Benzodiazepine Addiction and Treatment
Benzodiazepines are among the most prescribed drugs in the US. Over 35 million US adults used these drugs between 2015 and 2016. Among them, over 17% misused the drugs. Most notably, 1.5% had a diagnosis of benzodiazepine addiction.3
In 2008, there were 75 million benzodiazepine prescriptions. The number of prescriptions has surged in recent years. In 2010, about 186,000 people used benzodiazepines for the first time. The number of prescriptions for women is twice that for men.1
What is a Benzodiazepine?
Benzodiazepines or “benzos” are a class of mind-altering drugs. They are available only on a doctor’s prescription. Doctors prescribe them for patients with sleep problems, anxiety, and seizures. Moreover, some of these drugs are used to relax muscles and treat alcohol withdrawal. Examples of most commonly prescribed benzodiazepines in the US are:
In 2017, doctors wrote 45 million alprazolam, 26.4 million lorazepam, 29.2 million clonazepam, 12.6 million diazepam, and 7 million temazepam prescriptions.4
How Do Benzos Work?
Benzodiazepines enhance the activity of a brain chemical called gamma-aminobutyric acid (GABA). GABA is the most abundant brain chemical and has a calming effect on the brain.
During stressful events, brain cells become excited. The brain then increases the production of GABA to signal the brain cells to calm down. For this reason, GABA is called an inhibitory or a tranquilizing brain chemical.
Increased GABA activity induces sleep and relaxes muscles. Moreover, it also causes a temporary loss of memory (amnesia).
Are Benzos Controlled Substances?
Benzodiazepines are Schedule IV Controlled Substances. The DEA categorizes substances based on their approved medical use and addiction potential.
Substances in Schedule IV are less likely to cause dependence. Thus, they have low abuse potential. Other substances in this schedule are Zolpidem (Ambien), Talwin (Pentazocine), and Ultram (Tramadol).
What Are the Side Effects of Benzodiazepines?
Short-term use is generally safe and effective. The risk of side effects increases with the duration of use, doses, and individual factors, such as age. The side effects of short-term use can include the following:
Impaired motor coordination
Decreased energy levels
Problems with thinking
A feeling that you or your surroundings are spinning
Nausea and vomiting
Constipation or diarrhea
High doses of these drugs can cause excessive sleepiness. Other side effects can include:
Rapid mood changes
Hostile and aggressive behavior
Enhanced feelings of wellbeing
Long-term use increases the risk of:
Fractures, especially in older people
Motor vehicle crashes – driving under the influence of benzodiazepines is similar to driving after drinking
Problems with memory, focus, and decision-making – these problems can last months after stopping use
Can You Overdose on These Drugs?
Accidental or intentional overdose can occur. Deaths from the overdose of a single benzodiazepine are rare. However, mixing these drugs with alcohol or opioids significantly increases the risk of death. Compared to oral use, injecting the drug is more dangerous.
The number of emergency department visits involving benzos increased by over 90% from 46,966 in 2005 to 89,310 in 2011.5 In 2013, overdose involving prescription drugs caused 22,767 deaths. About 31% of these deaths involved benzodiazepines.6
An overdose is characterized by excessive sedation and amnesia. Other symptoms of overdose can include:
Low blood pressure
Coma or coma-like state
The risk of overdose is high in older adults. This is because older people commonly use more than one drug. Being older also means issues with clearing the drug from the body. Long-term use is more common in this age group.
Treating an Overdose
Treatment of an overdose is largely supportive. It includes steps to maintain the breathing and heart function of the person overdosing. An antidote for benzodiazepine is available, called flumazenil.
Flumazenil works by blocking benzodiazepines from binding to specific sites in the brain. That way, it prevents or reverses the effects of benzodiazepines. It is injected into your vein or below the skin over several days. However, the use of flumazenil is controversial in chronic users. In chronic users, flumazenil can cause seizures and withdrawal symptoms.
If you think an overdose has occurred, call 911 immediately.
Are Benzodiazepines Addictive?
Although substances in Schedule IV are less likely to cause dependence, benzodiazepines can be addictive if you do not use them properly. Taking them in larger amounts and longer than recommended can cause addiction. Having a history of mental illness also increases the risk of addiction. 4 out of every 10 people who abuse benzodiazepines have an underlying mental illness.8
Between 2015 and 2016, 2.1% of US adults reported misusing the drug at least once in their lifetime. Likewise, 0.2% fulfilled the criteria for benzodiazepine addiction.3 From 1998 to 2008, the number of people seeking treatment for benzodiazepine abuse increased threefold.9
Short-acting and intermediate-acting benzodiazepines carry the highest risk of addiction. You can become dependent on these drugs within a few weeks or months of use. Other risk factors for addiction are:
- Longer duration of use
- A history of anxiety or other mental illness
- High doses
Why Are They Used?
