06/9/20

An Epidemic Emerging from the Pandemic?

According to a report by Express Scripts, America’s State of Mind, the number of prescriptions filled per week for antidepressant, anti-anxiety and anti-insomnia medications increased 21% between February 16^th and March 15^th. COVID-19 was declared a pandemic on March 12^th. Prescriptions for anti-anxiety medications rose 34.1% during that four-week period, with an increase of almost 18% during the week ending March 15. “The number of prescriptions filled for antidepressants and sleep disorders increased 18.6% and 14.8%, respectively, from February 16 to March 15.”

More than three quarters (78%) of all antidepressant, antianxiety and anti-insomnia prescriptions filled during the week ending March 15^th (the peak week) were for new prescriptions.

Express Scripts is the largest pharmacy benefit management (PBM) company in the U.S., with $100.75 billion in revenues. The Express Scripts Drug Trend Report has been published annually since 1993 and provides a detailed analysis of prescription drug costs and utilization. Express Scripts said it was understandable that Americans have become more anxious as they’ve seen the COVID-19 global pandemic swiftly and dramatically upend their lives. “This analysis, showing that many Americans are turning to medications for relief, demonstrates the serious impact COVID-19 may be having on our nation’s mental health.”

The increase of anti-anxiety medications was particularly striking, given that Express Scripts’ research showed the use of these drugs had been declining over the past five years. Mental health medication trends from 2015 through 2019 recorded a decline of more than 12% in the use of anti-anxiety medications. This was among 21 million people with employer-funded insurance. There was a similar decline in the use of anti-insomnia medications, which were down 11.3%.

While the recent increased use of medications to treat anxiety, depression and sleep disorders is sudden, it is encouraging to see our members recognizing the need for help and seeking support from their physician. What’s crucial now is ensuring Americans who are experiencing symptoms of these mental health conditions have support and access to their physicians, therapists and educational resources, including digital tools and virtual care and counseling to help them cope during this time.

The rapid increase in anti-anxiety prescriptions is troubling, perhaps more troubling than the Express Scripts data indicates. Prolonged use of benzodiazepines is associated with tolerance and withdrawal symptoms, as well as misuse and substance use disorder. In older adults, benzodiazepines increase the risk of falls, hip fractures, cognitive impairment and drug-related hospital admissions. Contrary to what was reported by Express Scripts, the number of U.S. adults with a prescription for a benzodiazepine increased from 4.1% in 1996 to 5.6% in 2013, according to a report by the National Center for Health Studies released on January 17, 2020.

Overdose deaths that involved benzodiazepines increased from .58 per 100,000 in 1996 to 3.07 in 2010. “Data from the National Institute on Drug Abuse show that 11,537 overdose deaths involving benzodiazepines occurred in 2017.” About 85% of the 2017 overdose deaths involving benzodiazepines also involved an opioid, despite warnings that coprescribing benzos with opioids increases the risk of respiratory depression. The coprescription of benzodiazepines and opioids increased from .5% of doctor visits in 2003 to 2.0% in 2015; opioids were prescribed at 26.4% of the visits where there was also a prescription for benzodiazepines. In 2016, the FDA issued warnings on the concurrent use of opioid medications and benzodiazepines.

The data examined from the 2014-2016 National Ambulatory Medical Care Survey included office visits where opioids were coprescribed. “Among visits at which benzodiazepines were prescribed, approximately one-third involved an overlapping opioid prescription.” More women than men were prescribed benzodiazepines and this pattern went across all age groups. This was also true when benzodiazepines were prescribed with opioids for adult patients. See the chart below.

About one-half of the visits where a benzodiazepine was prescribed were with a primary care provider (48%) and one-half (50%) were with another type of provider. Among primary care providers, general or family practice (54%) and internal medicine (39%) were the most frequent specialties. Among nonprimary care providers, psychiatrists accounted for 28% of visits where benzodiazepines were prescribed. Patients who visited the doctor frequently, six or more times in the past 12 months, were more likely (40%) to receive a prescription for benzodiazepines.

Private insurance (39%) and Medicare (38%) were the primary sources of payment for office-based visits when benzodiazepines were prescribed, followed by Medicaid (9%) and no insurance (7%). One-half the visits by adults between 18 and 44 and 45 and 64 where benzodiazepines were prescribed used private insurance, whereas 79% of visits by adults 65 and over used Medicare as the primary source of payment. 88% of the visits where in which benzodiazepines were prescribed, benzos were a continued prescription. See the chart below for the data by age group and source of payment.

There were 23 million prescriptions of benzodiazepines, accounting for 35% of the doctors’ office visits at which benzos were prescribed. The percentage of visits having new prescriptions for a benzodiazepine and an opioid was significantly lower than the percentage of visits with continued prescriptions across all age groups. The percentage of visits with a new prescription for benzodiazepines decreased with age. But the percentage of visits with a continued prescription for benzos increased with age. See the chart below.

