OFFICIAL NAMES: Alprazolam (Xanax), chlorazepate (Tranxene) chlordiazepoxide (Librium, Novopoxide), clonazepam (Klonopin), clorazepate (Tranxene), diazepam (Valium, Vivol), estazolam (ProSom), flurazepam (Dalmane, Novoflupam, Somnol), flunitrazepam (Rohypnol), halazepam (Paxipam), lorazepam (Ativan), nitrazepam (Mogadon), oxazepam (Serax), prazepam (Centrax), quazepam (Doral), temazepam (Restoril), triazolam (Halcion)
STREET NAMES: Roofies, tranks, downers, benzos, goofballs, Mexican, roach, heavenly blues, valo, stupefy, date rape, anxiety
DRUG CLASSIFICATIONS: Schedule IV, depressant
Although they have been used for over 30 years, benzodiazepines are still widely prescribed in the treatment of anxiety disorders and other medical conditions. These drugs are classified as sedative-hypnotic agents, which depress or slow down the body. In the past 15 years, the development of the newer selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression and anxiety have pushed benzodiazepines aside as the first treatment choice because the SSRIs as a class of drugs have not yet been found to be addictive.
Benzodiazepines are used to treat a wide range of psychiatric and medical conditions. Because they work so quickly, benzodiazepines are often the first drugs chosen by physicians in treating new or suspected anxiety or psychiatric disorders. Compared to the newer SSRIs, which can often take weeks to have an effect, benzodiazepines can be felt to work within hours. This quick onset of action has both positive and negative sides. On the one hand, people feel better faster. On the other hand, this speediness of effect also makes benzodiazepines more likely to cause addiction than other medications prescribed by psychiatrists and psychologists. Physical and/or psychological dependence may occur within a matter of weeks, depending upon the individual taking them.
When taken alone, benzodiazepines have a relatively good safety record. Even when taken in overdose quantities alone these drugs rarely cause serious consequences. Unfortunately, however, when benzodiazepines are being abused, they may be used in combination with other drugs or alcohol, and it is these combinations that can lead to serious physical consequences, including depressed respiration, coma, and even death.
Benzodiazepines were developed in the 1950s as a safer alternative to barbiturates. Currently, about 2,000 different kinds of benzodiazepines are made. In the United States, only about 15 of these are approved by the FDA.
Some of the more commonly prescribed benzodiazepines include the following, which are ranked here approximately according to frequency of use:
- alprazolam (Xanax)
- clonazepam (Klonopin)
- diazepam (Valium)
- lorazepam (Ativan)
- clorazepate (Tranxene)
- oxazepam (Serax)
- prazepam (Centrax)
- clordiazepoxide (Librium)
- halazepam (Paxipam)
The top four—alprazolam, clonazepam, diazepam, and lorazepam—are consistently listed among the top 100 most commonly prescribed medications. Flunitrazepam (Rohypnol) has recently received a lot of attention, especially on college campuses, where its use as a "date rape" drug has placed it on the watch list of students and police. Flunitrazepam is one of the drugs, along with MDMA (ecstasy), used by teenagers and young adults as part of the nightclub, bar, "rave," or "trance" scene.
Flunitrazepam, also known by the brand name Rohypnol, and by the street names roofies, R2, Roche, roofinol, rope, rophies, forget-me pill, and Mexican valium, has received more press recently than most of the other benzodiazepines. It comes as a small, white tablet, with "Roche" on one side, and an encircled "1" or "2" on the other side, which indicats the 1-mg or 2-mg dose. It is usually consumed orally, often combined with alcohol, and can also be snorted after crushing the tablets.
This drug is produced legally in countries such as Brazil, Colombia, Ecuador, Mexico, and Peru. It is frequently smuggled into the country disguised as vitamins or in its original packaging as cold medicine. Flunitrazepam is not approved in the United States, but is has been used widely in Texas, and is readily available in Miami, Florida, where it is a growing problem.
The pharmacologic effects of Rohypnol include sedation, muscle relaxation, and anxiety reduction. The sedative effects are said to be seven to 10 times that of diazepam (Valium). In high doses, flunitrazepam can cause malignant hyperthermia, or a sharp increase in body temperature that can cause muscle breakdown and failure of the kidneys and cardiovascular system.
Because it is colorless, tasteless, and odorless, flunitrazepam can be added to beverages and taken unknowingly. After taking this drug, the user can feel intoxicated, then sleepy, for up to eight hours. Speech may become slurred, and judgment impaired. Partial amnesia is a common effect, and for this reason, flunitrazepam has been used in committing date rape or sexual assault. Victims are usually unable to remember the assault, or identify who assaulted them while they were under the effects of flunitrazepam. These effects occur roughly 15–20 minutes after taking the drug, and last for four to eight hours. Deep sedation and respiratory distress are some of the more serious possible effects of Rohypnol, as are blackouts that can last up to 24 hours.
In 1996, Congress passed the Drug-Induced Rape Prevention and Punishment Act of 1996, which increased the federal penalties for those who used any controlled substance to aid them in sexual assault. This law makes it a punishable crime to give someone a controlled substance without that person's knowledge of it and with the intent to commit a violent crime against that person. It also includes stiffer penalties for those who possess or distribute this drug.
Benzodiazepines are classified according to how long their effects last and by their potency. The ultra-short acting benzodiazepines include midazolam (Versed) and triazolam (Halcion); the short-acting benzodiazepines include alprazolam (Xanax) and lorazepam (Ativan); the long-acting include chlordiazepoxide (Librium) and diazepam (Valium). High potency benzodiazepines include alprazolam, lorazepam, triazolam, and clonazepam (Klonopin). Low-potency benzodiazepines include chlordiazepoxide, clorazepate (Tranxene), diazepam, and flurazepam (Dalmane).
Because benzodiazepines, as a class, are usually equally effective in treating anxiety (in combination with cognitive-behavioral theraphy), psychiatrists usually select which of these drugs to prescribe based on its side effect profile. This means that the physician will weigh all the individual factors of each patient, and decide which drug is best suited for the patient's individual needs based on which side effects that person can or cannot tolerate. For example, some of the benzodiazepines are more easily processed by the liver. This may be particularly useful in patients taking birth control pills, propranolol, disulfuram, ulcer medications, and other drugs that may affect liver function. In such cases, lorazepam (Ativan) may be chosen because it has less of an effect on the liver.
Alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax) are metabolized and cleared from the body more quickly than the other members of this family, and are therefore more likely to produce withdrawal symptoms when they are discontinued. These three drugs, however, are less likely to produce side effects such as impaired coordination, concentration, and memory; and muscular weakness or sedation.
Benzodiazepines do not depress breathing, blood pressure, or other vital functions, like many of the drugs used to treat psychiatric disorders. They are also less likely to cause damage to the body systems or death in cases of overdose.
Despite this, these agents still present a number of problems for many individuals, including the need for higher doses and addiction. Tolerance and physical and psychological dependence are common with continued treatment with all of these drugs.
When used for a longer period of time, a number of the benzodiazepines will slowly lose their effectiveness, and higher doses may be needed to achieve the desired effects. Further, if any of these medications are discontinued abruptly, withdrawal symptoms can occur, and these can be quite serious. These symptoms can include seizures, insomnia, nervousness, irritability, diarrhea, abdominal cramps, muscle aches, and memory impairment.
Several types of people should not take any of the benzodiazepines, because of the possibility of unwanted side effects. These include the following:
- People who have had previous negative reactions or serious side effects with any benzodiazepine.
- People who fly aircraft, drive, or operate heavy machinery.
- People with a history of drug or alcohol dependence.
- People with Alzheimer's disease, stroke, multiple sclerosis, or other brain disorders.
- People with anxiety that recurs after benzodiazepines are discontinued.
- People who are seriously depressed.
- Women who are pregnant.
- Women who are breastfeeding.
Benzodiazepines produce mild sedation when taken by slowing down activity in the central nervous system (CNS). These drugs act on the limbic system, the area of the brain that controls emotions. Specifically, they enhance the effects of a natural chemical neurotransmitter called gamma-aminobutyric acid (GABA), and heightens GABA's ability to block feelings of tension and anxiety by inhibiting neurons from firing and thereby dampening the transmission of nerve signals. The result is a calming effect.
Some of the benzodiazepines, such as alprazolam (Xanax) and triazolam (Halcion), bind especially tightly to the GABA receptors. This causes more intense sedation and hypnosis, as well as more severe rebound and withdrawal symptoms.
Benzodiazepines are usually taken in their pill form, although some people dissolve and inject them. Some of these drugs are also available in an injectable solution, including chlordiazepoxide, diazepam, and lorazepam. Diazepam is also available in a rectal solution. The onset of effect is roughly 30 minutes, and can last up to 48 hours.
Physicians use benzodiazepines to treat many disorders, including a number of anxiety disorders. These include acute anxiety, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. In addition, benzodiazepines can be used to treat agitation or anxiety that is caused by other psychiatric conditions such as acute mania, psychotic illness, depression, impulse control disorders, and catatonia or mutism.
Involuntary movement disorders also respond well to this class of drugs. These include restless leg syndrome, akathisia associated with neuroleptic use, choreiform disorders, and myoclonus.
Benzodiazepines are used to treat insomnia and for the acute treatment of epileptic seizures, convulsive disorders, and spastic disorders such as cerebral palsy, multiple sclerosis, and paraplegia caused by trauma to the spine.
Benzodiazepines can be used during detoxification from alcohol and other substances, as well as in surgery, dentistry, diagnostic studies (computed tomography, MRI, and endoscopy), cardioversion, and chemotherapy. They help reduce fear and anxiety, and in cases of detoxification, can actually lessen the symptoms of alcohol withdrawal.
Benzodiazepines are very commonly prescribed, and have consistently made the annual list of drugs most prescribed by physicians for many years. According to Pharmacy Times, the category of benzodiazepines ranked seventh in the list of the "Top 20 Product Categories," according to the total number of new prescriptions of benzodiazepines that were dispensed that year, which was 39,322,000. They ranked ninth on Pharmacy Times list of the "Top 20 Leading Product Categories for 2000," according to the total prescriptions dispensed, which were 66,564,000 for that year.
Alprazolam (Xanax), which was developed and introduced in 1981, is still the most prescribed benzodiazepine. It causes fewer side effects, because the body can eliminate it in less than 12 hours. Chlordiazepoxide (Klonopin) is the second most commonly prescribed benzodiazepine.
Benzodiazepines are most commonly prescribed for women and elderly patients. This may be partially due to the fact that women, in general, seem to be more willing to seek psychological help than men. In addition, four out of five people who experience panic attacks are women. Elderly patients are commonly afflicted with other conditions, such as insomnia and depression, which respond well to treatment with benzodiazepines.
Although benzodiazepines are the most commonly prescribed psychoactive drugs in the world, they are rarely used as recreational drugs because they have only mild to moderate euphoriant effects. According to reports from the United States Drug Enforcement Agency, these drugs are not valued on the street in the same way cocaine, heroin, or even alcohol is; therefore they are relatively inexpensive. Abuse of benzodiazepines is high among heroin and cocaine abusers. Abuse is found among adolescents and young adults as well, who may take these drugs to get buzzed. According to an in-depth review of the benzodiazepines in American Family Physician in 2000, about 80% of benzodiazepine abuse is in those who use other drugs, opioid users being the most common.
The dark side to benzodiazepines is that they are the most commonly implicated substances in drug overdoses, many of which are a result of combining benzodiazepines with other drugs, including alcohol. Two of the benzodiazepines commonly prescribed for sleep—flurazepam (Dalmane) and temazepam (Restoril)—were associated with the most deaths per million prescriptions.
Hospital admissions due to benzodiazepine abuse have been studied as well. According to the Treatment Episode Data Set (TEDS) from the Substance Abuse and Mental Health Services Administration (SAMHSA) of the United States Department of Health and Human Services, tranquilizers such as the benzodiazepines were the primary substance of 0.3% of TEDS admissions in 1998. In addition, 39% of patients admitted for tranquilizer use reported abuse of alcohol as well as tranquilizers. Admissions for tranquilizer abuse were mostly female (48%) and white (90%).
A full 61% of the hospital admissions were aged 35 and older. Interestingly, the data also show that 32% of tranquilizer admissions patients first used tranquilizers after the age of 30. This is consistent with other data and surveys, which also show that the use of tranquilizers, including benzodiazepines, increases with age.