Alprazolam (Xanax), chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), and midazolam
Clonazepam (Klonopin), clorazepate (Tranxene), lorazepam (Ativan), clobazam (Onfi), and diazepam (Valium)
Estazolam (Prosom), flurazepam (Dalmane), quazepam (Doral), temazepam (Restoril), and triazolam (Halcion)
Midazolam (Versed), lorazepam (Ativan), and diazepam (Valium)
- Muscle relaxation
- Alcohol withdrawal
Can a Pregnant Woman Use Benzodiazepines?
1 out of 10 women develops anxiety during pregnancy.10 Among these, up to 26% need benzodiazepines to control anxiety symptoms. Diazepam and oxazepam are the two most commonly used drugs.
The big questions are: Are these drugs safe for use during pregnancy? How will they affect the health of the unborn baby? Will they affect your child’s behavior?
So far, scientific studies have found mixed results. A few studies suggest that use in pregnancy can cause behavioral problems during early childhood. However, other studies have found no such links. An older study suggests that use in pregnancy increases the risk of birth defects, such as cleft palate.11
Doctors recommend avoiding benzodiazepines during pregnancy, especially during the first trimester. However, they may prescribe these drugs if the benefits outweigh the risks. In such cases, your doctor will check your baby’s heart rate and breathing rate.
Types of Benzodiazepines
Benzodiazepines are categorized based on three factors:
How long they stay in the body
Method of use
How fast they show their effects following use
How Long They Stay in the Body (Duration of Action)
The medication stays in the body for 3 to 8 hours. Examples: Triazolam (Halcion), Midazolam (Versed), and Clorazepate (Tranxene).
The medication stays in the body for 11 to 20 hours. Examples: Alprazolam (Xanax), Lorazepam (Ativan), Estazolam (ProSom), and Temazepam (Restoril).
The medication may stay in the body for up to 72 hours. Examples: Chlordiazepoxide (Librium), Clonazepam (Klonopin), Diazepam (Valium), and Flurazepam (Dalmane).
Method of Use (Route of Administration)
Drugs for oral use
Oral tablets, capsules, extended-release tablets, solutions/suspensions, and concentrates. Examples: Xanax, Xanax XR, Klonopin, Tranxene, Librium, Valium, Ativan, Restoril, and Halcion.
Injectable forms are reserved for cases where rapid drug effects are necessary. A doctor may also use these drugs when you are not able to use other forms of drugs because of some reason. These drugs are injected into a vein or muscle. Examples: Valium injection, Ativan Injection.
Drugs for rectal use
Diazepam rectal gel is occasionally used to treat seizures that occur in clusters. This treatment is not for long-term management of seizures or preventing seizures. Examples: Diastat, Diastat Pediatric.
How Fast They Show Their Effects on Users (Onset of Action)
Fast-acting (15 to 30 minutes)
Examples: Alprazolam (Xanax), Diazepam (Valium), Flurazepam (Dalmane), Triazolam (Halcion), and Lorazepam (Ativan).
Ultrafast-acting (shorter than 15 minutes)
Example: Midazolam IV (Midazolam Injection).
Medium-acting (30 to 60 minutes)
Examples: Chlordiazepoxide (Librium), Clonazepam (Klonopin), Clorazepate (Tranxene), and Temazepam (Restoril).
Slow-acting (longer than 60 minutes)
Examples: Estazolam (ProSom), Oxazepam (Serax), and Quazepam (Doral).
Note: The brands ProSom, Versed, Dalmane, and Serax are no longer available in the US.
Mixing Benzodiazepines With Other Substances
Benzodiazepines and Stimulants
Using a combination of stimulants and benzodiazepines is never safe. Doing so can mask the signs of benzodiazepine overdose. Stimulants can increase oxygen demand. Benzodiazepines cause slowed breathing. This can deprive the body of oxygen.
In 2014, Alprazolam was the fourth most common drug involved in cocaine overdose deaths. Likewise, Alprazolam was the fifth most common drug involved in methamphetamine overdose deaths.12
Only a doctor can decide if using a combination is safe for you. For example, in emergencies, a doctor may use a benzodiazepine to counteract the effects of a stimulant.
Benzodiazepines and Opioids
Using benzodiazepines with opioids causes excessive sedation. Moreover, both of these drugs slow breathing. Thus, using a combination can be fatal.
Opioids and benzodiazepines contribute most to overdose deaths involving prescription drugs. In 2010, three-fourths of (prescription) drug overdose deaths mentioned opioids, and about one-third mentioned benzos.13 Alprazolam and diazepam are the top benzodiazepines involved in drug overdose deaths.
Benzodiazepines are the most frequently mentioned drugs in opioid-related overdose deaths. Of all cases of opioid overdose deaths, nearly one-third mention benzodiazepines.14 In 2014, researchers detected Alprazolam in:12
- of hydrocodone overdose deaths 26% 26%
- of oxycodone overdose deaths 23% 23%
- of methadone overdose deaths 18% 18%
Benzodiazepines and Alcohol
People often use these drugs with alcohol. When benzos are abused with alcohol, larger amounts of the drug are more likely to be used. Both of these substances depress brain activity. Thus, combined use can severely affect thinking ability, memory, judgment, and consciousness.