In “The Disturbing Rise in Benzodiazepine Prescriptions,” Christopher Lane reported for Psychology Today that the results of the National Center for Health Studies report were “discouraging and disappointing.” He thought we should be concerned with bringing these numbers down. “Between 2003 and 2015, the number of ambulatory visits with one or more prescriptions for a benzodiazepine increased sharply from 27.6 million to 62.6 million.” Keith Humphreys of Stanford, said “The enormous growth of benzodiazepine prescribing has flown under most policymakers’ and clinicians’ radar.” He speculated it may be because many people with a dependency on benzos are older; fewer are violent. “Or maybe people think that since they come from a doctor, they can’t be all that bad.”

While primary care physicians and psychiatrists may be prescribing in good faith for anxiety, pain, and insomnia, the concern is that they are not getting the message about the risks of overprescribing and are instead inadvertently helping to fuel the crisis.

Not only are benzodiazepines a concern in office-based visit Benzodiazepines were implicated in a high rate of ED visits in the U.S., according to Medscape. About a quarter of patients brought to an emergency department (ED) were unresponsive or in cardiopulmonary arrest. More than half (55.9%) of ED visits involving benzos were for the nonmedical use (recreational use or using someone else’s medication) or for self-harm (30.4%). Among visits involving the nonmedical use of benzodiazepines, 54.8% were made by patients between the ages of 15 and 34. About 20% of ED visits for the nonmedical use of benzos involved the concurrent use of other substances. “A quarter (24.9%) of visits involved prescription opioids, a quarter (26.4%) involved alcohol, and almost half (47.8%) involved illicit drugs.”

The noted decrease in anti-anxiety medication prescriptions over the past five years by Express Scripts was likely due to its limited population sample—only those individuals with private insurance. If this assumption is correct, what is happening with benzodiazepines during the COVID-19 pandemic among patients with Medicaid and Medicare? And if benzodiazepine prescriptions tend to be renewed or continued as noted above, what does the future hold for the already problematic coprescription of benzos and other medications, especially opioids, according to the National Center for Health Studies report? It seems we may be facing an epidemic of benzodiazepine addiction emerging from the current pandemic of COVID-19. For more information on the problems with benzodiazepines, see “Doubling the Risk of Overdose,” “Are Benzos Worth It?,” “It Takes Away Your Soul” and “Dancing with the Devil.”

01/22/19

Doubling the Risk of Overdose

In February of 2018 The New England Medical Journal published an editorial titled “Our Other Prescription Drug Problem.” The authors said that between 1996 and 2013 the number of prescriptions written for benzodiazepines increased by 67% and the quantity of pills dispensed tripled. The number of overdose deaths from benzodiazepines also increased. Three fourths of those deaths involved an opioid; and co-prescribing rates of opioids and benzos have almost doubled since 2001. “Despite this trend, the adverse effects of benzodiazepine overuse, misuse, and addiction continue to go largely unnoticed.”

Both Medscape (“Benzodiazepine Harms Overlooked, Especially in Older Adults”) and Mad in America (“Psychiatrists Warn Policymakers Benzodiazepine Overuse Could Lead to Next Epidemic”) cited the editorial and quoted the above comment. But they seem to have spun the article’s content in different directions. The Medscape article was primarily about benzodiazepine use among older adults, as the title suggests, so readers would likely get the impression ”Our Other Prescription Drug Problem” was as well. The NEMJ article cited and discussed two additional articles on the problems of “benzodiazepine use among the elderly.” But that is not what “Our Other Prescription Drug Problem” was about. In fact, seniors using benzos was not even mentioned there.

Another slight-of-hand was with how the concluding paragraph of the Medscape article sanitized the rhetoric of the authors of “Our Other Prescription Drug Problem,” which referred to opioids and benzodiazepines as “life-threatening drugs.” The final paragraph of the Medscape article is followed by the original paragraph quoted in its entirety from “Our Other Prescription Drug Problem.”

If measures designed to discourage people from using opioids divert them to benzodiazepines instead, “[i]t would be a tragedy,” Lembke and colleagues conclude in their editorial. “We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well.” (Medscape)

It would be a tragedy if measures to target overprescribing and overuse of opioids diverted people from one class of life-threatening drugs to another. We believe that the growing infrastructure to address the opioid epidemic should be harnessed to respond to dangerous trends in benzodiazepine overuse, misuse, and addiction as well. (NEMJ; emphasis added)

The readers of Medscape did not get a clear sense of what Dr. Lembke and her coauthors were saying in “Our Other Prescription Drug Problem.” Lembke et al. said benzos had proven utility if they were used intermittently and for less than 1 month at a time. “But when they are used daily and for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase.” They noted how prescribers often don’t realize the potential problems with benzos and that safer alternatives are available.

