While news about the opioid epidemic has captured the public’s attention, “benzo” abuse and addiction is the prescription drug crisis that nobody seems to be talking about.
From a public health standpoint, that’s unfortunate, because roughly 30% of all overdose deaths in America are because of benzodiazepine-class medications. And considering that up to 65,000 fatal overdoses happened in 2015, that there were over 19,000 preventable deaths.
First Things First – What Are Benzo Medications?
“A lot of the focus has been on deaths due to opioid misuse, but research is now showing that many of these people with opioid overdoses have benzodiazepines on board too. So, in order to manage opioid prescriptions, we also have to look at decreasing other risk factors that may be contributing to these dangerous cocktails that cause overdose.”
~Dr. Amy Swift, MD, New York City’s Mount Sinai Beth Israel Hospital
In use for over 60 years, benzo drugs are prescription-only psychiatric medications that are given as minor tranquilizers. Benzos have numerous legitimate medical uses, including as treatment for:
- Panic Attacks and Panic Disorder
- Obsessive-Compulsive Disorder (OCD)
- Insomnia and Other Sleep Disorders
- To Calm Patients before Surgery or Dental Procedures
- Compulsive or Spastic Conditions
- Alcohol Detox
- Alcohol Withdrawal
- Benzodiazepine Withdrawal
The Benzodiazepines List You Need to Know
“For people needing or using benzodiazepines, it seems crucial to encourage physicians to carefully balance the benefits and risks when renewing the prescription.”
~ Dr. Sophie Billotti de Gage, PhD, University of Bordeaux
Because they are prescribed for so many different kinds of conditions, there is an extensive list of benzo drugs approved for use by the US Food and Drug Administration. Some of the more common medications include:
- Conditions: Panic and/or Anxiety disorders
- Alprazolam is the most-frequently-prescribed and most-commonly-abused benzo medication.
- Conditions: Alcohol Withdrawal, Severe Anxiety
- Chlordiazepoxide was first synthesized in the mid-1950s, making it the first benzodiazepine.
- Conditions: Epileptic Seizures, Anxiety
- Unlike most benzo-class medications, Clobazam is approved to treat children.
- Conditions: Panic Disorder, Seizures
- Within an hour after it is taken, Clonazepam begins working.
- Conditions: Insomnia, Anxiety, Epileptic Seizures, Alcohol Withdrawal
- Clorazepate has a half-life of up to 179 hours.
- Conditions: Panic Attacks, Anxiety, Insomnia, Alcohol/Benzodiazepine/Opioid Withdrawal, Anxiety, Stimulant Overdose, Spastic Conditions, Eclampsia
- Between 1969 and 1982, Diazepam was the most-prescribed medication in the country.
- Condition: Insomnia
- Estazolam lengthens sleep duration by reducing/eliminating incidences of nighttime awakening.
- Condition: Insomnia
- Flurazepam has a half-life of up to 250 hours
- Conditions: Anxiety, Insomnia, Alcohol Withdrawal, Seizures, Surgical Amnesia, Chemotherapy-Induced Nausea and Vomiting
- Lorazepam is the second-most-frequently prescribed benzodiazepine.
- Conditions: Anxiety, Insomnia, Medical/Dental Procedure Sedation, Anesthesia
- Midazolam is listed as an “Essential Medicine” by the World Health Organization.
- Conditions: Insomnia, Epilepsy
- Use of Nitrazepam by the elderly can lead to brain disease misdiagnosis.
- Conditions: Insomnia, Anxiety, Alcohol Withdrawal
- Oxazepam has been in use since 1965
- Condition: Insomnia
- Quazepam use results in less tolerance and fewer withdrawal issues than other benzo medications
- Condition: Severe Insomnia
- The Air Force prescribes Temazepam for pilots
- Conditions: Medical/Dental Procedure Sedation, Jet Lag
- Triazolam only puts people to sleep for around two hours.
If you have any of the listed conditions and have been prescribed a benzo medication, it may be time to revisit the conversation you had with your doctor about any associated risks of dependence and addiction.
Is Benzo Abuse REALLY That Big of a Problem?
“Overdoses rose at a faster rate than prescriptions, suggesting that people were using benzodiazepines in a riskier way over time.”
~Dr. Marcus Bachhuber, Assistant Professor of Medicine, Albert Einstein College of Medicine
When considering why the number of benzo-related overdose deaths is so high, we must first look at how prescribing practices and patient behaviors have changed:
- The percentage of American adults filling a benzodiazepine prescription has increased by 37% since 1996.
- The amount of medication in those prescriptions has tripled.
- During that same interval, the rate of benzo-related deaths jumped 500%.
- The death rate due to benzo poisoning continues to rise among Hispanics, African-Americans, and in particular, people over the age of 65.
- Between 5 and 6 MILLION Americans have used a benzo drug non-medically within the past year.
- Approximately 2 MILLION have done so within the past month.
- Since 2004, Internet searches for “Xanax” have almost doubled.
- Every year, there are almost 200,000 new benzo abusers.
- There are over 120,000 benzo-related Emergency Room visits every year.
