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ANXIOUS AND ADDICTED
July 26, 2003
by Clara Pirani
It was prescribed for dozens of ailments, including stress, panic attacks, back pain, insomnia, and calming patients before and after surgery, creating a new and unsuspecting class of drug addicts. Four decades later, many are questioning why the drug is still so popular, given that doctors and drug addiction workers believe Valium, and drugs like it, create more health problems than they solve.
Valium Latin for "strong and well" was developed in the early 1960s in the US by Dr Leo Sternbach, a Polish chemist working for pharmaceutical giant Hoffman-LaRoche. Sternbach had also created Valium's famous predecessor, Librium, in 1960.
Approved for use in 1963, Valium quickly became a favourite among mental health professionals and general practitioners. Valium was the most prescribed drug in the US between 1969 and 1982. At its peak in the 70s, Hoffman LaRoche's parent company, The Roche Group, was selling about two billion Valium pills a year, earning the company $US600 million a year. Diazepam the generic name for Valium was created from a simplified version of Librium.
Valium quickly became a household name, the drug of choice for millions of people, from the rich and famous to the stressed executive and the frustrated housewife. The pills were the subject of author Jacqueline Sussan's 1966 bestseller, Valley of the Dolls.
In 1967, the Rolling Stones released Mother's Little Helper, a song about a housewife who copes with a demanding husband and children by using Valium. These days Valium is still a popular choice.
Diazepam is sold in Australia by several pharmaceutical companies as Valium, Antenex, Ducene and Valpam. In 2002-2003, 50 per cent of prescriptions for diazepam in Australia were for Valium. Almost two million scripts were issued for diazepam in 2002, costing consumers and government more than $13 million.
Diazepam belong to a class of drugs known as benzodiazepines, which include tranquillisers to ease anxiety and hypnotics to treat insomnia. Valium and other benzodiazepines were marketed as fast-acting, non-addictive and as having no side-effects. It seemed too good to be true. And it was.
Dr Jean Lennane was director of Drug and Alcohol Services at Rozelle Hospital in Sydney during the 1980s. Lennane believes naivety about benzodiazepines created countless drug addicts people who suffered from stress and social anxiety and innocently followed their doctor's instructions.
"There was a time when I was seeing heaps and heaps of people addicted to benzodiazepines. There were a lot of them and they were in two groups: the poly-drug addicts, who will take anything they can get their hands on, and the other group people who have not had any other drug problem and they find they have become hooked by talking a normal small dose of one of these drugs. And they were the much larger group. It became glaringly obvious, very quickly, that there was an enormous problem with benzodiazepines," says Lennane.
However, initially Lennane says doctors considered benzodiazepines to be quite safe, especially compared with other drugs on the market. "Barbiturates were very toxic and a small overdose would kill you." One of the great advantages of benzodiazepines over their predecessors, barbiturates, was that you can take a truck-load of them and you'll be very sick and go to sleep, but you won't kill yourself. I think that lulled people into a false sense of security about benzodiazepines and they were prescribed a lot more than they should have been."
Lennane argues the addictive qualities of the drug should have been noticed earlier. "The first paper appeared in the early '60s, showing that withdrawal for people who had been on it for a significant period was problematic. Within the next 10 years, there were a group of people who became dependent on Valium in the usual way that is they would start taking more and more of it, to try and get the same effect and end up on a very large dosage."
Some doctors, including Lennane, began to observe other alarming facts about benzodiazepines that weren't well known during the 1960s and 1970s and are still true today. They were addictive, even in small doses; they should be prescribed only for a very short period; the body adapted to the drug within a week, which usually led the user to seek higher dosages or more tablets; and the withdrawal process took six months and could be just as difficult as withdrawing from heroin or alcohol.
"What wasn't well known until the early 1980s is that a much larger group of people had become dependent on these benzodiazepines, including Valium, by taking the normal dose. They were only taking 2mg three times a day and within a week they were becoming dependent. And they were becoming very ill if that dose was reduced or withdrawn," says Lennane.
