Benzodiazepines are a class of sedative, hypnotic, and anxiolytic prescription drugs that act as central nervous system (CNS) depressants. These drugs are some of the most widely prescribed in the country. The top five prescribed benzodiazepines in 2011, as reported by the Drug Enforcement Administration (DEA) were:
- Xanax (alprazolam): 49 million prescriptions
- Ativan (lorazepam): 27.6 million prescriptions
- Klonopin (clonazepam): 26.9 million prescriptions
- Valium (diazepam): 15 million prescriptions
- Restoril (temazepam): 8.5 million prescriptions
According to Psychology Today, Xanax is the number one selling psychiatric drug in America. Other common benzodiazepines include Librium (chlordiazepoxide), Halcion (triazolam), Doral (quazepam), and the drug Rohypnol (flunitrazepam), which is illegal in the United States due to its illicit use as a “date-rape” drug.
The Appeal of Benzos
Benzodiazepines, or known as benzos for short, are beneficial in treating anxiety, insomnia, panic disorder, and even seizures by slowing down some of the CNS and brain activity related to the fight-or-flight response. Blood pressure, heart rate, respiration, and body temperature are all lowered by benzodiazepines, and the neurotransmitter gamma-aminobutyric acid, or GABA, which acts as a natural tranquilizer calming nerve firings, is elevated. The result is a calming and sedative effect, and individuals may be able to sleep better and feel calmer and more relaxed.
Benzodiazepines are also commonly abused since they reduce tension, and when taken recreationally, they may also produce a high. In 2013, the National Survey on Drug Use and Health (NSDUH) published that 1.7 million Americans over the age of 11 had used a prescription tranquilizer for nonmedical purposes in the month before the survey was administered.
Due to their addictive qualities and high potential for abuse, benzodiazepine drugs are controlled substances in the United States and internationally, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) publishes. Benzodiazepines are generally meant for short-term relief of symptoms, as they are considered highly addictive and potentially habit-forming. For example, the U.S. Food and Drug Administration (FDA) reports that long-term usage of Xanax in high doses (i.e., more than 4 mg a day for more than three months) can lead to dependence.
When someone takes a benzodiazepine drug, the chemistry of the brain may be artificially changed, increasing the production of GABA. Over time, the brain may begin to rely on the drug to stimulate its production and to make less of these natural chemicals on its own. A tolerance can build up, and an individual may need to increase the dosage amount in order for it to remain effective. A physical and psychological dependence may also form. The brain may experience a kind of rebound if the drug is removed suddenly, causing a difficult and even potentially dangerous withdrawal syndrome that may include an increase in the anxiety, insomnia, panic, and seizures that the drug was meant to treat.
Drug cravings and a desire to keep withdrawal symptoms at bay often make it hard for people to stop taking benzos on their own without professional help. Medical and mental health professionals can wean someone off a benzo safely and with few side effects.
Benzo Use, Abuse, and Effects on the Mind and Body
Regardless of the dangers that benzodiazepine drugs may present, the journal JAMA Psychiatry reported that in 2008, approximately 5.2 percent of Americans between the ages of 18 and 80 took a benzodiazepine drug. Twice as many women as men took them, prescription rates rose with age, and close to a quarter of those who took benzos were prescribed long-acting versions of the drugs. In 2011, the Drug Abuse Warning Network (DAWN), which measures emergency department (ED) visits related to drug abuse and drug interactions, reported that almost 30 percent of ED visits related to the recreational use of pharmaceuticals involved benzos, and close to a third of those involved Xanax. The number of people admitted to a public drug treatment program for benzodiazepine abuse or dependency tripled in the 10 years between 1998 and 2008, and the Treatment Episode Data Set (TEDS) also published that 95 percent of these admissions involved more than one drug.
Benzodiazepines are commonly abused with other drugs, especially opioids or alcohol, which increases health complications and risk factors, and heightens the odds for a potentially fatal overdose. In 2013, the National Institute on Drug Abuse (NIDA) reported that around 7,000 people died from a drug overdose involving a benzodiazepine drug, which was four times the number of overdose fatalities in 2001. Benzodiazepines may not be problematic when taken as directed for short periods of time; however, long-term use, or abuse, can create a wide range of physical and psychological issues.
