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

3 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.

    Reply
  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.

    Reply
  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.

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