By Walter Armstrong
"Killed by Prescription Drugs" was the soundbite that headlined much of the instant media coverage of Whitney Houston's sudden death on Saturday. Some reports even named Xanax, a benzodiazepine, as the culprit; others repeated rumors of a Xanax/Ativan/Valium triple-benzo cocktail. If by Monday, after 24 hours of nonstop Whitney news -- or non-news -- the benzos were set to become the new Rx drug we love to hate, today it appears that medical reality has been, to some extent, restored, with the media reporting that a combination of benzos and booze took her life. But a TMZ story sourced to a law-enforcement officer reported that Houston had what in the context of celebrity culture passes for a genuinely modest set of prescriptions: Xanax, Ibuprofin for pain, Midol for menstrual cramps and the antibiotic amoxicillin for an upper respiratory infection. (A toxicology report will not be available for a month or more.)
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The fact is that Xanax taken on its own is rarely lethal. Benzos in general are simply not very toxic, except when taken in huge amounts -- as in a suicide attempt. The problem with the Death-by-Xanax headlines, then, is that not only are they misleading, but that they also confuse the public, simultaneously obscuring the benefits of this class of sedatives and their more serious dangers: their addictiveness. When prescribed to a chronic addict like Whitney Houston, Xanax and the other benzos are likely to become habit forming -- and downright harrowing to kick.
In certain morning-after eulogies, Houston, who blazed trails as the first African-American R&B singer to take pop music by storm, was likened, talentwise, to Judy Garland, widely regarded by her peers as the world's greatest-ever entertainer. Oddly, it appears the two women's deaths share several distressing details -- both perished at 48, from heart and lung failure due to a combination of alcohol and sedatives, in a bathroom, alone.
The toxicology report on Judy Garland, who died in 1969, revealed that her blood contained the equivalent of 10 capsules of the barbiturate Seconal.
Ironically, when the first benzodiazepines hit the market -- Librium in 1960 and Valium ten years later -- they were hailed as a great advance over barbiturates for the very reason that benzos appeared to be far less toxic and therefore harder to OD on. But just as Seconal, Nembutal and other "dolls" bagged some of Hollywood's biggest hides, including Marilyn Monroe, Jimi Hendrix and Tennessee Williams, so Xanax can claim a star-studded (and growing) roster of RIPs, including, Michael Jackson and Heath Ledger. These and the vast majority of other fatal overdoses involve Xanax taken, not alone, but with a cocktail of other psychoactive drugs and/or alcohol. Anna Nicole Smith OD'd on nine such drugs, including four different benzos.
Xanax, approved in 1980 for the then-brand-new diagnosis of "panic attack," is America's most (over)prescribed psychiatric drug, outpacing even the antidepressants that made us "The Prozac Nation." Every year, doctors write more than 50 million benzo scrips -- more than one per second -- and 11 percent to 15 percent of all adult Americans have a bottle in their medicine cabinet, according to the American Psychiatric Association (APA). While only 1 percent are daily benzo users -- denoting abuse or addiction -- the prevalence of benzos is, somewhat paradoxically, exceptionally high in psychiatric and addiction treatment centers. These very addictive molecules are commonly given to alcoholics and opiate addicts to quell the existential fear and trembling that accompanies withdrawal during detox.
The popularity of benzos can be measured by their blockbuster sales: Xanax is ranked number nine on the list of the nation's top-earning drugs; Klonopin, no. 32, Ativan no. 33 and Valium (still, after 40 years!) no. 51. These rankings are even more remarkable when you consider that all four drugs are available as generics, costing pennies per pill. Are we really, as a nation, that panicked?
Whitney Houston's benzo abuse appears to have resembled that of millions of other Americans -- 80 percent of such abuse involves combining the drug with another substance, most often alcohol, according to the National Institute on Drug Abuse. Similarly, anywhere from 3 percent to 41 percent of alcoholics have reported abusing the sedatives. In fact, benzos have become a mainstay of many styles of drugging -- just what the doctor ordered when coming down off a crystal high, say, or to boost the euphoric effect of smack or Oxy. The addicted mind is ingenious in its rationalizations, and Houston may have thought, as alcoholics do, that a few benzos will get her drunk faster, so she would end up drinking less.