Effects on the Brain
Short-term usage of a benzo may impair brain functions and be similar to the symptoms of alcohol intoxication, including:
- Impaired reaction time
- Potential increased hostility, aggression, violence, and agitation
- Trouble making sound decisions
- Difficulties focusing or paying attention
- Decreased inhibitions leading to potentially risky behaviors
- Suicidal thoughts or actions
- Anterograde amnesia
- Potential delusions or hallucinations when used in large doses
Using or abusing a benzodiazepine for a longer period of time may create further issues in the brain as the chemical makeup is altered and may even be permanently changed. Depression, anxiety, panic, and heightened levels of stress all may be side effects of benzo dependency and withdrawal, and all of these may have been symptoms that triggered the initial prescription of a benzo.
Benzodiazepine abuse may increase the odds for addiction and dependency as well. When someone continuously abuses a psychoactive substance like a benzodiazepine, the reward, motivation, and pleasure centers of the brain are all impacted, and normal functioning may be impaired. It may be more difficult for an individual dependent on a benzo to feel pleasure without the drug, possibly increasing the risk for suicidal or self-harming behaviors.
Long-term benzo usage affects memory, verbal learning, processing speed, and other cognitive functions. Psychiatric Times reports on several studies that used CT scans and other brain imaging techniques to discover that long-term benzodiazepine use makes changes in regions of the brain, such as the amygdala, that are involved in some of these cognitive functions as well as the stress reaction that is suppressed by benzos. The elderly may be particularly at risk for damaging brain regions and memory functions when using benzodiazepine medications, as this population may be prescribed these drugs at higher rates and for longer periods of time than other age groups. Studies published in the British Medical Journal (BMJ) found that benzodiazepine use in older adults increased the risks for developing Alzheimer’s disease, which is the most prevalent cause of dementia.
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Effects on Body Systems
Benzodiazepine use or abuse affects the physical body systems and functions, especially those of the central nervous system. The following side effects are possible:
- Slowed breathing
- Low blood pressure and body temperature
- Slurred speech
- Sedation and drowsiness
- Nausea and/or vomiting
- Ataxia, or staggering gait
- Blurred vision
- Dry mouth
- Increased risk of falls and potential fractures in the elderly
- Cardiac arrest
- Impaired motor skills
- Decreased appetite
- Irregular heart rate
- Muscle weakness
Overdose is a real risk factor of using a benzo recreationally. Individuals may crush tablets to snort or inject the drug, which increases the chances for an overdose, as does mixing a benzo with other drugs or alcohol. Opioids and alcohol are also CNS depressants, and mixing them with benzos can slow down breathing, heart rate, and blood pressure to fatally low levels. In 2011, benzodiazepine drugs were involved in 31 percent of the opioid overdose deaths the American Journal of Preventative Medicine reported.
Abusing a benzo by injection increases all the potential risks that IV drug use incurs, such as a heightened chance of developing an infectious disease from sharing dirty needles, scar tissue at injection sites, collapsed veins, and damage to the heart. Snorting the drug can damage sinus and nasal passages, cause irritation of the skin around the nose, and potentially damage the lungs, leading to respiratory infection or disease.
Benzodiazepines may build up in the fatty tissues of the body, and an individual may inadvertently take too much. The elderly population may again be especially at risk for this, as older adults have slower metabolisms. As a result, benzodiazepines may reach toxic levels more quickly, and this can result in overdose or other health complications.
When to Get Help
If an individual is experiencing labored breathing, is cold to the touch, has an irregular heart rate or chest pain, is experiencing psychosis or extreme confusion, has bluish-tinged skin, cannot remain awake, or is vomiting, it may be the sign of an overdose, and immediate medical attention should be sought.
Recognizing an addiction, or problematic pattern of benzo abuse, may not be quite as simple to identify. Anytime a prescription medication is used for nonmedical purposes (i.e., recreationally) or used outside of the scope of a doctor’s prescription, it is considered abuse, and it may be cause for concern. As of 2011, over 20 million Americans over the age of 11 had abused a benzodiazepine medication at some point in their lifetime, NSDUH and the DEAreported. Individuals may abuse these medications for different reasons. For instance, they may be used to get high, to enhance the effects of other drugs or alcohol, in an attempt to self-medicate difficult psychiatric symptoms, to induce sleep, or to reduce stress, anxiety, or muscle tension.
Some behavioral signs that an individual may be abusing a benzodiazepine include:
- “Doctor shopping” or visiting multiple doctors in order to get more prescriptions
- Changes in personality that are not normal, such as increased aggression, hostility, or violent outbursts
- Taking the drug (found from other sources) after the prescription has run out
- Increased risk-taking behaviors, such as questionable sexual encounters
- Taking benzos without a prescription
- Withdrawal, secrecy, and an increased desire to be left alone
- Enhancing or making up symptoms to obtain a prescription
- Drop in production at work or school
- Mood swings
Regular abuse of a benzo may easily lead to dependence and addiction, which is psychologically characterized by drug-seeking behaviors; an inability to stop using benzos even if the individual desires to; increased amount of time spent getting, using, and recovering from benzo use; lack of interest in activities that were at one time pleasurable; potential increase in criminal behaviors or trouble with law enforcement; possible financial difficulties related to spending money obtaining drugs; trouble fulfilling family, work, or school obligations; using benzos in full awareness, and in spite of, personal, physical, or emotional concerns that the drug usage will exacerbate; and use of benzos in repeated risky or dangerous situations.
