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Diazepam — also known as Valium — is a synthetic depressant of the benzodiazepine class. It sits at mid-potency among classical benzodiazepines, between chlordiazepoxide and alprazolam.[1] Diazepam is a non-selective positive allosteric modulator of GABA-A receptors,[2][3] producing its effects by amplifying the brain's primary inhibitory signaling system.

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Threshold
< 2 mg
Light
2.5 – 5 mg
Common
5 – 15 mg
Strong
15 – 30 mg
Heavy
30+ mg
Bioavailability:90 – 100%
123450 h2 h4 h6 h8 h
1Onset
15m–45m2Come-up
30m–1h3Peak
1h–2h4Plateau
1.5h–3h5Resolution
2h–4hAftereffects6h–24h
Total4h–6h
Builduprapid
Full reset14 days
Cross-tol.
alprazolam, lorazepam, clonazepam +7 more
Absolute3 entries
severe respiratory insufficiencyconcurrent opioid usemyasthenia gravis
Relative7 entries
sleep apnea syndromehepatic impairmentCYP2C19 poor metabolizer statuspregnancybreastfeedingelderlyalcohol use disorder
Dosage varies by body weight, tolerance & metabolism · Not medical advice · Terms

Synthesized by Leo Sternbach at Hoffmann-La Roche and approved by the FDA in 1963, diazepam was the second benzodiazepine to reach the market.[1] Between 1969 and 1982 it was the most prescribed drug in the United States, peaking at over 2.3 billion doses sold in 1978.[1] It remains a WHO Essential Medicine and first-line treatment for status epilepticus, though prescribing has contracted following recognition of its abuse liability.

Subjective effects include anxiolysis, sedation, muscle relaxation, and anterograde amnesia. The experience is one of smooth, diffuse quieting — anxiety dissolves, the body loosens, and mental activity slows into a warm, unconcerned drift distinguished by a characteristic "delusion of sobriety" in which users consistently underestimate their impairment.[4] Psychomotor impairment, cognitive dulling, and memory gaps during intoxication are common unsought effects.

Diazepam produces physical dependence even at therapeutic doses with sustained use,[5] though isolated oral overdose carries low direct mortality. Combined with opioids, mortality increases approximately tenfold;[6] tolerance to sedation develops within days,[7] and individual response varies substantially with metabolizer status[8] and age. Six decades of clinical use and extensive pharmacological research make diazepam one of the most thoroughly characterized benzodiazepines.

History[edit]

Discovery

Diazepam was synthesized by Leo Sternbach, a Polish-American chemist at Hoffmann-La Roche in Nutley, New Jersey.[1] Sternbach had serendipitously discovered the first benzodiazepine, chlordiazepoxide, during a screen of quinazoline derivatives in the late 1950s; chlordiazepoxide received FDA approval in 1960. Diazepam was designed as a refined, more potent successor — approximately 2.5 times chlordiazepoxide's potency — and received FDA approval in 1963 under the trade name Valium.[1]

Commercial success and scientific significance

Diazepam's commercial trajectory was extraordinary: between 1969 and 1982 it was the most prescribed drug in the United States, peaking at over 2.3 billion doses in 1978.[1] The drug became emblematic of pharmacological management of everyday distress — the Rolling Stones' 1966 "Mother's Little Helper" captured the cultural unease around widespread suburban use. Despite this commercial dominance, the molecular mechanism remained unknown until 1977, when Möhler and Okada demonstrated specific, high-affinity CNS binding that correlated with pharmacological potency across the benzodiazepine class — establishing the benzodiazepine receptor as a drug target.[2]

Dependence recognition and prescribing contraction

By the 1980s, clinical evidence established that long-term benzodiazepine use produced physical dependence and a withdrawal that could include seizures.[1][9] Diazepam's arc — from most-prescribed drug to controlled substance with restricted prescribing — shaped regulatory approaches to all subsequent anxiolytic development and represents a recurring pattern in psychopharmacology: initial therapeutic enthusiasm followed by delayed recognition of long-term harm.

Chemistry[edit]

Structural class

Diazepam belongs to the 1,4-benzodiazepine family — a seven-membered diazepine ring fused to a benzene ring, with nitrogen atoms at positions 1 and 4. This scaffold is the parent structure for classical benzodiazepine anxiolytics, including chlordiazepoxide, nitrazepam, oxazepam, and lorazepam. Diazepam carries a methyl group at N1, a carbonyl at C2, a phenyl ring at C5, and a chlorine atom at C7 — the configuration that defines its receptor binding profile.