Many prescribers don’t realize that benzodiazepines can be addictive and when taken daily can worsen anxiety, contribute to persistent insomnia, and cause death. Other risks associated with benzodiazepines include cognitive decline, accidental injuries and falls, and increased rates of hospital admission and emergency department visits. Fortunately, there are safer treatment alternatives for anxiety and insomnia, including selective serotonin-reuptake inhibitors and behavioral interventions.

Lembke et al. did say some patients could benefit from long-term benzodiazepine use, but suggested it was best to avoid daily dosing. They also referred to the newer, highly potent forms of benzodiazepines on the illicit drug market, which are often indistinguishable from prescription benzodiazepines and said they were: “potentially as deadly as the synthetic opioid analogue fentanyl.” They called for efforts to shut down illegal online pharmacies and drug-trafficking networks where individuals purchase illicit benzodiazepines, particularly the “superpotent analogues.”

The Mad in America article by Zenobia Morrill had several quotes from the original editorial and additional discussion of its contents, which addressed how benzodiazepine overuse, misuse and addiction has not received the attention that opioid overuse, misuse and addiction has received. And Morrill did not spin the original editorial. Her article also reproduced the following graph of overdose deaths in the U.S. involving benzodiazepines found in “Our Other Prescription Drug Problem.”

Morrill said Lembke et al. hypothesized the acceleration of benzodiazepine-related overdose deaths may be overlooked because the concurrent use of opioids in 75% of those deaths. Given the dangers of benzodiazepine use alone and in conjunction with opioids, providers should strive to taper benzodiazepines in patients who have been stabilized using opioid-agonist therapy, “taking into account patient’s preferences, the risks and benefits of benzodiazepines, and possible alternatives.”

Hernandez et al. looked at how the risk of overdose changed over time with concurrent opioid and benzodiazepine use in “Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose.” The researchers looked at a random sample of data among Medicare Part D beneficiaries between 2013 and 2014. Their main outcome of interest was opioid-related overdoses—including fatal and nonfatal overdoses. They found that during the first 90 days of concurrent benzodiazepine use, there was a fivefold increase in the risk of opioid-related overdose.

Our study yielded 3 main findings. First, we found that 29% of Medicare Part D beneficiaries who did not have cancer and who used prescription opioids concurrently filled prescriptions for benzodiazepines. Second, we found that the risk of opioid-related overdose is particularly high during the first days with concurrent opioid and benzodiazepine use and then decreases over time. Specifically, during the first 90 days of concurrent benzodiazepine use, the risk of opioid-related overdose is 5 times higher compared with opioid use alone. Third, the numbers of opioid and benzodiazepine prescribers were associated with an increased likelihood of concurrent opioid and benzodiazepine use and an increased risk of overdose and were strong confounders in examining the association between concurrent use and overdose.

Among patients who used both medications longer than 90 days and did not overdose, they still had almost double the risk of overdose between 91 and 180 days of concurrent use. Concurrent use without overdose for more than 180 days did not predict an increased risk of overdose. But those results did not mean patients exposed to concurrent opioid and benzodiazepine use for longer time periods had a lower risk of overdose. “In fact, the longer the duration of concurrent use, the higher the risk of overdose, because the increased risk of overdose predicted during each time window (1-90, 91-180, 181-270, and 271 days of concurrent use) would be cumulative.”

Hernandez et al. said that despite the known increased risk of overdose associated with concurrent opioid and benzodiazepine use, “it is very common in the Medicare population.” They said policy interventions should advocate against concurrent use. Performance measures should be redefined to prevent or restrict their concurrent use. The risk of overdose is also exacerbated by fragmented medical care.

Overall, these results demonstrate the important role that fragmentation of care plays in the inappropriate use of opioids and in the subsequent risk of overdose, and warrant the extended use of prescription monitoring programs and the implementation of new policy interventions that further control the receipt of opioid prescriptions by multiple prescribers.

The bottom line is the concurrent use of opioids and benzodiazepines at least doubles the risk of an overdose.

07/3/18

Have a W-BAD Day

World Benzodiazepine Awareness Day (W-BAD) is July 11^th. It seeks to raise awareness about iatrogenic (medically) caused benzodiazepine dependence and adverse effects associated with the benzo withdrawal syndrome. This can occur with up to 90% of individuals who have used them daily for over 3 or four weeks. Globally, benzodiazepines are among the most widely prescribed drugs. According to PsychCentral, the benzodiazepines Xanax (alprazolam) and Ativan (lorazapam) were in the top ten most prescribed psychiatric drugs in the U.S. for 2018. An article in the American Journal of Public Health, said between 1996 and 2013 the number of U.S. adults filling a benzodiazepine prescription increased by 67%. And they were involved in 31% of the fatal overdoses in 2013.

