Benzodiazepines: Mothers little helper or a monster in a bottle?
Updated: Oct 3
Benzodiazepines: Mother’s little helper or a monster in a bottle? In 1966 the Rolling Stones had a hit record entitled: mothers' little helper. This observed the desperation of a suburban housewife who, to deal with the drudgery and the anxiety she experiences has become dependent on diazepam (also known as Valium). It is a story of the type of discreet dependency for which benzodiazepines has become associated with. Valium had only been on the market for three years in 1966 and yet the lyrics had already highlighted both a stereotype and a problem that has persisted, ever since, and is most certainly still a significant problem today. When Valium first made its way onto the prescription pads of GP’s it was hailed as a wonder drug. Indeed, by 1968 it was the most widely prescribed drug in America, and this continued until 1982. The drug instantly tapped into a huge market. It was touted as a cure for anxiety, as well as insomnia, and was a powerful tool for GP’s when patients presented with these two common problems. At the time, not only was it viewed as highly effective, but also did not appear to have any side effects. At the time, it was thought that it was not possible to overdose on benzodiazepines. Due to many high-profile deaths due to barbiturates, such as Marilyn Munroe, Valium was hailed as a game changer. In America there was very significant marketing associated with Valium which massively contributed to its phenomenal success. Indeed, the theme of the advertising was, very much, precisely the type of user so well encapsulated by Mick Jagger: The lonely, anxious housewife. While wholly unacceptable by today’s standards, the adverts of the 1960’s and 1970’s deliberately targeted women and informed them that, by popping pills, their lives could be so much better. https://www.historyhit.com/mothers-little-helper-the-history-of-valium/ Indeed, an advert in 1970 introduced a woman called Jan and depicted her as both single and “psycho neurotic”. At 35, she had encountered fifteen years of failed relationships which resulted in a matronly looking woman standing alone on a cruise ship. The message was that her self-esteem had stopped her finding a suitable husband who could measure up to her father. The message from this advert was abundantly clear: By taking Valium she would end her lonely existence, find the man of her dreams and live happily ever after. This was reinforced with a similar campaign, this time aimed at a middle-aged teacher who had been totally crushed due to depression following the menopause. By taking this wonder drug she is now “trim, smartly dressed and the way she was when school began”. Indeed, the advert read “Mrs. Raymond’s pupils do a double take!” While these adverts would not be acceptable today, they positioned Valium as America’s best-selling medication from 1968 until 1982 with a peak in 1978 where 2 billion tablets were sold in the country. Benzodiazepines have been around since the 1950’s. First invented by the Swiss manufacturer, La Roche. Their Austro-Hungarian--American chemist, Leo Sternbach. He discovered it by accident. The first benzodiazepine he discovered was Librium (Chlordiazepoxide) which is still the drug of choice for most alcohol detox cases, despite it being increasingly more difficult for pharmacies, especially in the community, to get hold of. https://link.springer.com/article/10.1007/s13181-022-00917-z What, of course, was not known then was the abuse potential for this class of drug or how it would lead to dependency. Within the hierarchy of drugs that are difficult to come off, Benzodiazepines are pretty much at the top end of the list. Depending on which benzodiazepine is being taken and for how long it has been taken it can take, in certain cases, over a year to reduce and stop. How do benzodiazepines work? Your body has a natural chemical called gamma aminobutyric acid (GABA). This chemical reduces the activity in the areas of the brain responsible for:
essential functions, such as breathing.
