Dancing with the Devil

© choreograph | stockfresh.com

© choreograph | stockfresh.com

I once knew a woman who had an anxiety disorder. She also abused benzodiazepines. She was able to conjure up a panic attack in a doctor’s office and walk out with a prescription for the benzo of her choice. At one time, she had four concurrent prescriptions for these anti-anxiety medications. Another person I know of has a ten-year history of using benzodiazepines at close to the maximum recommended dose. When he had an unexpected short-term hospital stay, the treating physicians were reluctant to continue prescribing benodiazepines at such a high level while he was in the hospital. When he returned home, in case his medical issue resulted in another unexpected stay, he put together an emergency hospital kit with various things—including extra benzodiazepines.

A study published in the American Journal of Public Health in April of 2016 found that benzodiazepines were the second most common drug in prescription overdose deaths for 2013. Given the common knowledge of the potential dangers of benzodiazepines and people becoming more aware of opioids, Marcus Bachhuber and a team of researchers thought that their study would show a steady of declining pattern for prescribing benzodiazepines. But they found exactly the opposite. Between 1999 and 2013 there was an increase of 30% among adult Americans who filled a benzodiazepine prescription. In addition, the amount of medication within a prescription doubled over the same time period.

Bachhuber was quoted by CNN as saying the study’s findings were very concerning. The risk of overdose and death from benzodiazepines alone is said to be generally lower in otherwise healthy adults. But in combination with other drugs like alcohol or opioids, they can be lethal.

Future research should examine the roles of these potential mechanisms to identify effective policy interventions to improve benzodiazepine safety. In particular, as underscored by several recent reports, interventions to reduce concurrent use of opioid analgesics or alcohol with benzodiazepines are needed.

The overdose problem with benzos has been overshadowed by the problems with prescription opioids. Writing for CNN, Carina Storrs said: “The current study could help shine a light on the problem of benzodiazepine abuse and overdose.” Dr. Gary Reisfield, a professor of psychiatry at the University of Florida, referred to the problem with benozdiazepines as a “shadow epidemic”:

Much attention has been paid to the explosion of prescription opioid prescribing and the associated morbidity and mortality. Much less attention has been paid to the shadow epidemic of benzodiazepine prescribing and its consequences.

A 2015 study by Jones and McAninch found that emergency department visits and overdose deaths involving opioids and benzodiazepines increased significantly between 2004 and 2011. Overdose deaths from combining the two classes of drugs rose each year from 18% in 2004 to 31% in 2011. This rate increased faster than the percentages of people filling prescriptions and the quantity of pills in the prescriptions.

As Dr. Indra Cidambi wrote in “Are We Ignoring an Escalating Benzodiazepine Epidemic?”,  she observed with increasing alarm the rising rate of concurrent use/abuse of benzos among opiate users. She pointed to two possible factors driving this trend. First, some opiate abusers use benzos to “spike” the euphoria from their opiates. Second, patients often receive their prescriptions from two different physicians. She said that it is “notoriously difficult” for doctors to refuse to prescribe these two medications.

Unfortunately, and ironically, pain and anxiety are neither verifiable nor quantifiable through medical testing! Consequently, self-reported symptoms by patients are the sole basis on which prescriptions for these medications are written, enabling individuals addicted to these medications to obtain them fairly easily.

Dr. Cidambi recommended the establishment of a national database for physicians to verify whether or not a patient has been prescribed one of these medications before prescribing or filling a prescription for the other. Second, she said physicians should develop limited, short-term treatment plans from the beginning to treat noncancerous pain with opiates and anxiety with benzodiazepines.

Studies have shown the decreasing efficacy of long-term treatment for pain with opioid medications, and evidence-based treatment protocols for benzodiazepines clearly indicate that long-term use of benzodiazepines is not recommended.