Lennane began an unpopular campaign to convince her colleagues and the drug's manufacturers that Valium and other benzodiazepines were dangerous. "I was not popular with the drug companies. Part of the battle was to force them to include in their prescribing literature the basic fact that these drugs commonly cause dependence, and that they should only be used for short-term treatment. But it took quite a while before they began including that information. I think it was probably threatened legal action that led them to include that information more than anything else," Lennane says.
Despite all the negative publicity during 1970s and 1980s, benzodiazepines including Valium, and later Xanax, were still widely prescribed without warnings about addiction or side-effects.
Sue Cleland was in her early teens when she began to suffer stress and anxiety. Cleland's doctor said her feelings were simply the usual teenage angst caused by typical teenager/parent conflict and that she was "a little uptight".
At age 15 Cleland was given a two-month prescription of Valium to help her sleep and she was given Xanax at age 22, without any other counselling or treatment. "I still had not been given a diagnosis for what was wrong with me. They just gave me prescriptions," Cleland says. "Valium was incredibly addictive and Xanax even more so. Even though I realised very quickly that I required more and more Xanax, that didn't stop me. I used to go back to the doctor and say that I'd lost the prescription. It was that sort of desperation. I used to move a lot, and so I'd go and see a new GP. It was very easy."
Cleland says doctors were only too eager to prescribe benzodiazepines. "At one point, after I'd quit Xanax, I'd also stopped smoking and was having problems with that, so I went to see a doctor and they tried to prescribe me Xanax for that. There was no diagnosis or even an attempt to help me understand what I was going through."
At age 30 after suffering a psychotic episode Cleland was taken to hospital, where she was finally diagnosed with social anxiety and depression.
Now a qualified social worker, Cleland runs a successful private practice called Anxiety Stress Management Service of Queensland, which also operates in Melbourne. She also runs an online group, called the Anxiety Network Australia, to help others faced with the same problems. Cleland is not the only mental health worker to question the benefits of benzodiazepines.
Dr Andrew Byrne runs a general practice and drug and alcohol service in the inner-Sydney suburb of Redfern. Byrne has written several papers, published in medical journals, that question the success of Valium and other benzodiazepines.
"The therapeutic benefits of Valium are very often outweighed by its cost and side-effects. Although most doctors prescribe benzodiazepines less now than they did 20 years ago, I think it's still being over-prescribed." Byrne says, however, there is sometimes no alternative.
"Patients look at you and say 'doctor I need a sleeping tablet because I've just started a shift job or my baby's been crying. And everyone's heard the term 'sleeping tablet', but the truth is there's no such thing as a good sleeping tablet. Benzodiazepines give you abnormal sleep; you're not refreshed when you get up. You have to keep taking it to get a good night's sleep."
Lennane shares the same concerns: "We have become a society of pill-poppers. We do tend to look for the answer in a bottle, when very often there's a better answer in exercise, meditation, diet, healthier living. The idea is that if you want to use any drugs in this class or for any of the drug prescribed for sleep problems, they should be used for a very short time in a very small dose. If you take any sleeping pill for more than two nights running, you are going to have a problem so they should be taken intermittently."
So when should Valium be prescribed? "Panic attacks are really the only strong reason to prescribe it these days. The withdrawal from Valium and other benzodiazepines can be brutal, and some doctors continue to prescribe the medication for fear of the patient's health during withdrawal. The other reason that I prescribe it is for people who are already addicted to it, like morphine and methadone," Byrne says.
He argues there's no point refusing to prescribe the drug until the patient is prepared. "Valium has a long half-life, which means it takes 30-plus hours for the body to get rid of half of the dose you've taken that day. As a result, withdrawals from Valium are just as serious as withdrawals of other drugs, including alcohol. You can have fits five or six days after they've stopped taking Valium. And that's one of the big risks."
It usually takes the body five to seven days to detox from alcohol or heroin. Withdrawal from Valium can take 6 months. "And the process should involve counselling and weekly or even daily monitoring of the patient's health," Byrne says.
