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Benzodiazepine medications are widely prescribed – with four of them, alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium) and lorazepam (Ativan) – listed among the top 100 most commonly prescribed medications. They are prescribed for a variety of conditions, particularly anxiety and insomnia and are often taken in combination with other medications by patients with chronic pain.
There is little doubt of the benefit of benzodiazepines in reducing anxiety, controlling panic symptoms and inducing sleep. Benzodiazepines generally produce almost immediate effects and are prescribed for short-term, intermittent, “as-needed” use. When used appropriately, they can be taken intermittently, just when patients feel the need to take them.
However, an understanding of the toxicity and side effects of benzodiazepines is extremely important. They are relatively safe – especially in short term use. But used chronically, benzodiazepines can have a number of significant harmful effects including being addictive. It is very important to understand the hazards associated with long-term use of the benzodiazepines.
Toxicity and Side Effects
When used alone and short-term, benzodiazepines have a low risk of toxicity. However, when benzodiazepines are used with pain medications, muscle relaxers (esp Soma) and/or alcohol or other sedatives, the toxic effects of benzodiazepines are potentially much greater. Although fatal overdose with benzodiazepines taken alone is rare, it is not uncommon when benzodiazepines are combined with alcohol and/or pain medications such as opioids and Soma. This circumstance is even more likely if person has unrecognized or undiagnosed sleep apnea that is not being treated. Due to reduced sleep levels of oxygen in the blood with sleep apnea, there is an even greater susceptibility to accidental overdose death, including death triggered by a heart attack or stroke.
Common toxic side effects include drowsiness, poor concentration, impaired balance and coordination, muscle weakness, dizziness and mental confusion as well as other effects. Benzodiazepines also slow reaction time and impair driving skills, increasing motor vehicle crashes in drivers who are taking them.
Memory Impairment and Cognitive Function
Benzodiazepines impair memory, particularly of recent events. This is even more pronounced in heavy alcohol drinkers taking benzodiazepines. Memory impairment is particularly common in patients who have taken therapeutic doses of benzodiazepines regularly for longer than one year. Such memory impairment is thought to be reversible when the medications are stopped. Studies have also shown that long term benzodiazepine use is associated with compromised cognitive function – that is, compromised intellectual functioning and problem solving.
Depression and Emotional Blunting
An association has been noted between benzodiazepine use and depression and, in some cases, suicidal ideation. Some evidence indicates that higher benzodiazepine dosages are associated with an increased risk of depression. Again, reducing the dosage or discontinuing therapy may resolve these depressive symptoms. Many patients also experience a blunting of emotional responses to the events of their life. Positive as well as negative emotions can be dulled by these medications leading to a flattened experience of living. In fact, such emotional blunting is often realized only after the patient has discontinued their medication with the resultant effect being a perception of life becoming more meaningful and real.
Effects in Elderly Patients
As one gets older, the risk of side effects and toxicity is amplified. Benzodiazepine use in the elderly is associated with increased falls that cause hip and femur fractures and an increased likelihood of motor vehicle crashes in elderly drivers. Thought impairment is common in the elderly and can be worsened by chronic use of benzodiazepines.
Though seemingly opposite to what might be expected, increased excitement, irritability, aggression, hostility and impulsivity may sometimes occur in patients who take benzodiazepines and may result in rage or violent behavior. These reactions occur most commonly in children, in the elderly and in persons with developmental disabilities.
Benzodiazepines may lead to the development of dependence and consequent withdrawal symptoms in the fetus. They are excreted in breast milk and should not be used by breast-feeding mothers.
Tolerance to Benzodiazepines
As with narcotic pain medications, tolerance to the effects of benzodiazepines develops at variable rates and to different degrees with each patient. Tolerance to the sleep-inducing effects tends to develop rapidly. Patients typically notice relief of insomnia initially, followed by a gradual loss of this benefit over several weeks, making long-term management of insomnia with benzodiazepines eventually ineffective.
