Anxiety attack

When most people hear the words “drug abuse” they think of opioids like oxycodone, hydrocodone or heroin. Other contenders include stimulants like cocaine and methamphetamine (“meth”), alcohol, ecstasy (MDMA) or LSD. Benzodiazepines (benzos for short) are rarely considered a problem because they are prescribed in such huge quantities. At last count over 13 million Americans filled more than 66 million prescriptions for drugs like alprazolam, clonazepam, lorazepam and diazepam. Many people do not realize there is something called benzodiazepine dependence and it can be hard to overcome.

The Benzo Bonanza:

When Librium (chlordiazepoxide) was first marketed by the Hoffman-La Roche company in 1960 it was wildly successful. Here was a pill that could calm the jitters, ease feelings of grief and help you get to sleep.

Not long after the success of Librium came the blockbuster Valium (diazepam). It rapidly rose to the number one most prescribed drug in America. Between 1969 and 1982 this benzo topped the doctors’ hit parade of most prescribed drugs. It’s been reported that during Valium’s peak popularity year (1978), approximately 2.3 billion pills were sold (Washington Post, Oct. 1, 2005). 

Why Were Benzodiazepines SO Popular?

Benzodiazepines were referred to as anxiolytics (anti-anxiety agents) or hypnotics (sleeping pills). The very names seemed calming: Restoril seemed restful. Tranxene seemed tranquil and Halcion sounded a lot like halcyon, which is defined as a tranquil and peaceful time.

One of the reasons the benzos were so successful was the belief that they were extremely safe. There had been headlines about famous personalities who had overdosed on barbiturates. Judy Garland and Marilyn Monroe were found dead after taking too many such pills.

Doctors believed that benzos could not be abused and would not lead to overdose deaths. In the early days there was little, if any, fear of benzodiazepine dependence.

The Rolling Stones Warned Us!

In their famous song “Mothers Little Helper,” Keith Richards and Mick Jagger wrote about the dangers of downers (there is some question whether this song was about barbiturates, Miltown (meprobamate) or 5 mg yellow Valiums (diazepam). Here are the famous words:

• “Mother needs something today to calm her down
• And though she’s not really ill, there’s a little yellow pill
• She goes running for the shelter of a mother’s little helper
• And it helps her on her way, gets her through her busy day…”

The song ends on a disturbing note:

•  “And if you take more of those, you will get an overdose
•  No more running for the shelter of a mother’s little helper
•  They just helped you on your way, through your busy dying day”

Benzo Dangers?

It is not that easy to OD on benzos. There is an exception to that rule, however. When benzodiazepines are added to opioid pain relievers, the danger of overdose death goes up significantly. A study of U.S. veterans shocked many health professionals (BMJ, online, June 10, 2015).  The authors concluded:

“Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.”

The FDA now acknowledges this risk. The black box warning that accompanies diazepam (Valium) states:

“WARNING: RISKS FROM CONCOMITANT USE WITH OPIOIDS
Concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death.”

Benzos and Dementia?

There is a growing recognition that benzodiazepines should generally not be prescribed to older people. Despite this, a study in the Journal of General Internal Medicine (Dec. 2018) notes that:

“Benzodiazepines (BZD) impair cognition and are associated with motor vehicle accidents, misuse and abuse, as well as falls and fractures among older adults. After opioids, BZDs are the second-most common medication class linked with pharmaceutical overdose deaths, the rate of which grew 13.6% per year from 1996 to 2013.”

The issue of cognition is not trivial. We have written about the association between benzos and dementia:

Will Benzos Increase the risk of Dementia?

Will Benzodiazepine Use Increase Your Risk for Alzheimer Disease?

No one should EVER stop a benzodiazepine suddenly without very careful medical supervision! Here is why.

Benzodiazepine Dependence:

The idea that people could develop benzodiazepine dependence came as quite a shock to many health professions. There was resistance to such a concept. Patients who stopped taking alprazolam or diazepam and complained of anxiety or insomnia were likely told that their original symptoms had returned. Many were advised to just keep taking the benzos and stop worrying.

We now know that people who take benzodiazepines regularly for several months are likely to experience withdrawal symptoms if they stop suddenly. The FDA has a sanitized name for this:

“discontinuation syndrome.”

