The Twelve Problems With Benzodiazepines

Anxiety is one of the most common presenting complaints for people who come to my psychiatric practice.  By the time people with anxiety visit a psychiatrist, they have usually discussed their symptoms with friends and family members, and some have been to their family care physician.  And as a result of these initial ‘consultations’, they often have been recommended or prescribed valium-type medications like Xanax or Klonopin— a class of chemicals known as ‘benzodiazepines.’

There have also been several highly publicized deaths from combining pain pills with benzodiazepines.  The medications are commonly prescribed, and there are a number of misconceptions among laypeople about their proper use.  I’ve written about this class of medications in the past, but given the frequency that they are prescribed and mis-prescribed, the topic deserves another visit.

Most experienced doctors have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are in a lose/lose position.  Why lose/lose?  Because the experienced doctor knows that the options are to do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.

A primary reason for the lose/lose proposition is that the non-medical community associates SSRI’s like Prozac or Zoloft with antidepressants, and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. But in reality, sedatives are useful in some situations, for example acute or short-term anxiety.  But for chronic anxiety, the proper treatment consists of SSRIs or closely-related SNRIs.

Today a new patient requested treatment of her addiction to pain medications. When I asked about other symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are dangerous for opioid addicts, and are intended for short-term use. She assured me that the milligram of alprazolam she is taking doesn’t even do anything, intending to inform me that her medications are not potent enough to worry about. But I took her assurances the opposite way—that she has taken benzodiazepines to the point where even very large doses of the medications have little effect because of ‘tolerance.’

She then said she also has attention deficit disorder and takes amphetamine. I explained that she is doing herself a disservice by taking both amphetamines and benzodiazepines, since benzodiazepines CAUSE attention problems; in fact, that is how they work! Anxiety essentially consists of too much attention to a problem or a fear.  Benzodiazepines treat anxiety by preventing the brain from attending, attaching and remembering.

Anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block memory. Most adults have had the experience of watching an anesthetic medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.”  For minor procedures they experience a loss of memory, not a loss of consciousness.  They transfer to the OR table when asked, but have no recall of doing so because of the benzodiazepine’s effects.   I repeatedly tell students in my university practice to avoid benzodiazepines, if nervous about an important exam.  Amnesia and studying don’t mix!

The patient described above said that she takes stimulants for attention deficit disorder.  Beyond amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.

A related question came to me by e-mail yesterday:

Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.

The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of meds by others suggest that she is asking for a benzodiazepine.

Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”

All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.”  Let’s run through the list of 12 things, just in time for Christmas—and don’t forget to check it twice!

  1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become ‘anxiety.’ Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
  2. Even if the medication is truly helpful, her relief will be short-lived due to tolerance.  The human body quickly adjusts to benzodiazepines (and many other medications) so that a continued effect requires a higher and higher dose. Patients often escalate their dose at some point, no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault; it is simply what these meds do. Dose escalation is difficult to control, once it has begun; patients will call two weeks into a month prescription to report that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
  3. Benzodiazepines turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzodiazepines upon arrival.  Several months later, the most amazing thing happened: the anxiety disorders went away!
  4. A problem specific to patients with addictions is that rather than take sedative medications to achieve the absence of anxiety, they take the medication until they feel relaxed. In other words, instead of seeking normalcy; they seek relaxation. There is a difference between the two states! The mistaken goal is simply a consequence of the conditioning process during addiction. People with addictions don’t often realize that they are seeking ‘fuzziness’— a feeling that people without addictive histories often find uncomfortable.
  5. Again specific to people with addictions, benzodiazepines (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. People with addictions are overly aware of how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
  6. People with addictions who favor one class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed. This phenomenon is called “cross addiction.”
  7. A final concern for people with addictions is that benzodiazepines help preserve the mistaken thought that the person cannot function without taking something.
  8. Benzodiazepines impair driving and working with dangerous machinery. And patients get anxious at work too—making the medications a poor choice. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzodiazepines.
  9. Benzos have been linked to fetal anomalies and early miscarriage.
  10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes a benzodiazepine during the day, he or she will go to bed just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzodiazepines both day and night, tolerance increases even more quickly.
  11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures (and worse) during withdrawal.
  12. Benzodiazepines may calm an anxious person, but they do not generally increase function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings!

I do prescribe benzodiazepines, usually for short-term or intermittent use. Some patients do fine with them, but for others, benzodiazepines are a Pandora’s Box that is best not opened. As a psychiatrist, I often see treatment plans that lead to a mess that I must try to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful;  comments are welcome!