Hand-wringing over America's epidemic of prescription drug abuse has become a familiar gesture, and Houston's death offers a most apt occasion to do so: This so-called epidemic is constituted, almost entirely, by two classes of drugs: opioid-based painkillers, such as Vicodin, OxyContin, percocet and the like and benzodiazepines. Together, they accounted for about 68 percent of the total emergency room visits for pharmaceutical overdoses (1.08 million) in 2009, with opioids first (39 percent, or 416,500) but benzos not far behind (29 percent, or 313,000). Since 2004 alone, benzo emergencies were up by 118 percent, opiates by 140 percent; by stark (if underappreciated) contrast, ER visits related to heroin, cocaine, marijuana and other illegal drugs remained stable or actually decreased. Hospital and treatment center admissions for benzo addiction garnered headlines when the CDC's Drug Abuse Warning Network (DAWN) announced the news last fall because it marked a 300 percent jump in just 10 years.
If the benzos' main selling point was their comparative safety, little attention was paid, early on, to their addictiveness. Yet this serious drawback quickly earned Valium the ironic encomium "mother's little helper." While only a conspiracy theorist would accuse drugmakers of intentionally designing to promote addictiveness, a business model with higher margins than addiction is hard to imagine.
Given how widely benzos are prescribed by doctors and how frequently patients (ab)use them, it is tempting to say that they turn people into addicts. But that charge is off the mark. What benzos do is almost unerringly find their way into the hands of addicts, typically on top of one or some already-established addictions, hastening the disease progression while increasing the risks.
Why is it so easy to become addicted to these sedatives? Partly because they work like a charm, melting that deer-in-the-headlights paralysis that accompanies stage fright or social anxiety, settling nerves, smoothing edginess, delivering the same sensation of "unwinding" as that first drink at happy hour. (I speak from experience.)
As Valium's addictive properties became a black eye, drugmakers aiming to come up with competitors faced a quandary. Because addictiveness is so poorly understood, they could not engineer an addiction-proof benzodiazepine molecule in the same way that, say, they could reformulate a pill to be abuse-proof by making it impossible to crush. What they managed instead was to "improve" the sedative with the usual pharmacological tweaks, making it stronger, faster acting and/or longer lasting. Ironically, these are the very qualities that make mood-altering chemicals more, rather than less, addictive.
The Food and Drug Administration, alert to the drug's habit-forming tendency, approved the sedative only for short-term use. The Drug Enforcement Agency further attempted to put the brakes on runaway abuse by making it a Schedule IV drug. Yet federal regulations can only intrude so far into the pharma-physician-patient triangle. Because the symptoms benzos treat, such as anxiety and insomnia, tend to be sporadic and/or intermittent, most prescriptions are "as needed," which is, for an addict, a minefield of an instruction. "As needed" can morph all too easily into "as wanted." At the same time, the drug's class strength -- its relative safety -- became, in practice, a liability, freeing doctors as it did from the restraints of ethical and especially legal fears.
Like all addictive substances, benzos foster tolerance, which in turn requires you to take more drug for the same effect; upping the dose accelerates dependence, and that way addiction lies.
Yet, in the final analysis, there is one sense in which Xanax did kill Whitney Houston. The active ingredient -- the benzodiazepine molecule -- works its sedative effect by increasing the release of GABA, the most common "inhibitory" chemical in the central nervous system (CNS): the more GABA, the less brain activity -- a desirable end when in the throes of a panic attack, but a hindrance when, say, taking the SATs. At the neuronal level, benzos dial up the sensitivity of the billions of CNS receptors to which GABA binds, intensifying its inhibitory effect.
But when taken with other GABA-inducing drugs (opiates, hypnotics, barbiturates, other benzos and, of course, alcohol), however, the risk of overdose rises exponentially because they all act on the receptor in similar ways and to similar ends. As your CNS is flooded all at once with billions of messages to slow down, the signals necessary to spark activity in the rest of your body fade out. The beating of your heart slows down. Your breathing stops.
Whether this scenario played out in the last minutes of Whitney Houston's life remains to be learned. It would be no surprise if her toxicology report, much like Judy Garland's, showed that her blood contained 10 times the prescribed amount of Xanax. She may have been popping these pills in like fashion for months or even years. She may have done so while consuming large amounts of alcohol. She may have believed that Xanax-and-booze were a healthier substitute addiction for her infamous cocaine addiction, which cost her so dearly in reputation and respect. She may have been right.
The search for a single bullet might be better served by heeding the sage Celine Dion, who told Good Morning America yesterday that she blamed the "bad people and bad influences" of celebrity culture for Houston's death. "What happens when you have everything?" she asked. Whitney Houston might provide a cautionary answer.