- That is more than DOUBLE the total in 2005.
- Annually, nearly 60,000 people are admitted to drug treatment because of benzodiazepine tranquilizers.
- In 2003, that number was less than 8000.
Polydrug Abuse Part 1: Benzos and Opioids
“Both benzodiazepines and opiates are brain depressants. Biological interactions… can lead to respiratory failure. Patients taking both benzodiazepines and opioids have a 15-fold increase in risk of death, compared with those who are not taking those medications.”
~Dr. Larissa Loukianova, Medical Director, Comprehensive Pain Rehabilitation Center, Mayo Clinic
In 2011, the Substance Abuse and Mental Health Services Administration reported that benzodiazepine/opioid combinations caused the majority of Emergency Department visits resulting from prescription medication misuse.
- Heroin addicts report that injecting Dalmane and heroin results in a “longer and stronger” high.
- 3 out of 4 heroin addicts have misused benzos within the previous year.
- 1 out of 4 abuse benzos daily.
- 1 out of 3 heroin addicts have had a legitimate benzodiazepine prescription within the previous month.
- 2 out of every 5 opioid maintenance patients have had a benzo prescription within the previous year.
- For perspective—That is EIGHT TIMES HIGHER than the rate for the general population.
- As many as 7 out of 10 people in methadone programs test positive for benzos and half of new admissions need benzo detox.
- 3 out of 4 methadone therapy patients who also abuse benzos report that diazepam boosts the euphoric effects of their methadone dose.
- 94% of methadone clients use benzos within their lifetime.
- Almost 60% of chronic pain patients are regular benzo users.
- In 2001, approximately 9% of patients prescribed opioids also used benzo drugs.
- By 2013, that percentage had nearly doubled – to 17%.
The use of benzodiazepines is a more accurate predictor of subsequent prescription opioid abuse than actual chronic pain.
Why Are Benzo-Opioid Combinations So Dangerous?
“You definitely should not be using benzos with opioids. They’re both overused, and the danger of both together is way worse than the danger of opioids alone.”
~Dr. Gary Franklin, Medical Director, Washington State Department of Labor and Industries
75% of all overdoses involve multiple substances, as do 98% of those that are fatal.
Benzo drugs and opioids are both respiratory depressants, and when they are combined, the effect is magnified – resulting in quicker-presenting and longer-last breathing difficulties. The tragic result can be respiratory failure.
In fact, benzodiazepines are involved in up to 80% of all heroin, buprenorphine, and methadone-related deaths. Moreover, between 2005 and 2011, there were almost 250,000 Emergency Room trips resulting from benzo-opioid combinations.
Another hazard is due to the fact that people who concurrently use benzos and opioids tend to have a longer history of abusing opioids – especially at higher doses. They also are more likely to abuse even more drugs than those people who “only” abuse opioids.
Benzodiazepines, Opioids, and Mental Illness
“Mood disorders increase vulnerability to addiction and vice versa in a circular relationship the National Institute on Drug Abuse terms ‘overlapping conditions—shared vulnerability.’”
~ Dr. Lynn R. Webster, MD, Lifetree Clinical Research & Pain Clinic, Salt Lake City, Utah
Mental conditions typically associated with drug use are much more common among individuals who co-abuse both benzos and opioids. Such a person is:
- At TRIPLED risk of psychiatric hospitalization.
- At DOUBLED risk of needing a prescription medicine for severe emotional problems, such as suicidal thoughts.
- More likely to suffer with anxiety and/or depressive disorders.
Polydrug Abuse Part 2: Benzos and Alcohol
“Rather than easing a mild panic attack, the introduction of alcohol may trigger a more intensive attack that requires a trip to a hospital emergency room. In like manner, people who tend to become irritable when taking alprazolam may find that every little thing going on around them causes unreasonable responses of anger that are almost impossible to control.”
~ Dr. Anjana Rao Kavoor
Methadone therapy clients co-abuse benzos are at MUCH greater risk for alcohol abuse – over 80% of benzo/heroin abusers are cross-dependent on alcohol.
This increases the risk of overdose even more, because like benzos and opioids, alcohol is also a depressant. 2005-2011, there were nearly 164,000 Emergency Room trips resulting from benzo-alcohol combinations. In addition, there were another 43,000 trips when ALL THREE substances—benzos, opioids, and alcohol—were involved.
Of special relevance, 40% of these multi-substance emergencies resulted in a “serious outcome”—long-term hospitalization, disability, or even death.
Because alcohol lowers inhibitions, people who take a benzo-class medication to help control their moods may find that drinking has the opposite effect and can trigger an emotional episode.
So the answer to the question asked by so many people new to anti-anxiety meds—“How long after taking benzos can I drink?” is—NEVER.
Why Do People Abuse Benzo Medications and Why Are They So Addictive?
“This is the first demonstration that acute benzodiazepine use can increase dopamine release, supporting its addictive potential.”
~ Dr. Roger Sorensen, the National Institute on Drug Abuse’s Functional Neuroscience Research Branch
To understand addiction, you first need to know about dopamine. Dopamine is the neurotransmitter linked to pleasure, learning, and motivation.