Molecular properties

Molecular formulaC₁₆H₁₃ClN₂O
Molecular weight284.74 g/mol

The diazepine ring contains an imine bond at position 4 and an amide carbonyl at C2. The N1-methyl group differentiates diazepam from N-unsubstituted benzodiazepines such as oxazepam and eliminates a site for direct glucuronidation, contributing to diazepam's longer half-life relative to its 3-hydroxy metabolites.

Stereochemistry

Diazepam is achiral — the molecule contains no stereocenters and no active isomers exist. This distinguishes it from 3-hydroxylated benzodiazepines such as oxazepam and Lorazepam, which possess a chirality center at C3.

Physical properties

Diazepam presents as a white to off-white crystalline powder, practically insoluble in water but freely soluble in organic solvents.citation needed This high lipophilicity underlies its rapid penetration into the central nervous system and large volume of distribution.[10]

Pharmacology[edit]

Mechanism of action

Diazepam is a positive allosteric modulator of GABA-A receptors — the brain's principal inhibitory ion channels.[2] It binds at the interface between α and γ2 subunits, a site distinct from where GABA itself binds, and increases the frequency of chloride channel opening when GABA is present. This amplifies the brain's own inhibitory signaling without directly activating the receptor — a key distinction from barbiturates, which can force channels open independently and carry a correspondingly higher overdose risk.

Diazepam acts on all four benzodiazepine-sensitive GABA-A receptor subtypes (those containing α1, α2, α3, or α5 subunits) with roughly equal affinity.[3][11] This non-selectivity produces the full pharmacological spectrum at any therapeutic dose: sedation and anticonvulsant activity through α1-containing receptors, anxiolysis and muscle relaxation through α2/α3-containing receptors, and memory effects through α5-containing receptors concentrated in the hippocampus.[12]

The inability to target one effect without the others is the central limitation of diazepam's therapeutic profile and the driver of research into subtype-selective compounds.[12]

Pharmacokinetics

Diazepam is rapidly and almost completely absorbed after oral administration, with bioavailability of 90–100% and peak blood levels at approximately 1–2 hours.[10][13] It is highly protein-bound and distributes extensively into body tissues.

The half-life is 24–48 hours in healthy adults but extends to 80–100 hours in people over 60 and roughly doubles in liver disease.[13] The liver converts diazepam into nordiazepam, its primary active metabolite, which has an even longer half-life of approximately 51 hours.[13] Nordiazepam accumulates with repeated dosing, meaning pharmacological effects persist well beyond what the user perceives as the duration of action.

Both diazepam and nordiazepam are eventually converted to oxazepam, which is excreted by the kidneys. Genetic variation in the liver enzyme CYP2C19 significantly affects how quickly individuals clear the drug.[8]

Neuroscience[edit]

Where it acts

Diazepam's effects map onto the regional distribution of GABA-A subtypes across the brain.[14] Anxiety suppression arises primarily from enhanced inhibition in the amygdala and limbic structures via α2-containing receptors, dampening threat processing and fear responses.[12] Sedation and cognitive slowing reflect potentiation of α1-containing receptors — the most abundant subtype — in the cortex and thalamus, where they gate the flow of sensory information to conscious awareness.[12]

Anterograde amnesia involves α5-containing receptors concentrated on hippocampal neurons, where they modulate memory encoding.[12] Muscle relaxation is mediated through α2/α3-containing receptors in the spinal cord and brainstem motor nuclei.[12] Chronic exposure reduces hippocampal dendritic spine density and impairs cellular mechanisms of memory formation in animal models.[15]

Tolerance and neuroadaptation

The brain compensates for sustained enhancement of inhibitory tone through a convergent program of downregulation. Calcium influx through voltage-gated channels triggers removal of surface GABA-A receptors,[16][17] while at the genetic level, transcription of key receptor subunits is suppressed[18] and epigenetic silencing via histone deacetylase upregulation further reduces receptor availability.[7]

These changes explain why sedative tolerance emerges within 10–14 days of continuous use.[7] When the drug is removed, the brain's reduced inhibitory capacity produces a hyperexcitable state — the neurological basis of withdrawal symptoms including rebound effect anxiety, insomnia, and seizures.[19]

