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A Guide to Benzodiazepines: Types, Side Effects, Use & Abuse, Overdose, Tolerance & Withdrawal and Treatment

Benzodiazepines are a relatively common class of prescription drugs. Pharmaceutical companies introduced benzodiazepines to the market at the start of the 1960s as a safer alternative to a class of sedative drugs called barbiturates. Benzodiazepines do have legitimate medical uses, but they are not without side effects, and some people may abuse them.

Medical Uses of Benzodiazepines

According to Harvard Medical School, the main use of benzodiazepines is the treatment of anxiety and sleep problems. Some doctors may prescribe them to alleviate drug and alcohol withdrawal symptoms or to treat muscle spasms, seizures, or tremors.

Benzodiazepines may be useful for anxiety and sleep disorders in several situations. For example, a doctor may prescribe a few benzodiazepine pills to a patient to use for occasional insomnia as needed. People who have generalized anxiety disorder may also benefit from taking benzodiazepines, and some people may use these drugs to treat temporary anxiety, such as that which occurs before boarding a plane, having a surgery, or during an agitating situation. For people with panic disorder, benzodiazepines can reduce the anxiety that triggers a panic attack.

Researchers have conducted studies to show that benzodiazepines are effective. A review of 24 different studies, published in a 2019 edition of the Cochrane Database of Systematic Reviews, showed that benzodiazepines seem to be more effective than placebos are for the short-term treatment of panic disorder. The authors of the review did caution that these studies did not assess long-term effects or risks like addiction associated with benzodiazepines.

How Benzodiazepines Work

A second review, included in a 2018 publication of Expert Opinion on Pharmacotherapy, analyzed the results of 54 studies and found that benzodiazepines were the most effective class of drug for treating generalized anxiety disorder, showing superiority over both selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors. Based upon research findings, benzodiazepines are useful for legitimate medical purposes.

Aside from their typical use as anxiety-relieving agents, benzodiazepines are routinely used in the treatment of alcohol withdrawal. According to the authors of a report in American Family Physician, benzodiazepines are the drugs of choice for treating withdrawal symptoms. They are effective for treating both seizures and a potentially fatal condition called delirium tremens that can occur during withdrawal.

Types of Benzodiazepines

Types of Benzodiazepines

There are several popular types of benzodiazepines, but according to Harvard Medical School, what they have in common is that they increase the activity of a brain chemical called GABA, which stops the activity of brain cells and creates a calming effect. Where the types of benzodiazepines differ is in how long their effects last, and for which purpose they are most effective.

Below is a list of common benzodiazepine drugs:

·        Xanax This drug takes effect moderately quickly and has effects that are moderate in duration. It is commonly prescribed for anxiety and panic.

·        Librium– With moderate onset of action and long-lasting effects, Librium is used to treat both anxiety and alcohol withdrawal.

·        Klonopin Klonopin’s effects occur within a moderate amount of time, but they are long-lasting, making this drug useful for anxiety, insomnia, seizures, and panic.

·        Valium This drug’s effects appear quickly and are long-lasting, making this type of benzodiazepine effective for anxiety, seizures, and alcohol withdrawal.

·        Ativan Among the benzodiazepines, Ativan has a moderate onset of action and moderately long-lasting effects. Doctors commonly use it to treat anxiety, insomnia, and seizures.

·        Halcion Commonly used to treat insomnia, this benzodiazepine has a fast onset of action with short-lasting effects.

·        Restoril With both moderately long-lasting effects and a moderate onset of action, this drug is prescribed for the treatment of insomnia. 

Benzodiazepine Side Effects

There are various types of benzodiazepine drugs, which, depending upon their features, can be useful for treating anxiety, panic, seizures, insomnia, or alcohol withdrawal. While these drugs are useful for medical reasons, they can produce some side effects. Harvard Medical School reports that the side effects associated with benzodiazepine use can include the following:

·        Drowsiness

·        Coordination and balance issues when taken in larger doses

·        Memory problems

·        Insomnia, the night after taking a short-acting benzodiazepine for sleep

It is also noted that these side effects tend to be more common among older adults when compared to those who are younger. In fact, benzodiazepines may come with significant risks for older adults. A 2014 study in the British Medical Journal found that benzodiazepines were linked to increased risk of Alzheimer’s disease among older adults, especially when they took these drugs for longer than 6 months or took a long-lasting benzodiazepine. 

How Common is Benzodiazepine Use?

The data seem to suggest that benzodiazepine use is on the rise. In 1996, 4.1 percent of adults obtained a benzodiazepine prescription, but this rate has increased to 5.6 percent of adults in more recent years, according to a 2016 edition of the American Journal of Public Health. The quantity of benzodiazepine drugs that doctors are prescribing has also increased.