In “Benzos: A Dance with the Devil,” Psychiatrist Kelly Brogan described some of her work helping patients taper off of benzodiazepines. A woman who had been placed on Remeron (an antidepressant) and Klonopin (a benzodiazepine) for eight years said of her original prescriber: “He never once told me there might be an issue with taking these meds long-term. In fact, he told me I probably needed them after I tried stopping them cold turkey and felt so sick I thought I was dying.” Brogan said no one ever discussed with this woman or her patients the true risks, benefits and alternatives to psychiatric medications like benzodiazepines, “perhaps because we as clinicians are not told the full story in our training.”

She went on to quote from a paper by another psychiatrist, Peter Breggin, on the risks of benzodiazepines, which include: cognitive dysfunction that can range from short-term memory impairment and confusion to delirium; “disinhibition or loss of impulse control, with violence toward self or others, as well as agitation, psychosis, paranoia and depression.” There can also be severe withdrawal symptoms, ranging from anxiety and insomnia to psychosis and seizures after abruptly stopping long-term larger doses. The person can re-experience their pre-drug symptoms as they taper. These so-called rebound symptoms of anxiety, insomnia and others serious emotional reactions can be more intense than they were before drug treatment began. And don’t forget dependency or abuse.

Psychiatrist Allen Frances, the former chair of the DSM-IV, recently wrote: “Yes, Benzos Are Bad for You.” He introduced his article by saying that he was going to say some very negative things about benzodiazepines in the hope that doctors think twice before prescribing them and patients are discouraged from taking them. Benzos were wonder drugs in the 1960s. Anyone remember the 1966 song, “Mother’s Little Helper,” by the Rolling Stones? These drugs were reputed to be safe, and so were used for a variety of “ills,” such as anxiety, alcohol use disorders (yes, really), to take the edge off of agitation in dementia, and to help people sleep. “Initially we were pretty oblivious to the risk of addiction.” So benzodiazepines quickly became the most prescribed medications in America.

A second craze began in the 1980s with the release of Xanax. Frances said the dose to treat panic disorder was “dangerously close” to the dose leading to addiction. “This should have scared off everyone from using Xanax, but it didn’t.” It remains a best seller, with its own “brand” that now leads to fentanyl be pressed into counterfeit Xanax pills. See “Buyer Beware Drugs” and Paul Gaita’s article on fake Xanax laced with fentanyl.

The real wonder of the benzos is that sales continue to boom, despite their having so little utility and no push from pharma marketeering (because patents have run out – thereby decreasing costs and profits.) Between 1996 and 2013, the percentage of people in the U.S. using benzos jumped more than one-third from an already remarkable 4.1 to 5.6 percent. Especially troubling is that benzo use is ridiculously high (nearly one out of ten) in the elderly, the group most likely to be harmed by them.

Frances said the beneficial uses of benzodiazepines can be counted on the fingers of one hand: short-term agitation in psychosis, mania and depression; catatonia; “as needed” use for times of special stress, like fear of flying, or for sleep. While they should be used very short term, in real life most people take them long term—“in doses high enough to be addicting, and for the wrong reasons. . . . Benzos are very easy to get on, almost impossible to get off.”

In addition to the harm from overdoses, Frances described the painful and dangerous withdrawal symptoms, which he said are a “beast.” Common symptoms are irritability, insomnia, tremors, distractibility, sweating and confusion. “The anxiety and panic experienced by people stopping benzos is usually much worse than the anxiety and panic that initially led to their use.”  Concurrent use or abuse of alcohol or other drugs, like opioids, complicates withdrawal even further.

The most insidious issues with benzos for Frances, is how they effect brain functioning. Especially with the elderly, ongoing benzo use can be devastating. Many elderly begin their downward spiral to death and disability from falls—that happen from their benzo use! He said: “If you meet an elderly patient who seems dopey, confused, has memory loss, slurred speech, and poor balance, your first thought should be benzo side effects — not Alzheimer’s disease or dementia.” See “Sedating Seniors” for more information on this topic. It’s been over 30 years since he last prescribed a benzo for anxiety.

