An epidemic growing silently in the shadow of the opioid crisis.
Although opioid addiction and overdoses are getting most of the headlines, a parallel process is underway with a sharp rise in benzodiazepine prescribing, with significantly higher numbers of prescriptions and dosages being written in recent years. A shared dynamic is connected to the fact that the evaluation of pain, for which opioids might be prescribed, and anxiety, for which benzodiazapines might be prescribed, are both based on the self-report of the patient as opposed to objective measures. This makes it very difficult for physicians to ascertain the risk/benefit ratio when prescribing. Charles Sigler highlights the issues providers are facing...Richard Juman, PsyD
I once knew a woman who had an anxiety disorder. She also abused benzodiazepines. She was able to conjure up a panic attack in a doctor's office and walk out with a prescription for the benzo of her choice. At one time, she had four concurrent prescriptions for these anti-anxiety medications. Another person I know of has a 10-year history of using benzodiazepines, at close to the maximum recommended dose. When he had an unexpected short-term hospital stay, the treating physicians were reluctant to continue prescribing benzodiazepines at such a high level while he was in the hospital. When he returned home, in case his medical issue resulted in another unexpected stay, he put together an emergency hospital kit with various things—including extra benzodiazepines.
A study published in the American Journal of Public Health in April of 2016 found that benzodiazepines were the second most common drug in prescription overdose deaths for 2013. Given the common knowledge of the potential dangers of benzodiazepines and people becoming more aware of opioids, Marcus Bachhuber and a team of researchers thought that their study would show a steady declining pattern for prescribing benzodiazepines. But they found exactly the opposite. Between 1999 and 2013 there was an increase of 30% among adult Americans who filled a benzodiazepine prescription. In addition, the amount of medication within a prescription doubled over the same time period.
Bachhuber was quoted by CNN as saying the study's findings were very concerning. The risk of overdose and death from benzodiazepines alone is said to be generally lower in otherwise healthy adults. But in combination with other drugs like alcohol or opioids, benzos can be lethal.
"Future research should examine the roles of these potential mechanisms to identify effective policy interventions to improve benzodiazepine safety. In particular, as underscored by several recent reports, interventions to reduce concurrent use of opioid analgesics or alcohol with benzodiazepines are needed."
The overdose problem with benzos has been overshadowed by the problems with prescription opioids. Writing for CNN, Carina Storrs said: "The current study could help shine a light on the problem of benzodiazepine abuse and overdose." Dr. Gary Reisfield, a professor of psychiatry at the University of Florida, referred to the problem with benzodiazepines as a "shadow epidemic":
"Much attention has been paid to the explosion of prescription opioid prescribing and the associated morbidity and mortality. Much less attention has been paid to the shadow epidemic of benzodiazepine prescribing and its consequences."
A 2015 study by Jones and McAninch found that emergency department visits and overdose deaths involving opioids and benzodiazepines increased significantly between 2004 and 2011. Overdose deaths from combining the two classes of drugs rose each year from 18% in 2004 to 31% in 2011. This rate increased faster than the percentages of people filling prescriptions and the quantity of pills in the prescriptions.
In "Are We Ignoring an Escalating Benzodiazepine Epidemic?" Dr. Indra Cidambi observed with increasing alarm the rising rate of concurrent use/abuse of benzos among opiate users. She pointed to two possible factors driving this trend. First, some opiate abusers use benzos to "spike" the euphoria from their opiates. Second, patients often receive their prescriptions from two different physicians. She said that it is "notoriously difficult" for doctors to refuse to prescribe these two medications.
"Unfortunately, and ironically, pain and anxiety are neither verifiable nor quantifiable through medical testing! Consequently, self-reported symptoms by patients are the sole basis on which prescriptions for these medications are written, enabling individuals addicted to these medications to obtain them fairly easily."
Dr. Cidambi recommended the establishment of a national database for physicians to verify whether or not a patient has been prescribed one of these medications before prescribing or filling a prescription for the other. Second, she said physicians should develop limited, short-term treatment plans from the beginning to treat noncancerous pain with opiates and anxiety with benzodiazepines.
"Studies have shown the decreasing efficacy of long-term treatment for pain with opioid medications, and evidence-based treatment protocols for benzodiazepines clearly indicate that long-term use of benzodiazepines is not recommended."