Unfortunately, benzodiazepine misuse does occur in same cases. Per a 2019 report in Drug and Alcohol Dependence, benzodiazepines and tranquilizers are the third most commonly-abused drugs in the United States, with 2.2 percent of the population misusing this class of drugs.

The United States Drug Enforcement Administration (DEA) classifies benzodiazepines as a Schedule IV Controlled Substance and cautions that people may develop a tolerance to this type of medication. According to the DEA, people may abuse benzodiazepines by seeing more than one doctor for a prescription or by purchasing them from illicit dealers on the street. Among all the types of benzodiazepines, Xanax and Valium are the most likely substances for people to abuse, and they may crush and snort them to become high.

Benzodiazepine Abuse and Addiction

As the DEA has explained, people may abuse benzodiazepine drugs. Abuse is especially likely among those who also use cocaine and heroin, and over time, people who misuse benzodiazepines may develop addictions. If a person does become addicted to benzodiazepines, a doctor or other addiction professional may diagnose an anxiolytic use disorder, which is the clinical term for a benzodiazepine addiction.

Benzodiazepine Abuse and Addiction

Signs of a benzodiazepine addiction can include taking larger doses of benzodiazepines than intended, being unable to cut down on use, spending significant amounts of time seeking or using benzodiazepines, and continuing to use despite serious consequences, such as health problems, trouble at work or school, difficulty meeting family obligations, or relationship conflict.

For instance, a person who is spending hours each day meeting with drug dealers, continuing to use despite marital difficulties, and continually showing up late for work or losing a job because of benzodiazepine use likely meets the criteria for a disorder. 

Benzodiazepine Overdose

Benzodiazepine abuse and addiction are possible despite the fact that these are prescription drugs with legitimate medical purposes, and unfortunately, overdose is also a possibility. According to the DEA, signs of benzodiazepine overdose include clammy skin, shallow breathing, dilated pupils, a weak but fast heartbeat, coma, and even death. According to the 2016 study in the American Journal of Public Health, the benzodiazepine overdose rate has increased from .58 overdoses per 100,000 people in 1996 to 3.07 per 100,000 individuals more recently.

Benzodiazepine Overdose

Fortunately, doctors writing for British Medical Journal Best Practice report that fatal benzodiazepine overdoses are not common, and most deaths are due to breathing problems from combining benzodiazepines with alcohol and opiates. Generally, an overdose results in excessive sedation and amnesia. In large doses, benzodiazepines can result in overdoses characterized by coma and respiratory issues. Treating an overdose involves managing symptoms and sometimes providing assisted breathing with a ventilator if a patient is suffering from respiratory depression. 

Benzodiazepine Tolerance and Withdrawal

Beyond overdose, tolerance and withdrawal are concerns associated with benzodiazepine misuse. One reason that benzodiazepines can become addictive is that people can develop a tolerance to them, meaning that they need more and more of the drug to achieve the same calming effects. In addition, withdrawal symptoms are often present when a person stops using benzodiazepines, because of physical dependence. That being said, tolerance and withdrawal are not considered symptoms of a benzodiazepine use disorder when people are taking these drugs under the care of a doctor.

Regardless of whether a person is taking benzodiazepines as a doctor prescribes or abusing them by taking multiple prescriptions or buying them illegally, withdrawal is likely and can be uncomfortable. According to Harvard Medical School, a person who is undergoing benzodiazepine withdrawal may experience the following symptoms:

  • Irritability
  • Sleep Difficulties
  • Restlessness
  • Feeling weak
  • Pain
  • Blurry Vision
  • Racing Heart

In rare cases, a person who has been taking large doses of a benzodiazepine over a long period of time or who suddenly stops taking a short-acting benzodiazepine will experience severe withdrawal symptoms like seizures or hallucinations. According to a report in The Journal of the Oklahoma State Medical Association, benzodiazepine withdrawal seizures can sometimes result in coma or death. Benzodiazepine withdrawal may therefore be dangerous, and it requires medical intervention. 

Treatment for Benzodiazepine Withdrawal

Benzodiazepine withdrawal is not only uncomfortable; it is potentially dangerous, so medical supervision and intervention is necessary for someone who wants to stop taking benzodiazepines. According to medical experts writing for Australian Prescriber, anyone taking benzodiazepines for upwards of three to four weeks is likely to experience withdrawal when discontinuing the use of these drugs.

In addition, abruptly stopping benzodiazepine use after taking them for as little as one to six months can cause fatal seizures, so it is critical that patients contact a doctor to develop a plan for safely withdrawing and detoxing from these medications.

The standard option for withdrawing from benzodiazepines is to taper daily doses in gradual increments until a patient no longer needs to take the drugs. Per the authors of the report in Australian Prescriber, dose tapering during benzodiazepine withdrawal is generally best achieved over a period of 10 weeks or more. This duration of tapering is linked to long-term abstinence from benzodiazepines. The tapering schedule and reduction in daily doses will depend upon each patient’s unique history, level of dependence, and usual benzodiazepine doses.