Benzodiazepine drugs increase the effects of GABA on your brain and body. This means these drugs can:
make you feel relaxed and sleepy (sedation)
reduce your anxiety
Relaxes your muscles
https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/about-benzodiazepines/#HowDoBenzodiazepinesWork Benzodiazepines are useful, clinically, for short term use. However, in 99% percent of cases, no one should ever be prescribed these for more than two to four weeks. They can be used for anxiety, severe insomnia and panic disorder. As they are, mostly, older drugs, they are relatively inexpensive for the NHS and on private prescriptions. GPs are under pressure to reduce the number of benzodiazepines they prescribe. Prescribing trends are monitored and the days of recurring repeat prescriptions for inappropriate items are coming to an end. I have come across patients who have been on benzodiazepines for decades: literally. As with other habit-forming drugs, the longer you take it, the less effective it becomes and the more you need to do what a lesser amount used to do. The world's leading expert on benzodiazepine reduction was Professor Heather Ashton of Newcastle university.https://www.benzo.org.uk/profash.htm Her seminal work has become a bible for clinicians around the world. As Professor Ashton pointed out, between 1990 and 1996 there were 1810 deaths attributed to benzodiazepines in the UK. Of these, 761 were due to suicide, 517 were accidental and 532 undetermined. As well as causing problems with dependency, they can also affect memory, emotional reaction and present specific problems for pregnant women. In addition, dependency on Benzodiazepines can also exacerbate potential difficulties for those dependent on gabapentinoids, alcohol, opioids, etc. Withdrawing from Benzodiazepines can cause very significant symptoms, hence why no one should ever attempt to do it at home by themselves. Symptoms can include:
Hallucinations (especially of insects under the skin)
Distorted body image
Muscle twitching and jerking
More serious symptoms, especially where there has been a rapid withdrawal/tapering include:
As such, it is imperative that anyone wanting to taper off/stop using benzodiazepines does so under appropriate supervision. The actual mechanics of tapering are quite straightforward. A patient is given a reduced amount of the drug in question over a period calculated using established guides such as the Ashton manual https://www.benzo.org.uk/manual/index.htm. For those dependent on shorter acting benzodiazepines, it can be useful to change, on admission, the medication to a longer acting one, such as diazepam. Nearer the end of the tapering process, it might also be prudent to use a liquid preparation of the drug as cutting tablets can, not only be an administrative issue (controlled drug) but a practical nightmare! Cutting tablets in halves and quarters should always be avoided. Pregnancy Drug trials never include pregnant women, so it is more difficult to research the effects of medications taken when pregnant. However, it is known that benzodiazepines can cross the placenta, meaning the fetus can absorb some of the medication. As such, especially if the mother takes the drug in the late stages of pregnancy, there can be complications. Indeed, after birth a child can exhibit signs of over sedation, inability to suckle and present with lax muscles. This is known as floppy infant syndrome. However, these problems may not be present for up to two weeks after birth and can be indicative of hyper excitability and a very high-pitched cry. Another indication can be that feeding becomes very difficult. Currently, there is no evidence to suggest that taking benzodiazepines causes any congenital malformations. However, there is evidence that chronic use may affect the brain development of the fetus. In addition, the child (in later life) might be more prone to neurodevelopmental difficulties such as ADHD, learning difficulties and autistic spectrum disorders. PTSD and benzodiazepines A 2015 study https://www.wolterskluwer.com/en/news/benzodiazepines-not-recommended-for-patients-with-ptsd-or-recent-trauma clearly suggests that patients with diagnosed post-traumatic stress disorder should not be prescribed benzodiazepines. This was the first comprehensive study of its kind. When the study was published, the researchers discovered that the use of benzodiazepines for PTSD was both common and controversial. They found disagreement amongst psychiatric professionals as some felt they were useful in reducing anxiety, insomnia and irritability: Core signs of PTSD. However, there is another school of thought that benzodiazepines prolong and worsen the condition. This paper was a review of eighteen studies and involved more than five thousand participants who had experienced significant traumas, and not just psychological ones. The study looked at cases where the root cause was sexual trauma as well as exposure to disaster. The conclusion of the review was that there was no improvement in the symptoms, indeed that benzodiazepines could be responsible for the worsening of conditions. More worrying was the discovery that benzodiazepines can actually increase the risk of PTSD when used by those recently exposed to trauma. The review did acknowledge that benzodiazepines have their uses for other anxiety disorders, but the conclusion was that PTSD develops differently than other disorders. The hypothesis being that benzodiazepines are indiscriminate in the areas of the brain they act upon. This research also reinforces the findings of Professor Asthon in that benzodiazepines have ongoing effects on memory and that they may, indeed, hinder patients from learning how to cope with the symptoms of PTSD. The study concluded that patients would benefit from evidence based, trauma focused psychotherapies so that patients can experience anxiety and then learn how to master it. When this review was conducted in 2015, there had only been four randomized trials: to date. Clearly, a lot more research needs to be done. The conclusion was that benzodiazepines were not indicated for use in patients with trauma. Tolerance: what does it mean and what effect does it have? This is a phenomenon that occurs when consistent amounts are taken over a prolonged period. In short, the original dose becomes