Subjective Effects[edit]

Summary

Diazepam's experiential character reflects its non-selective action across all benzodiazepine-sensitive GABA-A subtypes — every dose produces an inseparable blend of anxiolysis, sedation, amnesia, and muscle relaxation rather than cleanly isolated effects. In anxious individuals, the dominant experience is relief and stillness; in non-anxious users, sedation and cognitive dulling predominate. Set, setting, and individual pharmacogenetics — particularly CYP2C19 metabolizer status and prior benzodiazepine exposure — modulate both intensity and quality substantially.

Compared to alprazolam, diazepam produces a slower, smoother onset with less abrupt offset — the experience feels less "punchy" but carries greater accumulation risk with repeated dosing. Relative to alcohol at comparable sedative doses, diazepam produces similar psychomotor impairment but with more pronounced amnesia and less gastrointestinal distress.[4]

Effect Grid

Dose Level:
Description

At common doses (5–15 mg oral), the full anxiolytic and sedative profile emerges. Anxiety suppression is pronounced — situational worry and social anxiety are substantially reduced. Sedation becomes prominent, with noticeable thought deceleration, emotional suppression, and a sense of calm detachment. Anterograde amnesia begins at this range, particularly at the upper end, with impaired recall of events during intoxication.

Physically, muscle relaxation is marked. Motor control impairment is objectively measurable — comparable to alcohol at 0.8 g/kg at 10 mg. Dizziness and mild ataxia are common. Respiratory depression remains minimal in healthy individuals at these doses.

Delusions of sobriety — underestimation of one's own impairment — are characteristic at this range. Driving and complex tasks are significantly impaired for 4–5+ hours.

Modeled from the effect's dose-dependence curve — not per-substance measurements.

Perception(9)likelihood · intensity
Dreaming suppression
likely
Visual acuity suppression
possible
Vestibular distortion
possible
Proprioceptive distortion
possible
Spatial disorientation
possible
Depth perception distortion
possible
Visual haze / noise
possible
Double vision!
rare
Visual processing suppression
rare

Spatial disorientation · Depth perception distortion · Visual haze / noise · Visual processing suppression

Body(22)likelihood · intensity
Sedation
likely
Muscle relaxation
likely
Motor control impairment!
likely
Physical fatigue
likely
Dizziness
possible
Bodily heaviness
possible
Breathing alteration
possible
Respiratory depression!
possible
Temperature dysregulation!
rare

Dizziness · Bodily heaviness · Breathing alteration · Body high · Nystagmus (eye wobbles) · Yawning · Dry mouth · Pain suppression · Sexual arousal suppression · Tactile euphoria · Constipation · Headache · Laughter fits · Nausea · Temperature dysregulation · Restlessness · Vomiting

Body high · Nystagmus (eye wobbles) · Yawning · Dry mouth · Pain suppression · Sexual arousal suppression · Tactile euphoria · Constipation · Headache · Laughter fits · Nausea · Restlessness · Vomiting

Thinking(20)likelihood · intensity
Cognitive impairment
likely
Decision impairment!
likely
Thought deceleration
possible
Analysis suppression
possible
Memory suppression
possible
Cognitive fatigue
possible
Focus suppression
possible
Delusions of sobriety!
possible
Compulsive redosing urge!
possible

Memory suppression · Cognitive fatigue · Focus suppression · Information processing suppression · Motivation suppression · Language suppression · Creativity suppression · Memory fragmentation · Thought disorganization · Compulsive redosing urge · Confusion · Suggestibility enhancement · Humor enhancement · Cognitive dysphoria · Amnesia

Information processing suppression · Motivation suppression · Language suppression · Creativity suppression · Memory fragmentation · Thought disorganization · Confusion · Suggestibility enhancement · Humor enhancement · Cognitive dysphoria · Amnesia

Feeling(9)likelihood · intensity
Anxiety suppression
likely
Emotional suppression
possible
Emotional lability
possible
Euphoria
possible
Irritability
rare
Depression!
rare
Dysphoria
rare
Anxiety
rare
Paranoia!
rare

