When Benzodiazepines are prescribed for people with Substance Use Disorders (SUD)

Those struggling with substance use disorders, abuse and addiction to opiates, alcohol and other substances frequently fall into the trap of physical dependence to benzodiazepines. This happens because they are prescribed benzodiazepines, like Klonopin, Ativan or Xanax, by their addiction specialist doctors with the intention to assist with a substance use disorder. This happens often at rehab or detoxification centers for people coming off of alcohol, cocaine, heroin, etc. In some cases, the ex-addict takes the benzodiazepine exactly as prescribed and in other cases, the addict continues in their addiction and abuses the benzodiazepine alone or in combination with other drugs of abuse. The latter can prove to be lethal, as warned by the FDA in a recent press announcement.

Higher Risk of Dangerous Effects and Overdose Death

Benzodiazepines mixed with alcohol increase the risk of adverse effects including enhanced psychomotor impairment. According to Matthew Hirschtritt, M.D.:

When benzodiazepines are consumed with alcohol, overdose can result from the impact of two central nervous system depressants. Their effects can reduce motor coordination, impact judgment and decision-making, and result in falls and accidents. Long-term use can lead to cardiovascular, gastrointestinal, liver, kidney and neurological injury, as well as psychosis or suicidal ideation for those with pre-existing psychiatric conditions.

Benzodiazepines and opioids are dangerous. More than 30% of opioid overdoses include benzodiazepines. Benzodiazepines were present in 33.1% of prescription opioid overdose deaths and 17.1% of synthetic opioid overdose deaths in 2017. In 2016 benzodiazepines were given a boxed warning by the FDA warning of risk of death when combined with opioids.

Physical Dependence, Withdrawal and Protracted Withdrawal Risks

Benzodiazepine prescribing for substance abuse is short-term thinking. It creates new, even bigger problems for the individual while providing a false sense of security that, since the benzodiazepine drug is prescribed by a medical professional, the prescription must be safe. 

Professor Malcolm H. Lader, O.B.E., LL.B., D.Sc., Ph.D., M.D., F.R.C. Psych., F. Med. Sci, Emeritus Professor of Clinical Psychopharmacology, Institute of Psychiatry, Neurology, and Neuroscience, King’s College London, UK, is quoted as saying: 

It is more difficult to withdraw people from benzodiazepines than it is from heroin.

Benzodiazepines can be useful in the treatment of severe alcohol withdrawal, but they are intended to be used short-term for symptom management of the acute alcohol detoxification and then stopped before the patient becomes physically dependent. The two most commonly prescribed BZDs for alcohol withdrawal are chlordiazepoxide (Librium) and diazepam (Valium). Short-acting benzos like lorazepam are less frequently used for treating alcohol withdrawal. But, benzodiazepines are a class IV controlled substance in the United States. The FDA Prescribing information for them clearly states: 

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.

Prescribing benzodiazepines long-term for those recovering from substance abuse creates a risk for physical dependence to (which occurs more frequently in prescribed patients) and withdrawal syndromes. 

Amphetamine Use Disorder

According to a 2022 Swedish study, Benzodiazepine treatment in patients with methamphetamine or amphetamine use disorder is linked to a higher risk of death and hospitalization than other pharmacotherapies.

Incarceration

Due to laws that frequently punish those with substance use disorders, incarceration is a risk. A 2010 National Center on Addiction and Substance Abuse report found that 65% of US inmates meet the criteria for substance abuse or addiction. Jails and prisons across the United States do not have consistently safe benzodiazepine cessation policies. Because of this lack in policy, physically dependent benzodiazepine patients suffering with other substance use complications frequently are forced to withdraw from benzodiazepines while incarcerated, leading to patient injury and death, both from suicide and from the medically unsafe cessation’s frequently performed in the criminal justice system.

Further Reading on This Topic:

Incarcerated Benzodiazepine Population Deaths