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It’s Rarely About Substance Abuse or Addiction

Addiction language is usually inaccurate and can harm compliant patients who were injured by their prescribed dose.

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Commonly Prescribed Benzodiazepines

  • alprazolam (Xanax, Xanax XR)
  • clobazam (Onfi)
  • clonazepam (Klonopin)
  • clorazepate dipotassium (Tranxene)
  • diazepam (Valium)
  • chlordiazepoxide (Librium)
  • lorazepam (Ativan)
  • temazepam (Restoril)
  • triazolam (Halicion)

Benzo Basics

Learn About Benzodiazepines

Prescribing

Fundamentals

Risks

Risks of Prescription

The current prescribing information for benzodiazepines does not provide adequate warnings about these serious risks and harms associated with these medicines so they may be prescribed and used inappropriately.

FDA
Drug Safety Communication, 09/23/2020

Deprescribing

How to Stop

Risks

Risks of Cessation

Populations

Special Populations

Fast Facts About Benzodiazepines

A brief overview of the problems with prescribed benzodiazepines.

For over 50 years, advocacy and support for harmed patients has been mostly handled by laypeople due to the lack of medical help for benzodiazepine-related injury. Although several patient-led movements and support groups have existed since the 1970s, there continues to be insufficient mainstream resources and medical recognition, resulting in sustained patient harm.

  • Scope of Prescribed Use
    Alprazolam, clonazepam, and lorazepam are among the 10 most commonly prescribed psychotropic medications in the United States. Prescriptions are on the rise with at least 25.3 million (10.4%) adults in the United States reporting prescribed benzodiazepine use from 2015-2016, nearly doubling the 4-6% estimated in 2013-2014, with the highest consumers being those adults aged 50-64. From 2003 to 2015, the percentage of outpatient medical visits that led to a benzodiazepine prescription doubled, as well as the prescribing rate among primary care doctors. Additionally, the rate of co-prescribing benzodiazepines with opiates quadrupled from 0.5% in 2003 to 2% in 2015.
  • Indications and Safety
    Long-term prescribed use (>2-4 weeks) can result in heightened anxiety, increased incidence of falls and accidents, persistent insomnia, impaired learning, higher rates of suicide, a greater risk of dementia, the development of new or worsening symptoms, and a reduction in efficacy of nonpharmacologic interventions for PTSD and Panic Disorder, impairing recovery from these conditions. Existing estimates are disparate indicating 20-80% of patients stopping a benzodiazepine will experience withdrawal effects, of which a percentage will be severe. 
  • Detrimental Prescribing
    Current medical training does not provide adequate education about the risks of benzodiazepines or safe tapering practices. Therefore, many are prescribed to patients without full informed consent. An informal poll of patients prescribed benzodiazepines ≥4 weeks revealed that, of the 606 respondents, 570 (94%) reported receiving no warnings about physical dependence or withdrawal. Of those warned, many reported it insufficient in regards to the severity and/or difficulty of withdrawal.
  • Inappropriate Cessation
    Patients are often unable to obtain useful cessation advice from the prescribers, and frequently have their prescriptions abruptly stopped to their detriment. Inpatient “detox,” rapid taper, cold turkey and forced cessation are dangerous and inappropriate for prescribed patients. The result can be reinstatement, disabling protracted symptoms or death. Slow (≤5-10% every 2-4 weeks), patient-controlled tapers are the best way to discontinue use in patients agreeable to cessation.
  • Long Term Disability
    Many patients while taking benzodiazepines, as well as during and after cessation, will experience long-term disability which may persist years. More research is needed to predict who will suffer detrimental effects from prescribed benzodiazepines and to determine how to help those already harmed.
  • Patient Groups
    For over 50 years, advocacy and support for harmed patients has been mostly handled by laypeople due to the lack of medical help for benzodiazepine-related injury. Although several patient-led movements and support groups have existed since the 1970s, there continues to be insufficient mainstream resources and medical recognition, resulting in sustained patient harm.

Frequently asked questions

Commonly prescribed benzodiazepines include Ativan (lorazepam), Klonopin (clonazepam), Valium (diazepam) and Xanax (alprazolam). A complete list can be found here.

Informed consent is the process by which doctors empower patients with sufficient information to accept or decline treatment based on a full understanding of the relevant risks, benefits, and uncertainties related to the proposed intervention, as well as alternatives. For more information, see here.

While exact numbers are difficult to come by, an industry study conducted in 2012 found that 94 million prescriptions for benzodiazepines were filled annually in the United States.

Non-benzodiazepines (“Z-drugs”) are a class of psychoactive drugs that are benzodiazepine-like in nature. Non-benzodiazepine pharmacodynamics offer very similar benefits, side-effects, and risks as benzodiazepines. However, non-benzodiazepines have different chemical structures, and therefore differ from benzodiazepines on a molecular level.

Common side effects include memory and cognitive impairment, increased or new sleep impairments, increased or new anxiety, neuropathy, pins and needles sensations, unexplained new health or psychiatric problems, increased risk of Alzheimer’s disease, lack of balance with an increased risk of falling and related physical injuries, digestion issues, sleep apnea, and tremors. For a more complete list of side effects, see here.