The tough question is what to recommend for those many unfortunates already suffering the tyranny of benzo addiction. Should they stay the course to avoid the rigors and risks of withdrawal or should they make the great effort to detox? This is an individual decision that can’t be forced on someone. But the longer you are on them, the harder it gets to stop, and the cognitive side effects of benzos create more and more dysfunction as your brain ages. The best bet is to stick with a determined effort to detox, however long and difficult, under close medical supervision. On a hopeful note, some of the happiest people I have known are those who have overcome their dependence on benzos.

So it was encouraging to see that the FDA will require class-wide changes in drug labeling to bring attention to the dangers of combining opioids and benzodiazepines. The changes will include boxed warnings on nearly 400 products with information on the risks of combining these medications. The FDA Commissioner, Robert Califf said: “It is nothing short of a public health crisis when you see a substantial increase of avoidable overdose and death related to two widely used drug classes being taken together.” He implored health care professionals to carefully and thoroughly evaluate on a patient-by-patient basis whether the benefits outweigh the risks when using these drug classes together.

Used alone or in conjunction with opiates, benzodiazepines are potentially lethal and addictive. A too sudden withdrawal from benzodiazepines can be fatal, where the same is rarely true with opiates. They work quickly and effectively for anxiety and sleep problems and yet they can have a multitude of side effects, including addiction. Did I say they are addictive? Using benzodiazepines has become a dance with the devil for too many unsuspecting individuals … those that are still alive to regret it, that is.

This article previously appeared on the addiction and recovery website “The Fix” under the title of “Dangerous Dance.”


Sedating Seniors

© Vera Kuttelvaserova Stuchelova | 123RF.com

© Vera Kuttelvaserova Stuchelova | 123RF.com

In September of 2014, the British Medical Journal published an article titled: “Benzodiazepine use and risk of Alzheimer’s disease.” It received a good bit of public attention because of its conclusion that there was an increased risk of up to 51% of Alzheimer’s disease with the use of benzodiazepines —for as short a period of time as three months. There was concern expressed by Psychiatric News, which quoted Davangeere Devanand, the director of the geriatric psychiatry program at Columbia, who said: “These findings emphasize the importance of restricting the use of benzodiazepines in the elderly population.”

Philip Hickey reviewed the article and noted where the study’s authors commented there findings were congruent with five previous studies. The authors also said their findings were of major importance for public health, particularly considering the widespread chronic use of benzodiazepines with older people. Guy Goodwin, a professor of psychiatry at Oxford, voiced a common assessment of the study, namely that it was more likely that the drugs were being given to people who were already ill. I’ve heard similar comments made by pharmaceutical researchers. This dismissal of the study’s results was despite the fact that the researchers specifically attempted to control for this factor. They said:

Our study was designed specifically to reduce the possibility of reverse causation bias and to provide additional arguments linking benzodiazepine use with Alzheimer’s disease, such as a dose-effect relation.

To a certain extent, this is a rehashing of old news, as I’ve previously addressed the BMJ study in “What a Drag It Is Getting Old.” But the concern over the use of benzos with older people hasn’t gone away. There was an article published in the February 2015 issue of JAMA Psychiatry that looked at “Benzodiazepine Use in the United States.” The article first appeared online in December of 2014. You can watch a short YouTube video by the lead author summarizing the study’s results here.

The study found that about 1 in 20 (5%) people between the ages of 18 and 80 received a benzodiazepine prescription in 2008. However, the percentage increased with age, rising to 8.7% among individuals 65 to 80. Women were twice as likely as men to receive prescriptions in all age groups. Most of the prescriptions—two thirds—were written by non-psychiatrists. For adults 65 to 80, this was 9 out of 10. Thomas Insel, the director of the National Institute of Mental Health (NIMH), voiced the following concerns with the NIMH-funded study’s results:

These new data reveal worrisome patterns in the prescribing of benzodiazepines for older adults, and women in particular. . . . This analysis suggests that prescriptions for benzodiazepines in older Americans exceed what research suggests is appropriate and safe.

