Prescriptions of benzodiazepines – such as Xanax, Ativan, Valium, and many others – have exploded over the past decade, largely for use in managing anxiety. They are also among the leading drugs of choice for patients coming into treatment at Caron during the pandemic. According to the Wall Street Journal, Express Scripts saw prescriptions for such anti-anxiety medications rise 34.1% between mid-February and mid-March of 2020. But benzodiazepines are highly addictive, dangerous when mixed with alcohol and certain medicines, and difficult and potentially deadly to quit. Not unlike opioids, many people are highly susceptible to developing an addiction to benzodiazepines, without knowing it, simply by following their doctor’s orders.
60 Minutes recently put a spotlight on this largely unrecognized problem. The report touched on a young woman who was on day 240 of the long, slow process to wean herself off benzodiazepines. Detoxing from a benzodiazepine is no joke, and it doesn’t take long to become dependent. In fact, many people don’t realize that going cold turkey can be fatal.
I was an emergency physician for 20 years before I chose to move into addiction medicine, and even I didn't have a real understanding of the long-term effects of benzodiazepines until I saw firsthand the difficulties associated with withdrawal.
Yet millions of people are being prescribed benzodiazepines on a regular basis as a long-term solution without alternative recommendations to address anxiety, education about the class of drugs or an exit strategy. Over 92 million prescriptions were dispensed in 2019, and it’s not just psychiatrists who are doing the prescribing. Prescriptions by primary care physicians more than doubled between 2003 and 2015 and we’ve already noted reports that prescriptions have been on the rise during the pandemic. I expect when we eventually see the full data associated with the percent increase in prescribing it will be significant.
People feel better almost immediately when they take benzodiazepines because the get into the brain and begin to work quickly. In fact, I haven't met a person who told me benzodiazepines didn't work for them. In some cases, small doses for a finite period are appropriate. However, part of what makes them potentially hazardous is that people tend to remain on them for years without understanding the dangers of drug and alcohol interactions or the long-term impact on their body.
The danger of benzodiazepines
Benzodiazepines are addictive. You can become physically addicted to a benzodiazepine, just as you would to heroin or tobacco. You can build up a tolerance to the medication, so the same dose no longer gives you the same effect. People begin taking larger and larger doses, and they begin to experience breakthrough anxiety between doses. With continued use, they become physically dependent upon it.
Physical dependency can happen very quickly, causing you to feel withdrawal symptoms when you stop taking the benzodiazepine. Depending on how long you’ve been on the medication, this can range from transient insomnia to a rebound of your anxiety symptoms, to seizures. For those who have been taking a benzodiazepine for more than a few months, withdrawal can be fatal and needs to be carefully managed.
Mixing benzodiazepines with alcohol or other medicines can be deadly. Benzodiazepines rarely cause death by themselves, but they can be deadly if used with other substances, such as alcohol or opioids.
In fact, approximately 30% of the people who overdose on opioids also have a benzodiazepine in their system. The combination can potentially cause a person to stop breathing.
Withdrawal from benzodiazepine is both painful and dangerous. Benzodiazepines are a dangerous habit to kick. Withdrawal from benzodiazepines can be lethal, as can withdrawal from alcohol abuse. Withdrawal from benzodiazepines must be managed carefully under medical supervision.
Seizures are the most dangerous and potentially fatal withdrawal symptom. Other common symptoms include increased anxiety, panic attacks, insomnia, and dizziness. Basically, it is a rebound of all the feelings they were taking benzodiazepines to address.
Questions to ask a doctor who prescribes you benzodiazepine
The statistics show that doctors are prescribing benzodiazepines on a regular basis for many reasons. One of the reasons for this is that it works, at least for the short term: People feel better immediately. But I don’t think physicians understand how dangerous benzodiazepine can be for long-term use.
People tend to take a doctor’s prescriptions at face value without asking about cautions, possible side effects or alternative therapies. Here are some questions to ask your physician:
What are my other options? There are always other and probably better, safer options to benzodiazepines. Selective serotonin reuptake inhibitors (SSRIs) and even behavioral psychotherapy can be very effective. These alternatives can take longer to work, so perhaps benzodiazepines might be used as a short-term bridge while a second therapy is taking effect for the long term.
What's the exit strategy? This should be first and foremost in the minds of every patient and physician. Benzodiazepines should not be taken long term. They are best used for a specific period while an individual begins other therapeutic practices to address the underlying issues. Unfortunately, I see too many patients at Caron who have been taking a benzodiazepine for years. Anyone who has used benzodiazepine longer than 2 months will probably experience substantial withdrawal symptoms.
What’s our follow-up? Doctors need to monitor patients closely when prescribing benzodiazepines. You should know when you and your doctor are next going to check in about your use of the drug. From my perspective as someone who practices addiction medicine, no benzodiazepine prescription should last longer than 7-10 days.
Could it interact with any of my existing medications? Benzodiazepines are most dangerous when mixed with other medications. Benzodiazepines and opioids are a particularly deadly combination. Doctors should be fully informed of all prescriptions, over-the-counter medications, vitamins, and dietary supplements. It’s also wise to double check with the pharmacist when you pick up the prescription. Doctors should also review the appropriate Prescription Drug Monitoring Program (PDMP) to verify that the patient is not being prescribed medicines by other providers that might cause a dangerous interaction.
Should I drink alcohol while taking a benzodiazepine? Alcohol and benzodiazepines are a dangerous mixture.
Getting off benzodiazepines
One thing you should never do is quit cold turkey. Instead, talk to your primary care physician or the doctor who prescribed the medication. Stopping benzodiazepines should always be done under medical supervision – either on an outpatient or inpatient basis.
As an outpatient, it's a long taper down that can take weeks to several months to complete. On an inpatient basis, the taper can be as short as two weeks, but you're in a medically supervised environment, where you're being monitored regularly. Doctors watch for more dangerous symptoms, such as seizures, and can provide comfort medications to help with the anxiety and insomnia.
In my heart of hearts, as a doctor, I think there is a small role for benzodiazepines. They work, and they work quickly. But the use needs to be limited and temporary: It should be prescribed in a short-term capacity with close monitoring and follow up. For most people, there are better alternatives. I encourage anyone currently taking one or considering taking one to discuss longer-term, healthy strategies for addressing anxiety.
By Joseph Garbely, D.O., DFASAM
By Joseph Garbely, D.O., DFASAM