Prescribing Benzodiazepines As-Needed Leads to Abuse

Other risks include prescribing for depression, long-term use, and for patients with a history of substance abuse or medical conditions.

Peter Simons
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A new study reported on in Medscape, examined risk factors for misuse of benzodiazepines (drugs such as Xanax, Ativan, and Klonopin). The researchers found that patients who had been prescribed the medication on an as-needed basis were more likely to end up abusing it than those who had been prescribed a standing dose. The data was presented at the 27th annual meeting of the American Academy of Addiction Psychiatry (AAAP) on December 11.

Doctors prescribe medications on an as-needed basis in an attempt to actually reduce the amount of medication a person is taking—i.e. take it only when you need it, rather than, say, twice a day. However, the results of this study suggest that this practice actually increases the risk of misuse. Lead author Amy Swift, MD, was quoted in Medscape Medical News: “When [benzodiazepines] are prescribed as standing, people take them in the expected fashion, but when there is a little bit less standardization of what exactly is expected of the patient, then there is more room for misuse.” That is, when people are told they can take a medication whenever they need it, people tend to take it more than they would if they were told specifically how and when to take the medication.

According to Dr. Swift, as quoted in Medscape Medical News: “We theorize that this is because the prescriber is saying to take them only when needed, and the patient may be thinking, ‘I can take them as much as I need.’”

pill box
Photo credit: Flickr

The researchers asked the prescribers at their psychiatric outpatient clinic to report on their prescribing practices for benzodiazepines. Most of the patients reported on were women between the ages of 50 and 60 years old who had a diagnosis of major depressive disorder. 71% of them were receiving benzodiazepines. Dr. Swift noted that this was a startling finding, since benzodiazepines are not FDA-approved medications for the treatment of depression. Additionally, other researchers have found that benzodiazepines have been associated with the development of treatment-resistant depression—that is, benzodiazepines may actually prevent recovery from depression, rather than help. According to researchers Gordon Parker and Rebecca Graham, “Benzodiazepines, by their very action, suppress feelings, and this may worsen depression and the effectiveness of any treatment.”

Additionally, Dr. Swift found that 60% of the patients in her study had been prescribed benzodiazepines for at least 5 years. This type of long-term use is counter to recommendations in the scientific literature that urge short-term use only. Long-term use has been associated with dementia, cognitive decline, and cancer.

Benzodiazepines are one of the most commonly prescribed classes of medication. In 2008, 5.2% of the US population were prescribed at least one benzodiazepine, and that has likely only increased since that time.

Yet concerns about addiction and overdoses due to benzodiazepines have been growing in recent years. According to a recent study, “In 2013, an estimated 22,767 people died of an overdose involving prescription drugs in the United States […] Benzodiazepines were involved in approximately 31% of these fatal overdoses.” Dr. Swift also noted that although more attention has been paid to the opioid epidemic, many opioid overdoses involve benzodiazepines as well. Part of the problem is that benzodiazepines are notoriously difficult to discontinue using, with withdrawal symptoms including anxiety, tremors, headaches, aggression, seizures, panic attacks, nausea, depression, anorexia, and psychosis. Protracted withdrawal symptoms may include tinnitus, declining cognitive function, and decreased overall life satisfaction. Mad in America recently released a literature review that contains detailed information about benzodiazepine withdrawal symptoms.

Another recent study found that benzodiazepines were actually prescribed more to those who were at more risk of misusing them or encountering dangerous, possibly deadly side effects from them. Researchers found that benzodiazepines were prescribed at higher rates to patients with depression, substance abuse, osteoporosis, chronic obstructive pulmonary disease, sleep apnea, and asthma, all of which are contraindicated in the literature.

According to Dr. Swift, as quoted in Medscape Medical News: “More attention needs to be paid to prescribing habits and the appropriateness of prescriptions.” Although benzodiazepines may be an important element of treatment for some patients, more oversight is needed to ensure that prescribers are following best practices. This study suggests that benzodiazepines are inappropriately being prescribed for depression and long-term use, both of which are incongruent with current best practice recommendations. The researchers suggest that prescribers need to be aware that benzodiazepines carry particularly risk for addiction and overdose, and prescribe more carefully.

 

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Swift, A., & Perkel, C. (2016, Dec). Abstract B-29. Presented at the American Academy of Addiction Psychiatry (AAAP) 27th Annual Meeting, Bonita Springs, FL. (Abstract)

18 COMMENTS

  1. Everything was fine when I was taking a milligram of Xanax as needed to sleep until that next doctor I got refereed to 4 months later started my on that Clonopin all day long. Taking that all day long got me dependent cause it was in me all the time so I disagree with the idea that as needed is worse.

