Benzodiazepine abuse and addiction is not the most commonly reported drug abuse issue in America, but it does have far-reaching and devastating consequences. Benzodiazepines are well known in the drug abuse world, and they play a unique role in how they are abused. More women and people aged 65 - 80 are reported to use benzodiazepines on a medical and long-term basis, than men and younger populations, yet their abuse and misuse among younger male populations continue to grow.1 Despite their medical purposes, the wide variety of benzodiazepines have been subject to considerable abuse, leading to dangerous overdoses and deaths in many cases. The abuse potential of benzodiazepines is highlighted in studies, one of which identifies a four-fold increase in benzodiazepine related overdose deaths, from 2002 to 2015.2 Most commonly abused with opioids, benzodiazepines are a powerful ingredient in a deadly cocktail, which has claimed the lives of far too many Americans.
What Are Benzodiazepines?
Benzodiazepine is a long name with a big implication. Also referred to as "benzos" and "tranks", many people have heard of some of the more popular brand names:
There are about thirty different benzodiazepines on the market today, and they are hypnotic, sedative, and anti-anxiety medications. There are a wide range of uses for benzodiazepines, and they come in various strengths, and have varying lengths of activity in the brain. The way benzodiazepines work is by depressing the central nervous system (CNS). The CNS is responsible for most functions of the brain, controlling virtually every aspect of the human body, from movement to sensation. Benzodiazepines specifically enhance the effects of the GABA neurotransmitter, which is largely responsible for sedation, and produces a calming effect on users.
Uses of Benzodiazepines
When used medically and as directed, benzodiazepines have benefits in treating insomnia, anxiety, agitation, panic attacks, mania, and they are commonly used for pre-operative sedation. Because there are so many varieties of benzodiazepines, with many strengths, medical professionals have a wide range of options from which to choose for clinical purposes. Another common use of lower potency and longer acting benzodiazepines are in drug detox. Symptoms like anxiety, insomnia, and agitation are extremely common withdrawal symptoms, which present in virtually every set of drug withdrawal symptoms. Although it is not commonly disclosed in advertisements, many prescription sleeping pills are also benzodiazepines, z-drugs, or contain benzodiazepines as their primary active ingredient. Benzodiazepines have a plethora of positive and beneficial uses for medical purposes and are generally considered to be effective in treating various conditions. However, despite widespread abuse and diversion of benzodiazepines, they are listed as Schedule IV substances by the DEA.3 This scheduling indicates a low potential for abuse of benzodiazepines, a stark contradiction to data and studies worldwide. Although they have significant pharmaceutical uses, benzodiazepines are generally not recommended for long-term treatments, specifically because they are habit forming, even when taken as directed. These drugs can cause dependency on those who use them legitimately, and in those who abuse them, but they are especially dangerous and addictive when they are abused.
How Are Benzodiazepines Abused?
Benzodiazepines, like most depressant drugs are commonly abused because of their sedative and calming effects. When used clinically, these drugs serve an important and short-term purpose for individuals who suffer from a wide variety of conditions. However, benzodiazepines are most commonly abused in conjunction with other drugs, and often exacerbate their depressive effects. Many people abuse benzodiazepines with alcohol and other opioid drugs, whether heroin or prescription painkillers. In fact, the FDA released a warning in September 2017 regarding the combination of benzodiazepines and prescription opioids, citing serious side effects including death. This has prompted the agency to include boxed warnings, the FDA's strongest warning, on all prescriptions for benzodiazepines and prescription opioids.4 Any depressant drug mixed with another drug of the same type can result in catastrophic effects and significantly increase the chance of overdose and death. Some of the most common effects of benzodiazepine combinations with alcohol or opioids include the following:
slowed or labored breathing
loss of consciousness
loss of coordination
Benzodiazepines are not only abused in conjunction with opioids and alcohol, but they are abused to self-medicate, by many people who abuse stimulant and hallucinogenic drugs. This type of abuse often takes place when easing the "come down" after binges on stimulant drugs, like cocaine or crystal meth. Additionally, benzodiazepines are illicitly used to enhance the effects of other drugs like ketamine, and for stabilization during a hard or intense trip from hallucinogens like LSD, or psilocybin mushrooms (magic mushrooms). The abuse of benzodiazepines is extremely pervasive in the United States, ranking third for non-medical use, behind marijuana and prescription opioids. Substance abuse treatment admissions for benzodiazepines alone are very low, while poly-substance treatment admissions involving benzodiazepines are very high, and the number is increasing.5 This further supports the fact that benzodiazepine abuse is most prevalent when abused with other drugs.
Are Benzodiazepines Really Addictive?
