects show improvement after a period of abstinence. Some other sources however seem to indicate that there is no relation between the use of benzodiazepine medication and dementia. Further research is needed in order to assert that this class of medication does really induce cognitive decline. Abuse potential Recreational use of<unk>  is common. A monograph for the drug says: "Treatment with<unk>  should usually not exceed seven to ten consecutive days. Use for more than two to three consecutive weeks requires complete re-evaluation of the patient. Prescriptions for<unk>  should be written for short-term use (seven to ten days) and it should not be prescribed in quantities exceeding a one-month supply. Dependence can occur in as little as four weeks." Tolerance Tolerance to<unk> 's effects often appears with regular use. Increased levels of GABA in cerebral tissue and alterations in the activity state of the serotoninergic system occur as a result of<unk>  tolerance. Tolerance to the sleep-inducing effects of<unk>  can occur after about seven days; tolerance also frequently occurs to its anticonvulsant effects. However, other sources indicate that continuous use does not necessarily lead to reduced effectiveness, which implies that tolerance is not automatic and that not all patients exhibit tolerance to the same extent. Dependence and withdrawal<unk>  can cause dependence, addiction, and benzodiazepine withdrawal syndrome. Withdrawal from<unk>  may lead to withdrawal symptoms which are similar to those seen with alcohol and barbiturates. Common withdrawal symptoms include anxiety, insomnia, concentration problems, and fatigue. Discontinuation of<unk>  produced rebound insomnia after short-term single nightly dose therapy.
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