In 1955, the first benzodiazepine appeared, thanks to a Swiss researcher, Leo Sternbach, of Hoffman-LaRoche. The company marketed it as Librium. Three years later, the company developed a second version, which we know as Valium.
Fast-forward to the present. Now, this class of drugs is the most widely prescribed in the world. Of these, Ativan, Klonopin, and Xanax are the best-known brand names. Doctors fill over 90 million prescriptions every year, according to a recent article in The New York Times. Typically, doctors prescribe them for anxiety, or for patients with insomnia.
Perhaps inevitably, some people who use these medications also consume alcohol—sometimes in large amounts. (Also, benzodiazepines are sometimes used to quiet anxiety that results from alcohol withdrawal.) But combining benzodiazepines with alcohol is dangerous—and can be fatal.
How Benzodiazepines Work
Inside the brain, gamma-Aminobutyric acid (also known as GABA) is an amino acid, which tells the brain to relax. But sometimes people don’t have enough GABA, and the result is anxiety.
Benzodiazepines (commonly known as “benzos”) solve the problem in a different way: They block the brain’s nerve activity, producing calm. And the sedative effects are dramatic enough to make them highly desirable. Popular culture exalts the drugs’ effects, and their casual use: “Oh I’ll just have a Xanax and lie down.”
In an article for Psychology Today, Dr. Allen Frances writes, “Doctors love prescribing benzos because it’s the most efficient way to get a complaining patient out of the office in the shortest possible time…People love taking them but once hooked they can’t stop. In short, benzos are very easy to get on, almost impossible to get off.”
Benzos Are More Addictive Than People Realize
Patients may not be aware of the perils that await. The Times article calls them “highly addictive.” These drugs are commonly prescribed for sleep disorders, and can be effective in the short term. But over time, individuals develop tolerance and require larger and larger doses. Dependence lurks just around the corner.
In September 2020, the Food and Drug Administration changed its standard warning on benzos. “While benzodiazepines are important therapies for many Americans, they are also commonly abused and misused, often together with opioid pain relievers and other medicines, alcohol and illicit drugs,” said FDA Commissioner Stephen M. Hahn, M.D.
As a result, Hahn added, “We are taking measures and requiring new labeling information to help health care professionals and patients better understand that while benzodiazepines have many treatment benefits, they also carry with them an increased risk of abuse, misuse, addiction and dependence.”
Needed: More Research
Despite their popularity, there is little research on the drugs’ long-term effects. The Benzodiazepine Information Coalition notes, “Nearly four decades after Senate hearings on the dangers…research into these drugs and physician knowledge remain woefully inadequate.”
Dr. John Mendelson, founder and chief medical officer of Ria Health, comments, “Benzodiazepines have been controversial since their introduction.” As noted before, some doctors find them easy to prescribe, because of their immediate effects. In the short term, those effects may not cause problems. But some people use them for long periods of time. The results can be alarming at best, deadly at worst.
Dependence Can Develop
And for some, they can become a crutch. According to Mendelson, “They do produce dependence—meaning there is tolerance and withdrawal—but the withdrawal syndrome can be hard to distinguish from the symptoms the drug was initially prescribed for.” Dr. Frances concurs: “The anxiety and panic experienced by people stopping benzos are usually much worse than the anxiety and panic that initially led to their use.”
In addition, the Times article also notes the FDA advisement that “withdrawal can take months.” That’s a long time to suffer.
But Mendelson also notes that severe benzodiazepine addiction appears to be rare—certainly less than problems seen with alcohol. (He defines severe as “unsupervised dose escalation, marked by impairments in relationships, work or societal functioning, and illicit manufacture, sale or drug-associated violence.”)
These medications are extremely powerful. They take effect quickly, but patients can quickly become addicted to them, requiring larger and larger doses. And stopping them—especially suddenly—can be dangerous.
Special Cautions for Older Adults
According to the Mayo Clinic, older adults are more at risk for problems with benzodiazepines. The clinic is especially concerned about those with longer-lasting effects. In addition, a 2014 study found that risk of developing Alzheimer’s disease increased by up to 51 percent in those who have used benzodiazepines, with highest risk among those who used them more frequently or who used those that remain active longer.
Further, the clinic cautions, “Due to increased risk of side effects, many doctors recommend avoiding older generation benzodiazepines, and triazolam (Halcion) in particular.”
In a 2016 abstract, the clinic advises alternative treatments for insomnia and anxiety, including “nonpharmacological approaches such as sleep restriction–sleep compression therapy and cognitive behavioral therapy for anxiety or insomnia, and as well as alternative pharmacological agents.”
Benzodiazepines and COVID-19
With the advent of COVID-19 come further precautions. As the Cleveland Clinic advises, “Benzodiazepines should be used cautiously in patients with underlying acute or chronic respiratory illness, to avoid respiratory depression and precipitation of acute respiratory failure.”
Further, the clinic warns against “anxiety-induced hyperventilation,” which can compromise lung function. The result can be “acute respiratory decompensation…further aggravated by use of anxiolytics such as benzodiazepines.”
What This Means for Consumers
Benzodiazepines have helped many people deal with temporary psychiatric distress. But they are extremely powerful medications, and long-term studies of their results are thin on the ground. These substances also don’t play nicely with alcohol (or opioids, for that matter). And once people start taking them, stopping can be a problem. Patients should always consult a medical professional to help monitor the process.
Of course, reducing alcohol is the best solution to avoid any of these issues in the first place. At Ria Health, we talk with members about medications they’re already using. Our skilled medical team works with each individual to ensure their safety.
Dr. Mendelson again: “There is almost no research on treatment of benzodiazepine dependence or addiction.” And he adds, “There are no accepted medications or psychotherapeutic approaches to benzo dependence.” The implicit conclusion: Don’t get started on them in the first place.