There is little debate that benzodiazepines are very helpful and useful medications for a wide variety of medical purposes. When they are abused with opioids or alcohol, benzodiazepines are extremely dangerous. The additional sedative effects of benzodiazepines can easily lead to fatal respiratory depression. When abused on their own, benzodiazepines can also be dangerous, especially the stronger and shorter acting versions, like alprazolam (brand name Xanax ®). Benzodiazepines like these provide a more immediate and intense effect on the user. The risk of dependence on shorter-acting benzodiazepines is also higher because of a greater probability of rebound anxiety, and more severe withdrawal symptoms, upon cessation. Although risks are higher with drugs like alprazolam, all benzodiazepines carry a high potential for dependence, especially when they are used over a long period of time. Despite their effectiveness, chronic and long-term use of benzodiazepines is not recommended specifically because it often leads to increased tolerance, dependence, and decreased effectiveness. Even when they are used as directed for legitimate medical purposes, long-term use of benzodiazepines still leads to dependence. Even if dependence has been developed through legitimate use, extreme care must be taken in efforts to detox from these drugs. The safest and only medically recommended way to reduce, or stop the use of benzodiazepines is to slowly taper the dose, over a period of time which can take several weeks or longer, depending on the dosage.6 Without a medically supervised tapering down of benzodiazepine dosage, or attempting to quit cold turkey, a broad range of symptoms may occur, including a litany of uncomfortable and painful symptoms and possibly life-threatening seizures. Whether they are used medically or illicitly, withdrawal from benzodiazepines presents a myriad of unpleasant symptoms, referred to as benzodiazepine withdrawal syndrome (BWS), including the following:
death, in severe and typically unsupervised cases
Another important reason to seek professional help for reducing or quitting benzodiazepine use, is the unpleasantness of withdrawal symptoms. As is true for virtually every drug of addiction, the discomfort of withdrawal is more than enough to prompt abandonment of detox efforts and immediate relapse.
Each individual is different in how he or she will respond to various substances or medications. Further, medical and mental health conditions are also factors, along with the use or abuse of other substances. The following FAQs are for general information purposes, and medical consultation should be sought in each individual situation.
How long does it take to become addicted to benzodiazepines?
The length of time it takes depends heavily on the frequency and strength of benzodiazepine use. Therapeutic use of benzodiazepines is not generally recommended for longer than 4 weeks, due to the risk of growing tolerance and eventual dependence. Non-medical use may result in dependence much faster, especially with shorter acting, stronger benzodiazepines, such as Xanax®.
Does dependence on benzodiazepines mean addiction treatment is needed?
The way in which dependence occurred plays a large role. If benzodiazepine dependence developed from use as directed, it may not be necessary to participate in a treatment program, and a medically assisted and supervised tapering may be sufficient. However, if benzodiazepines have been abused, or used non-medically in any way, a treatment program is highly recommended, to avoid relapse in the future. Regardless of whether a treatment program is required, a medically supervised tapering and detox from benzodiazepines is always necessary, to ensure safety throughout the process.
What are the signs of benzodiazepine addiction?
Whether benzodiazepine use began with abuse or taking them as directed, signs of addiction include the following:
emotional use of benzodiazepines like taking a pill in stressful times, or when under pressure
increasing doses of benzodiazepines without medical authorization
worrying about how many pills are left and taking extra steps to ensure pills are always within reach
feeling physically ill when not taking benzodiazepines
unsuccessful attempts to cut down on amounts of benzodiazepines due to physical or psychological withdrawal symptoms
How common are seizures in benzodiazepine detox?
Most seizures associated with benzodiazepine detox, are grand mal seizures and occur when the medication is stopped abruptly. These seizures have been reported in individuals who have taken therapeutic and high doses of benzodiazepines, also reported in those who have taken benzodiazepines for long periods of time and as short as 15 days.7 The severity of seizures can range from mild to very severe and potentially fatal, however, probability of fatality due to seizure is significantly reduced in medical settings with supervision.
Are benzodiazepines bad drugs?
Not at all. Benzodiazepines are very useful, and medically relevant medications. Like any medication, when benzodiazepines are taken non-medically, they can have serious side effects which may be dangerous. While they do lead to dependence when taken over a long period of time, lowering dosages or stopping use can be safely completed with medical assistance.
Are Z-drugs safer than benzodiazepines?
Z-drugs are like benzodiazepines in their action on the brain, potential for dependence, and side effects. The only differences between the two classes of drugs are on a molecular level. Z-drugs and benzodiazepines are equally effective and equally dangerous if abused.
Can benzodiazepines cause long-term brain damage?
There are some studies which suggest alprazolam may lead to brain damage when taken over a long period of time because it is specifically engineered for short-term use. However, there is not enough evidence-based research to conclusively declare brain damage resulting from benzodiazepine use.