In a Psychiatric News Alert, one of the study’s authors was quoted as saying that it was alarming to find the highest rates of benzodiazepine use among the groups with the highest risks. “Given that safer, effective options are available for anxiety and insomnia, it’s hard to make a clinical argument for these results.” In an editorial written about the study in JAMA Psychiatry, the authors commented that there seems to be a societal addiction to using benzodiazepines with the elderly. They said these drugs should only be used for very short periods of time. With individuals susceptible to cognitive impairment or to falls and fractures, benzodiazepines should be avoided altogether.

The editorial authors also suggested that prescribing benzodiazepines should be restricted to psychiatrists. Their recommendation was based upon the perception that psychiatrists seemed prescribe them properly in the JAMA Psychiatry study. They further recommended that benzodiazepines be reclassified as a Schedule II Controlled Substance with limited-duration prescriptions and no refills. “Such barriers could help the public and prescribers think more about these risks before prescribing or using benzodiazepines.”

I don’t think limiting the prescription of benzodiazepines to psychiatrists is either practical or realistic. Despite the dangers reviewed here, restricting benzodiazepines, while permitting antidepressants, neuroleptics and mood stabilizers to be prescribed by all medical doctors is nonsensical. All these additional classes of drugs have their own serous side effects. Some are arguably more problematic than benzodiazepines. If only psychiatrists were permitted to prescribe benzos, then pharmaceutical companies would adjust their marketing strategies to concentrate on psychiatrists.

Reclassifying benzodiazepines as Schedule II Controlled Substance has more merit, but will be hard to accomplish. The process to reclassify any prescription drugs is complicated and difficult.

I’m also not convinced that all psychiatrists would be better monitors of benzodiazepine use/abuse. I know of one person whose primary care physician was reluctant to continue a long-term benzodiazepine prescription, but a psychiatrist wasn’t. I know of another individual who has been prescribed daily benzodiazepine use for sleep by a psychiatrist for over two years. My thought is that the more entrenched any medical doctor is within a biological view of psychiatric disorders, the more willing they are to prescribe benzodiazepines long-term.

Sadly, all these concerns with the use of benzodiazepines with the elderly were voiced and know twenty-five years ago. The journal Drug Safety published “Problems and Pitfalls in the Use of Benzodiazepines in the Elderly” by Wolfgang Kruse in its September issue for 1990. Dr. Kruse noted benzodiazepines were frequently prescribed for elderly patients; and that their use was more common with women. Prolonged use was likely for treating not only insomnia and anxiety in the elderly, but also a wide range of nonspecific symptoms. “Long term users are likely to have multiple concomitant physical and psychological health problems.”

He noted that long-term studies on unwanted effects were scarce, but there was some evidence that benzodiazepines were implicated in drug-associated hospital admissions. “There is suggestive evidence that benzodiazepines, especially compounds with long half-lives, may contribute to the falls which are a major health problem in old age.” Prophetically, he stated:

Problems in the use of benzodiazepines will arise if the available knowledge on altered pharmacokinetics and pharmacodynamics and principal guidelines for drug prescribing in the elderly are neglected. Poor prescribing habits are related mainly to inadequate clinical assessment, excessive prescribing and inadequate supervision of treatment. Unlimited repeat prescribing, particularly for the treatment of sleep disturbances, is seldom justified.


What a Drag It is Getting Old

Things are different today. Grandmother needs something to calm down. Although she’s not really ill, they’ll give her a little yellow pill. And it helps her on her way, and gets her through the day. So she goes running for the shelter of a mother’s little helper. Four will help her sleep right through the night; and might even help to minimize her plight.

“Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old.”

Above and below are the chorus and two paraphrases taken from the lyrics of the Rolling Stones 1966 song, “Mother’s Little Helper.” Following the runaway success of the first modern tranquilizer, Miltown, Hoffman-La Roche brought the newest benzodiazepine—Valium to market in 1963 and then targeted women in its advertising. “From 1968 to 1981, it was the best selling drug in the Western world.”