Here is what the FDA has to say about benzodiazepine dependence with regard to alprazolam (Xanax): 

“Dependence and Withdrawal Reactions, Including Seizures

“Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to XANAX. These include a spectrum of withdrawal symptoms; the most important is seizure.

“In a controlled clinical trial in which 63 patients were randomized to XANAX and where withdrawal symptoms were specifically sought, the following were identified as symptoms of withdrawal: heightened sensory perception, impaired concentration, dysosmia [smell disturbance], clouded sensorium, paresthesias, muscle cramps, muscle twitch, diarrhea, blurred vision, appetite decrease, and weight loss. Other symptoms, such as anxiety and insomnia, were frequently seen during discontinuation, but it could not be determined if they were due to return of illness, rebound, or withdrawal.”

What to do About Benzodiazepine Dependence?

Drug companies have not been highly motivated to study this phenomenon. As a result, there are no clear guidelines for stopping benzos. People may be advised to taper off the medicine gradually, but that could be interpreted as a few days, a few weeks or a few months.

Here is the official prescribing information for alprazolam (Xanax):

“Risk of Dose Reduction

“Withdrawal reactions may occur when dosage reduction occurs for any reason. This includes purposeful tapering, but also inadvertent reduction of dose (eg, the patient forgets, the patient is admitted to a hospital). Therefore, the dosage of XANAX should be reduced or discontinued gradually.”

Symptoms of Benzodiazepine Withdrawal:

  • Insomnia
  • Light-headedness
  • Anxiety
  • Fatigue and Tiredness
  • Nausea/Vomiting
  • Diarrhea
  • Abnormal involuntary movement
  • Headache
  • Irritability
  • Sweating
  • Rapid heart rate
  • Blurred vision
  • Cognitive disorder
  • Muscular twitching
  • Impaired coordination
  • Memory impairment
  • Depression
  • Confusional state

Dealing with Benzodiazepine Dependence:

What is it like to experience benzo withdrawal? Here are some stories from readers of this column:

“I am a retired RN who worked 20 of her 47 years in mental health. My observations of people on benzodiazapines are: long term administration of benzos resulted in addiction to substances within two weeks. The longer the time they were given, the more difficult to withdraw.

“During withdrawal, patients suffered complete cognitive disintegration, neurological tics and delusions, and were screaming and crying for hours on end. This can go on for months if it doesn’t kill the person.

“I think it is inhumane to discontinue benzos for a patient who has been taking them for long time without a long-term tapered withdrawal plan. I was aware of the dangers of benzodiazepines in the 1970s. Why has this knowledge not been transmitted to new nursing and medical students?”

Another reader offered this:

“I wish doctors would be better advised about how to help patients get off psych drugs. I’m in the heat of alprazolam withdrawal right now. It’s been six months, and there isn’t a doctor out there that acknowledges it. It’s so maddening and totally frustrating.”

Because older people are particularly vulnerable to confusion or falls from benzos, they need special assistance in weaning off such drugs. We wish the FDA would provide better guidance to prescribers when it comes to a tapering plan.

In the meantime, you may find this article helpful:

“What are the Most Dangerous Drugs for Older People”

What Are the Most Dangerous Drugs for Older Adults?

Reader Comments?

Share your own experience with benzos in the comment section below. We recognize that many older people rely on drugs like alprazolam or clonazepam to get to sleep at night. They may not recognize they have a benzodiazepine dependence problem. In no case should anyone ever attempt to stop a benzo suddenly or on her own. If the benzo needs to be discontinued it should be done VERY gradually over several weeks or months with medical supervision. Some people may need to take much longer to wean off a benzo. 

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  1. Jackie McClellan
    FL
    Reply

    I am nearly 78 and on Alprazolam for 12 years. I successfully weaned off for a year (2017), but panic attacks, depression, suicidal thoughts, began to return with a vengeance. Started again taking 1mg 2 times a day. I still have panic attacks and some anxiety. In Jan. 2019 my prescribing doctor tells me I can only be prescribed a 60 day supply at a time. Must visit him every 60 days for a prescription and a pay insurance co-pay each visit. Have wanted to try stopping medication again but even now my anxiety, depression, and suicidal thoughts are reoccurring. What is one to do?