Euphoria · Irritability · Dysphoria · Anxiety

Self(14)likelihood · intensity
Disinhibition
possible
Communication suppression
possible
Compulsive behavior reduction
possible
Sociability enhancement
possible
Craving
possible
Emotional susceptibility
possible
Sociability suppression
possible
Social connection
possible
Self-control suppression!
rare

Craving · Emotional susceptibility · Sociability suppression · Social connection · Trust enhancement · Depersonalization · Derealization · Social disconnection · Cognitive disconnection

Trust enhancement · Depersonalization · Derealization · Social disconnection · Cognitive disconnection

Time(2)likelihood · intensity
Temporal disorientation
possible
Time alteration
possible
Awareness(1)likelihood · intensity
Reality testing impairment!
rare
Likelihood: how common this effect is at the selected dose level.This effect has safety implications — review before use.

Timeline

Safety[edit]

Harm
Acute toxicity
Low
Chronic toxicity
High
Withdrawal
Life-threateningfatal risk
Tolerance buildup
rapid
Tolerance reset
14 days
Dependence
Physical
High
Psychological
High
Compulsive redosing
Moderate
Dose escalation
High
Cross-tol.
alprazolam · lorazepam · clonazepam
Risk Shape
TOXPHYPSYWDRREDTOL

Toxicity

Acute toxicity

Diazepam alone has a wide safety margin compared to older sedatives such as barbiturates.[1] Isolated oral overdose in otherwise healthy adults carries low direct mortality — this was a primary selling point during initial clinical adoption. The primary risk in overdose is respiratory depression, which is modest at therapeutic oral doses but becomes clinically significant with injectable administration, pre-existing breathing problems, or co-administration of other depressants.

Polydrug toxicity

The risk profile transforms when diazepam is combined with other depressants. Benzodiazepines are present in approximately 30% of opioid overdose deaths.[6] Mortality with opioid–benzodiazepine co-administration is approximately 10 times higher than with opioids alone.[6] Co-administration with alcohol produces mostly additive depression,[21][4] with unpredictably stronger responses in some individuals.[21]

Overdose management

Flumazenil is a competitive antagonist that reverses benzodiazepine-induced sedation and respiratory depression. In a multicenter trial, it achieved successful reversal in 77% of benzodiazepine-positive overdose patients.[22] The effect is short-acting (approximately 90 minutes), requiring monitoring for re-sedation.[22]

Flumazenil carries significant risk: systematic review found higher rates of adverse events, including seizures and abnormal heart rhythms.[23] It is contraindicated in patients with benzodiazepine dependence (risk of triggering withdrawal seizures) and should be avoided when antidepressant co-ingestion is suspected.[23][24]

Recommended emergency approach: support airway, breathing, and circulation first. Flumazenil only in cases of isolated benzodiazepine overdose in non-dependent patients.[24]

Chronic toxicity

Chronic diazepam use is associated with cognitive impairment, particularly in older adults. Animal studies demonstrate impaired learning, decreased hippocampal spine density, and reduced memory formation capacity.[15] Epidemiological data identify benzodiazepine exposure as a risk factor for cognitive decline in middle-aged and older patients,[25] and observational studies report associations with increased dementia risk.[20]

Pregnancy

Late third-trimester use and exposure during labor are associated with floppy infant syndrome — neonatal sedation, low muscle tone, poor feeding, breathing pauses, and impaired temperature regulation.[26] First-trimester data are inconsistent: early studies implicated diazepam in birth defects, but subsequent investigations found no clear increase in malformation rates.[26] Diazepam passes into breast milk at low levels.[26]

Psychological risks

Diazepam produces anterograde amnesia — impaired formation of new memories during intoxication.[27] A clinically significant phenomenon is the "delusion of sobriety," where users consistently underestimate their degree of impairment, leading to risk-taking behavior while objectively impaired.

Disinhibition, including paradoxical aggression, is a recognized behavioral effect. Chronic use carries risk of emotional and motivational blunting. Rebound anxiety during dose gaps or upon tolerance development can exceed baseline severity, creating a cycle where continued use appears necessary to manage drug-induced symptoms. Paradoxical reactions — increased anxiety, agitation, aggression — occur in a minority of patients, with higher rates in elderly and pediatric populations.