There have been reports of “blackouts” in people combining these substances. Engaging in risky behaviors during a blackout is common. Alcohol is a common finding in benzodiazepine overdose deaths. In 2014, out of 5,946 overdose deaths involving two benzos (alprazolam and diazepam), 1,026 involved alcohol.
Common Misconceptions About Benzodiazepines
Myth: Benzodiazepines are the Primary Treatment for Anxiety
Truth: Most experts agree that SSRIs are the first-line of treatment for anxiety. SSRIs have shown superior results compared to benzodiazepines. Benzodiazepines may be used when SSRIs do not work, or other treatments have failed.
A doctor may prescribe benzodiazepines if the symptoms of anxiety are severe. However, the duration of use is shorter than four weeks. The effects of benzodiazepines decline after 4 to 6 weeks when used for anxiety.
Myth: Benzodiazepines are the Primary Treatment for Insomnia
Truth: Insomnia is a type of sleep disorder. It causes problems with falling or staying asleep. A combination of CBT and relaxation techniques are the first line of treatment for sleep problems. If you have severe insomnia, a doctor may prescribe a benzodiazepine for 1 to 2 weeks.
Benzodiazepines are ineffective for long-term insomnia and late-night insomnia. Besides, stopping use can make your sleep problems worse (rebound insomnia).
Myth: Taking Low Doses of Benzodiazepines Doesn’t Cause Addiction
Truth: Long-term use (longer than 120 days) can cause addiction regardless of the doses you take. Physical dependence is common and often leads to withdrawal symptoms. A person may continue to use benzodiazepines to avoid withdrawal. This further raises the risk of addiction.
Myth: Benzodiazepines Can Be Used in People Who Have PTSD
Truth: Post-traumatic stress disorder (PTSD) is a serious mental health condition. It is common in people who have experienced or witnessed a shocking event. Severe anxiety, nightmares, and flashbacks of the event continue to haunt long after the event has occurred. The Anxiety and Depression Association of America states that 8 million people in America have PTSD.15
Benzodiazepines can give short-term relief from terrifying thoughts and calm a person. Nonetheless, long-term use can cause addiction. It can also make the person more vulnerable to stressful situations. Experts recommend talk therapy, such as CBT for treating PTSD.
Treatments to End Benzodiazepine Use
For someone who has used the drug for 1–6 months, suddenly stopping use can cause potentially fatal seizures. Drugs to treat seizures such as carbamazepine (Tegretol) or pregabalin (Lyrica) may be necessary in such cases.
Other withdrawal symptoms can include:
Prickling pain especcially in the neck and spine
Seeing or hearing things that do not exist
Problems falling or staying asleep
Increased sensitivity to light, sound, or touch
Doctors may use a drug called flumazenil for a rapid withdrawal.
Dose tapering is the process of gradually reducing the dose of an addictive substance. It may be done with talk therapy, such as CBT. Together with CBT, tapering significantly reduces the severity of withdrawal symptoms. Tapering usually lasts 30 to 45 days. However, the duration of tapering depends on how much drug a person has used before starting tapering.
Maintenance therapy is used in heavy benzodiazepine users who cannot tolerate withdrawal. It involves continued use of long-acting variants of the drug. A doctor may replace a short-acting benzodiazepine with a long-acting benzodiazepine. This helps to avoid fluctuations in the blood levels of the drug.
Taking an equivalent dose of diazepam at least 30 days before discontinuing the drug can help heavy users. Doing so has also shown favorable results for people using more than one benzodiazepine. Maintenance therapy is available in residential or outpatient treatment facilities.
It involves checking if a person is visiting more than one provider to get more prescriptions. Doctors can also order a urine test to see if you have taken any drugs other than the prescribed benzodiazepine.
Measures to Ensure Long-Term Abstinence
Once you have stopped taking benzodiazepines, the next step of treatment is to prevent relapse. The three critical components of successful long-term addiction treatment are:
- Strong support system
- High-quality aftercare services
- Continued counseling
Reducing the dose over at least 3 months is more likely to cause long-term abstinence. Relapse rates are low in people who have:
- Used lower amounts of the drug before starting tapering
- Not used alcohol
- No history of seizures or a mental illness
- Have not used any other addictive substance recently
Benzodiazepines are used to treat a wide range of conditions. These include insomnia, anxiety, and seizures.
Short-term use is safe and effective. However, long-term use can cause abuse, dependence, and addiction.
Overdose deaths from benzodiazepines are rare. Deaths usually occur from mixing benzodiazepines with alcohol and opioids.
Treatment for benzodiazepine addiction include medications, talk therapy, and participation in support groups.
- Treatment Episode Data Set. The TEDS Report.