    I was never warned about withdrawal reactions, I did not understand that addictive and habit forming meant you get withdrawal and need more to make withdrawal go away, I just thought you got to liking the drugs effect to much.

    I had no idea what withdrawal was, the first time I missed a doctors appointment and ran out I started feeling really anxious and got my girlfriend back then to bring me a case of beer. I blamed my withdrawal wicked anxiety on my vehicle being in the shop, people wrenching on it and being stuck at home and depending on rides. I kind of figured I needed one of those pills but I really did not know what was going on and thought some beer would do the trick but alcohol doesn’t work so well on benzo withdrawal.

    I drank alot of beer and was all messed up, I got my RX early the next week and felt beter right away and sort of figured out I was feeling like that from the lack of the pills but at that point mostly still blamed it on my own anxiety and circumstances.

    I think a proper explanation of how taking benzos steady state leads to those withdraws, how dependency really works, should be the explanation people get as part of informed consent. The words habit forming and addictive just don’t explain it at all and people think “I won’t get addicted to this half ass buzz” it feels nice but I can just quit. Then they try and find out how addiction really works when that anxiety insomnia hell hits.

  2. I disagree with the focus on this story. Lets make it about ‘abuse’, shall we??? In the scheme of things, how many are ‘abusing’ benzos compared to how many compliant patients, just taking the ‘medicine’ as the doctor ordered?

    Let’s not talk about the millions of prescriptions that are written for benzos, or the lack of *informed consent* or the ignorance about what this class of drugs do to the brain, and then the ADDED ignorance of prescribers who know NOTHING about how to wean the patients they’ve made dependent off the drug safely… or the lack of knowledge/recognition of interdose withdrawal, or how many get drugs on top of the benzos for *those* symptoms.

    Sorry, stories like this seem a bit like the Democrats screaming ‘the Russians! the Russians!’ to take the focus off their own corruption/ineptitude.

    • Humanbeing you are right too. I’ve never thought about it before in this context in that nobody has ever called me an addict, but people have accused me of being high many times and I guess in a way I was. For example, I went into court years ago for a minor civil infraction–the judge took one look at me (I was taking Klonopin at the time 2mg 3x a day) and the judge asked if I was under the influence. Not knowing any better, I said no. With good reason, the judge didn’t believe me. She had the bailiff detain me for two hours and run a drug screen. The court searched for, I don’t know, 14 different drugs or so. The only drug that appeared in their screening: Klonopin!! AND, get this: the judge dismissed it, knowing fully that something was off with my demeanor, but I guess since it wasn’t an “illicit” substance it’s considered okay in eyes of the law. It’s absurd. For me, it was insult to injury, shattering, and humiliating–so much so that I asked the bailiff to dose me while I was detained until we could proceed with the hearing.

      So, the plot thickens!! Not only are the crazy doctors (and others in the medical community) off the charts, our legal system is blindsided too.

  3. As I’ve detailed extensively in a post in response to Dr Netchitailova’s Dialogue with a Psychiatrist, benzos are an absolute “unintended” nightmare! By casually prescribing benzos like this as you describe, doctors are doing more harm than good. The Cat is right and I can relate: the insomnia and panic from benzos is the worst I’ve every experienced. We are not given appropriate informed consent about the dangers of dependence or whole host of other insidious medical complications that arise from these drugs.

    True, they are indicated for short-term use only, so I’m left wondering how I was prescribed Klonopin for 10 years. I’ve been iatrogenically dependent on them for a decade! Along with a host of medical complications that had real symptoms, but no physiological cause can be pinned to benzo prescription/use as prescribed. Other than psychiatrists, I had all kinds of evaluations from medical professionals like cardiologists, neurologists, psychologists, and gastroenterologists. The surprising thing about these drugs is that you can be on a steady dose and still experience interdose withdraw!

    Benzos exacerbate and distort moods and feelings of being high or low, which is not unlike many other drugs. Benzos, though, have a paradoxical effect: yes, they curb anxiety and panic, but the interdose withdraw/rebound is absolutely vicious to say the least. They exacerbate panic, tax the nervous system like nothing else I’ve ever experienced. Amazingly, this process went undetected not only by me (I thought they were helping and they do up to a limited extent) but also by the trained and steady eye of the concerned doctor!! The response by my medical support team was to shake up the drug cocktail, increase the benzo (mainly Klonopin, but there were times when I was on Atavan, Xanax, and hypnotic z-drugs likes Lunesta, Ambien). That is, the response was never to remove the drug, which is extremely difficult as The Ashton Manual outlines, but is doable and would’ve been better.

