Benzodiazepines

Tranquilizers are drugs that reduce feelings of anxiety and tension. Since the 1960s, benzodiazepines have been popular as prescription medications for the treatment of anxiety. Benzodiazepines are also effective at treating insomnia, an inability to fall asleep or stay asleep, and other sleep disorders. In the 1990s some health-care professionals as well as the public became concerned about the overuse of these drugs and possible complications.

Benzodiazepines that lessen the symptoms of anxiety include chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), oxazepam (Serenid; Serax), clonazepam (Klonopin), and alprazolam (Xanax). Benzodiazepines that cause a person to fall asleep and stay asleep include short-acting drugs such as triazolam (Halcion), medium-acting drugs such as temazepam (Restoril), and long-acting drugs such as flurazepam (Dalmane) and nitrazepam (Mogadon).

The Medical Uses of Benzodiazepines

Many medical professionals prescribe benzodiazepines for anxiety, or fear that occurs in a situation where no clear threat exists. Benzodiazepines successfully treat the disorder known as "generalized anxiety," which is often quite severe and comes on without any apparent reason. High-potency benzodiazepines such as Xanax or Klonopin can prevent panic attacks. Tranquilizers can also be used to treat "normal anxiety," the anxiety that people feel when under stress or when challenged by life's problems. In these instances, the reasons for feeling anxious are clear, and the degree of anxiety seems to match the level of the stress the person feels. Because some people need help coping with these symptoms, doctors may prescribe benzodiazepines. Unfortunately, the line between anxiety as a medical disorder and anxiety as a normal response to stress is not always clear. This makes the decision to prescribe benzodiazepines a complicated one. As a result, some doctors avoid prescribing benzodiazepines, while others, particularly psychiatrists, recommend them for many patients.

Similar caution applies to the use of benzodiazepines as sleeping pills. Doctors generally agree on the safety of short-term use of these drugs—for example, for sleep upset by jet lag, severe stress, or shift work. However, doctors do not encourage long-term use in someone who has sleeping problems for long periods.

Benzodiazepines can also be used as sedatives before surgical operations, as light anesthetics during operations, and to lessen back pain and muscle spasms, such as those caused by sports injuries. Some benzodiazepines can be used to treat certain forms of epilepsy, a condition in which a person has seizures.

Side Effects of Benzodiazepines

Benzodiazepines, like most drugs, can have unwanted side effects. The most common side effects are drowsiness and tiredness, especially within the first few hours after large doses. People taking these drugs also complain of dizziness, headache, blurred vision, and feelings of unsteadiness. The elderly are particularly sensitive to tranquilizers and may become unsteady on their feet or even mentally confused.

Of course, a person unable to sleep does want a sleeping pill to produce drowsiness. However, the longer-acting benzodiazepines, and higher doses of medium-duration or short-acting drugs, can leave the person feeling drowsy the morning after taking the pill or even well into the afternoon. Again, the elderly are more likely to experience this continued sleepiness.

Benzodiazepines can interfere with alertness, coordination, performance at skilled work, mental activities, judgment, and memory. Patients should not make important decisions during their initial treatment. Nor should they drive or operate machinery, at least until a doctor assesses their reaction and adjusts the dose if necessary.

As with many drugs affecting the brain, benzodiazepines can interact with other drugs, especially alcohol. People taking tranquilizers or sleeping pills should not drink alcoholic beverages. Benzodiazepines can also enhance, or increase, the effects of antihistamines (such as for hay fever), painkillers, and antidepressants. Cigarette smoking may lessen the effect of some benzodiazepines.

Patients taking benzodiazepines may show responses that are paradoxical—the effects produced are the opposite of those intended. Their anxiety symptoms may worsen rather than lessen, and they have more trouble sleeping. A more disturbing side effect is a feeling of hostility or even aggression. A person's emotional responses might become extreme, such as uncontrollable weeping or giggling. Although these paradoxical effects may not last long, the best course of action is to stop taking the drug.

Benzodiazepines can affect breathing in individuals who already have breathing problems, such as those caused by chronic bronchitis or emphysema. Other occasional side effects include excessive weight gain, rash, problems with sexual functioning, and menstrual irregularities. Pregnant women should avoid benzodiazepines, as there may be a risk to the fetus. In nursing mothers, these drugs pass into breast milk and may sedate the baby. Finally, many people have taken an overdose of a tranquilizer in suicide attempts. Fortunately, these drugs are quite safe, and the person wakes up unharmed after a few hours' sleep.