Recently there has been a good bit of press (Science Daily and Web MD and others) on a study published in the British Medical Journal that indicated benzodiazepine (benzo) use was associated with the risk of developing Alzheimer’s disease. A BBC report about the study quoted some Alzheimer’s experts who minimized the study’s findings by saying that it was hard to know the underlying reason for the link.  Other reports, such as that by Paula Span, on her New York Times blog, The New Old Age, noted how the study was designed to reduce the possibility of reverse causation. That is, reverse causation claims the correlation existed because individuals first diagnosed with Alzheimer’s were given benzos afterwards as part of their medical treatment.

Mad in America quoted from the study’s abstract, where the researchers said: “the stronger association [between Alzheimer’s and the use of benzos] observed for long term exposures reinforces the suspicion of a possible association.” The study’s authors further said:

Risk increased with density of exposure and when long acting benzodiazepines were used. Further adjustment on symptoms thought to be potential prodromes [precursors] for dementia—such as depression, anxiety, or sleep disorders—did not meaningfully alter the results.

The results of the study were consistent with five previous studies. It reinforced the suspicion of an increased risk of Alzheimer-like dementia among benzo users, particularly those who are long-term users. Their findings are particularly important when considering the wide spread use of benzos with older people, and the concurrent rise of dementia in developed countries. “Unwarranted long term use of these drugs should be considered as a public health concern.”

A JAMA Internal Medicine article noted that: “The American Board of Internal Medicine Foundation Choosing Wisely Campaign recommends against the use of benzodiazepine drugs for adults 65 years and older.” Paula Span reported in another article that a particular concern with older adults is falls, which are a leading cause of death and disability. The CDC estimated that one out of three older adults over the age of 65 falls each year. “In 2012, 2.4 million falls among older adults were treated in emergency departments and more than 722,000 of these were hospitalized.” Advice for tapering older adults off of benzos and other sleep aids like Ambien is available.  See the Paula Span article, “More on Sleeping Pills and Older Adults,” linked in this paragraph.

Not only are benzos problematic when given to older adults long-term, there is a well-documented concern with any long-term use of this class of drugs. Quoting Dr. Stevan Gressitt, Robert Whitaker indicated in Anatomy of an Epidemic that there was no evidence supporting the long-term use of benzos. Additionally, they could aggravate medical and mental health problems like anxiety, depression, cognitive impairment and functional decline.

Whitaker described a 2004 Australian study that looked at the potential deficits in cognitive functioning after long-term benzo use. The duration of benzo use by the patients in the research studies they looked at ranged from 1 to 34 years. The mean was 9.9 years. They found that long-term benzo users were consistently more impaired across all the cognitive categories examined. “The observation that long-term benzodiazepine use leads to a generalised effect on cognition has numerous implications for the informed and responsible prescription of these drugs.”

Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term, with dozens of studies subsequently confirming the wisdom of that advice, the prescribing of benzodiazepines for continual use goes on. Indeed, a 2005 study of anxious patients in the New England area found that more than half regularly took a benzodiazepine, and many bipolar patients now take a benzodiazepine as part of a drug cocktail. The scientific evidence just doesn’t seem to affect the prescribing habits of many doctors.” (Robert Whitaker, Anatomy of an Epidemic, p. 147)

“Life’s just much too hard today,”
I hear every grandmother say.
The pursuit of happiness just seems a bore
And if you take more of those, you will get an overdose.
No more running for the shelter of a grandmother’s little helper.
They just helped you on your way, towards your busy dying day.


