America Has a Benzo Problem
Everybody talks about the opioid epidemic — rightfully so. But what about benzos?
Ever since benzodiazepines, a.k.a. “benzos,” were introduced in the ’50s and ’60s, primary care physicians and psychiatrists have been handing them out like candy. By the mid to late ’70s, benzos were already some of the most frequently prescribed drugs in the country.
Feeling stressed at work? Here, have some Xanax. Having trouble sleeping? Take a Valium. It’s all fun and games until somebody gets addicted.
Benzos are a class of fast-acting medications usually prescribed for anxiety, panic attacks, and insomnia. The most common ones you’ve probably heard of (and maybe taken yourself) are Xanax, Klonopin, Ativan, and Valium. They work by affecting gamma-aminobutyric acid (GABA) receptors in the brain, thereby slowing down central nervous system activity and resulting in a feeling of relaxation.
They also happen to be extremely addictive and can be dangerous when used incorrectly. Overdose deaths involving benzos increased more than sevenfold between 1999 (1135 deaths) and 2015 (8791 deaths). Everybody’s been talking about America’s opioid epidemic, rightfully so. But what about this benzodiazepine problem?
Despite the risks that a patient may or may not be aware of, the concept of taking a benzo is extremely appealing. Swallow a pill and feel your panic or anxiety melt away soon after. When I was first prescribed Klonopin 14 years ago for panic attacks, I thought it was magic. Why try doing a breathing exercise that takes time and probably won’t even take the edge off when I can take a pill and be positive that I’ll be feeling better right away? I’ll admit, I still feel that way sometimes now when I take my as-needed dose, years and years into taking Klonopin.
The psychiatrist who first wrote the prescription never warned me about any dangers with the drug or its addictive nature. Neither did countless other psychiatrists who I saw throughout the years who continued to prescribe me Klonopin no problem, no questions asked. I know many other people who can say the same.
This class of drugs has become increasingly popular. To give you an idea: The number of adults filling a benzodiazepine prescription in 1996 was 8.1 million. By 2013 (the most recent data we have about this) that number had increased 67% to 13.5 million people.
“People really are looking for a quick fix, and taking a pill to change the way you feel has become normalized,” states Dr. Anna Lembke, medical director of addiction medicine at Stanford University School of Medicine. “Our modern health care system is really well set up to prescribe pills, but not well set up to offer non-medication treatments for mental health disorders.”
What doctors might not have been considering enough when prescribing benzos to these millions of people is how addictive they are. Lembke admits, “When I went to medical school in the ’90s, we didn’t learn anything about addiction, and we weren’t educated to be wary of people becoming addicted to the drugs we were prescribing.”
It wasn’t until about 15 years ago that the problem was really brought to light, as Lembke and countless other doctors were seeing patients becoming addicted... and overdosing.
It’s not just psychiatrists who are prescribing benzos. It’s also primary care physicians. Sadly, it can be extremely hard (and expensive) to get appointments with mental health professionals, so it’s no wonder patients are turning to their PCPs for benzo prescriptions — and that’s a problem.
“It’s hard for a primary care doctor who has a lot of patients to do consistent follow up to see how benzos or antidepressants are working,” says Dr. Jonathan Avery, director of addiction psychiatry at Weill Cornell Medicine and New York-Presbyterian. “[The primary care doctor] is not going to see the person for another year, so they just end up refilling the medication for months and months.”
Herein lies the problem: During this time, even if a patient takes the benzos as prescribed, they can become physically dependent on them. It’s not uncommon for the “as prescribed” to be taking the drug every day, which increases the risk of dependence and addiction, similar to what doctors see happening with opiates.
“You can be addicted without being dependent, and you can be dependent without being addicted. Dependence just speaks to the physiological changes as your body adapts to the presence of the drug,” says Lembke. This includes building up a tolerance (needing to take more of the drug to feel the same effect) or feeling withdrawal symptoms when reducing a dose or stopping the drug.
She continues, “Anybody who takes [a benzodiazepine] daily is likely to get dependent on it, and the longer that they take it and the higher the dose, the higher the risk for addiction.” And that’s not even taking into account the patient’s pre-existing addiction risk. Some risk factors she notes are personal history of addiction, family history of addition, and history of trauma.
“But you can have none of those risk factors and still get addicted through a doctor’s prescription,” she warns.
Tessa, age 32, who declined to share her last name for anonymity, is one of many who have gotten addicted to benzodiazepines having them prescribed. Her first benzo prescription was Ativan, to prevent seizures while withdrawing from alcohol at age 24. At the time, she was also suffering from anxiety and panic attacks, which showed no signs of stopping. At 26, she was prescribed Klonopin to take “as needed” and given a small amount of 10 pills per month. When she moved a year later, her new doctor gave her a prescription for 30 pills per month.