Patterns of benzodiazepine use in young adults can be found in a survey entitled Monitoring the Future: National Survey Results on Drug Use, 1975-2000. Volume II: College Students and Adults Ages 19-40. This is a compilation of data from a long-term research program conducted by the University of Michigan's Institute for Social Research, with funding from the National Institute on Drug Abuse.
The survey consists of a series of ongoing national annual surveys of high school seniors (begun in 1975) and of eighth and tenth grade students (begun in 1991). Follow-up surveys of the previous participants from each high school senior class were also conducted, starting with the class of 1976. Volume 2 of the survey is a compilation of the resulting surveys from graduating high school seniors (from the classes of 1976 through1999) as they moved into adulthood through age 40. These data were used to determine the most updated prevalence rates of benzodiazepine use in young adults.
Overall, the survey found that there were steady increases in the use of all agents that were CNS depressants, such as benzodiazepines among high school seniors, college students, and young adults. From the 1970s through the early 1990s, usage of these drugs declined. A small increase in the use of these drug, however, has become evident from the early 1990s through 2000.
According to the survey data, the annual prevalence of the use of benzodiazepines among college students dropped by 50% between the years of 1980 to 1984(6.9% to 3.5%, respectively), and then dropped by another 50% between 1984 and 1994 (to 1.8%). Then, usage rates began a steady increase, reaching 4.2% by2000. In young adults not considered to be college students, these rates dropped more sharply during the early 1980s. Similarly, in high school seniors, the use of benzodiazepines also dropped from 1977 to 1992 (from10.8% to 2.8%, respectively), and then rose to a total of5.7% in 2000.
According to this same survey, the lifetime prevalence of use of tranquilizers in the year 2000 for full-time college students was low, at 8.8%, as compared to young adults who were one to four years beyond high school in the same age group, which was 12.7%. This was higher among full-time college students who were male than in those who were female (10.0% vs. 7.9%, respectively). These drugs were most likely to be used by non-collegiate males (14.5%), and to a lesser degree, females (11.3%).
In this survey, college students were defined as high school graduates who were one to four years past high school and who were enrolled full-time in a two-year or four-year college at the beginning of March of the year reported on. For each year of the survey, roughly 1,100 to 1,500 respondents comprised the college student sample, and about 1,000 to 1,700 respondents comprised the group of young adults not considered college students.
Young men not enrolled in college were the most common users of benzodiazepines in the year 2000. Young adults who were not in college were also more likely than college studients to use these drugs. Annual use of benzodiazepines was again most likely in young adult men who were not full-time college students(7.6%), followed by women who were not students(6.3%), compared with only 4.8% of full-time college males and only 3.8% of full-time college female students. Overall, the annual prevalence of the use of benzodiazepines in all young adults enrolled full-time in college was 4.2%, compared with 6.8% in young adults not enrolled in full-time college.
In this same survey, many young adults reported that benzodiazepines were readily available to them (37–38%). This availability was decreased in the long term among young adults aged 19–22 years, with 36.5% saying that these drugs were "fairly easy" or "very easy" to get in 2000. This was a decrease from the 37.1% who reported this availability in 1999, and a decrease from the 67.4% who reported this in 1980.
Among 19–22 year olds, the percentage of youths reporting that most or all of their friends used benzodiazepine increased, from 1.9% in 1980 to 2.1% in 2000. There was also an increase of 0.9% in the number of 19 to 22 year olds who reported that most or all of their friends used benzodiazepines from 1999 to 2000.
The percentage of young adults aged 19–22 years who reported that they had any exposure to benzodiazepines also increased from 14.3% in 1999 to 18.5% in 2000, an increase of 4.3%. This was decreased, however, from responses in 1980, when a full 29.6% of young adults in this age group reported having any exposure to benzodiazepines. In those saying they were often exposed to benzodiazepine use, the percentage again increased, from 1.5% in 1999 to 1.7% in 2000, an increase of 0.2%.
Lifetime use of benzodiazepines has decreased slighty over the years, but this reduction has been minimal. According to the results from an annual survey done by SAMSHA (Substance Abuse and Mental Health Services Administration, of the United States Department of Health), use of tranquilizers or benzodiazepines has decreased. Data from SAMSHA's 2000 National Household Survey on Drug Abuse shows that in persons aged 18–25, lifetime use of tranquilizers decreased from7.9% in 1999 to 7.4% in 2000. Past year usage of tranquilizers in this age group also decreased, from 3.1% in 1999, to 3.0% in 2000. Finally, past month usage of tranquilizers in the 18 to 25-year-old respondents to the survey decreased, from 1.1% in 1999, to 1.0% in 2000.
Benzodiazepines work to reduce inhibition and anxiety. They depress the central nervous system. This in turn reduces emotional reactions, mental alertness, attention span, and feelings of anxiety, bringing a sense of relaxation and well being. In addition, benzodiazepines can cause drowsiness and mental confusion. These effects are immediate and can last hours or days. When taken long-term, benzodiazepines can cause increased aggressiveness and severe depression.
Several studies have shown that impairment of a person's cognitive or mental function can occur in people taking benzodiazepines. These effects can include problems such as lapses of memory, and confusion. For example, college students who take benzodiazepines before exams to help them relax or sleep may not remember some of what they have been studying.
Common side effects of benzodiazepines include drowsiness, loss of coordination, unsteady gait, dizziness, lightheadedness, and slurred speech. Some of the less common side effects include changes in sexual desire or ability, constipation, a false sense of well being, nausea and vomiting, urinary problems, and fatigue. Euphoria, restlessness, hallucinations, and hypomanic behavior have been reported, as have uninhibited bizarre behaviors, hostility, rage, paranoia, depression, and suicidal thoughts.
Serious side effects with these drugs are rare, but can include behavior problems such as outbursts of anger, depression, hallucinations, low blood pressure, muscle weakness, skin rash or itching, sore throat, fever and chills, sores in the throat or mouth, unusual bruising or bleeding, extreme fatigue, yellowish tinge to the eyes or skin, and difficulty concentrating. If any of these side effects occurs, a doctor should be contacted immediately.