Tolerance to the anxiety-reducing effect of benzodiazepines seems to develop more slowly than does tolerance to the sleep-inducing effects. However, most studies show that benzodiazepines fail to continue to maintain the same benefit for anxiety after four to six months of regular use.
Dependence on Benzodiazepines
Benzodiazepine create psychological and physiological dependence based on the drug’s dosage, duration of therapy and potency. For example, dependence will develop sooner in a patient who is taking a high dosage of a high-potency agent such as alprazolam (Xanax) than in a patient who is receiving a low dosage of a long-acting, low-potency agent such as Valium.
Psychologically, long-term use of benzodiazepines may lead to over-reliance on the need for the medication and loss of self-confidence. Patients may be reluctant to discontinue the drug because of fears or anxiety about not having the drug. Some patients dangerously combine alcohol with benzodiazepines when they are unable to obtain satisfactory relief from the benzodiazepine alone.
As a result of physiologic dependence, withdrawal symptoms occur with rapid dose reduction or abrupt discontinuation of the drug. Symptoms of withdrawal occur in a majority of patients who have taken benzodiazepines for more than a few months but have even been noted in patient’s taking them daily for only a few weeks. The severity and duration of withdrawal symptoms generally depends on the dosage and the rate at which the dosage is tapered.
Characteristic withdrawal symptoms commonly include anxiety, depression, insomnia, shaking, hyperactivity and sometimes seizures. Feelings of depersonalization are also common including the feeling that things don’t seem real and perceptual distortions. Muscle twitching and bizarre skin sensations can occur. Headaches, ringing in the ears, nausea, vomiting and diarrhea are not uncommon and fatigue and general weakness are frequent symptoms. Increased heart rate and blood pressure may also occur. Many other symptoms can also occur associated with the withdrawal from benzodiazepines.
Alternatives to Benzodiazepines for Managing Anxiety
The key to managing anxiety appropriately includes establishing the nature and character of the anxiety. Benzodiazepines are especially useful in the management of acute situational anxiety disorder and adjustment disorder (such as transient periods of stress related to divorce or family difficulties) – where the duration of pharmacotherapy is anticipated to be 6 weeks or less. Also, behavioral therapy including counseling, relaxation techniques and meditation can be particularly helpful in managing situational anxiety without the use of medications.
Management of long-term anxiety is more complicated. The problems with benzodiazepine dependence, tolerance, and withdrawal limit their use for long-term treatment. Benzodiazepines can be dangerous and should be used cautiously by patients taking high-dose pain medications. Patients should not drink alcohol while taking benzodiazepines, most especially when combined with narcotics and/or Soma or other muscle relaxers. For these reasons, alternatives to benzodiazepines may be preferable in the management of anxiety. The bulk of medical literature now recommends numerous other medications that are preferred to benzodiazepines in the treatment of chronic anxiety. These alternatives include Buspirone (BuSpar), the SSRI class of medications (such as Zoloft, Paxil, Prozac) and the SNRI class of medications (Duloxetine (Cymbalta) and Venlafaxine (Effexor), Buspirone (BuSpar).
See: Anxiety & Stress
Alternatives to Benzodiazepines for Managing Insomnia
Insomnia is a common problem associated with chronic pain. Management of insomnia includes maintaining a regular sleep-wake cycle, avoiding daytime naps, avoiding caffeine or heavy meals at night, and engaging in gentle exercise or utilizing other relaxation techniques.
Identifying a medication to be used for insomnia is difficult because no ideal sleep medication has yet been discovered. Most, if not all, sleep medications will fail to continue to work effectively when used nightly for much longer than one month. One key to maintaining their effectiveness is to simply not use them every night. Breaking the cycle of daily use is perhaps the most helpful way of obtaining continued benefit.
