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Benzodiazepines Abuse and Addiction

Benzodiazepines are a class of sedative, hypnotic, and anxiolytic prescription drugs that act as central nervous system (CNS) depressants. With millions of prescriptions dispensed each year, several benzodiazepine agents are extremely widely prescribed medications. For 2017, the Drug Enforcement Administration (DEA) reported that the five most commonly prescribed benzodiazepines (as well as the most frequently diverted for illicit misuse) were:1

  • Xanax (alprazolam): 45 million prescriptions
  • Klonopin (clonazepam): 29.2 million prescriptions
  • Ativan (lorazepam): 26.4 million prescriptions
  • Valium (diazepam): 12.6 million prescriptions
  • Restoril (temazepam): 7 million prescriptions

Other benzodiazepines include Librium (chlordiazepoxide), Halcion (triazolam), and the drug Rohypnol (flunitrazepam), which is not approved for use in the United States but has been implicated in incidences of illicit use as a “date-rape” drug.2

The Appeal of Benzos

Benzodiazepines—sometimes referred to as benzos—have several clinical uses and are beneficial in treating anxiety, panic disorder, sleep disorders, alcohol withdrawal, and some seizure disorders by inhibiting or slowing down certain types of brain activity.3,4Like other types of CNS depressants, benzodiazepines increase the effects of the inhibitory neurotransmitter gamma-aminobutyric acid, or GABA. The result is a calming and sedative effect, and individuals may be able to sleep better and feel calmer and more relaxed.4

In addition to their therapeutic uses, however, benzodiazepines may be misused non-medically for their ability to elicit a high or to augment/alter the effects of other abused substances.1 In 2018, results from the National Survey on Drug Use and Health (NSDUH) indicated that 5.4 million Americans over the age of 12 had used a benzodiazepine for nonmedical purposes in the past year.5

Benzodiazepines are generally prescribed for the short-term management of certain medical or mental health conditions, as longer-term use (as well as higher-than-recommended doses) may be associated with significantly increased risk of physiological dependence and/or addiction.4 Due to their known potential for abuse and dependence, benzodiazepine drugs are controlled substances in the United States.6

Long-term benzodiazepine use (and misuse) can result in a person requiring increasingly large doses to achieve the desired effects. As patterns of use escalate to overcome this tolerance, people may find that they essentially require continued drug to feel and function normally. This represents the development of dependence which, once established, may result in people experiencing 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.4

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. Additionally though, the drive to continue abusing benzodiazepines may also, like other addictive substances such as cocaine or heroin, be closely tied to a dopamine-mediated reinforcement of use.7

Benzo 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 have used benzodiazepines. 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.8

It’s safe to say that a lot of people use benzodiazepines—both those who use them therapeutically and those who might be misusing them. Benzodiazepines may not be significantly problematic when taken as directed for short periods of time; however, their use is associated with several potential adverse effects, and the risks of experiencing such effects may increase at relatively higher doses or when the drugs are used for longer periods of time.

Adverse Benzodiazepine Effects

Short-term usage of a benzo may impair brain functions and be similar to the symptoms of alcohol intoxication, including:1,3,10

  • Drowsiness.
  • Impaired reaction time.
  • Decreased motor coordination.
  • Slurred speech.
  • Memory loss.
  • Confusion.
  • Disorientation.
  • Depression.
  • Delirium.
  • Paranoia.
  • Potential increased irritability, hostility, aggression.
  • Decreased blood pressure.
  • Slowed breathing.

In addition to the above effects, benzodiazepine misuse can increase the risk of physical dependence and, ultimately, the development of addiction. In addition to the negative effects of benzodiazepines alone, certain health risks—such as cardiovascular and respiratory depression—may be compounded when used in combination with alcohol and certain other drugs, making overdose deaths more likely.10

Overdose Risks

In 2011, the Drug Abuse Warning Network (DAWN), which monitors drug-related emergency department (ED) visits, reported that almost 30 percent of ED visits related to nonmedical misuse of prescription pharmaceuticals involved benzos, and close to a third of those involved Xanax (alprazolam), specifically. Furthermore, from 2005 to 2011, nearly a million ED visits resulted from the misuse of benzodiazepines (either alone or in combination with opioids or alcohol).9

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 2001.11 As mentioned, 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.10

Benzodiazepine overdose, especially in the context of concurrent opioid, alcohol, or other CNS depressant drug use, can be life-threatening. If an individual is experiencing labored breathing, is cold to the touch, has a weak, slow, or irregular heart rate, has bluish-tinged skin, cannot remain awake, it may be the sign of an overdose, and immediate medical attention should be sought.