In particular, individuals taking nitrazepam (Mogadon) often report an increase in the incidence of nightmares, especially during the first week of use. Flurazepam (Dalmane, Novoflupam, Somnol) also occasionally causes an increase in nightmares, as well as anxiety, irritability, tachycardia, sweating, and garrulousness.
Benzodiazepines act on the central nervous system by slowing it down, thereby causing sedation and muscle relaxation. Immediate physiologic effects include depressed heartbeat and breathing, and physical unsteadiness. Side effects include skin rashes, nausea, and dizziness.
Regular use of any benzodiazepine can lead to physical and psychological dependence in as little as four to six weeks. Cravings for the drug, increased tolerance and the need for higher and higher doses, and withdrawal symptoms are all signs of dependence on the benzodiazepines. When stopped abruptly, individuals who are dependent on these agents can experience serious withdrawal symptoms and even seizures. Symptoms of withdrawal include anxiety, headache, dizziness, shakiness, loss of appetite, insomnia, and sometimes, fever, seizures, and even psychosis. People who are long-term addicts of the benzodiazepines may need to be hospitalized for withdrawal.
Harmful side effects
When taken in high doses, these drugs can produce some serious side effects. These side effects, which can be a signal that there is too much medication in the body or that toxic effects are being felt by the body, include drowsiness, confusion, dizziness, blurred vision, weakness, slurred speech, lack of coordination, difficulty breathing, and coma.
Driving and hazardous work should not be performed while taking benzodiazepines because they can impair mental alertness and coordination. Persons taking any of the benzodiazepine medications should never drink alcohol. Use during pregnancy and nursing should be avoided as well.
Benzodiazepines can have particularly potent effects when taken during pregnancy, and can cause congenital defects such as cleft lip or cleft palate. In addition, infants born to a mother addicted to the benzodiazepines can also experience withdrawal symptoms including respiratory distress, difficulty feeding, disruption of sleep patterns, decreased responsiveness, sweating, irritability, and fever. In addition, some benzodiazepines can accumulate in higher concentrations in the bloodstream and organs of an infant than in the mother. Also important to note is that these drugs may be present in higher concentrations in the breast milk of addicted mothers than in the bloodstream.
Long-term health effects
Use of any of benzodiazepines for as little as four to six weeks can lead to psychological or physical dependence. Dependence can develop sooner in patients taking short-acting, high-potency benzodiazepines like alprazolam (Xanax), as compared with someone taking a longer acting, low-potency agent such as chlordiazepoxide.
Benzodiazepines also should not be taken by people who have a history of alcohol or drug abuse, stroke or other brain disorder, chronic lung disease, hyperactivity, depression or other mental illness, myasthenia gravis, sleep apnea, epilepsy, porphyria, kidney disease, or liver disease.
REACTIONS WITH OTHER DRUGS OR SUBSTANCES
Benzodiazepines have an extremely low risk of acute toxicity when they are used alone. Unfortunately, these drugs are often used with other medications such as other CNS depressants, which can include commonly used antihistamines and alcohol, causing toxicity.
Drinking alcoholic beverages while taking any of the benzodiazepine medications will increase all the side effects of the benzodiazepine, especially the sedative effects and the tendency for slowed breathing. Concurrent use of alcohol and these drugs can also increase the memory lapses that occur with benzodiazepines. High doses of benzodiazepines and alcohol can impair an individual's ability to breathe and dangerously lower blood pressures. This could result in coma and death. Alcohol and benzodiazepines should never be taken together.
Use of benzodiazepines with narcotics, such as meperidine (Demerol), oxycodone (Percodan), codeine, morphine, or pentazocine (Talwin), increase their sedative effects. Combining these agents can lead to serious reductions in breathing rate, and even death. These two types of drugs should never be taken together.
Benzodiazepines should not be used with other drugs that inhibit the CNS, including hypnotic agents, sedating antidepressants, neuroleptic agents, anticonvulsants, and even antihistamines. Combined use with the barbiturates and other sedatives, such as phenobarbitol (Luminal), pentobarbital (Nembutal), secobarbitol (Seconal), and amobarbital/secobarbital (Tuinal), can also increase sedation and depress breathing to dangerous levels.
Combined use of more than one benzodiazepine is unnecessary and unsafe, as is combined use of benzodiazepines and sleeping pills.
Certain drugs can reduce the ability of the liver to clear benzodiazepines from the body. These include ulcer drugs, such as cimetidine (Tagamet), birth control pills, propranolol (used to treat hypertension, heart disorders, and migraines), and disulfuram (Antabuse), which is used for the treatment of alcoholism.
Finally, benzodiazepines should not be used to treat anxiety that is associated with depression because sometimes these drugs can actually make the depression worse. Instead, the choice for treatment in such cases should be one of the antidepressant medications.
TREATMENT AND REHABILITATION
Signs of addiction to benzodiazepines can be both specific and nonspecific. Chronic abuse can be signaled by the return of anxiety, insomnia, anorexia, headaches, and weakness in muscles. Changes in appearance and behavior that affect relationships and performance at work can be some of the nonspecific signs. Abrupt mood changes can also be a nonspecific sign. Addicted individuals will feel an intense craving for the drug, and then become ill if it is not obtained. Higher and higher doses are usually needed to achieve the same effects. Sudden cessation of the drug may cause withdrawal symptoms including shaking, nervousness, vomiting, fast heartbeat, sweating, and insomnia. Seizures or hallucinations can occur, but rarely.
Individuals who are addicted to benzodiazepines should not try to quit "cold turkey" on their own. Often, individuals addicted to a benzodiazepine have an addiction to another substance or drug, such as cocaine or alcohol. These multiple addictions are complicated. Recovery from these addictions should not be attempted alone. Withdrawal from abuse of benzodiazepines may cause life-threatening complications.
Withdrawal symptoms resulting from use of very high doses of benzodiazepines are comparable to those experienced by alcoholics when they stop drinking alcohol. The first signs of withdrawal develop two to 20 days after stopping the drug, and can initially include insomnia, irritability, and nervousness. This may progress to include abdominal and muscle cramps, nausea and vomiting, trembling, sweating, hyperarousal, and sensitivity to environmental stimuli. More severe withdrawal symptoms can include confusion, depersonalization, anxiety and obsession, psychosis, organic brain syndrome, and even seizures. Symptoms can takes weeks or even months to subside.
