It’s complicated.
Actually, it’s quite confusing.
But most of all and importantly, it’s mischaracterized.
Benzodiazepine-related problems are often categorized as “addiction,” when in fact, for the vast majority of those who have difficulties, that diagnosis simply does not apply. Involved in family medicine for 36 years and addiction medicine for 31 years, I have only treated one patient – precisely one – with true benzodiazepine addiction. It’s rare.
How do we make sense of this?
What is this thing called “addiction”?
And how does that differ from the challenges faced by most benzodiazepine survivors?
The disease of addiction is a disease of the brain reward system characterized by the three “C’s” – all of which must occur together in order to make the diagnosis:
- Compusion to use for reasons other than for which they are prescribed
- Loss of Control with amounts used significantly increased over time and more than intended by the prescriber and the patient
- Continued use despite adverse consequences which are recognized by the user as problematic
Although non-addicted benzodiazepine survivors may experience the third criteria, they are not driven to do so by craving that leads to inappropriate and excessive overuse. On the contrary, it is physical dependence including overwhelming withdrawal symptoms that binds them to continued use, not addiction. They have what is probably better termed as a benzodiazepine brain injury – “benzo brain” – which results in the wide array of symptoms that differ from person to person and can be so devastating.
Misapplying these criteria is compounded by a misunderstanding of how to use the detailed criteria found in the Diagnostic and Statistical Manual, version 5 (DSM-5) which are as follows:
A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
- Sedatives, hypnotics, or anxiolytics is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.
- A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.
- Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
- Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor performance related to sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household).
- Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).
- Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.
- Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).
- Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.
- Tolerance, as defined by either of the following: a) A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of the sedative, hypnotic, or anxiolytic.
- Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics. b) Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are taken to relieve or avoid withdrawal symptoms.
Tolerance and withdrawal (numbers 10 and 11) are criteria that are not to be used when benzodiazepines are prescribed because these are expected responses to normal prescribing and do not reflect non-medical use in that context. It is easy to see how a medical provider might view many of the other criteria (1, 2, 5, 6, 7, 9 especially) applicable to those with major benzodiazepine adverse reactions. However as above, for most of these patients, the reason for continued benzodiazepine use despite bad outcomes is not craving or non-medical use but rather the inability to discontinue use successfully – often because of the inability of the medical provider to assist in withdrawal. These criteria, therefore, should not be applied to these individuals.
We medical providers did not and generally still do not understand and act on this this for a number of reasons:
- Absence of updated knowledge that overplay benefits, in particular wrongly believing for most people benzodiazepine use long term remains effective
- Absence of updated knowledge that alternative treatments might work better and safer
- Absence of patient requests to increase dosing which could suggest non-medical use
- Insufficient recognition that important symptoms could be due to benzodiazepines, thinking rather they are related to: (a) Inadequate treatment of the medical condition treated (e.g., anxiety or insomnia), (b) Worsening of the medical condition treated (e.g., anxiety or insomnia, (c) Development of a new medical condition
- Focus on other medical problems like opioid addiction or pain felt to be of higher priority
- Focus on other medications like opioids felt to be of higher priority
- Insufficient training, skills, and patience to assist in the benzodiazepine withdrawal process
- Perception that withdrawal is more harmful and difficult than continued prescribing
- Absence of guidance from guidelines and key opinion leaders to highlight the evidence-based research and provide direction for best clinical practices
- Not listening at all or not listening closely enough to what patients are saying
Truly, we medical providers weren’t and aren’t listening,
and benzodiazepine survivors know this all too well.
Persons with substance-related problems often feel stigmatized. For persons with a valid diagnosis of addiction, “addict” puts them in a box that implies that that is all they are, when, in fact they are so much more: a mother, a father, a daughter, a son with a life with a career, a family, interests, hopes, aspirations, and dreams. Though it should not be the case, “addict” can carry the tone of being weak-willed, inherently flawed, morally degenerate, even criminal – none of which is necessarily true. Persons with addiction should not be stigmatized, nor should they feel stigmatized.
For non-addicted persons with benzodiazepine-related trouble, it goes beyond this. Helping them manage and treat benzodiazepine trauma is entirely different from addressing benzodiazepine addiction – a difference that makes difference. Wrong diagnosis translates to wrong treatment and will not lead to effective solutions. .
To become benzowise we need to understand this difference and respond accordingly.
Poor prescribing practices are built around misconceptions like this and so much more.
We can and must do better.
To all the benzodiazepine survivors who kept courage when we weren’t listening
and to all those who did not survive,
I apologize.

Steven Wright, MD, is a residency-trained family physician with a 36 year clinical career. Active in addiction medicine (board certified) 31 years and medical pain management 15 years, he focuses on issues related to controlled substances, addiction, and medical pain management through consulting, speaking, advocacy, policy development, education, medical provider assessment / supervision, and medical legal work. His clinical interests include the neurophysiology and treatment of pain and addiction (etiology, pharmacogenetics, treatment), non-opioid analgesia, opioids (medical and non-medical use), benzodiazepines (medical consultant for the Alliance for Benzodiazepine Reform), cannabis (medical and nonmedical use), adverse consequences, best practices, and systems of care.
Thank you for writing this. I wish this was better known information
Could be my sons story as well.Died victim of suicde. Nov1 2013.Dependant on Benzos..suicide a few weeks after released from In patient treatment.
It’s my true hope that articles like this can reach the greater public and the medical field. My died from this “benzo brain”. He took the medication, as prescribed from a general practitioner, for about 6 years. He clearly was having adverse effects. My family, not understanding, sent him to a detox center which stopped him cold turkey. After multiple hospital admissions, he committed suicide 4 months out. He greatly missed. He was an educated, bright, funny man with a family. I have a firm belief that if my brother never took this medication long term, that he would be alive today. He changed while he was on it and he developed multiple physical symptoms. He tried to get off of it under a doctor’s care more than once but was never successful. I hope that others suffering from the withdrawal find a peaceful space with lots of support to survive the withdrawal period which evidently can last years. My heart breaks for everyone going through this.
hypnotic
It gives me a good feeling that sum doctors are finally looking into this benzo horror that I’ve been living with over 32 years I wish no one has to go through what I have or worse now if just all the other doctors would get on board with you they could maybe fix this and stop the suffering
Thank you, Dr. Wright, for this excellent, humble, and heartfelt piece. I hope it will be read by an enormous number of people – prescribers, therapists, and patients alike.
I thank you as well!
Thank you BIC and Dr. Wright for this article. Very informative and insightful. All along I have been made out to be an addict suffering from drug abuse. It is all my fault. I have created my situation for myself. The only thing I ever did as a compliant patient was to take my Xanax Rx as prescribed for 14 years. But yet IT IS MY PROBLEM not the results of long term Benzo use and being taken off cold turkey in the Hospital due to my attempted suicide OD on Benzos.
2 years later Benzo free suffering I am still looked at like I did something wrong, It is my fault… Benzos are not to blame.
Jerry