The Bachhuber et al. study in the American Journal of Public Health reported that the number of U.S. adults filling a prescription for benzodiazepines increased from 8.1 million to 13.5 million between 1996 and 2013. The total quantity of benzodiazepines dispensed more than tripled during the same time period. And the rate of overdose deaths involving benzodiazepines increased from .58 per 100,000 adults to 3.07 per 100,000 before plateauing in 2010. See the following chart from the study. The researchers gleaned the data reported here from the Medical Expenditure Panel Survey.

The New England Medical Journal cited the same study in a February 2018 article, “Our Other Prescription Drug Problem.” The authors added that U.S. prescribers wrote 37.6 benzodiazepine prescriptions for every 100 individuals. Three quarters of the deaths involving benzodiazepines also involved an opioid. Yet, “Despite the increased risk of overdose in patients taking both benzodiazepines and opioids, rates of coprescribing nearly doubled, increasing from 9% in 2001 to 17% in 2013.”

Another growing problem is the distribution of benzodiazepine analogues in the illicit drug market. “Manufactured in clandestine laboratories in the United States and elsewhere, these drugs are indistinguishable from prescription benzodiazepines and are potentially as deadly as the synthetic opioid analogue fentanyl.” I’ve heard of an individual who blacked out and landed in the hospital after ingesting a benzo analogue. “Clonazolam, an analogue of clonazepam that is akin to a combination of alprazolam and clonazepam, is so potent that it needs to be dosed at the microgram level using a high-precision scale to prevent accidental overdose.”

Benzodiazepines have proven utility when they are used intermittently and for less than 1 month at a time. But when they are used daily and for extended periods, the benefits of benzodiazepines diminish and the risks associated with their use increase. Many prescribers don’t realize that benzodiazepines can be addictive and when taken daily can worsen anxiety, contribute to persistent insomnia, and cause death. Other risks associated with benzodiazepines include cognitive decline, accidental injuries and falls, and increased rates of hospital admission and emergency department visits.

Concern with the over use and over prescribing of benzodiazepines is truly a global issue. Look at the Statistics page for W-BAD to see dozens of surveys and studies from around the world. Some highlights include: Japan has the highest consumption rate of benzodiazepines in the world. In Thailand, 45% of GPs admitted their prescription of benzodiazepines in the previous year had been excessive. Positively, in Denmark it is illegal to prescribe a benzodiazepine for longer than four weeks. Afterwards, a full medical re-evaluation is needed to assess their continued use. Not surprisingly, benzo use in the Danish population decreased significantly from 1997-2008.

On the front page for W-BAD, you can see a short video about “The risks of taking benzodiazepines.” You’ll learn that experts estimate that 60% of people taking benzodiazepines for more than 2 to 4 weeks will experience withdrawal or adverse effects. About 30% will experience severe withdrawal or adverse effects. And this can even happen on low doses. There are also links to other YouTube videos, like “The 5 Myths of Benzo Withdrawal.”

Anna Lembke, a doctor and associate professor of psychiatry at Stanford, described receiving a call about one of her patients who almost died from overdosing on a benzodiazepine. He had taken clonazolam, a designer benzo compound first synthesized in 1971. It is a combination of clonzapam (Klonopin) and alprazolam (Xanax) and it is said to be 2.5 times more potent than Xanax. Her patient knew it was potent, but still overdosed. He said the amount he took “wasn’t enough to cover a fourth of my pinkie fingernail. I thought I was safe.” She was the lead author of the above linked NEMJ article.

Highly potent drugs like these designer benzodiazepines are a growing trend among those seeking a new high, fueled in part by doctors overprescribing benzodiazepines without appreciating their addictive potential. Just as overprescribing opioids contributed to the use of heroin and illicit fentanyl and related deaths, overprescribing benzodiazepines may herald the dawn of a new era of illicit and deadly benzodiazepines. Benzodiazepines work well to ease anxiety or insomnia when used intermittently and for less than a month at a time. When taken daily for an extended period of time, they stop working and can make anxiety and insomnia worse. Most doctors don’t realize how addictive benzodiazepines can be for some people and, because they don’t know better, prescribe them long term and without safety monitoring, like checking the prescription drug monitoring database. In addition to addiction and death, long-term use of benzodiazepines can also contribute to cognitive decline, accidental injuries, and falls.

She cautioned individuals taking benzodiazepines daily to talk to their doctor about starting a slow taper. “It’s important to go slowly, because abruptly stopping a benzodiazepine can precipitate life-threatening withdrawal.” She added that if you are a parent and notice a precision laboratory scale in your child’s bedroom, or see mysterious packages arriving for them, “get worried fast.”

Writing for Mad in America, Marjorie Meret-Carmen wrote of “My Ativan Affair and the Aftermath.” She was first prescribed Ativan eleven years ago to help her sleep and cope with her dementia-declining husband. She received no warnings about potential adverse effects from regular use. He died in 2009, but she continued using Ativan until January of 2012, where she tried a short-term residential treatment center to withdraw from the medication. Two week afterwards, she began experiencing Protracted Acute Withdrawal Syndrome (PAWS).