Another important issue regarding sleeping medications is that of maintaining quality of sleep including maintaining an adequate amount of REM, or dream sleep. The benzodiazepines suppress REM sleep and inadequate REM sleep has been shown to compromise memory and intellectual function.
Some prescription alternatives to the benzodiazepines include for treating insomnia include antidepressants such as trazodone (Desyrel), amitriptyline (Elavil) and doxepin (Sinequan), and newer antidepressant agents such as nefazodone (Serzone) and mirtazapine (Remeron). Other non-benzodiazepine alternatives include Zolpidem (Ambien), a hypnotic that unlike the benzodiazepines, does not interfere with normal sleep cycles such as rapid-eye-movement (REM) sleep. Tolerance and withdrawal symptoms do not seem to be as problematic with Ambien as with the benzodiazepines.
See: Sleep & Insomnia
Important Note on Xanax and Other Potent Benzodiazepines
Because the withdrawal symptoms from benzodiazepines mimic symptoms of anxiety, patients often continue using the drugs in order to suppress withdrawal states, even unrecognized ones. This is especially true for patients who have taken Xanax for a long time and have developed tolerance and physiological dependence on Xanax. Because Xanax is very potent and has a short duration of action, the long-term user may develop symptoms of anxiety as their last dose begins to wear off and withdrawal anxiety then starts to set in. This makes the patient feel the need to take more Xanax to fight off the impending anxiety and the process becomes a vicious cycle. It often leads to the perception that the patient needs a higher dose of Xanax when in fact the problem is not a worsening of the patient’s underlying anxiety disorder but instead the problem is a manifestation of Xanax dependence and withdrawal. Dosage escalation maintains this cycle of tolerance and dependence. The answer in such a case may in fact be to not increase the dosing of Xanax but instead recognize that the problem is the Xanax itself and the solution is to manage the dependence, including eventually eliminating Xanax by very slowly tapering it off.
First, don’t run out of your benzodiazepines and don’t cut your dosing dramatically! Seizures, though not frequent, can be life-threatening – not only to the patient but to others around them as well. Even without seizures, the withdrawal symptoms from Xanax and other benzodiazepines are very unpleasant and shoube be avoided.
Second, if you wish to taper or discontinue Xanax or other benzodiazepines, do so with the guidance of a physician knowledgeable in the tapering process. Done properly, benzodiazepines can successfully be weaned off with minimal problems and very successful results. The key is a very slow tapering schedule, generally reducing dosage by about 10% of the total dose every two weeks. In the case of Xanax and other short-duration benzodiazepines, it may also include the gradual switchover to Valium which has a longer duration of action and therefore allows a smoother taper with less symptoms and greater success. However, the tapering process should be tailored individually and not be rushed or pressured. Discuss the process with your physician.
Third, if you are currently on a benzodiazepine for anxiety or as a sleep aid, consider discontinuing your benzodiazepine in favor of a safer medication. Discuss your concerns with your physician.
Although benzodiazepines are effective in a wide range of medical and psychiatric conditions, caution must be exercised with their use – especially when associated with pain medications and other sedatives. Care must be taken to avoid long-term complications and side effects, especially with regard to dependence and withdrawal symptoms. Compared with benzodiazepines, other medications are often better agents for long-term treatment of anxiety disorders.
The choice of medication for anxiety is based on an assessment of the risks versus the benefits of therapy. Education is the key to the best management of all medical problems, especially the difficult problems associated with chronic pain and anxiety. Patients are encouraged to discuss their concerns and questions with our physician as well as with their primary care physician. In addition, patients are advised to seek consultation from specialists, including psychiatrists, for the best management of their anxiety.
This web site is an excellent resource for understanding the issues of benzodiazepine use with special attention to providing insights for discontinuing the use of Xanax and similar medications. Benzo.org.uk is the best resource to learn about discontinuing benzodiazepines.
This web page is written for physicians but provides in-depth discussion of the problems associated with long term use of benzodiazepine medications.
Benzodiazepines – Overviews
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
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