“I was open with my psychiatrist about my addiction history, and she advised me to only take benzos when I had a bad panic attack or difficulty sleeping for multiple nights,” Tessa recalls. “They worked so well. The panic was replaced with a sense of calm and ease, so as soon as I got prescribed 30 per month, I took them everyday because they made me feel like I was floating through life, breezy and weightless.”
On top of her Klonopin prescription, she was also being prescribed Temazepam, another benzodiazepine, primarily used to treat insomnia. She was receiving 90 benzo pills total per month: 30 Klonopin and 60 Temazepam.
Tessa developed a physical dependence on the benzos, and her tolerance grew. Soon, her use turned into an addiction. “I began taking multiple Klonopin or Temazepam pills at a time to chase that same numbing effect,” she says. She became numb not only to her anxiety, but also to external factors. She withdrew from friends and stopped caring about her passions.
“[Benzos] can become an answer to every question. They can become what to do when you’re anxious, but they can slip into what to do when you can’t sleep, what to do when you have a fight, or what to do when you’re bored.”
“I also stopped caring about being sober, then started doing heroin along with the benzos,” she says. “When I was 29, benzos were a full-blown obsession and ruled my life.” Once she ran out of pills, she took to the streets to try to buy more pills, as well as opiates.
“I knew this was a very dangerous combination, as both heroin and benzos are central nervous system depressants, but I didn’t care,” she says.
Taking more pills than prescribed on a regular basis is one of the telltale signs of a forming benzo addiction. Some other behaviors that can be marks of addiction, according to Lembke, are “using [benzos] for indications other than prescribed, hoarding and bingeing, going to multiple doctors to try to find the same or similar prescriptions, and spending a lot of time thinking about using the drug.”
Avery adds, “[Benzos] can become an answer to every question. They can become what to do when you’re anxious, but they can slip into what to do when you can’t sleep, what to do when you have a fight, or what to do when you’re bored. They can fill a lot of roles beyond what were initially prescribed for.”
With all of this known, is there really a “safe” way to prescribe or take benzos?
Both Lembke and Avery agree that they’re best-suited for either short-term acute use or intermittent use.
“I think [benzos] are a great tool when used very short term for emergent situations or very, very intermittently, for example, a once or twice a month when you have a panic attack, if that’s your problem, or if you have a flying phobia and you use it when you get on an airplane,” says Lembke.
Avery seconds the notion of intermittent use for panic attacks or phobias, and also says a good use for a benzo is to help with a patient’s initial treatment process, when they are first starting cognitive behavioral therapy (CBT) and/or waiting for a long-term antidepressant to kick in.
“We really think the treatment for anxiety is CBT or antidepressants, not these benzos, which are sort of a short term band-aid,” he states. As time goes on, you should ideally be taking less benzodiazepines, not more, as your anxiety and other symptoms should ideally be improving through other forms of treatment. “If you find yourself taking the benzodiazepines every day, then I think you have to really rethink your treatment plan,” he says.
Aside from ideal dosing for safety, there’s also the issue of safety when prescribing other medications along with benzos, specifically opiates.
Lembke believes that polypharmacy (taking multiple medications at once) is a main cause of the uptick in benzo overdose deaths. She says, “A lot of polypharmacy patients who are taking benzos are also taking other sedatives, sometimes prescribed by other doctors who aren’t aware of what the patient is taking. Then, the cumulative effect of taking them together is really what drives the overdose risk, even when taken as prescribed.”
This is particularly true with opiates being prescribed in conjunction with benzos. According to Avery, many people who overdose on benzos often have opiates in their system, and vice versa. Of course, there’s also the issue of accidentally taking benzos laced with opiates, which is becoming more of an issue, when buying them illicitly. “As people get cut off from their benzos from doctors, they go to purchase them on the street or from drug dealers, and often you can get contaminated products from that setting,” he says. Many of these illicit pills are laced with opiates, whether the buyer realizes it or not. As you can imagine, Avery’s advice is to not buy benzos off the street.
If you’re reading this and feeling nervous about your own benzo use, or maybe a loved one’s benzo use, be sure to voice your concerns to a doctor and discuss if the way that you use benzos is safe, or if the treatment plan should be altered. You should never stop a drug cold turkey, especially a benzo, as withdrawals can be severe and life threatening. You may experience hallucinations, seizures, and even suicidal thoughts and/or actions. If you and your doctor should decide to discontinue the benzo, a tapering plan will be enacted, and you’ll need to closely monitor symptoms.
As benzo awareness grows, the hope is that doctors across the board will stop overprescribing, will be more conscious of polypharmacy, and will educate patients about the risks of the medication, as well as information on how to safely take it.
There has already been a shift, at least in med school students. “Many medical schools now are trying to incorporate an addiction treatment curriculum and a safe prescribing curriculum,” says Lembke. Stanford has a new addiction medicine curriculum, for example.
“There’s definitely been a shift. There’s a lot more interest and enthusiasm from medical students to learn about addiction, so it’s really nice to see,” she adds. “That’s the silver lining of the epidemic.”