Until the beginning of 2015, I lived 24 hours a day, 7 days a week flu-sick, of a magnitude harking back to the worst morning sicknesses with each of my pregnancies. That was the year I was well enough to act on what was becoming a ‘mission’ — to find the common denominators in benzodiazepine toxicity and protocols to help people withdraw and get on with their lives.

That mission eventually included the organization of the International Benzodiazepine Symposium in September of 2017. “Something I decided to sponsor once I realized the medical practitioners I trusted did not know a damn thing about a long-term relationship with a benzodiazepine.” There is a link to a fifteen-minute video synopsis of the conference, which she hopes to expand into a full-length documentary. Within the video, you learn that since 1989 there has been a 4,900% increase in spending on psychiatric drugs in the U.S., from $800 million to $40 billion. Common withdrawal symptoms from benzodiazepines include: moderate to severe depression; extreme anxiety; poor memory; sensory hypersensitivity; heart palpitations; sweating, night sweats; and muscle twitching.

My sincere message to those whose vitality and lives have been sapped and zapped by this iatrogenic dis-order: most of us DO recover! And even if it is not without some benzo remnants lodged in our cellular memory, what we learn about our own resilience will guide us to places in our lives we didn’t expect to reach.

The Ashton Method or Ashton Manual was mentioned in the video. Dr. Heather Ashton wrote “Benzodiazepeines: How They Work and How to Withdraw,” which has become known as “The Ashton Manual.” A digital copy is available here on benzo.org.uk for free. A printed copy can be ordered. You can also watch “Dr. Heather Ashton- Benzodiazepine Withdrawal” and other videos about the Ashton Method on YouTube. It has become the standard reference for benzodiazepine tapering.

A group of Canadian healthcare professionals led by Dr. Kevin Pottie proposed new clinical guidelines to safely deprescribe benzodiazepines in “Deprescribing benzodiazepine receptor agonists.” You can also read a summary of the above article in “New Clinical Guidelines on Deprescribing Benzodiazepines.” The authors qualified their tapering recommendations primarily for patients who use benzos to treat primary insomnia (insomnia on its own). The guideline “does not apply to those with other sleep disorders or untreated anxiety, depression, or other physical or mental health conditions that might be causing or aggravating insomnia.” They recommend that deprescribing (slow tapering) be offered to all elderly adults taking benzos, regardless of duration of use and to other adults who have used them for more than four weeks.

Choosing Wisely Canada does not recommend BZRAs [benzodiazepines] as a first-line treatment for elderly patients with insomnia, as common side effects include increased risk of falls and accidents, memory problems, and daytime sedation. Furthermore, long-term BZRA use is associated with heightened risk of developing a physical or psychological dependence. Canadian family physicians, pharmacists, nurses, and geriatricians classified BZRAs as the “most important medication class for developing a deprescribing guideline” due to the adverse effects found in long-term use.

The Canadians developed an algorithm and a client information pamphlet to assist clinicians in the deprescribing process. You can find links for both in “New Clinical Guidelines on Deprescribing Benzodiazepines.”

You can read other articles about problems with benzodiazepines and World Benzodiazepine Awareness Day (W-BAD) here on this website: “It Takes Away Your Soul” and “Are Benzos Worth It?”

03/20/18

Are Benzos Worth it?

Holly Hardman is directing and producing a documentary film on benzodiazepines called “As Prescribed.” The film looks at the painful side effects and debilitating withdrawal symptoms individuals can experience when withdrawing from benzodiazepines like Xanax, Valium, Klonopin, Restoril and Ativan. Hardman is herself a survivor of benzodiazepine injury. It took her almost two years to taper off Klonopin. She experienced akathasia, the feeling that you are about to jump out of your skin, and aphasia, the inability to form words and sentences. Holly still has sporadic physical reactions from the withdrawal. “People are given these medications for normal life experiences and don’t realize what can happen.”

Hardman’s doctor assured her in the early 1990s that Klonopin was safe to take long-term for chronic fatigue syndrome. It wasn’t until 2012 that she discovered her persistent medical symptoms were the adverse side effects of Klonopin. “Hardman and other advocates against benzo overprescription want to get the message out benzos, like opioids, can be dangerous even when taken exactly as prescribed. . . . We shouldn’t assume these prescriptions are harmless.”

The Lown Institute noted in an article on benzodiazepines that there is a widespread but mistaken perception of benzodiazepines being “harmless quick fixes for insomnia and anxiety.” Over prescribing benzodiazepines (BZDs) commonly happens with elderly patients, who are often taking multiple medications. “Almost a third of older adults using benzos in 2008 were taking them long-term.” Elderly adults are also more likely to suffer negative side effects from BZD use.