Tolerance & dependence

Tolerance to sedative and sleep-inducing effects develops within days of continuous use. Tolerance to seizure-preventing effects develops within 10–14 days.[7] Tolerance to anxiety-reducing effects is slower and less complete.[5]

Three convergent processes drive tolerance: removal of surface GABA-A receptors triggered by calcium channel activity,[16][17] suppression of receptor subunit gene expression,[18] and epigenetic silencing that further reduces receptor production.[7]

Physical dependence develops even at low therapeutic doses (10–20 mg/day equivalent) with long-term use.[5] High-dose users develop severe dependence.[28] The withdrawal syndrome includes rebound anxiety, tremors, sweating, insomnia, and seizures. Abrupt cessation after 21 days of continuous treatment produces measurable withdrawal within 24 hours in animal models.[29]

Abrupt discontinuation of diazepam after regular use can precipitate life-threatening withdrawal seizures. Discontinuation should only be undertaken under medical supervision using a gradual dose taper.

Cross-tolerance exists with all benzodiazepines and partial cross-tolerance with Alcohol and barbiturates via the shared GABA-A receptor mechanism. Receptor downregulation during use correlates with withdrawal severity; receptor recovery after discontinuation contributes to rebound excitability.[19]

Drug interactions

Opioids

The combination of diazepam with opioids produces synergistic respiratory depression: opioids suppress brainstem breathing centers while diazepam enhances inhibition of the same circuits through a separate mechanism.[6][30] This combination carries the highest mortality risk of any common diazepam interaction.

Alcohol

Both diazepam and Alcohol enhance GABA-A receptor activity at different binding sites. Controlled studies show mostly additive depression,[21][4] with some individuals experiencing stronger-than-expected effects without clear pharmacokinetic explanation.[21] Psychomotor impairment exceeds that of either substance alone.[31]

Metabolic interactions

Several common medications slow diazepam metabolism by inhibiting liver enzymes[32]:

  • Fluvoxamine: reduces diazepam clearance, elevates blood levels
  • Fluoxetine: increases active metabolite levels
  • Omeprazole/esomeprazole: increases nordiazepam formation
  • Methadone: shifts metabolism toward alternative pathways

Cannabis

Cannabis may additively enhance sedation through its own depressant properties. No controlled human studies of the diazepam–THC interaction have been published. Additive sedation and psychomotor impairment are expected, though the risk is likely lower than with opioid combinations.

Contraindications

Absolute

  • Concurrent opioid use without clinical monitoring: 10-fold mortality increase[6]
  • Severe breathing problems: diazepam further depresses respiratory drive
  • Acute narrow-angle glaucoma: may increase eye pressurecitation needed
  • Myasthenia gravis: worsens muscle weakness

Relative

  • Pregnancy (especially third trimester): floppy infant syndrome risk[26]
  • Breastfeeding: excreted in breast milk[26]
  • Liver impairment: half-life approximately doubles; dose reduction required[13]
  • Older adults (over 60): half-life extends to 80–100 hours; increased fall and cognitive impairment risk[13]
  • CYP2C19 poor metabolizer status: significantly slower clearance[8]
  • Alcohol use disorder: enhanced effects and cross-dependence risk
  • Sleep apnea: worsens breathing interruptions
  • History of substance use disorder: elevated dependence risk

Harm Reduction[edit]

Forms & Identification

Reagent ResultsNot recorded+ add reagent results
AppearanceNot recorded+ add appearance
Red FlagsNot recorded+ add red flags

Pharmaceutical diazepam is manufactured in standardized tablet forms with consistent dosing, making identification relatively straightforward when obtained through legitimate channels. The primary risk lies in unregulated supply: tablets sold as "Valium" outside pharmacy chains may contain other benzodiazepines, novel benzodiazepine analogs, or fentanyl — any of which can dramatically alter potency and risk profile.

Standard immunoassay drug tests may not detect novel benzodiazepine analogs present in counterfeit products. Fentanyl test strips should be considered for any tablet obtained from unregulated sources, as conventional reagent testing provides limited utility for distinguishing between benzodiazepine compounds.