progressively less effective, and a higher dose is required to obtain the original effect. Historically, this has led to prescribers simply increasing the dosage in their prescription or to add in another benzodiazepine: on top of the original dose. Patients can develop tolerance to various actions of the drug at different rates and to different degrees. For example, recovery from the effects that benzodiazepines have on sleep can occur within a few weeks after tapering/cessation. Benzodiazepines and epilepsy In a hospital setting, or in the back of an ambulance, benzodiazepines are used to stop a seizure. However, tolerance makes them unsuitable for long term control of epilepsy. There are many, many patients within the prison system who will make spurious claims about nonexistent neurologists telling them that only benzodiazepines will control their epilepsy. Indeed, I spent many an hour, while working in prisons, trying to locate these consultants: many of whom were simply the figment of the patient's imagination. Therapeutic dose dependence Professor Ashton listed nine different characteristics of those who have been prescribed benzodiazepines and have become dependent on them. 1.Length of time: Patients have taken a “therapeutic” dose, often a low one, for some months, or even years. 2. need: In order for the patient to feel able, even to be physically capable of doing so, they “need” the benzodiazepine. 3. The reason as to why the patient was initially prescribed no longer presents itself. For example, to assist with bereavement, episode of severe anxiety. 4. They experience withdrawal if they suddenly stop taking it. 5. For those on short-term acting benzodiazepines, they experience anxiety between doses 6. The patient is in regular contact with their GP surgery to obtain prescriptions 7. Increased anxiety if their next prescription is not readily available and use before an anticipated stressful event. 8. The patient is taking more than the prescribed dosage. 9. Despite the use of benzodiazepines, the patient is still experiencing the symptoms for which the drug was first prescribed. What can the adverse effects of benzodiazepines be? The most significant problem is over sedation. This can be present in several ways, not just making the patient sleep. It can lead to poor concentration and well as poor co-ordination in addition to muscle weakness as well as mental confusion. Furthermore, it can cause significant dizziness. Patients are often prescribed benzodiazepines to help them sleep. This can cause what is known as a “hangover” as they leave you very tired the next day. This is a particular problem with the elderly and benzodiazepines can cause acute confusional states: Even at very low doses. Due to the potential for sedation, it is highly recommended that patients taking benzodiazepines do not operate heavy machinery or drive. This information is contained within the patient information leaflet and should someone have a road traffic accident as a result, the liability will rest with them. After all, it is not as if they were not warned! Other medications can also increase the risk of sedation, namely antidepressants. While benzodiazepines can be useful in the aftermath of a very significant psychological trauma, they can inhibit adjustment and recovery. They are not antidepressants and must not be used to treat depression. Indeed, there is the phenomena of emotional blunting and benzodiazepines can even cause depression by reducing serotonin levels. Indeed, patients suffering from chronic agoraphobia are often dependent on benzodiazepines yet may recover if these are withdrawn. In the elderly, benzodiazepines can cause what is known as pseudo-dementia: A set of symptoms that mirror dementia but are caused by benzodiazepines. Prescribing such drugs for the elderly must be done with very serious caution and dosages will always be considerably less than for younger adults. Tolerance: what does it mean and what effect does it have? This is a phenomenon that occurs when consistent amounts are taken over a prolonged period. In short, the original dose becomes progressively less effective, and a higher dose is required to obtain the original effect. Historically, this has led to prescribers simply increasing the dosage in their prescription or to add in another benzodiazepine: on top of the original dose. Patients can develop tolerance to various actions of the drug at different rates and to different degrees. For example, recovery from the effects that benzodiazepines have on sleep can occur within a few weeks after tapering/cessation. How is a taper calculated? There are many clinical guidelines that give advice to clinicians as to how to calculate a taper for a patient dependent on benzodiazepines. The Ashton Manual https://www.benzo.org.uk/manual/index.htm is the ultimate reference guide and the “go to” for any clinician who prescribes in the field of benzodiazepine dependency. While there may be mild variances across NHS guidelines, they mirror this seminal guide. The same rules apply to Benzodiazepine taper as they do with opioid dependency: Low and slow. No one should ever attempt a rapid withdrawal, as to do so could have very serious consequences. Indeed, from my experience, patients tend to go wrong when they taper down to a low dose then decide to stop. The issue is that they have then dropped their intake by 100%. Not a good idea. How long will it take? While I will not say “how long is a piece of string” that depends on the patients use, length of use and level of dependency. Be extremely wary of any center that gives you a timeline on a first inquiry. Remember: The person who answers the phone, while they may have been in treatment themselves, will not be a clinician and will not be able to give you a realistic time frame/costing. Any decent center will take your details, speak to their clinician, and call you back. There are prescription medications that might be useful while in rehab for benzodiazepine addiction. However, as with alcohol and opioid detox, they are adjunctive. Stay off caffeine, ensure you tell your prescriber all the medication you are taking (especially antibiotics) and be aware of any Center that wants to put you on a rapid programme. Yes, it may be costly when done properly, but can you put a price on health?