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Anxiety

The Trouble With Benzos

Xanax and related anti-anxiety medications pose hazards when misused.

Key points

  • Benzodiazepines are a class of drugs used to treat anxiety, insomnia, seizures, and muscle spasms.
  • Though they are generally prescribed by a doctor, "benzo" abuse can lead to addiction and overdose.
  • These medications are CNS depressants and can be especially life-threatening when combined with alcohol or opioids.

When I was 8, I remember my parents took me and my older sisters to the drive-in movies to see The Trouble With Angels (with Hayley Mills and Rosalind Russell). The movie was about an all-girls Catholic school run by nuns. The girls looked all innocent and angelic while kneeling in the church pews, but after Mass, they were playing pranks on the nuns, smoking cigarettes in the Bell Tower, and causing all sorts of mischief. It strikes me that The Trouble With Benzos (or benzodiazepines) is similar to The Trouble With Angels. On the surface, these “minor tranquilizers” are meant to bring calmness and ease anxiety, yet benzodiazepines are a class of medications that can be more hazardous than many realize.

What Are Benzodiazepines Used For?

luchschen/iStockphoto
Pills and capsules in medical vial.
Source: luchschen/iStockphoto

It is important to acknowledge that there is a place for benzodiazepines. They are typically prescribed for short-term relief of anxiety or insomnia, are frequently used for episodic panic attacks or flight anxiety, and may also be used to treat some seizure disorders and muscle spasticity. Alprazolam (or Xanax®) is one of the most prescribed psychotropic medications in the United States (nearly 40 million prescriptions written in 2018), and lorazepam (aka Ativan®) also made the top 10 (nearly 24 million prescriptions in 2018). The benzodiazepine class also includes Valium®, Klonopin®, and Librium® as well as others.

In the short term, benzodiazepines can be an effective treatment for anxiety, especially when combined with therapy and other interventions. All too often, however, patients end up taking them for longer periods of time or in greater doses than prescribed; and these medications can also be diverted, sold on the streets, and used to get “high.”

Dangers of Benzos on Their Own

Those who use benzodiazepines long-term may develop a tolerance toward these drugs. Tolerance occurs when the prescribed dose of the medication no longer has the same effect after repeated use, so the person has to use more of the drug to achieve the desired effects. This repeated pattern of needing to take more of the drug can eventually lead to physical dependency on the substance, an exacerbation of side effects, and risk of severe withdrawal when a person attempts to discontinue use.

Undesirable side effects of benzodiazepines can include cognitive deficits, memory loss, blackouts (especially when combined with alcohol or other substances), increased risk of falling or other accidents, as well as impulsivity and suicidal thoughts. Benzodiazepines are central nervous system (CNS) depressants and can worsen depression. Overdose — whether intentional or accidental — is another all-too-real consequence of benzodiazepine use and abuse.

Risks of Mixing Benzodiazepines With Alcohol and Opioids

The likelihood of experiencing adverse outcomes from benzodiazepine use multiplies when combined with alcohol or opioids. Alcohol, of course, is also a CNS depressant, and the concomitant use of these two substances can cause a worsening of depression symptoms. It also can adversely affect judgment and impulse control and can trigger significant cognitive impairments, including blackouts.

Similarly, the combination of benzodiazepines and opioids is well known to be a deadly mixture, as both depress the respiratory system. A 2020 study in JAMA Network discovered that benzodiazepine co-involvement in opioid overdose deaths more than doubled from 8.7 percent in 1999 to 21 percent in 2017.

Benzodiazepines in the Era of Coronavirus

The 2019 National Survey on Drug Use and Health indicates that past-year prescription benzodiazepine use among Americans aged 12 and older was actually falling: from 2.1 percent in 2015 to 1.8 percent in 2019. But a recent report has shown that, during the early months of the coronavirus pandemic, this downward trend may have stopped. The report, from Express Scripts, provides a clue about the prevalence of benzodiazepine use during COVID-19.

The company found that the number of benzodiazepine prescriptions soared by 34.1 percent at the start of the pandemic from February to March of 2020. As rates of anxiety and despair have risen during COVID-19, more Americans may be medicating with benzodiazepines (as well as alcohol and other drugs) to cope with stress and loneliness. The risks of addiction to these substances — along with all of the negative consequences associated with substance use disorders — are likely to continue to rise.

When Xanax® Isn’t Xanax®

While prescribed benzodiazepines do have both their pros and their cons, in the past several years there has been an increase in internet sales of “pressed pills” that can have truly frightening consequences. These pills are made illegally by using pill-presses that mold powder and a binding agent into a bar-shaped tablet. These substances are usually accessed through darknet websites and they may look like Xanax® and may even be marketed as “Xanax®” — but they are not. Instead, these bar-shaped tablets are often cut with other substances, including fentanyl, causing accidental overdose or death to the vulnerable consumer who thinks they are taking an authentic benzo.

How to Treat Benzodiazepine Addiction

If a client has developed a dependency on benzodiazepines, it is critical to reach out to a medical professional who can help provide treatment and support through each stage of the detox process to closely monitor withdrawal symptoms. Stopping benzodiazepines “cold turkey” is not recommended, as withdrawal seizures are common.

Detoxification — which involves physically clearing the substance from the body — can be done at an outpatient or inpatient facility. For motivated clients on lower doses of benzodiazepines, outpatient detox can be accomplished by closely monitoring and gradually lowering the dose of the medication over the course of four to six weeks. For those on higher doses, or for those who have been unsuccessful with previous attempts at an outpatient taper, inpatient detox may be required. Here, they are monitored closely by nurses and other medical professionals, and the medication is tapered based on their daily symptoms of withdrawal.

Common benzodiazepine withdrawal symptoms include: irritability, heart palpitations, insomnia, loss of appetite, fatigue, tremulousness, sweating, and worsening anxiety.

About That Anxiety…

After detox, an individual recovering from benzodiazepine addiction should develop an aftercare plan, which might include residential or outpatient treatment options. This is an opportunity to receive a comprehensive evaluation and to reassess the underlying or co-occurring disorders that might have led to the self-medication and addiction to begin with. Working with a skilled clinician, the individual can engage in therapies to better understand the motivations and triggers for their benzo use, as well as strategies to develop greater resilience in recovery.

Supplementary wellness practices, such as Qi Gong, yoga, meditation, acupuncture, and other mind-body-spirit therapies, can help inspire a greater sense of calm. And, of course, medication regimens — including antidepressants like Selective Serotonin Reuptake Inhibitors (SSRIs) — can help treat the anxiety disorder without reigniting the addiction or encountering further Trouble with Benzos. As Dr. Robert DuPont said in the Journal of Addiction Medicine, “Anxiety is not a benzodiazepine-deficiency disease.” Being anxiety-free and being sober are not mutually exclusive.

References

DuPont, Robert. (2017). “Should patients with substance use disorders be prescribed benzodiazepines?” No. Journal of Addiction Medicine, 11(2), 84-86. https://doi.org/10.1097/adm.0000000000000291

Express Scripts. (2020, April 16). America's state of mind report. https://www.express-scripts.com/corporate/americas-state-of-mind-report

Grohol, J. M. (2019, December 15). Top 25 psychiatric medications for 2018. PsychCentral. https://psychcentral.com/blog/top-25-psychiatric-medications-for-2018

Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/

Tori, M.E., Larochelle, M.R., and Naimi, T.S. Alcohol or benzodiazepine co-involvement with opioid overdose deaths in the United States, 1999-2017. JAMA Network Open, 3(4). https://doi.org/10.1001/jamanetworkopen.2020.2361

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