When to Get Help

The signs and symptoms of addiction, or a problematic pattern of benzo abuse, may not be quite as immediately recognizable as overdose. Anytime a prescription medication is used for nonmedical purposes (i.e., recreationally) or used outside of the scope of a doctor’s prescription, it may be cause for concern. Individuals may abuse these medications for different reasons.

Examples of nonmedical misuse include using benzos to get high, to enhance the effects of other drugs or alcohol, in an attempt to self-medicate difficult psychiatric symptoms or, even, to induce sleep, reduce stress, anxiety, or muscle tension without a prescription for such treatment.

While it can be important to recognize the signs of problematic use, it can be especially helpful, when possible, to seek the guidance of a professional in making a diagnosis of a sedative use disorder and making appropriate treatment recommendations.

Some of the diagnostic criteria used to make a diagnosis of a sedative, hypnotic, or anxiolytic use disorder (i.e., a benzodiazepine addiction) include:12

  • The benzodiazepine is used at greater doses or for longer periods of time than originally intended.
  • Repeatedly unsuccessful attempts at controlling benzodiazepine use or a persistent desire to curb use.
  • Considerable time and effort is spent to obtain, to continue using, and to recover from the effects of the benzodiazepine (e.g., doctor shopping, forging prescriptions).
  • Social, work, or recreational activities become relatively less important as a result of benzo use.
  • Benzo use continues despite an awareness of adverse physical and psychological consequences.
  • Diminished drug effects over time and/or the need to increase doses to achieve the desired effect.
  • Onset of a withdrawal syndrome when the drug is no longer taken, or a need to continue taking the drug to alleviate withdrawal.

Withdrawal Risks

There is significant physical dependence associated with long-term, compulsive, or otherwise problematic benzodiazepine use. When such dependence develops, there is an elevated risk of experiencing a severe and/or complicated withdrawal syndrome, which can include signs and symptoms such as:4

  • Anxiety.
  • Agitation.
  • Hallucinations.
  • Intense cravings.
  • Insomnia.
  • Racing pulse.
  • Elevated blood pressure.
  • Tremor.
  • Seizures.

Because of the risks, benzodiazepines should not be stopped “cold turkey” or without the supervision of a medical professional after a period of consistent, if not excessive use.4

Benzodiazepine Addiction Treatment

Because of the potential for a markedly unpleasant and potentially risky withdrawal syndrome, treatment for benzodiazepine addiction (or sedative use disorders) often begins with a period of medical detox. It is during this period that the specific agent being used is discontinued with a tapering schedule, or that another benzodiazepine agent (often, a longer-acting one) is first substituted, and then itself tapered. In this manner, an individual may be kept as safe and comfortable as possible in early recovery.4,13

Beyond the detoxification period, there are many different types of rehabilitation 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.

In an inpatient or residential 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. For many, this type of treatment setting provides the most supervision and structure in which recovery efforts can be made.

Each type of drug treatment program will likely prescribe ample amounts of behavioral therapy to help people identify factors that supported their continued drug use and to teach improved coping mechanisms and new life skills to help modify negative behaviors and actions. Counseling, family education, and peer support group participation are also generally included in many drug treatment programming.4

Picking a Treatment Program

Treatment details—in terms of setting, level of intensity, available therapeutic interventions, location—are likely to influenced by several factors, such as the level of physical dependence and the need for relatively intensive medical detox. Though not absolute, more severe or longstanding addictions may benefit from relatively immersive inpatient or residential programs, for example. If available, a thorough evaluation from a physician or other treatment professional can help with making treatment decisions.

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.

References

  1. Drug Enforcement Administration—Diversion Control Division. (2019). Benzodiazepines.
  2. United States Drug Enforcement Administration. (2017). Drugs of Abuse—A DEA Resource Guide: Rohypnol.
  3. United States Drug Enforcement Administration. (n.d.). Fact Sheet: Benzodiazepines.
  4. National Institute on Drug Abuse. (2018). Prescription CNS Depressants.
  5. Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.
  6. United States Department of Justice—Drug Enforcement Administration. (2019). Controlled Substances Schedules.
  7. National Institute on Drug Abuse—NIDA Notes Archives. (2012). Well-Known Mechanism Underlies Benzodiazepines’ Addictive Properties.
  8. Olfson M, King M, Schoenbaum M. Benzodiazepine Use in the United StatesJAMA Psychiatry.2015;72(2):136–142
  9. United States Department of Health & Human Services—Substance Abuse and Mental Health Services Administration. (2014). Benzodiazepines in Combination with Opioid Pain Relievers or Alcohol.
  10. (2019). Commonly Abused Drugs Charts.
  11. (2019). Overdose Death Rates.
  12. Diagnostic and statistical manual of mental disorders: DSM-5.(5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  13. Substance Abuse and Mental Health Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
About The Contributor
Scot Thomas, M.D.
Senior Medical Editor, American Addiction Centers
Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating... Read More