WARNING: I will be saying very negative things about benzodiazepines in an effort to force doctors to think twice before prescribing them and to discourage patients from ever using them. However, because withdrawal symptoms can be severe and dangerous, individuals already taking benzos in significant doses on a regular basis should not try to stop or reduce their dose without careful medical supervision. More on this later.
Most new wonder drugs turn out to be not so wonderful once we get to know them better. The family of drugs known as benzodiazepines (commonly called "benzos" for short) were wonder drugs of the 1960s. I and many others welcomed their introduction and began prescribing Valium or Librium not just for anxiety, but also for all sorts of other clinical problems beyond this primary indication -- for instance, to soothe psychotic patients' symptoms, to help people with alcohol use disorders quit drinking, to take the edge off agitation in depression and dementia, and to aid sleep. Benzos were reputed to be safe, and initially we were pretty oblivious to the risk of addiction. Before long, benzos became among the most frequently prescribed medications in America.
A second benzo craze began in the1980s when Xanax became the new wonder drug. Its maker, Upjohn (then run by a former head of the NIH), fashioned a brilliant marketing strategy -- hiding the company's wolfish greed for profit under the sheep's clothing of research sponsorship. Upjohn was able to co-opt the top academic psychiatrists from all around the world by organizing the first large-scale international clinical trial of any psychiatric drug. The results were disturbing to me as an outside observer. By then I had wised up to the great risk of benzos and was not surprised to discover that the dose of Xanax needed to treat panic disorder was dangerously close to the dose needed to result in addiction. This should have scared off everyone from using Xanax, but it didn't. Xanax quickly became, and remains, a best seller.
The real wonder of the benzos is that sales continue to boom, despite their having so little utility and no push from pharma marketeering (because patents have run out - thereby decreasing costs and profits.) Between 1996 and 2013, the percentage of people in the U.S. using benzos jumped more than one-third from an already remarkable 4.1 to 5.6 percent. Especially troubling is that benzo use is ridiculously high (nearly one out of ten) in the elderly, the group most likely to be harmed by them. (See below.) And women are twice as likely as men to be given a prescription.
You would expect such a ubiquitous drug to have many clinical uses but you would be wrong -- the psychiatric indications for benzos can be counted on the fingers of one hand. While benzos do wonders for patients with catatonia, this disorder is rarely encountered. Benzos are also useful short-term for severe agitation in psychosis, mania, and depression. And they are sometimes helpful for patients with severe panic disorder who need instant relief in the several weeks before SSRI's kick in. Benzos would be fine for occasional "as needed" use in times of special stress or insomnia. But since you can't predict who will get hooked, it is wise not to try them at all for this purpose. In my opinion, all of the legitimate indications for benzos are very short term. However, in real life most people take them long term, in doses high enough to be addicting, and for the wrong reasons.
Benzo popularity derives from their ability to quickly relieve anxiety, reduce worry, help people relax, and lubricate social anxiety -- kind of like drinking alcohol but in a convenient pill form. Doctors love prescribing benzos because it's the most efficient way to get a complaining patient out of the office in the shortest possible time. The patient is very satisfied at the moment, but may go on to develop a devastating addiction. People love taking them but once hooked can't stop. In short, benzos are very easy to get on, almost impossible to get off.
Benzos harm in three ways -- most dramatic dangers are deadly overdoses. Between 1996 and 2013, the death rate from benzo overdoses exploded by more than 500 percent, from 0.58 per 100,000 people to 3 per 100,000. Benzos are now involved in more than 30 per cent of all overdose deaths, usually in combination with opioids or alcohol.
Second on the list of harms come the painful and dangerous withdrawal symptoms that foster addiction. Benzo withdrawal is a beast- often terrifying, sometimes dangerous, and almost always drawn out over a very long period of time. The anxiety and panic experienced by people stopping benzos is usually much worse than the anxiety and panic that initially led to their use. Other common symptoms are irritability, insomnia, tremors, distractibility, sweating, and confusion. At the extreme, if doses were high and discontinuation is quick, the symptoms resemble alcoholic delirium tremens with hallucinations, psychosis, seizures, and the risk of death. Withdrawal is made even more difficult if, as is common, benzo dependence is complicated by concomitant abuse of alcohol and/or opioids or other drugs. Most people fail in their first attempts at withdrawal. Success rates increase if the withdrawal is done very gradually over a period of many months. Careful medical supervision is always a must.
Third and most insidious, but still very damaging, are the day-to-day impacts on brain functioning. On-going benzo use can be devastating, especially in the elderly, who (bizarrely) are the group most likely to receive a benzo prescription. If you meet an elderly patient who seems dopey, confused, has memory loss, slurred speech, and poor balance, your first thought should be benzo side effects -- not Alzheimer's disease or dementia. Many elders begin their downward spiral to disability and death after a benzo-induced fall that results in broken hips, concussions, or subdural hematomas (a collection of blood outside the brain.) Benzos are also a major risk factor for car and machine accidents.
Easier said than done. Along with opioids and methamphetamine, benzos are the most seductive of drugs. The combination of benzos and opioids is especially seductive and especially deadly. In my book, no one with any history of substance abuse should ever be prescribed a benzo. It will most likely just get added to the mix.
Benzos should never be used as they are most typically used. While safe and effective in low doses for just a few days, they are ineffective and unsafe when taken, as they usually are, in increasing doses over a long period of time. If prescribed at all in someone who has never used them before, it should be cautiously and with warnings. The time period should be short, the dose low, and quantity very limited at any one time. Real world practice flagrantly violates all these concerns - 90 percent of benzo prescriptions are written, often carelessly, by primary care doctors, who can spend only seven minutes with the patient without giving serious thought to the considerable risk of addiction.
The bottom line is that there is only one way to confidently avoid addiction to benzodiazepines: never start taking them. Since we can't predict who will eventually get hooked, the short term gains are rarely worth the long term risks.
It has been more than 30 years since I last prescribed a benzo for anxiety. In my view, the only legitimate uses in psychiatry now are very short-term relief of catatonia, for severe agitation, and for detox from benzos. For everyone else, risk of addiction outweighs the potential benefit of use.
The tough question is what to recommend for those many unfortunates already suffering the tyranny of benzo addiction. Should they stay the course to avoid the rigors and risks of withdrawal or should they make the great effort to detox? This is an individual decision that can't be forced on someone. But the longer you are on them, the harder it gets to stop, and the cognitive side effects of benzos create more and more dysfunction as your brain ages. The best bet is to stick with a determined effort to detox, however long and difficult, under close medical supervision. On a hopeful note, some of the happiest people I have known are those who have overcome their dependence on benzos.
This article was originally published on Recovery Brands' Pro Talk/Pro Corner
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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