Because withdrawal is linked to side effects, doctors may also provide services or prescribe medications to address withdrawal symptoms. For example, they may prescribe medications to address pain, headache, insomnia, nausea, and tremor. According to the research, anti-convulsant drugs are effective during benzodiazepine withdrawal. Patients may also receive behavioral therapies during withdrawal to address returning anxiety and insomnia.

Benzodiazepine withdrawal and detox should always occur under the supervision of a doctor to prevent complications, but detox can be completed in an outpatient setting if patients are committed to reducing their doses and are not high-risk for complications.

For example, a healthy patient with a moderate benzodiazepine dependence can gradually reduce benzodiazepine doses at home, while regularly checking in with a doctor for outpatient appointments to discuss the tapering process and monitor symptoms. On the other hand, those who have been taking large doses of benzodiazepines or who have other risk factors, such as alcohol abuse or severe psychiatric problems, may require hospital admission for treatment of benzodiazepine withdrawal. In a hospital setting, medical staff can taper doses and provide 24-hour care and monitoring.

Alternatives to Withdrawal

While benzodiazepines can be addictive and lead to withdrawal, some people may choose to take these drugs over the long-term instead of discontinuing their use and undergoing the dose tapering process. In some cases, patients may engage in maintenance therapy, in which they take a benzodiazepine with a long half-life while completing other holistic treatments to address benzodiazepine addiction.

Ultimately, the goal with these patients is to stabilize them so they are able to gradually reduce their doses and become abstinent. Maintenance therapy is usually a viable option for people who display significant concerns associated with drug misuse, such as abusing other substances or getting benzodiazepine prescriptions from multiple doctors.

Some patients may take benzodiazepines over the long-term and therefore not undergo withdrawal. In fact, a study of 740 adults experiencing generalized anxiety, panic, or social anxiety found that nearly 90 percent of this sample was comprised of long-term users, meaning they had been taking benzodiazepines for over 12 weeks.

Given the prevalence of long-term use, researchers have assessed the safety of taking benzodiazepines for extended durations.

For instance, a 2020 study in the Journal of Addiction evaluated the cognitive effects of long-term benzodiazepine use. The authors reviewed the results of multiple studies and concluded that there is little evidence that benzodiazepines have a significantly negative effect on cognitive functioning; however, three studies did suggest some level of cognitive impairment, so future research is necessary. The studies included in this review involved long-term users who had been taking benzodiazepines for periods ranging from one year up to nine years. 

Treatment for Benzodiazepine Abuse

Long-term benzodiazepine use may be common and perhaps safe, but benzodiazepines can still be problematic for some people. Those who find that they are abusing their prescriptions, engaging in illegal activities to obtain more drugs, and experiencing negative consequences associated with benzodiazepine use may need treatment for an addiction.

As discussed previously, those who wish to stop using benzodiazepines should consult with a doctor to begin tapering from benzodiazepines, but undergoing this withdrawal and detox process is just the first step in treatment. In order to achieve lasting sobriety from benzodiazepines, it is important to complete behavioral treatments to address the underlying issues that led to addiction.

One such strategy for treating benzodiazepine addiction is the use of cognitive behavioral therapy. This type of counseling teaches people to identify and correct unhelpful thoughts and feelings that are causing distress or impairment. For example, if a person is feeling anxious about everyday situations, cognitive behavioral therapy can provide new ways of thinking that do not lead to such high levels of anxiety. Cognitive behavioral therapy has demonstrated its effectiveness in the research.

A study in the Journal of Consulting and Clinical Psychology found that cognitive behavioral therapy was effective both for treating generalized anxiety disorder and for helping people to stop using benzodiazepines. Of those receiving cognitive behavioral therapy, 75 percent were able to stop benzodiazepine use altogether, compared to only 37 percent of people in a control group. Those who underwent cognitive behavioral therapy were still abstinent at a 12-month follow-up point, showing just how effective this form of treatment can be.

Treatment for benzodiazepine addiction may be necessary for some people, even if they take these medications as prescribed, since the body can develop a dependence upon them with ongoing use. These drugs do have legitimate medical uses, but because they can be misused, it is important to consult with a doctor and exercise caution when taking these medications. It is possible to benefit from benzodiazepine medications when taking them under a doctor’s care, but taking larger doses than intended can cause a clinical condition called an anxiolytic use disorder.

Anyone who uses these medications should assess both the benefits and risks and discuss the best course of treatment with a qualified medical professional. Benzodiazepines may be necessary in some cases, but there are also alternative treatment options that may carry less risk.

Sources & Additional Resources:

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