In Benzos: A Dance with the Devil, psychiatrist Kelly Brogan described some of her work helping patients taper off of benzodiazepines. A woman who had been placed on Remeron (an antidepressant) and Klonopin (a benzodiazepine) for eight years said of her original prescriber: "He never once told me there might be an issue with taking these meds long-term. In fact, he told me I probably needed them after I tried stopping them cold turkey and felt so sick I thought I was dying." Brogan said no one ever discussed with this woman the true risks, benefits and alternatives to psychiatric medications like benzodiazepines, "perhaps because we as clinicians are not told the full story in our training."
She went on to quote from a paper by another psychiatrist, Peter Breggin, on the risks of benzodiazepines, which include: cognitive dysfunction that can range from short-term memory impairment and confusion to delirium; "disinhibition or loss of impulse control, with violence toward self or others, as well as agitation, psychosis, paranoia and depression." There can also be severe withdrawal symptoms, ranging from anxiety and insomnia to psychosis and seizures after abruptly stopping long-term larger doses. The person can re-experience their pre-drug symptoms as they taper. These so-called rebound symptoms of anxiety, insomnia and others serious emotional reactions can be more intense than they were before drug treatment began. And don't forget dependency or abuse.
Psychiatrist Allen Frances, the former chair of the DSM-IV, recently wrote "Yes, Benzos Are Bad for You." He introduced his article by saying that he was going to say some very negative things about benzodiazepines in the hope that doctors think twice before prescribing them and patients are discouraged from taking them. Benzos were wonder drugs in the 1960s. Anyone remember the 1966 song Mother's Little Helper by the Rolling Stones? These drugs were reputed to be safe, and so were used for a variety of "ills" such as anxiety, alcohol use disorders (yes, really), to take the edge off of agitation in dementia, and to help people sleep. "Initially we were pretty oblivious to the risk of addiction." So benzodiazepines quickly became the most prescribed medications in America.
A second craze began in the 1980s with the release of Xanax. Frances said the dose to treat panic disorder was "dangerously close" to the dose leading to addiction. "This should have scared off everyone from using Xanax, but it didn't." It 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."
Frances said the beneficial uses of benzodiazepines can be counted on the fingers of one hand: treatment for short-term agitation in psychosis, mania and depression; for catatonia; "as needed" use for times of special stress like fear of flying; or for sleep. While they should be used very short term, in real life most people take them long term—"in doses high enough to be addicting, and for the wrong reasons ... Benzos are very easy to get on, almost impossible to get off."
In addition to the harm from overdoses, Frances described the painful and dangerous withdrawal symptoms, which he said are a "beast." Common symptoms are irritability, insomnia, tremors, distractibility, sweating and confusion. "The anxiety and panic experienced by people stopping benzos is usually much worse than the anxiety and panic that initially led to their use." Concurrent use or abuse of alcohol or other drugs, like opioids, complicates withdrawal even further.
The most insidious issue with benzos for Frances is how they affect brain functioning. Especially with the elderly, ongoing benzo use can be devastating. Many elderly begin their downward spiral to death and disability from falls—that often happen from their benzo use! He said: "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." It's been over 30 years since he last prescribed a benzo for anxiety.
"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."
So it was encouraging to see that the FDA will require class-wide changes in drug labeling to bring attention to the dangers of combining opioids and benzodiazepines. The changes will include boxed warnings on nearly 400 products with information on the risks of combining these medications. FDA Commissioner Robert Califf said: "It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together." He implored health care professionals to carefully and thoroughly evaluate on a patient-by-patient basis whether the benefits outweigh the risks when using these drug classes together.
Used alone or in conjunction with opiates, benzodiazepines are potentially lethal and addictive. A too-sudden withdrawal from benzodiazepines can be fatal, where the same is rarely true with opiates. They work quickly and effectively for anxiety and sleep problems and yet they can have a multitude of side effects, including addiction. Using benzodiazepines has become a dance with the devil for too many unsuspecting individuals...those that are still alive to regret it, that is.
About the author
Charles Sigler has over thirty years of counseling experience, primarily with drug and alcohol problems. He has two master's degrees, one in counseling from the University of Pittsburgh and one in religious studies from Westminster Theological Seminary. He also has a D.Phil. from Oxford Graduate School, located in Crystal Springs, Tennessee. He blogs on topics related to addiction and recovery, counseling issues, and religion (thinking God's thoughts) at Faith Seeking Understanding.
The article didn't mention that withdrawal can be fatal -- it should be done very slowly. I knew a guy that died during xanax withdrawal.