The first step in overcoming an addiction to any benzodiazepine is to undergo detoxification under strict medical supervision. The dosage of benzodiazepine must be gradually lowered over time. During this time, psychological counseling may be helpful, as well as cognitive-behavioral therapy, which focuses on changing a patient's thinking, expectations, and behavior and increasing his or her skills for coping with the everyday stresses in life.
PERSONAL AND SOCIAL CONSEQUENCES
The personal and social consequences of benzodiazepine abuse have not, to date, been extensively studied. A few seminal studies have shown, however, that use and abuse of the benzodiazepines carry the possibilities of impaired decision-making, decreased learning skills, released aggression, and an impaired ability to empathize, all of which can have profound effects on an individual's educational, social, and workplace environments.
Medical prescriptions are the primary source of benzodiazepines for those who abuse these drugs, although prescriptions can be rerouted illegally. Some people addicted to benzodiazepines also use a practice known as "doctor shopping," where the patients obtain several prescriptions by continuously switching doctors. In this way, they can get enough of their drug, via a doctor, to keep up with their addiction. The doctors used by the patient are usually unaware that the patient has already been prescribed the same drug by another doctor.
Writing fraudulent prescriptions on stolen prescription pads is a common practice used to obtain prescription drugs. Another means of getting prescription drugs such as benzodiazepines is by buying the drug from a patient who was legitimately prescribed the medication. These "legitimate" patients can be friends, parents, relatives, or even people on the street offering their prescriptions in exchange for money.
The legal consequences for the possession of a controlled substance such as a benzodiazepine without a prescription can be a felony conviction at the state or federal level.
Laws vary by state, but many have specific laws against the trafficking, possession, and use of drugs that are controlled substances, such as benzodiazepines. In addition, many other states have recently included laws against "doctor shopping" in attempts to stop prescription drug fraud.
Physicians who write prescriptions fraudulently are also subject to various legal consequences including felony convictions and the revocation of their license to practice medicine. However, the legal consequences tend to be less serious for the physicians involved as compared with lay persons. Many states now require the automatic suspension of medical, dental, and pharmacy licenses when these health-care professionals are convicted. However, many medical professionals convicted of prescription drug crimes have been able to keep their licenses. Unfortunately, the way current laws are written, most physicians avoid facing serious drug-trafficking charges after writing a prescription, even if it is fraudulent.
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National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, [email protected],<http://www.drugabuse.gov/Infofax/marijuana.html>.
Elizabeth C. Meszaros
What Kind of Drug Is It?
Benzodiazepines (pronounced ben-zoh-die-AZ-uh-peens) are depressants that relieve anxiety. Their names are easy to recognize because many of them end in the suffix "-am." Some common benzodiazepines are alprazolam, diazepam, and lorazepam. Benzodiazepines are only available legally with a doctor's prescription.
A number of medical terms apply to benzodiazepines. Just like alcohol and barbiturates, benzodiazepines are classified as depressants because they slow down both the mind and the body. They are also considered sedative-hypnotic agents and tranquilizers because they reduce anxiety and promote sleep. Benzodiazepines can be addicting.
Benzodiazepines are widely prescribed in the treatment of anxiety disorders, sleep disorders, and seizure conditions. They calm down users by acting on the brain to lower anxiety levels, relax muscles, and bring on sleep. Benzodiazepines were first used in the late 1950s. By the 1960s, physicians were regularly prescribing them to patients in place of barbiturates. Barbiturates, another class of depressants, can slow the breathing center of the brain to dangerously low levels. Benzodiazepines have less of an effect on breathing than barbiturates and are therefore considered safer. In addition, benzodiazepines are less likely to lead to death in cases of overdose.
Official Drug Name: Alprazolam (al-PRAZZ-oh-lam; Xanax), chlordiazepoxide (klor-dye-az-uh-POKS-ide; Librium), clonazepam (kloh-NAZZuh-pam; Klonopin), clorazepate (klor-AZZ-uh-pate; Tranxene), diazepam (dye-AZZ-uh-pam; Valium), flurazepam (flor-AZZ-uh-pam; Dalmane), flunitrazepam (Rohypnol), halazepam (huh-LAZZ-uh-pam; Paxipam), lorazepam (lorr-AZZ-uh-pam; Ativan), midazolam (Versed), oxazepam (oks-AZZ-uh-pam; Serax), prazepam (PRAZZ-uh-pam; Centrax), quazepam (KWAY-zuh-pam; Doral), temazepam (tuh-MAZZ-uh-pam; Restoril), triazolam (try-AY-zoe-lam; Halcion)
Also Known As: Benzos, tranks, downers
Drug Classifications: Schedule IV, except for flunitrazepam (Rohypnol), which is a Schedule III drug; depressant
The likelihood of addiction among benzodiazepine users did not become an issue until several years after their introduction. When taken for a limited amount of time in doctor-prescribed doses, benzodiazepines are generally quite safe. Problems develop when they are taken for more than several months or in larger-thanrecommended doses. Psychological and physical dependence on benzodiazepines can actually occur within a matter of weeks. It has also been reported that benzodiazepine abusers usually combine their "benzos" with other drugs or alcohol. These combinations can lead to very serious physical consequences, including slowed breathing, coma, and even death.
About fifty different kinds of benzodiazepines were being used throughout the world in 2005. However, only fifteen of these have been approved for use in the United States by the Food and Drug Administration (FDA). According to The Pill Book, four of the top seventy-five prescriptions written by U.S. doctors in 2003 were for benzodiazepines:
- alprazolam (Xanax) ranked 12th
- lorazepam (Ativan) ranked 32nd
- clonazepam (Klonopin) ranked 52nd
- diazepam (Valium) ranked 68th
Of these benzodiazepines, alprazolam was the most frequently abused in the United States in the early 2000s. This likely occurs because it acts so quickly—within twenty to thirty minutes. As Lance P. Longo and Brian Johnson, writing in American Family Physician, put it, "drugs that work immediately tend to be addictive."