Anything longer than 2-4 weeks.

Tolerance occurs when a higher dose of the drug is needed to achieve the same response achieved initially. Tolerance can be likened to a mini withdrawal for someone dependent on benzodiazepines, because the body demands the drug, and is technically receiving the drug but is too acclimated to the dose to respond in the intended manner.

Interdose withdrawal refers to the withdrawal effect experienced when the drug wears off prior to the next scheduled dose.

No. Patients, especially those still on the drug, tend to experience multiple “unexplained” issues and receive multiple incorrect diagnoses.

Yes. They impede the ability to retain information and form memories, which are essential for the most highly effective anxiety therapies, CBT and exposure therapy. They can also interfere with EMDR and first-line PTSD trauma processing therapies.

There are no notable differences in safety for any of the classes of benzodiazepines. We see an equal amount of injury from each brand within the class. They all have comparable side effects and all can result in tolerance, withdrawal, post acute withdrawal and disability. Some prescribers believe Klonopin, Ativan or Onfi are non-dependency causing. These beliefs are patently false.

Very much so. Benzodiazepines appear on the BEERS List for Potentially Inappropriate Drugs for Elderly. In spite of this, elderly prescriptions continue to rise.

“Low dose” terminology is deceptive. Even 0.5 milligram of Klonopin (equivalent to roughly 10 milligrams of Valium) can create dependence after two weeks and requires a slow taper. For more on benzodiazepine dosages and risks, see here.

Irresponsible prescribing is daily or frequent prescribing beyond 2-4 weeks. Occasional or “as needed use” that is not daily or biweekly for more than 2-4 weeks rarely creates physical dependency problems but may still subject patients to other problems associated with the drug.

No. Some patients do not experience any detrimental side effects while taking benzodiazepines. In other cases, they do experience side effects — such as digestive issues, autoimmune or thyroid problems — which are misdiagnosed or not correctly attributed to the drug.

Benzodiazepines are contraindicated in PTSD, can exacerbate depression, and are especially dangerous to anyone on opiates, all of which are situations many veterans experience

Children can be harmed just like adults. Many children under the age of 10 tapering off benzodiazepines like Onfi (clobazam) experience more severe issues than adults.

Sudden cessation of benzodiazepines is highly dangerous, with the possibility of seizures, severe and/or protracted withdrawal syndrome, and even death. A sensible taper plan can avoid the risk of seizures and mitigate, although not eliminate, the risks of severe withdrawal symptoms. Some patients will suffer at any taper rate.

Withdrawal and healing from benzodiazepines can be very time consuming, varying greatly between individuals. Tapering may last weeks, months, and even years. Likewise, post-cessation healing can last weeks, months, and, in some cases, many years. For some, central nervous system sensitivity may last decades, or even be permanent.

There is not enough evidence in the literature to recommend a specific adjunctive medication at this time. In this area, too, more studies are needed, as there are no drugs currently approved to treat benzodiazepine withdrawal. Off label, very small studies (less than 40 patients) and case reports have shown that drugs such as carbamazepine, and propranolol may help as aids in withdrawal. Trazodone, mirtazapine, and quetiapine may be helpful in some patients for insomnia. But not everyone finds them helpful; they must be tapered off; and they carry the potential of causing their own injury and withdrawal syndromes. Some patients have reported relief of withdrawal symptoms with the use of CBD oil or medical marijuana. Many patients are able to successfully complete a taper without the use of adjunctive medication.

A taper is a gradual reduction in benzodiazepine dosage. Depending on your individual situation, a taper may last weeks, months, or even years.

When used long term (more than 2-4 weeks) all doses, even the lowest available doses of each benzodiazepine can cause patient injury and require a taper. The presence of physical dependence will dictate this. We have received many reports of patients being injured on doses that are typically regarded in medicine as small, such as .25 milligrams of Xanax (alprazolam), .5 milligrams of Ativan (lorazepam), 5 milligrams of Valium (diazepam) or .125 milligrams of Klonopin (clonazepam).

There are numerous ways of tapering, including cut-and-hold, microtaper (via scale or liquid titration), compounding and taper strips. You may choose to taper from your original drug or “crossover” to a longer acting benzodiazepine. For more information go here.

Although there is no research to document this, it is intuitive that GABAA receptors upregulate during the taper process, especially during a slow, symptom-guided taper, as long as the taper doesn’t surpass their body’s ability to compensate for reductions. However, full upregulation and healing may take months to years after the taper is complete.

“Half-life” is the amount of time for the concentration of drug in the blood to fall by 50 percent. This time-period will vary between individuals. Commonly used “short” half-life benzodiazepines include Ativan and Xanax, while “long” half-life benzodiazepines include Klonopin, Valium, and Librium. Of note, Valium and Librium are further transformed into “active” metabolites, each with their own elimination half-lives. This means that they accumulate gradually and are cleared more slowly from the body, which can provide an advantage in tapering, as it can help prevent withdrawal between doses. Elimination half-lives are often doubled or tripled in the elderly, due to less efficient metabolism in the liver.

