Benzodiazepines - Peace or Slippery Slope?
I empathize with those struggling with daily anxiety or panic. I've had it also and been too anxious to even ask for help.
Benzodiazepines (Benzos) are a class of controlled medications with sedative, anti-anxiety, and amnestic properties. Benzos act on the central nervous system by attaching themselves to receptors called gamma-aminobutyric acid - A - commonly referred to as GABA-A. This mechanism of action makes the nerves in the brain less sensitive to stimulation, which has a calming effect. They vary quite a bit in their onset, duration, and intensity of action. Common brand names include Ativan, Xanax, Librium, Klonopin, Valium, and many more. The generic names typically end in “pam,” i.e., lorazepam (Ativan).
Medical practitioners utilize Benzos for a variety of medical procedures and disease management. They are often used before invasive procedures and surgery to calm the patient and also diminish unpleasant memories - think Colonoscopy. They are used as continuous intravenous drips in critical care units for patients on ventilators or with severe illness to aid compliance with mechanical ventilation and long hospitalizations. In excess, they can make weaning off the ventilator difficult and increase ICU-associated delirium (2).
Benzos are also used to prevent and treat seizure disorders and acute onset seizures in hospital settings. They effectively provide safety and symptom support during alcohol withdrawal when patients are at risk for seizure activity. A short-term benzo taper is typically ordered as part of detox protocol for clients coming off daily alcohol consumption. One should never abruptly discontinue a daily benzo prescription. A gentle taper prevents seizures and makes the process more comfortable and sustainable for the patient.
Though typically not a stand-alone drug of abuse, they have strong dependency potential. A discussion of the associated withdrawal risks is very important for anyone taking them consistently, even if using them directly as prescribed. Benzos are also misused by intentionally combining them with other substances to increase impact. Benzos can also be crushed and sorted to speed the onset and intensity. Patients with a history of addiction should use caution even with prescribed benzodiazepines.
If they have the potential for dependence and misuse, why even use them? Often, they are appropriately prescribed for short-term use, 2-4 weeks, for acute anxiety/panic (1). As a stand-alone approach, the medication may ease immediate discomfort, but the underlying cause of anxiety should be addressed. Example: A person needing medicine for the loss of a loved one may benefit from a benzo to sleep, but the intent is not to substitute the emotions for medication or avoid the natural grieving process that helps us heal.
Benzos may be medically necessary for some seizure disorders or chronic diseases that cause muscle spasticity or impaired life quality. Often benzos are added to other medications to increase the potency so that patients aren’t on dangerous amounts of monotherapy. Multiple Sclerosis and Cerebral Palsy are some examples. Benzos are therapeutic during the end of life to ease death anxiety and provide comfort if the patient struggles to breathe or is in uncontrolled pain.
There are many non-habit-forming medication options for anxiety that a patient may benefit from without risk of sedation, dependency, or misuse. Generalized Anxiety Disorder may be treated short-term with scheduled benzos, however, not instead of working on self-soothing, calming, and coping skills.
Why can’t I just take the pills? I don’t want to do therapy.
Medication can be a painful bandaid, leaving the outside looking clean while suppressed emotions fester under the surface, causing even deeper wounds. One will develop a tolerance for the medication overtime requiring increased doses or more medications (1). Not dealing with the issues at hand will make discontinuation in the future much more difficult.
If you have a history of substance use disorder or sensitivity to medications, it is a good idea to talk to your provider about alternatives to benzos for anxiety. Medication should be reserved for a crisis, unmanaged symptoms, or after alternative methods of stress relief have proved ineffective. I don’t expect a patient with crippling anxiety and fear to leave their home to go to yoga before getting medication. I am suggesting that the patient can also work towards measurable goals to incorporate lifestyle changes in conjunction with medication.
Whether taking benzos as prescribed or dosing yourself with self-obtained pills, it is essential to talk to a healthcare professional about safe weaning to prevent withdrawal. In addition to seizures, patients may experience increased anxiety, sadness, suicidal thoughts, irritability, insomnia, shakes, and appetite disturbance if coming off too quickly. Even with a slow taper off benzos, it is not uncommon to experience some side effects and a slump in mood that can be very discouraging. The onset and length of withdrawal symptoms depend on the type and amount of benzo used. Typically, symptoms peak at 4-7 days and can persist as post-acute withdrawal mood disturbance up to a month or even longer.
As a nurse, I’ve administered a lot of benzos in the critical care, medical, procedural, substance use, and outpatient settings. They absolutely have their place. However, I’ve also had patients on scheduled daily benzos, and when I inquire why they are on them, not uncommon to hear oh “I’ve been on those for years, for my nerves.” There is no evidence to support the long-term use of benzos for intermittent anxiety. Contrary to what many believe, benzos are also not indicated for PTSD (post traumatic stress disorder) (ptsd.va.gov) and may cause more harm.
Benzos are not the easy button. They are controlled medications that can interact with other medicines and substances and strain metabolizing organs (kidney and liver) over time. They can grip hold of a person making it very difficult to feel calm without them, and they have dangerous and unpleasant withdrawal symptoms. Benzos may also mask the symptoms of other disorders and make recovery from trauma more difficult.
● Do not abruptly discontinue prescribed medication.
● Do not self-dose symptoms with someone else’s medications or those obtained without a prescription.
● Do not mix benzodiazepines with alcohol, opioids, or other sedating substances.
● Do not drive under the influence of benzodiazepines.
● If struggling with anxiety, talk to your provider and or counselor about alternatives to medication.
● If medication is needed, see if a non-benzo could work for you, and take only what you need for only as long as you need it.
● In addition to medication, explore methods of stress reduction and coping skills - walking, yoga, meditation, pet/equine therapy, counseling, peer support, art, dancing, music, and many more.
Medications are often needed for short-term stabilization until a sustainable self-care routine can be established. Be easy on yourself, but also be honest about what you are doing, besides medication, to live the type of life you want.