We’re living through an unprecedented time in America – one of long-term isolation, uncertainty, political strife, financial difficulties and unemployment, among other challenges. Stress and anxiety are near historic levels. In fact, the Census Bureau recently reported that nearly a third of Americans meet the clinical guidelines for anxiety and depression. Many people are managing their anxiety and depression symptoms with easily accessible substances - alcohol, marijuana and digital devices. Because it is the most socially acceptable and readily available, alcohol has become essential for many to manage the roller-coaster of emotions they’re experiencing – a sentiment cemented by sales of alcohol, which have skyrocketed 34% compared to this time last year.
At the same time alcohol use is up, the use of anti-anxiety medication also increased by 34%. Although this statistic demonstrates that people are seeking professional help for mental health concerns, it’s imperative that patients talk to their healthcare provider about their use of alcohol before asking for anxiety, depression or chronic pain medication or to increase an existing prescription. Alcohol use complicates any anxiety and depression diagnosis or management. In addition, mixing alcohol with prescription medicine heightens the effects of both and dramatically increases the chances of accidental overdose and death.
Anxiety and interdose withdrawal
Interdose withdrawal is largely unrecognized, but both physicians and the general public should be aware of it, as one of the main symptoms of interdose withdrawal can present as heightened generalized anxiety.
It’s common knowledge that people addicted to opioids experience horrendous withdrawal symptoms when they try to quit. What’s less well-known is that people using opioids long-term start experiencing mild withdrawal symptoms as it becomes time for their next dose. That’s called interdose withdrawal.
What’s even less well-known is that people experience interdose withdrawal with both benzodiazepine and alcohol as well.
If your anxiety is being treated with a benzodiazepine such as Xanax, over time you're going to need more Xanax to achieve the desired effect. Of course, there's a limit to how much Xanax a doctor will prescribe. Eventually, you will get “breakthrough anxiety” between doses. Because you are no longer taking a strong enough dose, you will begin to withdraw from the Xanax before it is time for your next dose, leading you to experience a rebound of the very anxiety you’re treating.
Alcohol has similar issues. It’s not uncommon to use alcohol as a way to deal with anxiety. The cocktail hour was invented as a way for people to use alcohol as a situational treatment to get over their social anxiety. It works remarkably well as a social lubricant. But alcohol is short-acting, and people build up a tolerance to alcohol very quickly. If someone is self-medicating with alcohol to deal with a generalized anxiety or panic disorder they experience daily, the alcohol will end up causing more frequent panic attacks or a greater anxiety between periods of drinking.
The dangers of mixing medication and alcohol
Special care should be taken not to mix medications like benzodiazepines or sleeping aids with alcohol. The combination can be deadly. It worries me that sales of alcohol and anti-depressants are up simultaneously. It’s likely that people are mixing them without understanding the danger.
There is a fast-acting and inhibitory neurotransmitter found naturally in the body called gamma amino butyric acid, or GABA. The three things that stimulate the uptake of GABA with tremendous efficacy are alcohol, benzodiazepine, and barbiturates. Now barbiturates are not very common these days, so let’s put them aside.
But benzos and alcohol are very common, and if you mix the two together, they have a synergistic and possibly dangerous effect. Alcohol facilitates GABAergic activity, increasing the duration and intensity of the opening of the chloride channel in the brain. Benzodiazepines work through allosteric modulation. They bind to different receptors, but indirectly they increase the frequency of opening the chloride channel. Combining alcohol with benzodiazepines can overload the system and knock out a person’s respiratory drive, where a person simply stops breathing. That’s how people die of inadvertent overdose by mixing benzodiazepines and alcohol.
Either substance might be able to kill someone by itself, but it’s hard to do and not very common. People die of alcohol poisoning, but it takes a massive amount of alcohol. And a massive overdose of benzodiazepine will also kill you. But it doesn’t take very much to kill you when you mix alcohol and benzodiazepine, and, unfortunately, it happens far too often.
Alcohol, sleep, and depression
Many people use alcohol to help them sleep, but here again alcohol is a false friend. Alcohol does help you fall asleep, but it will prevent you from traversing the different phases of sleep correctly. You will fall asleep, but it will be a poorer quality sleep and not the proper amount of deep, REM sleep needed.
Good, quality sleep is unbelievably important to the maintenance of mental health. The longer you go with inadequate sleep, the greater the chance for experiencing anxiety and depression. Sleep is so important and, yet, so underrated in our society. You can get away with less than four hours of deep sleep for one night, but if you're doing it for consecutive nights on end, you will start to experience both depression and anxiety. If you have already underlying anxiety or depression, using alcohol as a sleep aid will make them worse.
Sleep aids are another potential source of drug overdoses. A medication might be called a “non-benzo hypnotic,” but it acts similarly to benzodiazepine in the body, especially when taken with alcohol.
The guidelines for consuming alcohol in a “low-risk” vs. “high-risk” wayare documented by the National Institute for Alcohol Abuse and Alcoholism. I encourage people to take time to educate themselves about alcohol serving sizes. For women and anyone over 65, they should have no more than seven drinks per week. For men who are under 65, it's 14 drinks per week. Most importantly, it’s critical to keep in mind that there is really no “safe” amount of alcohol and that drinking while taking prescription medicine can jeopardize your life.
We are living through complicated times, but there are many productive ways to handle the range of feelings you may be experiencing. While alcohol and benzodiazepines seem like an easy way to escape our stress and anxiety, using alcohol to self-medicate for anxiety and depression is a trap, because no matter how well alcohol works in the short-term, it actually increases your anxiety and depression long term. A better coping strategy is to seek healthy coping strategies – eating right, exercising more, meditating, doing hobbies, etc. If you are feeling anxious or depressed, I encourage anyone struggling to seek professional help to learn how to create an individualized strategy for a healthier path forward.
By Barbara Krantz, D.O., MS, DFASAM, MRO