Kindling refers to the neurological condition resulting from repeated withdrawal episodes from sedative–hypnotic drugs such as alcohol and benzodiazepines. Each withdrawal leads to more severe withdrawal symptoms than the previous withdrawal syndrome. Individuals who have had multiple withdrawal episodes are at an increased risk of severe withdrawal symptoms.

See here.

No. Many people avoid severe symptoms with a slow and sensible taper. Roughly 20 percent will experience no withdrawal symptoms at all, no matter the cessation method. But nobody should assume any given patient is in this minority. Anyone attempting to discontinue a benzodiazepine should err on the side of caution and taper slowly, and thus avoid or mitigate the most severe and/or protracted withdrawal symptoms. Some patients have horrible side effects on the drug, and relatively mild withdrawals. Everyone’s experience is different.

No. If you are able to follow your prescription, you are able to follow a taper plan. Most detox programs end up causing more problems for benzodiazepine-dependent patients. Many have even stopped treating benzodiazepine patients altogether, because tapering properly is a drawn-out process, and benzodiazepine detox is high risk with a low success rate. If a rehab program promises you a successful detox, do not be fooled, as there are no certainties with benzodiazepine cessation. We are contacted regularly by patients, even those who went to the most “prestigious” rehabs, who were made worse, only to have their symptoms denied, be sent home to either reinstate and have to taper again, or ride out the post acute withdrawal symptoms for months to years, waiting to get their life back. Evidence shows that overly-rapid detox or taper puts the patient at risk for a longer, more debilitating withdrawal.  See our blog on this topic here.

Many patients are told they are doing a slow taper, when they are actually doing a fast taper. The rule of thumb is not more than 5-10% of the current dose every 2-4 weeks. Most tapers take 10 months or much longer.

All benzodiazepines have an estimated dose that is equivalent to doses of other benzodiazepines. Unlike opiates, equivalence conversions between different benzodiazepines are not defined or required by the FDA. Evidence-based information on benzodiazepine equivalents is limited and many different sources report dissenting information. For this reason, some equivalence rates are listed in a range, as they are estimates and mostly based on clinical observation and judgement. People who take prescribed benzodiazepines are unique and will not all have identical experiences. An equivalent dose that works for one person may be too low or too high for another person taking the exact same drug and dose.

Patients should become their own best advocate. A good prescriber allows you to control your own taper based on symptoms and proceed at a speed that is comfortable for you. Additionally a good prescriber will not require you to use adjunctive medication if this is against your wishes. If your prescriber doesn’t meet the minimum requirements in terms of knowledge and support, it is advisable to find someone more suitable to oversee your taper. Given the dangers of benzodiazepine cessation, you should not stay with a doctor who is not qualified or helpful. Some things to ask: Will the prescriber provide access to your “crossover” drug of choice (if you plan on crossing over)? Does the provider understand tapering can be a long term (longer than a year) venture that includes the risk of disability? Do they understand benzodiazepines and withdrawal both can be life altering and disabling? Are they willing to sign any disability forms, if needed? How often will they want to see you?

Many doctors are not educated on the capacity of benzodiazepines to cause injury. So they dismiss the symptoms or believe them to have another cause. If another cause cannot be found, they frequently attribute the symptoms of injury to hypochondria. This has been observed in the history of many other conditions, like fibromyalgia and endometriosis, that were initially dismissed by doctors until research and medical training caught up with patient experience. It is likely the physician has not knowingly seen it before, as most patients and doctors misdiagnose benzodiazepine-related symptoms as something else. Additionally if the disbelieving doctor was the original prescriber, self preservation and fear of litigation may play an additional part in remaining blind to the patient’s experience.

This is a silent epidemic, driven by ignorance on the part of doctors, patients, and society at large. Many patients are too sick or ashamed to speak up, or unaware they are affected. By the time they discover the cause they often are too sick to even advocate for themselves, and are silenced or ignored when they attempt to.

Currently there is not enough knowledge about the way benzodiazepines affect the entire body and how different patients respond to them. This is why further research is desperately needed. At present, there is no way to screen a patient for the risk of being injured. We do know these injuries can occur, through no fault of their own, in patients adhering to their prescribed dose.

There is not yet adequate awareness in the U.S for the FDA to require this of manufacturers.

Crossovers are not required, but some patients who are taking a shorter acting benzodiazepine may prefer to follow the Ashton Manual and switch to a longer-acting benzodiazepine, such as Valium. A patient who prefers to taper directly from their own drug can look into compounding, liquid compounding, tapering strips, a 0.001 gram scale, or liquid titration.

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Support Benzodiazepine Awareness and Help Us:

  • Gain recognition of the existence and severity of prescribed benzodiazepine injury
  • Hold and participate in events to educate prescribers and the public
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  • Protect those presented with benzodiazepines as a treatment option by giving them true informed consent
  • Create more media awareness about this silent epidemic
  • Advocate for more prescriber training in safe prescribing and cessation
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