In addition to the anecdotal evidence of the personal stories in the film, adverse effects from long-term benzodiazepine use are well documented in the research literature. Hata et al. authored “What can predict and prevent the long-term use of benzodiazepines?” in the Journal of Psychiatric Research. They said adverse effects of BZDs include: daytime drowsiness, light-headedness, ataxia (loss of full control of bodily movement), psychomotor disturbance, and anterograde amnesia (loss of the ability to form new memories). “Various studies suggest that long-term use may be harmful. Long-term use carries the risk of dependence, withdrawal syndrome, cognitive impairment, diminishing effect, tolerance, and difficulty in discontinuing treatment.”

Hata et al. also found older age to be one of the predictive factors for long-term use of BZDs. Additional factors predictive of long-term BZD use were: high dosage (equivalent to greater than 5 mg of diazepam per day), psychiatric prescribers (versus a PCP), and concurrent use of more than one benzodiazepine. “Continuation of BZDs for more than 36 months was observed in 57.8% of 3470 new users.” The authors noted where this was a significantly higher percentage of long-term users than what was found in a previous study. They speculated it might be because of the higher proportion of patients over the age of 65 in their study. Among the elderly, they found there was a statistically significant risk of serious falls, fractures and cognitive decline with BZDs.

In response to these risks, although several international clinical guidelines and expert consensus statements have been published that recommend limiting the long-term use of BZDs, especially in older patients, the prevalence of long-term use remains widespread. Thus, reducing the long- term use of BZD is an important worldwide issue.

When reviewing the Hata et al. research for Mad in America in “Preventing Long-term Benzodiazepine Use,” Hannah Emerson pointed out how the study supports the global efforts to limit the use of benzodiazepines and provides research that illustrates how to predict and prevent such use. She lamented that despite the widely known harmful effects of long-term BZD use, their long-term use continues unabated. However, “by augmenting a list of predictors for long-term BZD use and highlighting nuances that lead to discontinuation, studies like this serve to influence prescription practices to be better informed, designed, and executed.”

Crowe and Stranks did a meta-analysis of the effects of benzodiazepines on cognitive functioning in long-term current users. They also commented that while BZDs are useful in the short-term, “the published evidence indicates that when they are used for longer periods, they often culminate in significant harm.” Despite this, BZDs continue to be widely prescribed across the globe. They described some of the previous meta-analyses of long-term BZD use, which found there was significant impairment across all the measured cognitive domains, “including sensory processing, psychomotor speed, non-verbal memory, visuospatial processing, speed of processing, problem-solving, attention/concentration, verbal memory, general intelligence, motor control/performance, working memory, and verbal reasoning.”

Some previous meta-analyses found evidence of improvement for individuals in cognitive functioning following the discontinuation of BZDs. However, others discovered significant impairment persisted long after discontinuation. Wanting to incorporate studies published since the previous meta-analyses, Crowe and Stranks decided to do their updated review of the residual cognitive effects of BZDs in current users and those who had recently withdrawn from them.

“Statistically significant negative side effects were found for the cognitive domains of working memory, processing speed, divided attention, visuoconstruction, recent memory, and expressive language.” Cognitive deficits associated with BZD use persisted following withdrawal; and statistically significant negative effects were found with all cognitive domains except for executive functioning. When BZD use was followed up after withdrawal, cognitive deficits persisted in all cognitive domains except for sustained attention. These deficits were statistically significant and evident in some individuals 42 months post-withdrawal.

Crow and Stranks found the greatest deficits for long-term BZD use in the areas of working memory, processing speed, divided attention, visuoconstruction, recent memory and expressive language. Their findings largely confirm those found be previous meta-analyses. However their analysis found a larger magnitude of negative effects with working memory for current long-term BZD users. Findings for users who had withdrawn from long-term BZD use were consistent with the results of previous studies. They continued to have significant impairment in all areas of cognitive function.

In conclusion, the results of this meta-analytic study are important in that they corroborate the mounting evidence that a range of neuropsychological functions are impaired as a result of long-term benzodiazepine use, and that these are likely to persist even following withdrawal. Furthermore, the findings highlight the problems associated with long-term benzodiazepine therapy as well as the important clinical implications of these results.

So where can you turn for help? There are a number of resources out there. For BZD support groups, try Benzo Brains on YouTube; W-BAD (World Benzodiazepine Awareness Day); BenzoBuddies; benzo.org.uk; and others. Try another article on this website, “It Takes Away Your Soul,” where the above organizations and others are linked. Holly Hardman’s documentary, “As Prescribed,” has a website with a short trailer on the documentary.

If you are seriously considering an attempt at tapering off of BZDs, do your research first. Listen to some of Jocelyn Pedersen’s videos on Benzo Brains. Start with “What is Benzodiazepine Withdrawal Syndrome?” Join BenzoBuddies. Try the information on w-bad.org. W-BAD also has a YouTube channel.