  2. Willa
    HOUSTON
    Reply

    After 12 years of 2mg estazolom nightly, I’ve been benzo free for 25 months. It took me 18 additional months to titrate off of the medication. I decided to stop taking benzo’s when my dose stopped working and I realized that I was going to need ever increasing dosages just to stay stable. While the worst of my suffering is over it is difficult to overstate just how bad things were. In fact for months I longed for death and seriously considered suicide. After all of this time I am still not sleeping well and continue to have frequent uncomfortable days. However, things are much better and I’m hoping these continuing will resolve within the next year.

  3. Trina
    Wisconsin
    Reply

    I’ve been taking diazepam for years, originally prescribed as a muscle relaxant for neck, shoulder and upper back tension. It also helps me sleep. But, I only take it on work nights when I need it for sleep and to relax tension in my muscles from working at a computer all day. No weekends. No holidays. I don’t think I’d have any withdrawal since I don’t take it daily and don’t have any problems on weekends when I don’t take it. I’m sure some people do have problems with withdrawal and it’s good to have the information from this article available.

  4. LI
    Reply

    Patricia H. raises an important point. Benzodiazepines enable some individuals to live a normal life. Yes, one can become dependent on them (which is not the same thing as being addicted to them). But one can also become dependent on medications such as beta-blockers for hypertension. Neither type of medication should be abruptly discontinued.

  5. Leah
    California
    Reply

    I’ve been taking clonazepam (Klonopin) daily for almost a decade. I’ve never needed to increase my dose, it still works just as well. I also take low dose propranolol (a beta blocker) daily for anxiety & a heart arrythmia.
    There is no reason to feel bad if you need medication. Over the years I desperately tried practically everything: from medications to meditation, herbs, yoga, diet, exercise, counseling, you name it & nothing else ever worked in any substantial way. I never wanted to be dependent on a pill which is why I waited until age 29 to try it. What a shame I was afraid & didn’t try it sooner, so many wasted years & so much unnecessary suffering. Now my anxiety is completely manageable. I just feel “normal” for the first time in my life and I can function (leave my house, make phone calls, talk to people, work, completed my degree, etc).
    My theory: I think an unfortunate combination of genetics and childhood traumas caused my brain to produce an abnormally low level of GABA (the main inhibitory neurotransmitter in the brain). For me clonazepam feels like it simply corrects that deficiency without any side effects or impairment. It saved my life.
    However, it does create a physical dependency when used daily and must be tapered very slowly. I’ve done that also because my anxiety had been so well managed for so long I felt maybe I didn’t need medication anymore. Despite therapy and a healthy lifestyle my anxiety once again took over to the point that I couldn’t function at all and I wanted to die rather than live like that. My psychiatrist put me back on clonazepam and now I am the “real me” that I was always meant to be again!

  6. Leah L.
    California
    Reply

    https://www.bmj.com/content/352/bmj.i90
    Benzodiazepine use and risk of incident dementia or cognitive decline: prospective population based study
    BMJ 2016
    Conclusion –
    “The risk of dementia is slightly higher in people with minimal exposure to benzodiazepines but not with the highest level of exposure. These results do not support a causal association between benzodiazepine use and dementia.”

  7. WK
    Raleigh
    Reply

    I have a relative with severe panic attacks . For years he used a 5 mg Valium daily (PRN ) to treat himself . A new Family Physician decided in his 80s, after 50 years of being on a Benzo that he needed to stop . I am still angry with the abrupt cessation that was demanded
    I once worked as an Addiction Medicine specialist . At that time , being a state facility we could treat people as long as we needed to do so to help them . Our elderly Benzo addicts could take up to three months to gently wean off their meds . A new director decided we could no longer offer that level of care ……more of Medicine going the wrong way in my opinion
    Bottom line —some people need the medications we have created. . Some people abuse them but not everyone
    Not every soul on this planet fits under a bell-shaped curve . We need to treat individuals and avoid a lock step mentality to the Party Line in Medicine . Some people benefit from low dose Benzodiazepines