J T Junig

9 thoughts on “The Twelve Problems With Benzodiazepines

  1. Heidi

    The very first doctor I saw for mood swings prescribed me xanax. It only made things worse. However, now that I am being successfully treated for bipolar disorder (on lithium orotate), I can take klonopin intermittently without having any of the problems you discuss here.

    So, as a patient, I basically agree with you – it depends on the person and the situation. I wasn’t complaining of anxiety, I was complaining about labile moods. I needed a mood stabilizer. However, now I sometimes have breakthrough anxiety, and I can recognize the feeling of anxiety as distinctly different, and take the benzo as needed.. which may be a few times a month or a few times a week, depending on how things are going.

  2. Never Again

    I was given Versed/Midazolam for some kind of “anxiety” which I can assure you I was unaware of. Since then I HAVE had anxiety, panic attacks, fuzzy thinking, paranoia and all the other horrid amydala stuff that my brain can dish out. It has gotten slowly better, but if anybody values their brain, especially it seems, those of us with a high IQ RUN, NOT WALK away from any kind of benzo drug. The sheer arrogance of a mid level anesthesia provider is also shocking to me. I forbade the administration of any kind of drug like Versed and got it anyway because “he knows what’s best for me.” So a lifetime of battling a mental disorder (PTSD) is his idea of what’s best for me. Unbelievable.

  3. Melissa Striegel Chamberlin

    I found this article very informative. Being a person who has gone through the addiction cycle to clonazapam, I concur that it is spot on. I did not realize that I had memory issues until I was taken off, and boy were they bad! I was taken off cold turkey, which makes me believe that I was fortunate to not have the issues listed above. What happened in my situation is that I was prescribed 3 pills PRN daily. I did well on that for about 6 months, and then I started squeaking into the next month by getting my script filled early. By the end of this abuse, which I do not recall fully, it is kind of blurry (again, memory issues) I was taking all of my dose right before bed, and when I had a day off, I was taking more than that through out the day so that I could sleep. My life literally fell apart. It took me a good three months to get to the point (after removal of the medication) that I could work one day and return the next and remember where I left off. I became a great note taker and very organized in order to keep my job, which to no surprise (hind site) I ended up losing in the end.

    This medication turned out to be a disaster for me. What I find very surprising is that anytime I mention sleepless nights, doctors turn to Zanex immediately and tell me how great it is. I never go to the doctor for sleepless nights, as I have figured out a sleep hygiene that suits my needs, that does not include medication, but inevitably, the questions about sleep surface during initial appointments with Doctors, and medication is almost always recommended. (I know that there is mention of my addiction in my records, so this sort of pisses me off, but that is a topic that deserves its own blog.) I have struggled with anxiety my whole life, and with good reason, but medication does nothing but dull the senses, and it does nothing about the thoughts that cause the anxiety, except for stop them, until the next dose is needed. Nobody wants to be anxious, nobody. Therapy has done the trick with me, and I have a toolbox of occupational therapy tricks that provide me with relief from my thoughts. It was not an easy transition, and I did have some sleepless nights initially, but that is in my past. There is hope. There is great hope, but it takes work and a trusted ally to guide us through the thought cycles so that we can understand them and change them. This is just my story for anyone that can glean something from it.

  4. Jack

    I have taken Valium 40mg daily for GAD since 1987 with no problems whatsoever. I can attest that after several weeks of use, Valium becomes ineffective as a sedative and as a hypnotic because of tolerance. But importantly, there is no tolerance to the anxiolytic effect, which is why the drug is so useful. I can attest that after tolerance to the sedative and hypnotic effects of Valium has occurred (again, one month for me), there is no effect on memory or coordination.

    Why am I here writing this? I am currently in a foreign country attempting to obtain a stable supply of Valium from a group of doctors who really don’t want to prescribe it. I found this site while learning about the current hysteria concerning benzodiazepines, which reminds me of Reefer Madness. Yes, Valium can be abused, but it can also be used responsibly. It also can be prescribed responsibly.

    It appears that the current hysteria has made it difficult for doctors to prescribe long term use of benzos in more than a few countries. This is genuinely scary. I will be glad to be back in the U.S. where sanity seems to be prevailing and doctors are able prescribe the medicines that help their patients.

    1. admin Post author

      On one of my other blogs (suboxone talk zone) I write about the hysteria surrounding the prescribing of buprenorphine. I can assure you that my thoughts about benzodiazepines are not ‘hysteria’, but are candid descriptions of what I have observed in patients, after 20 years as a physician and neuroscientist.

