Benzodiazepines are drugs to help reduce anxiety, cause sedation, as a preanesthetic, with agitated patients, for alcohol withdrawal, and acutely during seizures. When adding a new medication to a patient’s regimen, the practitioner should always ask themselves if the medication could cause more harm than good. The American Psychiatric Association does not endorse using benzodiazepines long-term in the treatment of anxiety, except in very rare instances. When they are used, it is recommended they not be used for longer than 2-4 weeks. If there is a need, lower doses and benzodiazepines with a shorter half-life should be used. The “BEERS CRITERIA,” a guideline that was developed for drugs being used by the elderly, recommends against their use in people over 65 years. ” Benzos” used to be used very commonly, but as time has progressed, it has been found these drugs can often cause more harm than good. Multiple studies have supported this finding.
Since 2010, 6507 overdose deaths have involved benzodiazepines. 124,902 Americans were taken to the emergency room due to xanax alone. In 2011 there were 49 million prescriptions written for xanax alone.
Of the many problems associated with benzos, one of the worst is they are very addictive. It has been shown, that for some, this does not take very long, if they are taken frequently. Some people get addicted in as little as two weeks. Once a patient is addicted, it is very hard to get a patient to stop them. Patients will often say, “This works well for me, and I have never had any problems with it. I have taken it for years and it is the only one that works for me. I have tried many others that did nothing.” Patients often get angry and agitated if the practitioner tries to initiate a conversation about decreasing the use or stopping the medication.
Common side effects that may be experienced can be drowsiness, oversedation, or dizziness. If they drink alcohol with them there is a high risk of overdose/oversedation. In fact, this combination is often joked about in the media. This combination can be a deadly one, for it greatly increases the risk of an accident, or over-dose. This occurs because of central nervous system depression. Using opioids and benzos together increases the risk of overdose and death by over a third. Nonbenzodiazepine drugs such as zaleplon, eszopiclone, and zolpidem (ambien) (the Z-drugs) have similar bad side effects including delirium, falls and fractures, with minimal sleep improvement. When you combine the z-drugs with a benzo, the combination is much riskier with a higher chance of a fall, accident, or overdose.
Unusual behaviors while sleeping can occur, and people will sometime “sleep-walk or sleep-drive” . This has been documented to occur for the first time in people on these drugs for years. Anterograde amnesia has been found to occur, where people start losing the ability to create new memories, and this can lead to partial or incomplete ability to recall their recent past. Feeling drowsy the next day may cause driving to be more impaired. More recent studies have shown people can develop reduced thinking and reasoning ability. If a patient stops these meds suddenly, they can potentially have a life-threatening seizure.
People over 65 years of age, are at greater risk for problems with these medications. Some of the medication can remain in their system much longer, as the liver and kidneys do not excrete or detoxify substances as well or fast as those younger. If they have liver or kidney disease, this can worsen that problem. Dizziness, confusion, unsteadiness or feeling off balance can occur, and it has been shown that falls and fractures occur more commonly in the elderly when on these drugs.
Many herbal supplements and grapefruit when combined with benzos, can greatly increase problems with bad interactions. Among these, kava may increase CNS depression, St. John’s Wort can increase risk of dizziness, impaired thinking, and concentration abilities. Drugs such as 3A4 inhibitors and CYP2C19 may increase benzos effects. (clarithromycin, ketoconazole, nefazodone, fluconazole, or fluvoxamine are examples). They should not be used in pregnancy or with breast-feeding mothers in general. Benzodiazepines are also not recommended for long-term use in general as they become less effective and tolerance is increased. They can actually start causing the very anxiety they are being used to treat. It has been found that long-term, they can change the way the brain functions. Over time, the patient begins to rely on the drug to feel normal. This is called dependence. Other long-term side effects that can happen include cognitive decline, confusion, impaired judgement, increased risk of falls and accidents, memory problems, muscle weakness and slurred speech. Some studies have shown cognitive dysfunction in visuospatial ability, speed of processing, and verbal learning with long-term use. While cognitive function did improve after being taking off the benzo, the patients did not return to their previous level of functioning.
Withdrawal symptoms can include sleep disturbances, rebound insomnia, restlessness, irritability, increased anxiety, weakness, blurry vision, panic attacks, tremors, sweating, flushing, nausea and/or vomiting, headaches, seizures, psychosis, hallucinations and even death. It can take from 4 to 6 weeks, to several months or even up to a year to taper someone off these medications.
In summary, clinicians should reexamine their prescription practices, if they find themselves starting with a benzodiazepine when a patient presents with anxiety or sleep disorder. There are many other choices available, that have less risks, are not controlled substances, and work well to treat anxiety or sleep. If you are a patient who has been on a benzodiazepine frequently for some time, you might want to initiate a conversation with your provider about tapering off this medication and trying a different medication.
Sources: Drugs.com, Psychology Today, “The Hidden Dangers of Benzodiazepine by Christopher Lane, Ph.D”