This is part two of a series responding to a particularly inaccurate article published in the Aiken Standard by Dr. Greg Smith of Aiken, South Carolina.  Subsequent parts to follow until the entire article is addressed in full. The original article can be read here. Dr. Smith’s statements from the article are bolded and italicized for reader convenience.

Part one of the response can be read here.  

Well, benzodiazepines can be extremely useful in the treatment of muscle spasms and stiffness that come from various neurological diseases.

Sure they can. But, again, when used short-term or sporadically. According to benzodiazepine expert Dr. Heather Ashton, Emeritus Professor of Clinical Psychopharmacology at the University of Newcastle upon Tyne, England:

Drug withdrawal syndromes, in general, tend to consist of mirror images of the drugs’ initial effects. Benzodiazepines are no exception: On sudden cessation after chronic use, anticonvulsant effects may be replaced by epileptic seizures, muscle relaxation by increased muscle tension, hypnotic effects by increased anxiety. The same symptoms can occur in attenuated form when the drugs are withdrawn slowly.

When used long-term, benzodiazepines can cause tolerance, physical dependence, and withdrawal syndromes that result in rebound symptoms and worsening muscle spasms and stiffness, compounding the very problem they were prescribed for. Benzodiazepine use may also result in many other distressing symptoms that the patient never had prior to taking the drug.

They may be used in the management of seizure disorders.

Tolerance to the anticonvulsant effects of benzodiazepines makes them generally unsuitable for long-term control of epilepsy.

They may be helpful when trying to sedate someone for a diagnostic test or a surgical procedure.

This would be a one-time use, and as such would not put the patient at risk for physical dependence, tolerance, or a withdrawal syndrome. Some patients, however, may be at risk for a more rare paradoxical stimulant reaction.

They may be helpful short-term sleep aids when you just can’t get your rest at night.

“Short-term” is the key phrase here. The problem is that many medical providers are prescribing benzodiazepines, (and similar medications such as the Z-drugs long-term, without informing their patients of the risks of doing so. Tolerance to the hypnotic effects of benzodiazepines develops rapidly, and sleep recordings have shown that sleep patterns, including deep sleep (slow wave sleep) and dreaming, which are initially suppressed by benzodiazepines, return to pretreatment levels after a few weeks of regular benzodiazepine use.  Similarly, daytime users who take the drugs for anxiety no longer feel sleepy after a few days. Patients who become physically dependent and/or tolerant to the benzodiazepines often report rebound insomnia that is worse than the insomnia the drugs were initially prescribed for, while those who are prescribed benzodiazepines for another condition may experience new-onset insomnia.

They are still used in some settings to treat acute withdrawal from alcohol.

Yes, benzodiazepines can be useful in the treatment of severe alcohol withdrawal, but again, they are intended to be used in the short-term for symptom management of the acute alcohol detoxification, then stopped before the patient develops therapeutic dose dependence or tolerance. The FDA prescribing information for Klonopin, for example, clearly states:

Addiction-prone individuals (such as drug addicts or alcoholics) should be under careful surveillance when receiving [benzodiazepines] or other psychotropic agents because of the predisposition of such patients to habituation and dependence.

Should a person who has undergone alcohol withdrawal become physically dependent on benzodiazepines, then try to discontinue them, some of the resulting withdrawal symptoms might mimic those seen in alcohol withdrawal—with the key difference being that benzodiazepine withdrawal can be more severe and persist for much longer. Dr. Heather Ashton, a benzodiazepine expert who ran a clinic specifically for benzodiazepine withdrawal, is quoted as saying:

Withdrawal symptoms [from benzodiazepines] can last months or years in 15 percent of long-term users. In some people, chronic use has resulted in long-term, possibly permanent disability.

Similarly, research scientist and benzodiazepine expert Malcolm H. Lader, Emeritus Professor of Clinical Psychopharmacology, Institute of Psychiatry, King’s College,

London, stated:

With benzodiazepines, a proportion of patients go on to long-term withdrawal, and they have very unpleasant symptoms for month after month. I get letters from people saying you can go on for two years or more. Some of the tranquilliser groups [in the UK] can document people who still have symptoms ten years after stopping.

In addition, both alcohol and benzodiazepines put patients at risk for a phenomenon known as “kindling.” Kindling refers to the neurological condition that occurs with repeated withdrawals from sedative-hypnotic drugs such as alcohol and/or benzodiazepines. With each incidence of withdrawal from these substances, individuals may have an increasing likelihood of experiencing more-severe withdrawal effects—up to and including seizures, psychosis and/or death. Kindling may also be a concern if a patient prescribed benzodiazepines for alcohol withdrawal takes the drugs long enough to develop physical dependence, then attempts to stop taking them. The subsequent withdrawal symptoms may be more-severe than they would be otherwise, due to the prior history of alcohol withdrawal.

Finally, they are also pretty darned good medications for anxiety.

Benzodiazepines may be effective for anxiety in the short-term, or when used intermittently. The Ashton Manual states:

Tolerance to the anxiolytic effects develops more slowly than to some of the other therapeutic actions of benzodiazepines, but there is little evidence that benzodiazepines retain their effectiveness after a few months. In fact long-term benzodiazepine use may even aggravate anxiety disorders. Many patients find that anxiety symptoms gradually increase over the years despite continuous benzodiazepine use, and panic attacks and agoraphobia may appear for the first time after years of chronic use. Such worsening of symptoms during long-term benzodiazepine use is probably due to the development of tolerance to the anxiolytic effects, so that ‘withdrawal’ symptoms emerge even in the continued presence of the drugs. However, tolerance may not be complete and chronic users sometimes report continued efficacy, which may be partly due to suppression of withdrawal effects. Nevertheless, in most cases such symptoms gradually disappear after successful tapering and withdrawal of benzodiazepines.

In addition, in a Xanax study conducted for the FDA, manufacturer Upjohn noted that patients became physically dependent after eight weeks of use and that, at that point, panic symptoms increased 350 percent upon withdrawal. At the end of the 14-week study, the drug-exposed patients were much worse off than the placebo group. They were more anxious, more panic stricken, and doing worse on a “global scale” that assesses overall well-being. Forty-four percent had been unable to get off the drug.

Many patients who take benzodiazepines as prescribed report increased and sometimes severe rebound anxiety, panic, and terror upon attempts at cessation. If the drugs were initially prescribed for anxiety, the rebound anxiety is often experienced as much worse, and if the drugs were prescribed for something else, new-onset anxiety may occur.  Incidentally, this increased or newly emerging anxiety is often misdiagnosed by psychiatrists and other medical providers as “mental illness” or as a “recurrence of the underlying disorder” for which benzodiazepines were initially prescribed, setting patients up for prescribed benzodiazepine dose escalations and/or polydrugging with additional psychiatric drugs. Some patients are even placed on an additional benzodiazepine or on a Z-drug (a class that is pharmacologically similar to the benzodiazepines) in an attempt to control anxiety, insomnia, or other symptoms that were brought on by tolerance to the initial benzodiazepine itself.

Continue to Part 3