      All thinking doctors have gone through the mental exercise of considering whether the anxiolytic actions of benzodiazepines can be separated from their other effects. My PhD work in neuroscience helps me read and understand the basic science research surrounding the actions of benzodiazepines in the brain. Benzodiazepines bind to a subunit of the GABA receptor, increasing transmission through inhibitory circuits. The pathways activated by benzodiazepines are responsible for ALL of the effects of those medications.

      In other words, ‘anxiolysis’ and reduced memory go hand in hand. After years of administering benzos IV in the operating room, I believe that the anxiolysis REQUIRES effects on memory— which is consistent with the basic science studies about those medications. Anxiety involves a form of mental obsession— whether over a fear, a hope, a regret, etc– and benzos reduce ‘anxiety’ by reducing the mental attachment that underlies obsession.

      The good news for you, I suppose, is that there are plenty of non-thinking docs out there who will buy into your theory. That, in turn, will guarantee a never-ending line of patients who knock on my door, asking for help with stopping benzos because of a lack of sleep, panic attacks, and the fear of walking down the street unless under the influence of a medication. The first thing I do is congratulate them for their insight, because most people don’t notice the obvious– that their self-confidence has only deteriorated since starting a benzo.

  5. harleybluz

    Oh my god. I have been on Clonazepam for 22 yrs. I was put on it because I was really upset after taking a summer off work when I moved. Felt I didn’t have the skills I needed. I was NOT told that they were addictive and don’t believe, now, that I needed them but did what the Dr. said to do. I’m so angry now. I, of course, grew tolerant and am now so bad I don’t leave my house except for work. I am so afraid to come off this stuff. My Shrink doesn’t want to use the Ashton manual and he is the only shrink in this small town. So now I’m wondering how the hell to get off this awful drug and still be able to keep my job. No time seems to be a good time to come off it. People visiting, Holidays, etc. Wishing I never started it to begin with is pointless. The anger is pointless. The fear is very, very real. I tried once and went back to it within a couple of day. It is truly an evil drug that made me a person I don’t even know. I’m not as sharp, funny or fun as I used to be before this med. I would not recommend this med to anyone.

    1. admin Post author

      I’m very sorry to hear about your plight– a situation that is way too common. Some people find success using the medication Gabapentin as a substitute for the benzodiazepine, and then stopping Gabapentin after a month or two. Gabapentin is essentially an anticonvulsant, and it reduces the brain excitation caused by benzo withdrawal without causing tolerance or dependence. It is not a controlled substance, and I have never seen a patient have problems stopping it. Good luck!

  6. Jennifer J

    We need to warn people of the dangers of benzos.Benzos have caused many people to suffer terrible symptoms that mimic different mental disorders and other illnesses that doctors Won’t even tell us about!People experience tolerance and interdose withdrawals while still on their benzos and some unlucky people will suffer horrific symptoms while trying to slowly taper off of them.People can get benzo withdrawal syndrome and suffer for up to 2 years with debilitating withdrawal symptoms even after they have quit them.Not everyone experiences this from benzos,but people should be warned that this could happen!Benzos can cause horrible neurological damage that can take years to heal from.Educate yourselves so that you or anyone you love can be aware of these drugs and the effects they can cause.I suffered for over a year not knowing wth was wrong with me and my doctor never told me it was benzo related until i caused myself worse damage by quiting cold turkey.I found great benzo groups here on fb and learned so many things about benzos and was shocked that my doctor never told me about any of this!
    Benzo group with great people and lots of information
    Here’s something that explains what benzos do to the brain

    Glutamate and GABA are the brain’s major “workhorse” neurotransmitters. Over half of all brain synapses release Glutamate, and 30-40% of all brain synapses release GABA.

    GABA and Glutamate regulate action potential traffic.

    GABA, an inhibitory neurotransmitter, stops action potentials.

    Glutamate, an excitatory neurotransmitter, starts action potentials or keeps them going.

    Since GABA is inhibitory and Glutamate is excitatory, both neurotransmitters work together to control many processes, including the brain’s overall level of excitation.

    Tranquilizers (Benzodiazepines) increase GABA activity. (Calming the CNS and PNS)

    Alcohol increases GABA activity (Just like benzos).
    Alcohol decreases Glutamate activity but it spikes back higher when the alcohol wears off (hangover, anxiety and tremors the next day).