Most drugs of abuse trigger an artificial surge in dopamine production. When the substance is consumed, the resultant surge causes the user to feel extremely pleasurable sensations. From the very first initiation, the user’s brain learns to associate the action – the substance use – with a pleasurable reward. Neurochemical changes happen within the brain, keeping the user motivated to repeat the action.
Benzodiazepines act in a similar fashion. But instead of causing a surge in dopamine production, benzos interfere with the inhibitory neurons responsible for turning production off. This means that the brain’s dopamine switches are, in essence, locked in the “ON” position.
Over time, the switches burn out out—the body stops producing dopamine naturally. The only time the person can feel pleasure—or even function normally—is when there are benzos in their system. They are now drug-dependent.
The Dangers of Long-Term Benzo Use
“…the benzodiazepines may be changing the central nervous system in a way that the anxiety-related features are amplifying.”
~ Dr. Steven Wright, Denver, Colorado
Here’s the thing—this benzodiazepine dependence can develop in as little as two weeks. This is why benzo tranquilizers are generally only considered safe for short-term use. Despite this, however, long-term benzodiazepine use remains a problem. Among benzo-prescribed patients:
- Almost 15% of adults age 18-35 used the medication long-term.
- But among those age 65-80, long-term use increases to over 31%
Long-term benzo use can result in serious problems with your physical and mental health:
- Mental Illness – anxiety, panic attacks, depression, PTSD, suicidal thoughts, hallucinations
- Sleep Problems – insomnia, poor sleep quality, wakefulness
- Cognitive Impairment – shortened attention span, poor memory, verbal difficulty, diminished motor skills
- Increased Cancer Risk – especially of the brain, lung, bowel, breast, and bladder
And all of these risks are in addition to the possibility of developing a Substance Abuse Disorder – dependence, addiction, and overdose.
The Stages of Benzodiazepine Withdrawal
“Benzodiazepines are grossly overprescribed and many people don’t necessarily benefit from them.”
~ Dr. David Juurlink, Head of Clinical Pharmacology and Toxicology at Toronto’s Sunnybrook Health Sciences Center
Benzo dependence is usually accompanied by withdrawal symptoms that manifest whenever the person stops taking the drug. Withdrawal can begin within hours after the last dose is taken.
Benzodiazepine withdrawal syndrome is characterized by distressing, debilitating, or even dangerous symptoms, the mildest of which include:
- Mood Swings
- Increased Anxiety
- Panic Attacks
- Nausea, Vomiting, Dry Retching, and Diarrhea
- Profuse Sweating
- Muscular Tremors. Pain, and Stiffness
However, people who have used benzos long-term and/or at high dosages may experience symptoms severe enough to be potentially life-threatening, including:
- Autonomic Imbalance
- Delirium Tremens
Because of this, benzos should NEVER be discontinued abruptly, and even gradual tapering should ONLY be under the close supervision of medical personnel.
For a more complete list of benzodiazepine withdrawal symptoms, click here.
Benzo withdrawal occurs in three stages:
- Stage I (1-4 Days)—Anxiety and Insomnia
- Stage II (10-14 Days)—Full Withdrawal, during which any or all symptoms may occur
- Stage III (2 months-1 Year)—Prolonged Anxiety and Tension, lessening with treatment
The Bottom Line: Are Benzos Helpful or Harmful?
“In most cases of benzodiazepine dependence, addiction begins with a legitimate prescription.”
~ Tiffany Jones-Rouse, licensed social worker, Baltimore
When it comes to benzodiazepine tranquilizers, there are two things we know for certain –
FIRST, there are millions of people who suffer from legitimate health concerns such as anxiety or insomnia. Prescription benzo medications have a decades-long proven track record of being safe and effective – but only when they are:
- Cautiously prescribed
- Taken as directed
- Never used in combination with opioids or alcohol
- Given as a short-term solution
- Monitored closely by the prescribing doctor
SECOND, when those directives aren’t followed to the letter, the patient is exposed to hazardous that can be life-altering, including dependence, addiction, disability, and even death.
To be perfectly clear – as effective as benzodiazepines are, they are nonetheless dangerously-addictive drugs that are involved in the needless deaths of thousands of Americans every year.
There is a growing discussion that perhaps some of the strategies used to combat the opioid epidemic should be applied to the benzo problem.
- Prescribers need thoroughly screen patients, not only for other current medications – especially opioids or other benzodiazepines –, but also for any personal or family history of alcoholism or drug addiction.
- NEVER prescribe benzo tranquilizers as a first-line solution.
- ALWAYS attempt other therapies first:
- Individual Counseling
- Group Therapy
- Stress Reduction
- Dietary Changes
- Lifestyle Alteration
- OTC Medicines
- Non-Benzo Prescriptions
- Peer Support Groups
- When benzos absolutely MUST be used, they should be prescribed at the lowest dose for the shortest duration possible, with extremely frequent follow-up.
Above all else, there needs to be a paradigm shift in both the medical and patient communities where we move away from the idea that EVERY problem can be permanently alleviated with yet another pill.