Finally, benzodiazepines can have a different kind of side effect: They can turn a normal problem in someone's life into a medical problem. For example, taking the drug may lessen a symptom of nervousness, but it cannot solve the underlying problem—which might be an unhappy relationship or an unstable situation at work. In fact, by lessening the symptoms, the individual may feel less motivated to identify, confront, and tackle the basic problem. People can also develop personal problems after difficult events, such as the death of a loved one or a divorce. Events like these need to be worked through and mourned. Benzodiazepines can stop this normal process and actually prevent the individual from coming to terms with loss. For these reasons, benzodiazepines have become controversial as a treatment for certain conditions that are not necessarily medical problems.

Tolerance, Dependence, and Withdrawal

Tolerance to a drug develops when a person needs to increase the dose to achieve the effect of the original dose. When taking tranquilizers, people can become tolerant to the sedative effects. However, patients generally report that the drugs remain effective at controlling symptoms of anxiety. It is not yet clear whether benzodiazepines continue to be effective after long-term daily use. According to patients, side effects usually lessen over time. Problems with memory may continue, but most patients learn to cope with this by using written reminders.

Individuals who take benzodiazepines for long periods may become dependent on them, showing signs and symptoms of withdrawal when they stop taking the drugs. Minor symptoms of withdrawal include anxiety, insomnia, and nightmares. Less common and more serious symptoms include psychosis , seizures, and, very rarely, death. Serious withdrawal problems are more likely to occur in patients who have taken high doses for four or more months. Stopping the drug gradually can reduce the severity of withdrawal symptoms.

Some withdrawal symptoms that appear after the person stops taking a benzodiazepine may actually be a return of the symptoms for which the drug was originally prescribed. For example, a person who took Valium for anxiety might feel anxious again after he or she stops taking it. Because this is not true withdrawal, doctors sometimes use the term "abstinence syndrome," which is a set of symptoms that occur when a person stops taking a drug.

Although many patients may experience some symptoms of withdrawal, they are not addicted to benzodiazepines. This is because they have taken their medications for medical reasons, as directed by their doctors. It is also very unlikely that they will seek out benzodiazepines once their course of treatment has ended.

Abuse of Benzodiazepines

Patients who take a benzodiazepine drug with a doctor's prescription rarely abuse it by taking more than the recommended dose. However, if abusing the drug, the user may become intoxicated , with slurred speech and incoordination, or clumsiness. An estimated 2.7 million people aged 12 or older used tranquilizers such as benzodiazepines for nonmedical purposes in 2000, about the same number as in the previous few years. In 2001 about 6.5 percent of 12th grade students reported using tranquilizers such as benzodiazepines for nonmedical reasons within the past year, an increase from the previous year. Nonmedical use of these drugs increased in 2001 among 10th graders as well.

In general, benzodiazepines have a lower abuse liability—the likelihood that they will be abused—than barbiturates , opiates , or stimulants . However, benzodiazepines are frequently used by individuals who abuse other drugs. Some people with alcohol problems also abuse benzodiazepines. Alcoholics who have had no success in treatment programs for alcohol abuse have high rates of benzodiazepine abuse. People who use stimulant drugs such as cocaine and amphetamines may take benzodiazepines to relieve the nervous feelings that stimulants can produce.

Intravenous injection of benzodiazepines is an increasing problem. Some heroin addicts inject heroin along with benzodiazepines. Injection of benzodiazepines can result in clotting of the veins. It also carries the risk of getting infectious diseases from sharing dirty syringes, such as hepatitis and the AIDS virus. As a result of increased abuse by injection, the United States has established legal controls on the manufacture and prescription of benzodiazepines.

Conclusion

Once hailed as wonder drugs, benzodiazepines were prescribed widely and for long periods of time. Health-care professionals now better understand the risks as well as the benefits of these medicines. For short-term treatment in the severely anxious and sleepless, they are still useful—although new and better drugs continue to be investigated and developed.

see also Addiction: Concepts and Definitions; Anxiety; Complications from Injecting Drugs; Sedative and Sedative-Hypnotic Drugs; Sleeping Pills.