Regularly you will hear about the Ashton Protocol or Ashton Method for benzodiazepine withdrawal. There are YouTube videos about Heather Ashton’s method; and a digital copy of The Ashton Manual is available on benzo.org.uk for free. There are links for all of these in “It Takes Away Your Soul.” Mad in America has also compiled a helpful annotated bibliography on “Withdrawal from Benzodiazepines.” In closing, here is a quote from Jocelyn Pedersen’s video, “What is Benzodiazepine Withdrawal Syndrome?”

If forty to eighty percent of people are potentially at risk for being this severely disabled, we really need to start weighing the risk versus the benefits of these drugs. . . . Is it worth it to be prescribing benzodiazepines?

08/22/17

It Takes Away Your Soul

In case you missed it in July, there was an annual day of awareness … for the problems that result from the prescription and use of benzodiazepines. World Benzodiazepine Awareness Day (W-BAD) is on July 11^th. The first W-BAD was in 2016, so it’s just getting started. The need for greater awareness of the adverse effects from benzos can be seen in the 2016 W-BAD promotional video, here. It’s over 24 minutes long, so be prepared to spend some time. If that’s too much time for you to take at the moment, here’s one take away quote from Wendy in Melbourne Australia about her experiences while on and then getting off of benzos: “It takes away your soul.”

I was pleasantly surprised to see an extended quote on the dangers of benzodiazepines from Dr. Neil Capretto was used in the 2016 W-BAD video. Dr. Capretto is the Medical Director for Gateway Rehabilitation Center, a drug and alcohol treatment program I’m familiar with in Western Pennsylvania, Dr. Capretto said:

People were innocently put on this medication [benzodiazepines] and in some instances it works out well. [But] there is a significant risk and we see it all of the time. Many people who have lost many years of their lives, who have lost jobs, been on the verge of suicide. I’m aware of cases where people have committed suicide. The drug can be dangerous, it can be fatal. During withdrawal the heart rate can go up, they may have a seizure, sometimes the body temperature can go up and in some cases it’s fatal.

The W-BAD video has individuals from around the world, telling about their experiences while using benzos, when tapering off them, and the ongoing protracted withdrawal experiences they suffered through. For some individuals, those adverse effects lasted months and in some cases were permanent. There were three W-BAD objective listed towards the end if the video, which are listed below.

To encourage the establishment of a mandatory maximum prescribing period of no more than 4 week, including taper period (based on the Committee on Safety of Medicines’ 2-4 week prescribing guidelines).

To encourage the establishment of ‘specialized’ withdrawal facilities for those who so desperately need them.

To encourage the provision of proper training for doctors and medical staff and to help them learn more about proper tapering practices to discontinue the drugs as well as about the serious implications of benzodiazepines.

The Committee on Safety of Medicines is an independent advisory committee that advises the UK Licensing Authority on the quality and safety of medicines. In 2005 it was replaced by the Commission on Human Medicines, combining the functions of the Committee on Safety of Medicines and the Medicines Commission. The Committee issued guidelines for UK physicians and medical professionals on the use of benzodiazepines in January of 1988. Pause for a minute. These concerns were evident almost thirty years ago.

The original document said there had been concerns regarding benzodiazepine dependence for several years, and cited a British Medical Journal article from 1980 to support the claim. It noted that withdrawal symptoms could include anxiety, confusion, insomnia, depression, and perceptual disorders. These symptoms could occur even when following therapeutic doses over SHORT periods of time (emphasis in the original). “These may sometimes be difficult to distinguish from the symptoms of the original illness.”

They discouraged the use of benzodiazepines to treat insomnia, unless it was severe and subjecting the person to extreme distress. If used, they should be used intermittently. “The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate and unsuitable.” When the anxiety is severe, disabling or subjecting the person to unacceptable distress they can be used for short-term relief—“two to four weeks only.” The Committee then gave the following quote from the above noted article in the March 29, 1980 issue of the British Medical Journal. The point of all this is these concerns and recommendations with benzodiazepines have been know since the 1980s, but have been largely ignored on a global scale, as illustrated in the 2016 W-BAD video linked above.

The committee further noted that there was little convincing evidence that benzodiazepines were efficacious in the treatment of anxiety after four months’ continuous treatment. It considered that an appropriate warning regarding long-term efficacy be included in the recommendations, particularly in view of the high proportion of patients receiving repeated prescriptions for extended periods of time.It further suggested that patients receiving benzodiazepine therapy be carefully selected and monitored and that prescriptions be limited to short-term use.

Finding a “specialized” withdrawal facility can be difficult. Be careful of what the centers promise and their cost. Do your homework when searching for a “specialized benzodiazepine withdrawal facility.” A mere “benzodiazepine withdrawal facility” search will net multiple residential drug and alcohol treatment centers. Not every person who has been using benzodiazepines long enough to need medical inpatient detoxification support has been abusing benzos, and treatment at a drug and alcohol treatment center is often inappropriate. Plus the withdrawal protocol is often too rapid.

