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Benzo Blunders is a Benzodiazepine Information Coalition series educating our readers about the latest benzodiazepine misinformation.

Emily Laurence’s recent article, Do Prescription Sleeping Pills Actually Work?, appeared May 31 in the online outlet Well + Good. While I’m glad to see someone ask the question, the piece ultimately misses the mark, as it fails to warn about the most common issues with sleeping pill (benzodiazepine and Z-drug) prescription. It also ignores the dearth of literature about risk/benefit and harm and confuses physical dependence with addiction. 

In her article, Laurence correctly identifies the lack of data around sleeping pill prescription:

The lack of data is startling, especially taking into account that the pandemic has made insomnia more prevalent.

And she correctly suggests that benzodiazepines (such as Klonopin and Xanax) and Z-drugs (such as Ambien and Lunesta) aren’t particularly effective as sleep aids:

Here’s what else is interesting: Scientific studies show that prescription sleeping pills aren’t all that effective at helping someone fall asleep. Some doctors even say they do more harm than good. So why are so many people taking them?

The article even identifies the fact that doctors aren’t really trained about how these drugs work

The article even identifies the fact that doctors aren’t really trained about how these drugs work:

Dr. [W. Chris] Winter says it also isn’t exactly helpful that doctors don’t get very much training about how sleeping pills work when they’re in medical school. “Trouble sleeping or feeling tired all the time is one of the top complaints from patients, and yet the average doctor probably got one hour of education in medical school around sleep,” he says.

Laurence reports the stories of two patients who successfully used sleeping medications, one well beyond the two- to four-week week recommended window, without any issues or withdrawal: 

For her, they worked great. She slept well, didn’t have any side effects, and woke up well-rested. (And she was still able to hear her baby when he cried out.) But when she went back to her doctor for more, she wouldn’t prescribe them to her, worried she’d get addicted. Rawlinson obtained another prescription through another doctor and kept taking them for about a year and a half. “It sounds like a long time, but I actually didn’t have any negative effects or any type of withdrawal,” she says.

She also quotes doctors who, unfortunately, resort to tropes over evidence. For example:

“Sleeping pills are a Band-Aid, but sometimes people need Band-Aids,” [Frank Lipman, M.D.] says.

Citing two sources, the article inaccurately reasons:

The problem, both doctors say, is when it becomes a habit and not something that’s coming from a place of purpose.

Laurence does include one or two negative anecdotes, such as an interview with someone who had an adverse reaction to the Z-drug Ambien:

In one particular instance, Ilana says she woke up to find that she’d texted a guy she went on a second date with that all she wanted was to eat truffles with him forever. She decided to stop taking both medications after that. Instead, she focused on managing her anxiety and stress holistically, and she says that’s ultimately what worked for her.

And she offers an entirely insufficient warning about “addiction”:

Both Dr. Lipman and Dr. Winter also say that sleeping pills can be addictive. This is a major reason why Dr. Lipman compares them to opioids.

But she winds up with a conclusion that leaves those educated about the risks of benzodiazepines wanting:

The reality is, just like alcohol, sleeping pills affect people differently. They can cause some people to black out and do weird things. They can help others fall asleep and wake up fresh as a daisy. They can be addictive and habit-forming and they can not be. And they may or may not work.

Both the author and the doctors she quotes seem to confuse physical dependence with addiction: 

What these stats also show, however, is that for many people sleeping pills aren’t addictive. Rawlinson, for example, had no problem stopping taking them after a full year and a half.

Laurence and her sources would be well served to understand the difference, in order to properly inform readers (and patients). The fact is that having trouble starting or stopping a benzodiazepine does not indicate a state of addiction. The problem is usually one of physical dependence. For those who may be unaware, the FDA has made the distinction between physical dependence and addiction clear. According to the FDA

Physical dependence is not synonymous with addiction; a patient may be physically dependent on a drug without having an addiction to the drug. Tolerance, physical dependence, and withdrawal are all expected biological phenomena that are the consequences of chronic treatment with certain drugs. These phenomena by themselves do not indicate a state of addiction.

The problems with prescribed benzodiazepines are most often related to adverse effects, tolerance, interdose withdrawal, physical dependence, benzodiazepine withdrawal syndrome, and protracted damage. Most of these concepts are never mentioned in her piece.

On balance, Laurence’s article misses that very important point. In a preponderance of cases, the problem is not addiction, “habit” or “place of purpose.” The problems with prescribed benzodiazepines are most often related to adverse effects, tolerance, interdose withdrawal, physical dependence, benzodiazepine withdrawal syndrome, and protracted damage. Most of these concepts are never mentioned in her piece. And that’s a shame, as their absence misinforms readers about the real risks of prescription. 

For most patients prescribed benzodiazepines longer than two to four weeks—an estimated 40% to 80%—physical dependence will develop, regardless of willpower or life circumstances. It’s estimated that 10% to 15% of those patients with physical dependence will ultimately experience a protracted withdrawal syndrome, which can damage them for years, or in some cases permanently. Many patients are forced to slowly taper off benzodiazepines over a period of many months to years, with some becoming fully disabled by the painful process. As the article correctly states, doctors aren’t really trained on how sleeping pills work, so those patients who most need help, those who develop the most chronic symptoms, are forced to taper and manage their symptoms alone, without useful medical guidance or support.

The benzodiazepine problems cited above aren’t from “addiction” or “lack of purpose.” They’re the expected outcome of chronic, long-term prescription. It would have been beneficial for an article about sleeping pills (including benzodiazepines) to mention these common risks, or to include an interview with a benzodiazepine expert, or to give voice to one of the nearly 100,000 harmed patients sharing their experience on BenzoBuddies or various other benzodiazepine support groups. Maybe next time. We’d be more than happy to help.