Drug companies classify benzodiazepines according to the length of time it takes for them to begin working. The ultra-short acting benzodiazepines kick in almost immediately and are mainly used in a hospital setting as a form of anesthesia. Two common ultra-short acting benzodiazepines are midazolam (Versed) and triazolam (Halcion). The short-acting benzodiazepines typically begin working in less than half an hour. These are among the most commonly abused drugs and include alprazolam (Xanax) and lorazepam (Ativan). The long-acting benzodiazepines, such as chlordiazepoxide (Librium) and diazepam (Valium), take a longer time to produce effects.
The strongest benzodiazepines, known as high-potency benzodiazepines, include alprazolam, lorazepam, triazolam, and clonazepam. Among the less powerful, or low-potency, benzodiazepines are chlordiazepoxide, clorazepate, diazepam, and flurazepam.
"Mother's Little Helper"
Historically, tranquilizers were not the drug of choice among the biggest drug users of the 1960s. College students, hippies, and concertgoing youths of that decade were more likely to experiment with hallucinogenic drugs. Benzodiazepines and minor tranquilizers were associated more with stay-at-home moms. Their practice of taking Valium—the "little yellow pill"—was widespread in the United States and the United Kingdom during this time. The Rolling Stones recorded a song in 1966 called "Mother's Little Helper" about this trend. As noted on CNN.com, the Stones sang: "Mother needs something today to calm her down / And though she's not really ill, There's a little yellow pill / She goes running for the shelter of a mother's little helper.…"
It is estimated that in the 1970s, as many as 30 million women were taking minor tranquilizers. "In promoting these drugs, the manufacturers portrayed stresses of everyday life as disease states treatable by prescribing their products," explained Andrew Weil and Winifred Rosen in From Chocolate to Morphine. Some advertisements "suggested giving tranquilizers to harried mothers and bored housewives." One particular ad aimed at physicians suggested they carry syringes of injectable diazepam "ready to use, when something must be done to calm the patient in emotional crisis." As Weil pointed out, ads like these always seemed to feature pictures of women as emotionally distressed patients in need of help. Psychiatrists were freely prescribing these minor tranquilizers to women with little regard of their potential for addiction.
What Is It Made Of?
Benzodiazepines consist of chemical substances known as amines. All benzodiazepines are produced in laboratories. Like the other amines, they are derived from ammonia, a gas that consists of one molecule of nitrogen and three molecules of hydrogen.
How Is It Taken?
Benzodiazepines are usually taken in capsule or tablet form, but some are available as an injectable solution. The tablets are typically pastel shades of yellow, green, or blue. Some users dissolve the pills in water, mix them with other drugs, and then inject them directly into a vein.
Are There Any Medical Reasons for Taking This Substance?
Physicians use benzodiazepines in the treatment of many anxiety disorders. For example, they are used to treat panic attacks, which are unexpected episodes of severe anxiety that can cause physical symptoms such as shortness of breath, dizziness, sweating, and shaking. The drugs also help people suffering from post-traumatic stress disorder (PTSD), an illness that can occur after someone experiences or witnesses a life-threatening event such as a serious accident, violent assault, or terrorist attack. PTSD symptoms include reliving the experience through nightmares and flashbacks, having problems sleeping, and feeling detached from reality.
Benzodiazepines also help with obsessive-compulsive disorder (OCD), an anxiety disorder that causes people to dwell on unwanted thoughts, act on unusual urges, and perform repetitive rituals such as frequent hand washing. Benzodiazepines may also be used to relieve tension, agitation, insomnia, muscles spasms, and epileptic seizures.
Patients undergoing surgery, dental procedures, diagnostic studies, and cancer treatments are sometimes given benzodiazepines to help reduce their fear and anxiety. In addition, benzodiazepines may be prescribed for alcoholics and addicts undergoing the detoxification process. When used under strict medical supervision, these drugs can lessen the symptoms of withdrawal that occur as the user cuts back on the amount of a drug being taken until use can be discontinued entirely.
Benzodiazepines are very commonly prescribed, but they are supposed to be used only for brief periods of time. Benzodiazepine drugs have a number of genuine medical uses, but they are most frequently prescribed to relieve anxiety and fear. According to the American Psychiatric Association (APA), approximately "8 percent of all adults have suffered from a phobia, panic disorder or other anxiety disorder" during any given six-month period. "For millions of Americans, anxiety disorders are disruptive, debilitating and often the reason for loss of job and serious problems in family relationships."
Anxiety disorders are sometimes controllable without drugs. Patients are often able to reduce their anxiety to manageable levels through weekly "talk therapy" sessions with trained psychotherapists. One type of psychotherapy, called cognitive-behavioral therapy (cbt), has a very high success rate. Cognitive-behavioral therapy helps patients change their outlook on life and recast their negative feelings into positive ones.
In certain cases, however, therapy is not enough. Patients may require medication to control their symptoms. Psychiatrists often prescribe benzodiazepines to such patients. According to the APA, these drugs "relieve the fear, help end the physical symptoms such as pounding heart and shortness of breath, and give people a greater sense of control." Along with that greater sense of control comes the ability to recognize and "reduce the stress that can trigger anxiety."
Benzodiazepines are most commonly prescribed for women and elderly patients. Four out of five people who experience panic attacks are female. Elderly patients are commonly diagnosed with conditions such as insomnia and depression. These conditions respond well to treatment with certain benzodiazepines. But long-term use of these drugs among the elderly increases the likelihood of these patients developing a physical dependence on benzodiazepines.
In one study cited by Mental Health Weekly, 60 percent of older women taking benzodiazepines by prescription were on the drugs for more than four months. That time period is longer than recommended. In addition, the National Institute on Drug Abuse (NIDA) reported in its "Prescription Drugs: Abuse and Addiction" that "elderly persons who take benzodiazepines are at increased risk for falls that cause hip and thigh fractures, as well as for vehicle accidents."
Part of the Multi-Drug Mix
Among drug abusers, benzodiazepines are hardly ever used alone. The White House's drug policy publication "Pulse Check" revealed that multi-drug use "increased steadily" between 1993 and 2003. About 80 percent of benzodiazepine abuse occurs in people who regularly abuse other drugs. This has led to "increased complications for drug treatment," noted the "Pulse Check" report, because "it is hard to determine what clients are using."
illicit drug users report that benzodiazepines increase and lengthen the high they get with other drugs. Heavy drinkers have reported that benzodiazepines enhance the effects of alcohol. These drugs can also ease the process of "coming down" from a stimulant high. So, many multi-drug abusers use it as part of their regular drug mix.