The New Beginnings Recovery Center in North Palm Beach Florida is an example of a treatment program that uses a protracted withdrawal method. I have no experience with their treatment program and can’t endorse it. But what I’ve seen of their methods fits with a patient or client-centered method of withdrawal, which I do think is best with benzodiazepines. Here is a link to the New Beginnings page on their Benzodiazepine Withdrawal Treatment Program. Here is a short YouTube video clip discussing the Heather Ashton Method for benzodiazepine withdrawal used at the New Beginnings Recovery Center.

Going slowly, at a pace controlled by the individual withdrawing from benzos, is the method most likely to produce positive results. It will take several weeks, months, and even in some cases, years. I’ve run across two medical professionals who advocate for this protracted withdrawal method, Dr. Peter Breggin and Dr. Heather Ashton.

I am personally familiar with Dr. Breggin’s work and have read many of his resources, including two that would be helpful for benzodiazepine withdrawal: Your Drug May Be Your Problem and Psychiatric Drug Withdrawal. Start with Your Drug May Be Your Problem for personal information on the process and try Psychiatric Drug Withdrawal for more technical discussions, if that’s needed. Both books discuss withdrawal from multiple classes of psychiatric drugs. There is a YouTube channel for Peter Breggin. He also has his own website with more information at: breggin.com.

The Ashton Protocol, or Ashton Method, is new to me, but from what I’ve reviewed it fits with the protracted withdrawal process I’m familiar with in Dr. Breggin’s material. Here is a YouTube clip, “Dr. Heather Ashton- Benzodiazepine Withdrawal.” You can see several other YouTube videos about her method with a “Dr. Heather Ashton” search on YouTube. Dr. Ashton also wrote “Benzodiazepines: How They Work and How to Withdraw,” which has become known as “The Ashton Manual.” A digital copy is available here on benzo.org.uk for free. A printed copy can be ordered.

From the brief review I’ve done so far, it seems likely to be a very helpful resource for individuals looking for assistance in getting off of benzodiazepines. Within a documentary by Shane Kenny, “The Benzodiazepine Medical Disaster,” which is linked below, Dr. Asthton said she wrote the manual for patients who weren’t getting help from the doctors. They seemed to know better what to do than the doctors. “It was for them. And the interesting thing is, although patients from all over the world have snapped it up, doctors still don’t read it.”

Protracted withdrawal will extend far beyond any acute medical withdrawal phase, and ongoing medical and therapeutic support on an outpatient basis is advisable. Getting medical support for protracted benzodiazepine withdrawal as an outpatient could be challenging. You may have to educate a willing physician on the necessity of an extended, rather than a shorter-term withdrawal. You can use the material recommended above from Peter Breggin and Heather Ashton to first educate yourself, and then any physician or psychiatrist willing to work with you on a protracted benzodiazepine withdrawal.

There are also many online information and support groups, such as: benzo.org.uk, which as been around since July of 2000. “Benzo.org.uk is dedicated to sufferers of iatrogenic benzodiazepine tranquilliser addiction.” In addition to the link to The Ashton Manual noted above, it has a wealth of information, including a FAQ document and links to online benzodiazepine withdrawal support groups on a support page. They also called out a specific support group called BenzoBuddies.

BenzoBookReview.com is a website with a list of books on benzodiazepine withdrawal. Information there includes memoirs and how-to guide books, with reviews and summaries of each book. The site is for anyone interested in information about benzodiazepine misuse and how to help benzodiazepine sufferers. That includes their families, doctors, psychologists, psychotherapists, drug counselors, and all professionals.

Other helpful resources include: Benzodiazepine Information Coalition, Beyond Meds, and Mad in America. Search the Mad in America site for “benzodiazepines.” Information on their “Withdrawal Resources” page will include a scientific literature review on withdrawal from benzodiazepines, as well as other classes of psychotropic drugs. Mad in America linked a short video by the group Benzodiazepine Recovery, “Benzodiazepine Withdrawal Symptoms” where individuals shared their top three most debilitating benzodiazepine withdrawal symptoms.

There are several helpful YouTube resources, such as Benzo Brains, by Jocelyn Pedersen. W-BAD also has a YouTube channel and a website: w-bad.org. Their YouTube channel has a short informational video (almost 3 minutes) on the risks of taking benzodiazepines. Start there to begin the education process with someone.

Look under Resources on w-bad.org for the Documentaries link. You will find information on “As Prescribed” by Holly Hardman, which is in production. Scrolling further down you will see a link to another documentary, “The Benzodiazepine Medical Disaster” by Shane Kenny. It features an in depth interview with Heather Ashton. Also remember what Melanie said about why this information on benzodiazepines is so important: “It takes away your soul.”

10/18/16

Dancing with the Devil

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.”

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: benzos