    Benzo withdrawal or benzo neurotoxicity is like getting your body and mind set on fire. Nothing can put out the flames and it hurts like hell!! To use another analogy: Imagine your pills are giant bands with lots of ointment covering all of the GABA-A receptors all over your body and when you stop taking your pills or when you have a physiological need for the drug (an interdose withdraw), you have ripped off the bandages and now you have a huge, gaping wound: it’s raw nerves all other the body.

    Our medical community, detox centers, and rehabs are not equipped for this, which leaves many benzo sufferers on their own.

    Nervous system healing from the brain and CNS injury that benzos cause takes time and a new framework of understanding. In the meantime, medicators are creating new benzo victims everyday in this country and around the world! After all, this is the stuff they give to people trying to come off of alcohol, heroin, and the like. But, what do you give one trying to come off of benzos?

    I acknowledge the focus of your article and hope that you will continue to expand on this issue of benzo prescription and misprescription. The implications are huge and perhaps we as a society (I would hope) are starting to address the benzomania of doctors.

    The Ashton Manual
    http://www.benzo.org.uk/manual/

    As Prescribed (upcoming documentary film)
    http://www.asprescribedfilm.com/

    The Benzodiazepine Medical Disaster
    https://vimeo.com/188181193

  4. I got accused of “abusing” them, I got that tolerance withdrawal thing where my tolerance went up higher then the prescribed dose so unless I “abused” them I would get that withdrawal anxiety from hell. In the end that bottle rarely made it to the end of the month. I took 5 today and I only have 15 left and I don’t get a refill for another 6 days, so if I take only three tomorrow… I turned into a real bad mathematician, I always messed up that math. The ER staff got to know me, I would just tell them ran out and am bugging and always hope NOT to get sent up to psych.

    Abuse is using them to party I guess. What fun is that? If you have fun you forget half of it anyway.

    Its a shame though cause I do have anxiety and benzodiazepines do work very well for it but I can’t be on them all the time, NOW I know what happens. You have to treat them like they cost $100 a pill, use them only for special situations you know are going to be a no fun anxiety bug out.

  5. I think the Medscape article doesn’t show ANY understanding of these pills at all!! I read the article and was angry. First of all, the term “as needed” is a loaded term when it comes to benzos. What happened to me is that when I took the pills sporadically, they built up in my system, anyway, and soon I developed anxiety and panic attacks. Naturally, since the bottle said “as needed,” I took another pill when the panic or anxiety reached high levels. That in turn caused a cascade of symptoms down the line, something I had absolutely no understanding of. I wasn’t given any warnings to speak of by the person who prescribed them to me. I didn’t realize that dependence on such a small pill (Ativan) could be so rapid. I do wonder if I was given a dose to take every day if I wouldn’t now be in protracted withdrawal, because I’m now in my 34th month after stopping Klonopin (the drug I was switched to because of its longer half-life), and it’s not over yet.

    Doctors DO NOT understand this drug. They tell patients that it’s okay to cold turkey or do a rapid taper, little realizing that it’s like ripping the CNS to shreds. Not only that, it can cause a kindling effect, which makes withdrawal that much more difficult and can cause the symptoms to last much, much longer, as in years. Doctors simply don’t know what we experience in withdrawal. It is horrendous. Only the very strongest can go through it. We are belittled, laughed at, looked at as if we’re from Mars, by doctors and family members. There is nowhere to get support except through online sources. Having been a member of BenzoBuddies has truly been a lifesaver. Who can understand what’s happening when the nerves have been shattered? I was out walking one day and felt my face go numb and slack on the right side. That was quite scary. Luckily it only lasted for about 10 seconds. And I could read posts from others who mentioned the same thing. In other words, I wasn’t alone. But it is sad that we have no one to confide in, in person.

    There are few people that I’m aware of who have abused these drugs. Most have been taking them as prescribed. Yet they are very, very potent. I can’t stress this enough. It’s easy for me to see how I became dependent so easily. Sometimes I would take two pills instead of one. I had reached tolerance withdrawal. One pill wasn’t enough at times because of breakthrough anxiety due to the pills. I had never had a panic attack before benzos, and although I was nervous at times, NEVER have I suffered the type of anxiety I have gone through while on the pills and after. Then I developed vertigo, which was quite scary because I’d never experienced it before. I had high blood pressure as a result of benzos and would take a couple of pills before seeing the doctor. I was careful to make certain there were pills left in the bottle at the end of the month, but if I think back then, I know there were times I was sweating it out.