Reading up on Rohypnol
Flunitrazepam (Rohypnol) is an extremely powerful and fast-acting benzodiazepine. The drug began receiving a lot of attention in the mid-1990s, especially on college campuses because of its use as a "date rape" drug. Flunitrazepam is one of the drugs, along with ecstasy (MDMA), used by teens and young adults as part of the nightclub, bar, or "rave" scene. Raves are wild overnight dance parties that usually involve huge crowds of people, loud techno music, and illegal drug use.
Flunitrazepam is also known by the brand name Rohypnol and the street names roofies, R2, Roche, roofinol, rope, rophies, forget-me pill, and Mexican valium. It comes in the form of a small, white tablet with "Roche" on one side and a "1" or "2" in a circle on the other side. The numbers indicate a 1-milligram or 2-milligram dosage. It is usually taken by mouth, often combined with alcohol. Or, it is sometimes snorted after the user crushes the tablets.
The effects of Rohypnol include sedation, muscle relaxation, and anxiety reduction. Its sedative effects are said to be seven to ten times stronger than diazepam (Valium). Because it is tasteless and odorless, flunitrazepam is hard to detect in beverages. After taking this drug, users begin to feel intoxicated rather quickly. The "drunken" feelings soon turn to extreme sleepiness. Speech becomes slurred, and judgment is most definitely impaired. Partial amnesia is a common effect, as well. For this reason, flunitrazepam has been used in date rape.
Victims of date rape are usually unable to remember the assault or identify their attacker because Rohypnol affects one's memory. Rohypnol begins working within minutes of being consumed. Its effects can last up to eight hours. Deep sedation, respiratory distress, and daylong blackouts are some of the more serious possible effects of Rohypnol. In high doses, flunitrazepam can kill.
Rohypnol has never been approved for use in the United States. It is smuggled in from other countries in Europe, Central America, and South America. The U.S. Congress passed the Drug-Induced Rape Prevention and Punishment Act of 1996. This legislation increased the federal penalties for individuals using any controlled substance to aid them in sexual assault. The law makes it a crime to give others a controlled substance without their knowledge or with the intent to commit a violent crime against them. (A separate entry on Rohypnol is available in this encyclopedia.)
Abuse of benzodiazepines is especially high among heroin, cocaine, and methadone abusers. (A separate entry on each of these drugs is available in this encyclopedia.) According to S. Pirzada Sattar and Subhash Bhatia in an article for Current Psychiatry Online, nearly half of all intravenous (v) drug abusers also take benzodiazepines. However, "even patients who begin taking benzodiazepines for legitimate reasons may end up abusing them."
Who's Using Benzodiazepines?
Patterns of benzodiazepine use in America have been documented in two long-term surveys. One is the Monitoring the Future (MTF) study conducted by the University of Michigan (U of M) and sponsored by research grants from NIDA. The second is the National Survey on Drug Use and Health (NSDUH), previously called the National Household Survey on Drug Abuse or NHSDA. It is conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), a division of the U.S. Department of Health and Human Services.
The results of the 2004 MTF study were released to the public on December 21, 2004. Since 1991, U of M has tracked patterns of drug use and attitudes toward drugs among students in the eighth, tenth, and twelfth grades. (Prior to that, from 1975 to 1990, the MTF survey was limited to twelfth graders.) The 2004 MTF survey revealed that the use of tranquilizers and sedatives remained relatively "stable among all grades." About 2.5 percent of eighth graders, 5.1 percent of tenth graders, and 7.3 percent of high school seniors reported using drugs like Xanax between 2003 and 2004.
SAMHSA's 2003 NSDUH was broader than the MTF survey. The NSDUH traces drug use in the United States among people of all ages, not just among eighth, tenth, and twelfth graders. The NSDUH obtains information about nine different categories of illicit drug use. One of those categories includes the nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives.
Benzodiazepine users can be young or old, male or female. Illicit users—individuals who were not prescribed the drug for a medical reason—typically range in age from their late teens to early thirties. About two-thirds of these users are male.
NSDUH reports combine the four prescription-type drug groups into a category referred to as "any psychotherapeutics" (SY-koh-ther-uh-PYOO-tiks). Numerous drugs are covered by this category. All of them are available through prescriptions and sometimes illegally "on the street." Over-the-counter drugs and legitimate uses of prescription drugs are not included in the NSDUH report. Respondents are asked to report only uses of drugs that were not prescribed for them or drugs they took only for the experience or feeling they caused.
The results show that a number of Americans became "new users" of psychotherapeutic drugs in 2002. Roughly 1.2 million people began using tranquilizers, and 225,000 began using sedatives. Among fifteen benzodiazepines, the nonmedical use of two specific drugs—alprazolam (Xanax) and lorazepam (Ativan)—rose the most between 2002 and 2003, from 3.5 percent to 4 percent of those surveyed. Use among twelve to seventeen year olds was unchanged, reflecting the same trend as the MTF survey. The biggest jump was seen in users who were slightly older, age eighteen to twenty-five. From 2002 to 2003, usage in that particular age group increased from 6.7 to 7.5 percent.
In Canada, benzodiazepine use is tracked by the Centre for Addiction and Mental Health (CAMH). The CAMH publishes a series of leaflets on drugs under the title "Do You Know. … " The "Do You Know… Benzodiazepines" leaflet states that "approximately 10 percent of Canadians report using a benzodiazepine at least once a year, with one in ten of these people continuing use regularly for more than a year."
Effects on the Body
Benzodiazepines act on the area of the brain that controls emotions. They do this by boosting the effects of a neurotransmitter called gamma-aminobutyric acid (GABA). GABA receptor sites are especially numerous on cells in the part of the brain responsible for fear and worrying. Benzodiazepines work by increasing GABA activity. Higher levels of GABA activity help block feelings of tension and anxiety. The result is a calming effect. Some benzodiazepines bind more tightly to GABA receptors than others, causing more intense sedation.