  8. Susan Barber
    Fort worth texas
    Reply

    I was on valium for 20 years after failed back surgery. Last September 2018 I found myself with severe anxiety and insomnia, I realized that I was having reactions from the valium. I took my last pill October 2018 and have suffered terrible anxiety, insomnia, sensory and eating problems. Eating has become a chore and have lost over 20 lbs. Trying to stop the decline. Doctors will not talk about the issues that it has caused just look at me scared of me and say you need a psychiatrist. I am sleeping some but this is a hard journey and one which I will be glad when I’m on the other side of it.
    I’m 65 years old and never thought I would be wrestling with this. I really thought because I didn’t take a pill everyday I was okay. I was and am not okay please be aware this is a horrible withdrawal.

  9. Elaine C.
    Flat Rock, NC
    Reply

    I secessfully quit Lorazepam in six weeks within the last three months!! I am 82 yrs old and have been taking this sleeping drug for 20 years. I Started reducing my dosage from 3 nightly pills of 0.5mg . ( I took 2 at bed time and one more at 3:00am if needed to return to sleep) . I reduced intake to 1mg (2 .05mg) starting reduced again dosage to .05mg. (1 .05mg.) within three weeks. I cut the .05mg in half and took the tiny .25mg pill until I was freed of most of the terrible side effects, about another couple weeks. It is not easy, But absolutely necessary.
    I downloaded all necessary info on Wikipedia and followed all referenced pages. I studied this for two days. This info is so scary…..why didn’t my doctors explain how this innocent little .05 mg pill could cause such devastating side effects? My go to supliment was Melatonin and “CALM” the name of a nutrient formula which specifics calming sleep. This formula helps me to catch even a couple hours of uninterrupted sleep. My symptoms were exactly as described online: sleep-less, fussy, dizzy, shaky , anxious, irritable ..impossible to live with, But know your goal and do it.
    My strong motivation for quitting Benzos was my body built up a resistance to the drug and I was having strange effects similar to TIAs…sleep walking…memory loss (amnesia) ….zoning off, like in another world! Scary, very scary. I am healthy now and happy.

  10. Dianne
    Spokane WA
    Reply

    Lorazepam aka Ativan was prescribed for me in 1993. That’s 26 years ago. I’m still on it and am now 78. The reason for the original prescription was that I was having horrible trouble sleeping and I needed to sleep so that I could go on a 2400 mile car trip by myself. Being so sleep-deprived, I couldn’t get ready for the trip. This “holistic” doctor failed to mention the fact that the drug could cause tolerance and should be taken only short-term.
    The reason for my sleep trouble was pinned on menopause, but is now know to be, after FIVE overnight sleep studies, “central sleep apnea”. All treatments for this condition have failed so I still depend on lorazepam in order to get any sleep at all. I became INSTANTLY dependent upon it. From an original dose of 1mg. I am now on a 2 mg. dose, taken only at bedtime. There is no way I can ever get off this drug. I’m writing only as a cautionary tale to others. Benzos are dangerous. I sincerely wish I had known this fact in 1993.

  11. Christine
    WA
    Reply

    I was on a benzo for insomnia for 10+ years and finally found the Ashton Method to slow taper off. After 15 months of agonizing taper I am now 9 weeks off. The symptoms can be quite hellish and can last for many months. Most medical professionals do not know about benzo dependency and the need to slow taper. Sadly, many cut off their patients, causing a very dangerous situation. Other doctors do not accept that the benzo is the problem and will INCREASE the dose instead. Most of us in the prescribed harm community depend on each other in our support groups to get through this life-changing experience. Doctors need to come into the light and get educated.

  12. Ray
    Arizona
    Reply

    I’ve been using low dose Lorazepam for 30 years. I’m 76 and never had a problem with the drug. I consider it a life saver for me. It also helps me sleep.
    I’m aware people are different and may abuse it or it or may get addicted.
    Many of the symptoms of withdrawal are the symptoms I get when I’m anxious and need it.
    Is Insulin addictive? If you don’t take it symptoms return just like anxiety but because it’s mental it’s looked at differently.

  13. Barbara C.
    NY
    Reply

    This is a very well thought-out article. However, it doesn’t relate to everyone. I had taken Valium for quite awhile and did not have a problem stopping it. It seems to be different for everyone.