    Some people get off these drugs the first time easily. I wasn’t one of them. I wish so much there was a test you could take to determine if you’d have a bad reaction to the benzos. It’s been nothing short of hell, though in my 34th month out, I have regained a sense of normalcy in some respects. I still have anhedonia and anxiety. My head still feels “stuffy.” I get dizzy every day. But I’m no longer agoraphobic, and I don’t have to lean against a building for 20 minutes to wait for the dizziness to pass. Most of my other symptoms have left, only showing up periodically and then leaving. I am left with the most stubborn of symptoms, but I truly am looking forward to complete healing, even if it takes another year. (I was only on the drugs for 20 months, and that included tapering.)

    The benzos are a very misunderstood pill, especially by doctors. I had one doctor, who saw me in the hospital when I ended up with hyponatremia after I stopped Klonopin, tell me flat out that the drug was out of my system (after a month) and that I shouldn’t have any symptoms. He forgot one very important thing: the CNS, which has been badly crippled. And nerves take a very long time to heal.

    “The average daily benzodiazepine dose was equivalent to about 2.8 mg/day of Ativan (lorazepam, Valeant), but 11% of the patients were getting what the literature has deemed a high dose, which is 6 mg/day of Ativan or more,” she said.

    Another thing doctors don’t understand at all are the doses. 2.8 mg. of Ativan is A LOT. I was only on .5-1 mg., and that was enough to cause extensive damage.

    “The majority of the patients in the sample (60%) had been receiving benzodiazepines for 5 years or longer.”

    Doctors need to realize that this pill CANNOT be prescribed this long unless it’s a severe case. These pills should only be prescribed for two weeks maximum, and then safely tapered down. I know someone who was on Ativan for 19 days. A year later she was still going through symptoms because she had just stopped taking the drug and didn’t taper. (Actually, I think personally that they should only be given out for days. That’s it.)

    The doctor had better be willing to give informed consent if a case is severe enough to warrant a longer go of benzos. Also, to be knowledgeable about the many and varied symptoms a person could have. Few doctors are aware of this. Wikipedia has a good sample. That’s a good start. I say “good start” because there are many more symptoms than are reported there. https://en.wikipedia.org/wiki/Benzodiazepine_withdrawal_syndrome

  6. I knew someone who had a diagnosis of bipolar who had ECT in the past and who was on lithium, an antidepressant, a daytime benzo and sleeping pills.

    She had Chronic Fatigue and also had fallen over several times and walked with a frame to prevent further falls. No one linked the falls to the benzo’s or other drugs.

    She thought all this was fine until her kidneys started to fail. Even then she was convinced that her decades without a manic episode was due to all the drugs she was taking when it was probably because she had divorced her appalling husband sometime after the original manic episode.

  7. I’m going to very unpopular for this comment, and I’ll say that up front.

    I am a mental health patient. Twelve years ago I was diagnosed with bi-polar disorder and panic disorder. Among the many medications I’m taking for bi-polar (well regulated 4 years now), I was also prescribed benzos (Ativan).

    Twelve years!! I’m sure everyone is up in arms, but this is not a cause for alarm. I don’t understand people getting addicted and having such awful withdrawals. I am prescribed 4 1mg tablets to be taken daily. I don’t take them daily. I take them when I have a panic attack. I often go for weeks without taking any pills and it does not phase me in the least. I have no physical symptoms, although it is a psychological safety net of knowing that I have them in case I need them. I’m sure people can/will say it is irresponsible of my doctor to prescribe in this method/quantity, but it has not been a problem for me (even when I was prescribed 8mg a day).

    Just because my doctor prescribed it does not mean I need to take it or abuse it. Some responsibility needs to be on the patient to take their medication responsibly.

    • Jhamlin6668,

      You’re situation seems ironic.

      You irresponsibly ignore your doctors prescription to take the medication daily and by pure chance escape the worst of the withdrawal symptoms of these highly toxic medications by doing so.

      And then you claim the patient’s who legally follow their doctor’s prescription properly and end up experiencing severe withdrawal are behaving irresponsibly.

      Doesn’t seem to make a lot of sense.

      You also claim you go for weeks without the medication and it doesn’t phase you.

      Benzos are highly toxic and dangerous. I don’t suggest it for a moment, but I wonder how unphased you would be if you allowed yourself to experience a panic attack without the medication?

      The manufacturers’ recommend the medications be taken for no more than two weeks and yet you’ve been taking them for twelve years. Who is responsible for this situation?

      A responsible person might also investigate natural, non-toxic remedies for panic attacks, such as relaxation techniques, yoga, tai chi, qigong, etc….

      And If you think you’ve escaped benzo injury so far I suggest you research effects of long term usage, eg links to dementia and alzheimers, among many other serious conditions.

