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”
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:
No one should EVER stop a benzodiazepine suddenly without very careful medical supervision! Here is why.
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:
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:
- Fatigue and Tiredness
- Abnormal involuntary movement
- Rapid heart rate
- Blurred vision
- Cognitive disorder
- Muscular twitching
- Impaired coordination
- Memory impairment
- 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:
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.