  14. BB
    NC
    Reply

    I am a 74 year-old man who was prescribed Valium for sleep after heart procedure. After a few weeks, was switched to Ativan to help with anxiety. Dr. prescribed very low dose and said dependency would not be an issue. After a month and experiencing many side effects, I asked how to taper off and was given advice. None of it worked, and after 2 months I was desperate. Thank heavens I found the Ashton manual online and tapered onto valium to get me off ativan. Now am in 4th week off all bentos and slowly improving. My doctors never understood the addictive problem with benzos. You have to educate yourself, as doctors keep prescribing these horrible drugs! Never use benzos!

  15. Patricia H.
    Wantage, NJ
    Reply

    Why, after using benzos for over 40 years would I consider giving them up? I have a high level of this drug in my brain and only take perhaps one 1mg pill a week. I have suffered severe child abuse, and traumatic memories yield poorly to therapy. I have lost a husband and two children out of four. One died during surgery two years ago and another 18 years ago in an auto accident. My father committed suicide when I was in my thirties. My mother’s sister, my grandmother’s sister, and maternal grandfather all committed suicide.

    I have been in therapy on and off for years and have never been hospitalized. Why? Because of my deep faith in the Lord, bentos, and a few good therapists. I currently see a psychologist. I avoid psychiatrists. I became an RN, earned my Masters, and choose to work in the ER, crisis, in-patient behavioral health and chemical dependency. I am also a certified Parish Nurse.

    Who would know better than I about these areas? I am a deeply caring person. I am involved in animal rescue and in helping the poor and the needy. I am this way because I had chemical help along with the help of others and my faith. I am frankly sick and tired of methods of coping that do not include the use of medications when indicated. Drop it!

  16. Prunie22
    VA
    Reply

    Have been taking Valium for years, mainly one at night to sleep for anxiety and depression. If I need something to help with migraine, I half a Vicodin. I don’t take meds for the sport of it, however, there are people out there that just want to abuse these medications. Use common sense! Unfortunately, there is no common sense in people that just want to take meds for fun.
    I wish I didn’t need to take any meds at all. That would be great!

  17. James
    Under God's Grace
    Reply

    I do not take prescriptions at all for anything and for good reason my Mother was prescribed Valium in 1965 after the death of my sister from a malpractice delivery . My Mother never recovered from my sister’s death and began the downward spiral of the AMA and there never ending pill solution for everything. She suffered through 54 years of thousands of doctors visits begging for a cure and the doctors would write another prescription and each new pill created another downward spiral . As I read the warning signs of withdrawal above I checked off most if not all as this is what prescriptions do to people and at the very end it gets so bad they bring in the end of life drugs ( HOSPICE ) and finish you off !

  18. cheryl
    Arizona
    Reply

    I have been weaning from Lorezpan for insomnia issues! I was on this drug for 12 years and my doctor gave it to me like candy. It was a pain mgmt doctor that urged me to get off due to the dementia risk. I am in month 7 of the weaning process with three weeks to go. I have been using a liquid form of the drug made by a compounding pharmacy to easily reduce the dose. I have been having insomnia issues again and it is maddening. If I were to tell my prescribing doctor she would just tell me to give up on the weaning process! Tried everything I have read about how to sleep again normally. I think my brain has to heal from the abuse of the drug and I am not sure when or if I can sleep normally again. Good luck to everyone who is trying to get free. It can be done.

  19. Caryn
    North Carolina
    Reply

    I looked up the research
    The Ashton Maunual is what I followed to kick this habit.

  20. Caryn
    North Carolina
    Reply

    I was able to get off Ativan after a 14 year addiction. There is a titration expert. It took me more than a month. It’s a slow process, not without side effects. I’m retired so I was able to do this. I looked this up. There is a doctor who researched and wrote this up. (A woman, maybe from Switzerland).
    I handed a hard copy of the research to my then Internist. He handed it back to me. He was not interested in learning how difficult the problem was and helping future patients. He is no longer my doctor.
    After kicking the habit, I went to a sleep specialist. She commended me for my hard work and said that she works with people to help them get off the diazepams. She said that it was harder to kick this habit than heroin.
    Caryn

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