      Also, overwhelming evidence now strongly suggests benzos not only don’t treat panic attacks (albeit misleadingly mask the symptoms to some degree), they cause them, or at the very least exacerbate them.

      I wish you luck finding a healthy alternative to benzos.

  8. I agree with the criticism raised by most of those commenting here.

    I believe the there were good intentions in the posting of this article. However, the way in which it combines multiple viewpoints and a collection of conflicting half truths leads readers to some dangerous conclusions that ends up minimizing the nature of the worldwide benzodiazepine disaster.

    In my 25 years of working around psychiatrists, many often emphasized that their patients needed to take benzos “only as prescribed,” that is, several times a day on a particular schedule, and “not as needed.” We now know that it doesn’t really matter how benzos are taken, they will, in short order, lead to serious and harmful consequences.

    As Humanbeing has pointed out in her comment, the onus for problems are more often put on the patients and NOT on the doctors, Psychiatry, and Big Pharma – which is where the ultimate responsibility belongs.

    The concluding remarks of this article that end up emphasizing that benzos need to be prescribed “more carefully” is a gross minimization of the problem. This is a line that is often repeated by many mainstream doctors and psychiatrists, but is virtually meaningless in the context of the actual benzo crisis that is taking place across the planet.

    Richard

  9. I agree–the language about and around benzos is so reckless, irresponsible and it is highlighted in these reports. Those of us who have experienced this harrowing hell (to say the least) have something to say, but medicators don’t want to hear it. They’d rather prescribe a benzo!

    Terms

    The correct terms for dependency are Iatrogenic Sufferer, Iatrogenically Dependent, GABA Receptor Down-Regulation or Neuroadaptation, Benzo Victim or Benzo Survivor. For the epic shit storm surrounding that feeling, mood, body sensations when benzos start to wear off are phrases like Interdose Withdraw or Physiological Need for the Drug. For when arriving at the point to stop benzos permanently, dexox words like Tapering, Titration, or Removal of the Drug. For the state of acute withdraw (when not tapering anymore) Benzo Neurotoxicity/Injury, Benzo Drug Damage, Nervous System Healing, Brain & CSN Injury. The Benzo Withdrawal Syndrome or PAWS is encapsulated by Benzo Neurotoxicity, Drug Neurotoxicity, or Ashton Syndrome.

    I’m coming to contextualize benzos as psychiatry’s gateway drug to their medicine cabinet (until it comes up with a new one–if it hasn’t already!)!! I was prescribed benzos for 10 years consistently while medicators jacked around with a whole host of other drugs while never looking at or touching the benzo as a possible root cause or exacerbater or distorter of symptoms.

  10. I can use klonopin but I only get 20/month and it’s to AID the bipolar/ADHD combo. I used to take Xanax. Starting around 13 I am however having a longer time stopping the ADHD medication, Dexedrine. Lamictal will be a taper down. I nutritionally supplement as well even though I am, pretty much off all meds. If a #20, 1 mg Klonopin rx/month is a threat, it’s minimal. I take Lamictal and amphetamines and both can have their moments. I take them all as indicated but I I have moments too. I came off Xanax and this hasn’t been anything like that was.

    I don’t like them. They are a better option that being put on an Antipsychotic since it is an alternative to that. I do have ativan and haldol. I was 5 on meds. My gateway RX was Ritalin.

  11. The article fails to acknowledge that benzodiazepines (especially the high potency ones) can bring about tolerance, physical dependence and many side effects in a very short-time, regardless of how they are prescribed. It’s more about understanding their mechanism of action than anything else. If one understands the effect they have on the brain and body as a powerful GABA catalyst, it is obvious that these medications are meant for emergency use only. A lot of people being prescribed these medications on daily basis and instructed to take multiple times a day are most likely already iatrogenically-dependent on them. If they are not, they will soon be. Such every day “prophylactic” treatment of treating underlying condition before it occurs leads to physiological dependence very quickly. Then, we have perfect patients who never take an extra pill, yet, they have become enslaved to their prescription and are dependent on that next refill in order to keep functioning, not to get sick or worse. So, the “take every day, clearly spelled out prescriptions” only make sense if the prescription is very time limited (several days), or if the patient is already iatrogenically dependent and/or being tapered down.

    Other than that, in new benzo users, as-needed prescribing, not without its pitfalls is probably the safest way to go. Basically, try to prescribe the lowest dose for as needed use and warn the patient that this is a sub-optimal treatment of anxiety/panic/insomnia, etc., as well as offer safer alternatives (therapy, other medications, etc.). Also warn the patient of likelihood of physical dependence and potential inability to stop taking these meds with the result of worsening health and side-effects.