Benzodiazepines are designed to produce feelings of relaxation and an increased sense of well-being in the user. But, along with reducing anxiety, these drugs decrease emotional reactions, mental alertness, and attention span. Common side effects of benzodiazepine use include confusion, drowsiness, loss of coordination, dizziness, and light-headedness. More serious side effects caused by these drugs are rare but can occur. They include outbursts of anger, severe depression, hallucinations, muscle weakness, extreme tiredness, loss of memory, skin rashes, itching, fever and chills, and sores in the throat or mouth.
High doses of benzodiazepines lead to symptoms similar to those caused by excessive use of barbiturates or alcohol. These include slurred speech, impaired memory, slowed breathing, and lowered blood pressure. Although overdosing on benzodiazepines alone is not likely, it has occurred. In these cases, the patients' rate of breathing and blood pressure dropped so low that they went into a coma and eventually died.
Use Interferes with Learning and Memory
Benzodiazepines seem to interfere with memory formation and learning. They "can prevent the brain from recording and adapting to new information," explained Cynthia Kuhn and her coauthors in Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy. "Someone who needs to learn new information should never use these drugs and expect to do so to their full potential."
For example, college students might take benzodiazepines while studying. They might use the drugs in an attempt to relax or to get a good night's sleep. However, such drugs can make it difficult for students to recall the information they need on exam day. Impaired memory is limited to events that occur during the time the drugs are being used. When the dosage wears off, new learning and memory formation become possible again.
Because they decrease mental alertness, benzodiazepines should never be used when driving or operating heavy machinery. "Benzodiazepines slow reaction time and impair driving skills, increasing the risk of motor vehicles crashes in patients who are taking [them]," explained Longo and Johnson. In addition, benzodiazepines should not be taken by pregnant women or by people suffering from lung, kidney, or liver disease.
Addiction and Withdrawal
Benzodiazepines are addictive substances. Regular use of any benzodiazepine can lead to physical and psychological dependence in as little as four to six weeks. According to a 2002 Mental Health Weekly article, taking Xanax "for more than eight weeks carries a high
risk of dependency." Both psychologically and physically addicted users may experience cravings for the drug, but those with physical addictions will actually experience withdrawal symptoms if they suddenly stop taking benzodiazepines. In other words, they will become ill if they don't get the drug into their systems. Withdrawal symptoms can be quite serious and range from insomnia, nervousness, irritability, and nausea, to tremors, seizures, and even hallucinations.
Reactions with Other Drugs or Substances
When taken with other depressants such as alcohol or barbiturates, benzodiazepines can be extremely dangerous. The combined effects of two or more depressants can greatly lower blood pressure and reduce a user's ability to breathe. This, in turn, can lead to coma and death. Use of benzodiazepines with meperidine, oxycodone, codeine, or morphine can be deadly as well. (Entries on each of these drugs are available in this encyclopedia).
Treatment for Habitual Users
The potential for addiction to benzodiazepines is very real. That potential is even greater among certain segments of the population, especially those undergoing treatment for substance abuse. "Among psychiatric patients," wrote Sattar and Bhatia, "substance abusers are most likely to abuse benzodiazepines and become addicted to them." Multiple addictions are complicated. Users should seek professional help when trying to stop using the drug.
The withdrawal process can take weeks or even months and requires a combination of physical and psychological care. Benzodiazepine abusers must undergo the process of detoxification under strict medical supervision. During this time, the dosage of the drug is lowered gradually, and eventually use is phased out completely. Cognitive-behavioral therapy helps provide habitual users with the support they need to kick their habit. This type of psychotherapy focuses on increasing a patient's skills for coping with the everyday stresses in life.
Unwanted Side Effects
Interesting evidence has surfaced about the effects of benzodiazepines on some patients. Although such drugs are routinely prescribed to treat the anxiety that comes with depression, benzodiazepines—especially when taken in high doses—may actually increase the risk of depression. This theory was reinforced in 2004, when a study was conducted on soldiers returning home from war. War, terrorist attacks, and other life-threatening events can trigger post-traumatic stress disorder (PTSD) in people who have experienced these events firsthand. A Harvard Medical School doctor noted in Newsweek that "anxiety-muting benzodiazepines such as lorazepam and clonazepam may actually raise the risk of chronic PTSD if taken continuously." The reasons for this unwanted side effect were still being studied in 2005.
"It is dangerous to combine any sedative, including benzodiazepines, with anything else that makes a person sleepy," stated Kuhn. Mental Health Weekly reported that in 2001, bad reactions to Xanax and other benzodiazepines were responsible for a high percentage of prescription drug-related emergency room visits. The use and abuse of benzodiazepines can impair decision-making, decrease learning skills, and bring on aggression. Each of these factors can have a significant effect on an individual's educational, social, and workplace environments.
"The nonmedical use or abuse of prescription drugs remains a serious public health concern," wrote the NIDA director in his introduction to "Prescription Drugs: Abuse and Addiction." Medical prescriptions are the primary source of benzodiazepines for abusers, but some of these prescriptions are obtained illegally. Benzodiazepine addicts often use a practice known as "doctor shopping" to keep up with their addiction. They switch doctors and visit emergency rooms regularly in the hopes of getting multiple prescriptions for benzodiazepines. The doctors used in this scheme are usually unaware that another physician has already prescribed the same drugs for the patient.
Writing fake prescriptions on stolen prescription pads is a common practice used to obtain prescription drugs. Another means of getting prescription drugs such as benzodiazepines is by buying the drug from a patient who was legitimately prescribed the medication. These "legitimate" patients can be friends, parents, relatives, or even people on the street offering their pills in exchange for money.
The Drug Abuse Warning Network (DAWN) collects data on drug-related hospital emergency room (ER) visits throughout the United States. ER trips resulting from benzodiazepine abuse numbered more than 100,000 in 2002, an increase of 41 percent since 1995. Complete results of the DAWN report can be found at http://www.oas.samhsa.gov.
Regardless of how the drugs are obtained, it is against the law to possess or use controlled substances such as benzodiazepines without a doctor's prescription. Selling or distributing benzodiazepines to others is a more serious offense. Physicians who write fraudulent prescriptions are also subject to various legal consequences. These include felony convictions and the possible loss of their medical licenses.
For More Information
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Preston, John D., John H. O'Neal, and Mary C. Talaga. Consumer Guide to Psychiatric Drugs. New York: New Harbinger Publishers, 1998.
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