Individuals may have regular lapses in memory, periods of confusion, and difficulties concentrating or other cognitive deficits due to chronic benzo abuse or dependence. Family members may notice pill bottles in easy-to-reach locations, or an increased amount of empty bottles in the trash. Depression, anxiety, and suicidal behaviors are frequently emotional signs of addiction to benzodiazepines.
Physically, benzodiazepine addiction and abuse can have outward signs, such as:
- Tolerance to the drug and needing to take more each use to feel the effects
- Withdrawal symptoms when the drug leaves the system
- Drug cravings
- Weight loss due to decreased appetite
- Lack of concern about personal hygiene
- Muscle weakness
- Changes in sleep patterns and energy levels
- Regular symptoms of intoxication (slurred speech, ataxia, vertigo, etc.)
Withdrawal and drug cravings are common symptoms of benzo abuse and addiction. The withdrawal syndrome may include psychosis, rebound anxiety and paranoia, insomnia, irritability, restlessness, and potentially even life-threatening seizures. Benzodiazepines should not be stopped “cold turkey,” or without the supervision of a medical professional. Opting for at-home detox could be a deadly decision; medical detox is always required for benzo withdrawal.
Benzodiazepine Addiction Treatment
There are many different types of drug treatment programs available to help individuals with benzodiazepine abuse and addiction issues. Some are outpatient programs that can range from intensive and highly structured day programs, where an individual receives treatment during the day and returns home at night, to less structured programs with fewer therapy and counseling sessions and the ability to schedule these around other life happenings. Residential treatment is often the best option. In this type of program, an individual will stay at a specialized facility 24 hours a day, seven days a week, for a length of time that is dependent on the specific circumstances. These programs are generally more comprehensive and offer the most structured environment.
Each type of drug treatment program will likely include therapy sessions to determine why an individual has abused drugs and to teach coping mechanisms and new life skills to help modify negative behaviors and actions. Counseling, family education, and peer support groups are also generally included in most drug treatment programs. As stated above, medical detox is needed for benzodiazepine withdrawal. Shorter-acting benzodiazepines may be switched out for longer-acting ones, in some cases, but this is always determined on an individual basis. Other medications are being explored for use during detox. For example, the British Journal of Clinical Pharmacology highlights the potential effectiveness of flumazenil during benzodiazepine withdrawal.
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Picking a Treatment Program
The optimal treatment program will depend on several factors, such as the level of dependency. The more dependent, both physically and emotionally, an individual is, the more comprehensive the treatment program needs to be. Levels of dependency can be influenced by several things, including:
- Length of time using or abusing benzodiazepines
- Amount of benzodiazepine abused with each dose
- Polydrug or co-occurring alcohol abuse
- Method of abuse (ingesting, snorting, or injecting the drug)
- Medical history and biological factors
- Genetics and family history of addiction
- Age at first use
- Co-occurring mental disorder
- Environmental influences
The longer someone has been abusing a benzo, the more of the drug taken each time, snorting or injecting the drug, and use of other drugs or alcohol concurrently can all contribute to a more serious dependency. Personal and genetic influences as well as environmental factors (e.g., highly stressful or unsupportive living arrangements) factor into the choice of treatment. For example, those with unsupportive home environments should likely opt for residential treatment. Individuals with low-stress and supportive environments, or with lower levels of chemical dependency, may be able to work with an outpatient treatment program.
Someone with an anxiety or mood disorder may have double the chance of also suffering from a drug use disorder, NIDA reports. This may be due to an individual attempting to self-medicate mental illness symptoms with substance abuse, or it may be that substance abuse increases mental illness symptoms. Either way, co-occurring mental illness and substance abuse and addiction are common. Since each disorder interferes with treatment of the other disorder, a comprehensive and integrated treatment model that addresses both issues is ideal.
As people grow throughout treatment, their individual needs may change over time. Addiction treatment programs may be modified accordingly, as new evaluations are performed periodically throughout treatment and recovery. The key to any effective treatment program is that it must be customized to each individual, and it must be flexible as the person progresses in recovery.