Guidelines

  • Test any tablet not obtained from a licensed pharmacy — at minimum, use fentanyl test strips
  • Start at the lowest effective dose, especially with no prior benzodiazepine exposure
  • Allow the full onset window (up to 2 hours orally) before considering redosing — the slow onset invites premature redosing that leads to excessive sedation
  • Do not drive or operate heavy machinery for at least 24 hours after a dose — impairment outlasts perceived effects
  • Avoid daily use beyond 2–4 weeks; physical dependence can develop even at prescribed doses
  • Arrange a sober companion if using at higher doses, especially with any history of paradoxical reactions
  • Keep a written log of doses taken — anterograde amnesia during intoxication makes it easy to forget a dose and redose unintentionally

Set & Setting

Diazepam's psychomotor impairment and "delusion of sobriety" create a specific environmental risk: users feel capable of driving, operating machinery, or making complex decisions while objectively impaired. Plan the environment to eliminate access to vehicles and situations requiring coordination or judgment.

The long duration of action — pharmacological effects persist well beyond perceived sobriety due to the parent compound and active metabolites — means these precautions extend for significantly longer than the user feels affected. A safe, comfortable environment with a trusted companion is particularly important at higher doses.

Aftercare & integration. Diazepam's long half-life and active metabolites mean residual sedation, impaired coordination, and cognitive dulling can persist for 24–48 hours after a single dose and longer after repeated use. Avoid demanding cognitive tasks, important decisions, and driving during this window.

Adequate hydration and a regular sleep schedule support recovery. If memory gaps from the experience are distressing, writing down what is remembered as soon as possible can help reconstruct the timeline. Persistent anxiety that feels worse than before the dose (rebound effect anxiety) is a pharmacological effect, not a sign of a worsening condition — it typically resolves within 24–72 hours after a single use.

Recovery & Support

Benzodiazepine dependence is a recognized medical condition, not a moral failing. Physical dependence can develop at prescribed therapeutic doses and does not require misuse.

Discontinuation after regular use should always be medically supervised — abrupt cessation risks life-threatening seizures. Standard medical practice is a gradual dose taper over weeks to months, often converting to a longer-acting benzodiazepine (diazepam itself is commonly used as the taper agent for dependence on other benzodiazepines). Support resources include prescribing physicians, addiction medicine specialists, and peer support communities. Withdrawal symptoms — including rebound anxiety, insomnia, and sensory sensitivity — can persist for months after the final dose in some individuals. Professional support through this period substantially improves outcomes.

Recovery resources, crisis lines, and support pathways → View all

Emergency Response

Recognizing an emergency:

Immediate steps:

  • 1. Call emergency services immediately if breathing is slow, stopped, or the person cannot be woken
  • 2. Place the person in the recovery position (on their side) to prevent choking
  • 3. Monitor breathing continuously until help arrives
  • 4. Do not induce vomiting
  • 5. Do not attempt to "walk them off" — this does not reverse respiratory depression

What to tell the dispatcher:

State what was taken (diazepam or "a benzodiazepine"), approximate amount, time of ingestion, and any other substances involved. Good Samaritan laws in many jurisdictions protect people who call for help during a drug emergency.

Reversal agent:

Flumazenil can reverse benzodiazepine sedation and respiratory depression, but it is a hospital-administered medication with significant risks — including triggering seizures in dependent users. It is not available as a take-home reversal agent. If opioid co-ingestion is suspected, naloxone should be administered if available.

references

  1. [1] 
    ^abcdefghWick JY (2013) The history of benzodiazepines — The Consultant Pharmacist doi:10.4140/tcp.n.2013.538
  2. [2] 
    ^abcMöhler H, Okada T (1977) Benzodiazepine receptor: demonstration in the central nervous system — Science PMID:918669
  3. [3] 
    ^abFradley RL, Guscott MR, Bull S, et al. (2007) Differential contribution of GABAA receptor subtypes to the anticonvulsant efficacy of benzodiazepine site ligands — Journal of psychopharmacology PMID:17092983
  4. [4] 
    ^abcdErwin CW, Linnoila M, Hartwell J, et al. (1986) Effects of buspirone and diazepam, alone and in combination with alcohol, on skilled performance and evoked potentials — Journal of clinical psychopharmacology PMID:3734141
  5. [5] 
    ^abcdBusto U, Sellers EM (1991) Pharmacologic aspects of benzodiazepine tolerance and dependence — Journal of substance abuse treatment PMID:1675689
  6. [6] 
    ^abcdeDeHaan M, Radtke L, Hensley C, Hogue A (2020) Determining Efficacy of Intervention in the Limitation of Opioid and Benzodiazepine Co-Prescription — South Dakota medicine PMID:33264528