Back in March, as the COVID-19 pandemic was gearing up in Boston, my neighbor was struggling with anxiety and sleep. My response was, “can’t your PCP just call something in for you?” I still can’t believe these words came out of mouth.
Like many clinical psychologists who specialize in exposure therapy for anxiety, I have a big beef with benzodiazepines. These fast-acting anxiety reducers (e.g., Xanax, Klonopin) are among the most commonly prescribed psychiatric medications in the United States—more than 1 in 20 adults fills a prescription for a benzodiazepine annually (Agarwal and Landon, 2019).
Benzodiazepines help by immediately reducing the physical sensations of anxiety. They are intended to be used short-term, for acute episodes of anxiety. For example, they can be very helpful when used before an outpatient medical procedure or by someone with a fear of flying who rarely needs to fly. They were invaluable in helping my dearest friend dying of cancer get some sleep.
Although benzodiazepines are intended for brief, specific use, as a psychologist specializing in anxiety treatment, I have seen many of my clients use benzos differently. For anxious people, benzodiazepines can work a little too well in the moment and fuel a maladaptive goal of avoiding anxiety.
For example, in the midst of a panic attack, benzodiazepines provide sweet, sweet relief. But just like any form of avoidance, they can make things much worse in the long-term. I’ve seen benzodiazepines undermine people’s ability to learn or use other coping skills to deal with their panic or anxiety symptoms, and ultimately diminish their self-confidence.
I’ve also seen people really struggle with benzodiazepine dependence and withdrawal. They start taking benzodiazepines more and more frequently because they work so quickly, and they are understandably desperate for relief. Normal levels of stress or anxiety start to feel overwhelming because people become used to feeling sedated. They may start to experience strong withdrawal symptoms on days they don’t take a benzodiazepine, including intense anxiety, which leads them to take more, and so on. Thus, paradoxically, the more often they take a benzodiazepine, the more anxious they feel.
Personally, I’ve had a family member who experienced a seizure while driving due to benzodiazepine withdrawal (thankfully, they were not seriously injured, nor did they hurt anyone else). In addition to the horrible withdrawal syndrome, benzodiazepines are increasingly contributing to drug overdose deaths (VanHouten et al., 2019) and have been associated with increased risk of suicide (Dodd et al., 2017).
Symptoms of benzodiazepine withdrawal may include:
· sleep disturbance
· increased tension and anxiety
· hand tremor
· difficulty concentrating
· dry retching and nausea
· heart palpitations
· muscular pain and stiffness
· perceptual changes
While the serious risks associated with benzodiazepine use are quite clear, it is surprising how little we know about benzodiazepine misuse. Misuse can be defined as taking more than prescribed (either more frequently or higher dosage) or taking without a prescription.
Studies in people with substance use disorders report very high rates of benzo misuse (e.g., 27% to 70% depending on the substance and study) (Votaw et al., 2019). However, there isn’t much data available about misuse in people without a substance use disorder.
To better understand benzodiazepine usage in a population without primary substance use diagnoses, my colleagues at McLean Hospital and I recently surveyed 589 people attending the Behavioral Health Partial Hospital Program at McLean (McHugh, Peckham, Björgvinsson, Korte, and Beard, 2020). Most people who attend this program are seeking treatment for depression, anxiety, bipolar disorder, and borderline personality disorder.
We found that:
· 68% reported having a benzodiazepine prescription at some point in their life
· 26% reported misusing benzodiazepines at some point in their life
· People with a history of benzodiazepine prescription had four times higher odds of misusing benzodiazepines than people without a prescription
· Of people who misused benzodiazepines, reasons for misuse included:
o Anxiety (85%)
o Depression (44%)
o Sleep (32%)
o Curiosity (22%)
o Relieve bad memories (18%)
o Recreationally/to get high (12.5%)
o Because someone offered them (12.2%)
o Increase the effects of alcohol (10.3%)
Rates of lifetime misuse in our study (1 in 4 people) were much higher than epidemiological studies (large surveys of the general population), e.g., approximately 7.5% in the National Survey of Drug Use and Health (SAMHSA’s PSAS, 2020). While our study only illustrates the prevalence of misuse within a single general psychiatric clinic, our findings underscore the importance of talking about the potential for benzodiazepine misuse, particularly for those who are receiving benzodiazepine prescriptions, who are at greater risk for misuse.
Of note, most people who misused benzodiazepines reported that when they misused, they most often obtained them from family or friends. Thus, this study also highlights the importance of safe medication storage and disposal.
So back to my neighbor. Given what I know about benzodiazepines, why on Earth did I recommend she try to obtain a prescription? At the time, COVID-19 seemed like a brief, acute, and unusual circumstance. I knew that she needed sleep immediately to be able to effectively use other coping skills and take care of her kids. But now, over three months later, I worry about the risks of long-term use and potential for misuse for her and so many other people struggling with anxiety during this pandemic.
For many people, the potential benefits of benzodiazepines outweigh the risks. But it is crucial for anyone considering benzodiazepines to know the risks and to discuss them with their provider. If you are already taking a benzodiazepine and are considering stopping, tapering off should always be done in consultation with your prescriber.
There are many effective treatments for anxiety and sleep problems that don’t put people at risk for dependence and withdrawal—Exposure Therapy (a main component of Cognitive Behavioral Therapy for anxiety), Acceptance and Commitment Therapy, and others. If you or someone you love is struggling with anxiety, check out some of these resources.
· Anxiety and Depression Association of America—of particular relevance is their page on “Coronavirus Anxiety—Helpful Expert Tips and Resources” and online support group
· SAMHSA’s National Helpline, 1-800-662-HELP (4357)—a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.
To find a mental health care professional near you, visit Psychology Today's therapy directory.
Agarwal, S. D., & Landon, B. E. (2019). Patterns in outpatient benzodiazepine prescribing in the United States. JAMA network open, 2(1), e187399-e187399.
Dodds, T. J. (2017). Prescribed benzodiazepines and suicide risk: a review of the literature. The primary care companion for CNS disorders, 19(2).
McHugh RK, Peckham AD, Björgvinsson T, Korte F, & Beard C. (2020). Benzodiazepine Misuse among Adults Receiving Psychiatric Treatment. Journal of Psychiatric Research, 128, 33-37. https://doi.org/10.1016/j.jpsychires.2020.05.020
VanHouten, J. P., Rudd, R. A., Ballesteros, M. F., & Mack, K. A. (2019). Drug overdose deaths among women aged 30–64 years—United States, 1999–2017. Morbidity and Mortality Weekly Report, 68(1), 1.