    Caffeine increases Glutamate activity.
    Caffeine inhibits GABA release. —> (You feel anxious, wired)

    Benzodiazepines effect GABA by unnaturally boosting it’s intake and keeping it elevated (alcohol has the same effect) resulting in sedative, hypnotic, anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties. Conversely, the body produces more Glutamate (taking in higher amounts of Glutamate) to compensate for the now elevated levels of GABA being absorbed. (the body likes to stay in balance.)

    Here is where is all goes wrong..

    Over a long period of time (4 weeks or more) Benzodiazepines slowly down-regulate your GABA receptors since they don’t need to work as hard to utilize large amounts of GABA. (They become lazy, weaken and unnecessary GABA receptors are absorbed back into the body.) At this point Inter-dose withdrawal might start occurring or worse, tolerance of the

    When Benzodiazepine Tolerance hits (the medication starts to fail) your GABA intake slows down and it’s like you’re slowly letting off the brakes on the now elevated Glutamate system. This causes Inter-dose Withdrawal symptoms i.e. anxiety, panic attacks, anger, rage, insomnia, phobias, depression, memory issues, etc. (even though you are taking your medication as prescribed). Doctors will prescribe more of the Benzodiazepine to compensate for this event (Up-Dosing) and some relief may be experienced but your body will adjust and withdrawal symptoms come roaring back. This is an endless cycle which must be avoided. When all else fails your doctor will prescribe an SSRI, Anti-Depressant or SNRI to try to put a band-aid on the symptoms, but it’s too late and you must now come off of the medication.

    Your GABA receptors, now damaged, weak and under-performing due to benzo use (unnaturally forcing high levels of GABA through them), must “Up-Regulate” (heal) back to their original, natural, non-medicated state before they can once again function properly balancing out GABA and Glutamate levels, however your Glutamate receptors are now Up-Regulated (taking in more Glutamate than normal) and these Glutamate receptors must adjust back down (Down-Regulate) for your body and mind to once again perform normally. This imbalance of high glutamate levels and low GABA levels is what causes Inter-dose Withdrawal and the horror of tapering off. Only time and patience can heal GABA receptors once the medication is completely out of your system. Slowly tapering off of your Benzodiazepine over a long period of time is the only safe, logical and bearable method to rid yourself of Benzodiazepines and restore your health. Your GABA receptors must Up-Regulate back to normal and your Glutamate receptors must Down-Regulate back to normal to balance out. Tapering allows this very slow process to begin while slowly reducing benzo levels forcing the body starts healing your remaining GABA receptors and growing new ones.

    If you Cold Turkey (abruptly quit taking) your Benzodiazepine, Glutamate levels spike (no brakes) and the excitatory neurotransmitters go nuts causing insomnia, anxiety, panic, muscle tightness, elevated heart rate, muscle twitches. seizures, psychosis, and many other horrible side effects. Do Not Do This!!

    For most of us it took years to get into this mess (GABA receptor down regulation) and it’s going to take years to get out of it. Try not to fear what side effects might occur as you taper off. Everybody is different therefore the experience of withdrawal, for you, will be different as well. Just take it a day at a time.

    P.S. .5mgs of Klonopin, or .5mgs of Xanax, or 1mg of Ativan are not low doses.. they all equate to 10mgs of Valium.. If you have been taking any of these medications for more then 3 weeks you are already physically dependent and cannot just stop. The record for physical dependency is 9 days. Additionally, some people take years to reach tolerance, some overa decade, while others can hit tolerance in a matter of weeks or less. If you require more and more of the medication to experience a therapeutic effect, you are already in tolerance. Slowly tapering off is your only option. Look up Liquid Titration of Benzo, or Dry Cutting Benzo to start your education. Do not taper faster than 5 – 10% per month. Above all, look up and read the Ashton Manual for more information and safe tapering instructions.

    DO NOT drink alcohol during your taper or for 18-24 months after it has ended!!

    Benzos also heavily impact the Limbic System of the brain causing horrendous depression, OCD like compulsions, overblown states of fight or flight responses, (i.e. over exaggerated startle response) and incredibly wild depressive, hopeless states while experiencing Inter-Dose withdrawal, tolerance of the medication, while tapering off and in recovery.. This brain system also needs to heal back to it’s original, non-benzo state. Some people have compared what benzos do to the Limbic System to a chemical stroke from which it needs to recover.

  7. Pingback: Xanax, I Love You but my Brain Needs to Break Up With You – The Awakened Insomniac

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