Homegrown Epidemic

The White House reported that the Centers for Disease Control and Prevention (CDC) identified prescription drug abuse as an epidemic.  The 2012 National Survey on Drug Use and Health (NSDUH) reported that 4.9 million people, 1.9% of the population, abused prescription drugs. Nonmedical use of psychotherapeutics, particularly pain relievers, was the most commonly used illicit substance after marijuana. “In our military, illicit drug use increased from 5% to 12% among active duty service members from 2005 to 2008, primarily due to non-medical use of prescription drugs.” Drug induced deaths have almost doubled since 1999 and are now second only to motor vehicle fatalities.

At the end of 2013, Genetic Engineering & Biotechnology News (GEN) published a list of the top 17 abused drugs of 2013. The table below combines most of the given statistical information in the list of abused drugs and presented them in rank order, from one to seventeen.

There is no surprise that seven of the listed drugs are either prescribed for some kind of “pain” condition or are opioids (OxyContin, Suboxone, Opana, Fentora [fentanyl], Percocet, Soma, Vicodin). Vicodin is now classified as a schedule 2 controlled substance. Soma is now a schedule 3 controlled substance. Suboxone  (schedule 3) is an opioid approved for opioid drug treatment.

Three of the medications are used to treat ADHD (Concerta, Ritalin, Adderall); all three are in the top 8 most abused drugs. Four of the drugs are benzodiazepines (Xanax, Klonopin, Ativan, Valium; schedule 4).  Two medications are sleep aides (Ambien, Lunesta). One, Zoloft, is an SSRI used to treat depression.



2012 Sales

2011 Sales





2.7 billion

2.8 billion

until 2025




1.4 billion

1.2 billion

until 2020




1.1 billion

1.3 billion



Ambien CR


671 million

661 million

until 2020




554 million

550 million





541 million

573 million





447 million

420 million

until 2014


Adderall XR


429 million

533 million





299 million

384 million

until 2025




274 million

308 million





194 million

211 million





161 million

186 million

until 2019




103 million

104 million





30 million

25 million





27 million

46 million

expired 1/12




8 million

11 million






168 million



Suboxone is likely on the list because of its use by opioid abusers and addicts as a “back up” to forestall withdrawal when the opioids aren’t available. However, along with other opioids it can be combined with benzodiazepines for a heroin-like euphoria. The combination of these two classes of drugs has increasingly become one of the signatures of accidental overdose deaths worldwide. The 2012 NSDUH reported that 4.8% of the population over the age of 12 had used pail relievers illicitly within 30 days of being surveyed.

In their own right, benzodiazepines have a long history of abuse. Valium was the best selling drug in the Western world from 1968 to 1981. It wasn’t until 1975 that the U.S. Justice Department required that benzodiazepines be listed as schedule 4 drugs under the Controlled Substances Act. As Robert Whitaker noted: “This designation limited the number of refills a patient could obtain without a new prescription, and revealed to the public that the government had concluded that benzodiazepines were, in fact, addictive.” The 2012 NSDUH reported that 2.3% of the population over the age of 12 had used tranquilizers illicitly within 30 days of being surveyed.

Attention-deficit disorder did not appear as a “disease” in the Diagnostic and statistical Manual until 1980. In 2007, the CDC reported that one in every twenty-three American children between the ages of four and seventeen is taking an ADHD medication. Concerta, Ritalin and Adderall are all schedule II controlled substances; classified to be as potentially addictive as OxyContin, Opana, Fentara, Percocet, and Vicodin. Concerta and Ritalin are the brand names for the generic drug, methylphenidate.  The 2012 NSDUH reported that 1.3% of the population over the age of 12 had used stimulants illicitly within 30 days of being surveyed.

The medications on the GEN list of abused drugs include some of the most commonly prescribed classes around: drugs for pain relief, anxiety, ADHD, and sleep problems.  The Daily Beast reported that: “The US, which holds 5 percent of the world’s population, is responsible for 75 percent of global prescription drug use.” So the chances that at some time in your life you will be prescribed one of these 17 drugs for a legitimate medical reason is high. Be careful in how you use them and most especially, how long you use them.

Do you think it is overstating the problem to say that prescription drug abuse is an epidemic?