There is only one safe way to detox from benzodiazepines, and that is with a slow tapering down of the drug. Abrupt cessation of benzodiazepines can result in severe withdrawal symptoms, often including seizure. Many people find trouble with the process of detoxing from these drugs because very few hospitals are equipped to accommodate in-patient care during the process, which takes several weeks or months in many cases. On an outpatient basis, individuals who are detoxing need support to ensure dosages are being taken as directed, and behaviors which are detrimental to the completion of the detox are not occurring. The best way to detox from benzodiazepines is under the careful supervision of a physician who is familiar with specific dosages and usage habits. Although tapering is the safest way to achieve sobriety from benzodiazepines, it can be done in a few ways.
The most common, yet highly scrutinized method of tapering involves cutting dosages by 25% each week until it is down to nothing. The scrutiny of this method comes from many professionals who consider it to be far too rapid, resulting in severe withdrawal symptoms and the development of post-acute withdrawal syndrome (PAWS), which can linger for 18-24 months or longer.
A physician may recommend crossover to a longer acting benzodiazepine, and then begin tapering. This is especially common with those who are accustomed to short-acting benzodiazepines.
The Ashton method calls for a tapering of 5%-10% every 2-4 weeks, and a specific crossover to diazepam (brand name Valium®) because of its availability in very low strengths with a longer half-life. Whereas the lowest doses of benzodiazepines like Xanax and Klonopin are 0.125mg and 0.25mg respectively, diazepam's equivalent doses are 2.5mg and 5mg respectively. Its availability in 1mg doses allows for a much more gradual tapering process, preventing severe withdrawal symptoms in most people.
While it does take some time to achieve, a safe and comfortable benzodiazepine detox is possible, regardless of the length of time of use or the strengths of the specific benzodiazepines used. Not everyone who is dependent on benzodiazepines will require the same period of time for completing detox and the severity of symptoms will vary from person to person. For the purposes of addiction treatment programs which offer detox from benzodiazepines, this lengthy process may extend beyond detox and into the therapeutic phase of treatment, so long as an individual is medically stable enough to carry on with the treatment program. The goal is to have a patient fully engaged in the program and the process of building a recovery plan, while also avoiding the discomfort of withdrawal symptoms and risking relapse.
Benzodiazepine Addiction Treatment
For some people, benzodiazepine use has been according to doctor’s orders and need only to be tapered off of the drugs, addiction treatment may not be necessary. However, individuals who have abused benzodiazepines and those for whom benzodiazepine use has become a part of normal life, addiction treatment should be strongly considered in conjunction with detox. Freeing oneself from dependence on benzodiazepines is more than ridding the body of the drug, but it is also a matter of retraining the brain to function without it. Even after detox is complete, and withdrawal symptoms have faded, the effects of long-term benzodiazepine use may still sway and influence behaviors and functions. One effect of addiction is that life begins to function around the drug; behaviors, activities, social groups, schedules, and routines are all organized to facilitate the continuation of the addiction. Often, these accommodations are not made consciously, but eventually become part of the fabric of existence for a benzodiazepine dependent individual. Some of these unconscious accommodations may include things like:
doctor shopping to have extra benzodiazepines on hand, ensuring that supply levels are never depleted
establishing and maintaining groups of friends and associates who have regular access to benzodiazepines
establishing habits of taking benzodiazepines in situations of high stress or disappointment
always having benzodiazepines on hand when going out socially, or in situations where alcohol or other drugs may be used
beginning, or increasing use of other drugs, to counter or enhance the effects of higher quantities of benzodiazepines
The way these changes may manifest in an individual's life are often very subtle, but nonetheless impactful. When benzodiazepines have taken over to the degree at which continued abuse is facilitated through behaviors and habits, addiction treatment is especially important in the recovery process. Effective drug treatment helps each individual to identify the parts of life which are most directly connected to benzodiazepine use and abuse and work towards transitioning to healthy and sober habits. There cannot be a blanket approach to this, as every person is unique, with individual needs and preferences. For this reason, addiction treatment is most effective, when it can be focused on the individual and truly establish a recovery plan which not only fits with but compliments the lifestyle and needs of each person. If you or a loved one is struggling with how to be free from benzodiazepine dependence, an individualized and compassionate addiction treatment program can help to establish a workable plan for recovery, increased health, and a piece of mind for everyone. At Pax House in Pasadena, CA, we maintain a small population so we can focus on each individual and his or her family in working towards a brighter and sober future. Benzodiazepine dependence can feel like a trap, but it doesn't have to be one. We are here to help. Please make the confidential call to speak with one of our caring treatment consultants right away. Freedom from the cycle of benzodiazepine dependence can begin today.