Benzodiazepines are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion.
Because of several highly publicized deaths from combining Suboxone with benzodiazepines or “benzos”—a class of sedative medications that includes Xanax and Valium—I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are about to be placed in a difficult position. They will either 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.
The problem is that the non-medical community sees SSRI’s as “antidepressants,” and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. Whereas the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.
Today, I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t do anything, she said—intending to mean that the meds are not potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (ie, amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long-acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the 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 the 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.”
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 we get it right, her relief will be short-lived due to tolerance. 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. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks, reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
3. Benzos 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 benzos upon arrival; several months after the benzos were discontinued, the most amazing thing happened: the anxiety disorders went away!
4. A problem specific to addicts is that they don’t take sedative medications to achieve the absence of anxiety, but rather until they feel relaxed. They are not seeking normalcy; they are seeking relaxation. There is a difference between the two states: one is feeling normal without feeling excessive worry or panic; the other is feeling relaxed, something other than feeling normal. This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a fuzziness that non-addicts often find to be uncomfortable.
5. Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict becomes obsessed with 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. Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called “cross addiction.”
7. A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without taking something.
8. Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. 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 benzos.
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 the benzo during the day, he or she will be trying to sleep 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 benzos 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 a truly anxious patient, but they do not generally increase the patient’s 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 the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist, I often resent the treatment that led to the mess that I try my best 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 anyone?