Roche Products, which distributes Valium in Australia, is quite frank about the drug's limitations. Its consumer information warns of many side-effects, including drowsiness, loss of memory, slurred speech and confusion. However, its leaflet still claims Valium can be used for two to four weeks, despite warnings from doctors that users can become addicted within one or two weeks. Valium is also commonly sold in packets of 50.
Cleland says despite all the warnings about benzodiazepines, they are still misused, and some doctors are still prescribing benzodiazepines for long periods, and without any counselling. "I've seen clients who have been on Xanax for five years. They're going to have major problems coming off that drug. Unfortunately many clients who come into my practice think of benzos (benzodiazepines) as a cure. And so many of them have been prescribed benzos, it's horrific really. There's not enough management of these people when they come off the drugs," Cleland says.
Cleland believes the medication gives people a false sense of hope and argues that while many patients feel better when they initially begin taking the medication, the feelings are short-lived. "The medication is just a Band-Aid."
Byrne agrees: "In the case of benzodiazepines they should only be taken as part of an overhaul examination of the patient's overall lifestyle. Doctors need the talk about what's causing the stress and alternative treatments and relaxation techniques. To think that Valium could be used in isolation is ludicrous, it should always be used only as a last resort."
Valium: What is it?
Launched in 1963, Valium is one of the brand names for diazepam. Fifty per cent of diazepam prescriptions in Australia in 2002 were for Valium. Diazepam is a tranquilliser belonging to the benzodiazepine class of drug. It is prescribed to treat anxiety and sleep disorder. Valium is habit forming and should only be taken in small doses for a short periods. Side-effects include drowsiness, confusion, memory loss, dizziness, staggering, unpleasant dreams, headache. Withdrawal from Valium can take up to six months and should be undertaken under the supervision of a doctor. Benzodiazepines should only be prescribed as part of a broader counselling program.
Troublesome side-effects a caveat for new drugs
Dr Stephen Phillips, Chair of National Prescribing Service Ltd
VALIUM (diazepam) continues to be popular and for good reason. But its role has changed. Forty years ago Valium was mainly used as a sleeping tablet and to treat a whole range of psychological conditions, including depression and anxiety.
Initially it may have seemed a safer alternative to many other similar drugs (known as barbiturates). However, the potential problems and side-effects, that have since been identified, have limited its usefulness.
The majority of the side-effects associated with Valium are related to its use over a long time. These side-effects can be anything from drowsiness and unsteadiness to muscle weakness it's well known that falls and fractures are common complications in elderly people taking these medications for insomnia. However, the issue of most concern is dependence. Managing the way in which people stop taking these drugs, especially after long-term use, is a difficult issue for doctors.
Stopping suddenly can cause what's known as withdrawal syndrome. This can be unpleasant and often includes panic attacks, dizziness, confusion and even fits. Ideally a gradual reduction helps to avoid a withdrawal syndrome and, although challenging, enables some people to stop the drug altogether.
Despite these drawbacks Valium does play an important role in the treatment of some medical conditions in the short term. These conditions include the treatment of epileptic seizures, muscle spasm and managing the symptoms of withdrawal from alcohol and other drugs of abuse.
The difficulties related to the use of Valium have resulted in an important development the use of psychological therapies such as cognitive behavioural therapy, directive counselling and supportive psychotherapy as well as lifestyle changes to manage insomnia and anxiety. In some cases Valium may also have a role in supporting these psychological therapies but only in the short term.
Guidelines have been developed to support doctors and patients when using Valium and other benzodiazepines. These play an important role in ensuring these drugs are used appropriately. The flip side of the coin is that consumers also need to take ownership of the medicines they are taking.
Talking to your doctor about why you are taking a particular medication, how long you will need to take it, the side-effects and the impact the medication has on your health is very important. This also helps doctors to help you manage your health.
The emergence of side-effects from Valium, originally hailed as the wonder drug of its day, is a warning for us all to be cautious about newer drugs. What it all boils down to is that doctors and patients need to carefully monitor the use of all medicines (prescription medications, over-the-counter medications and herbal and natural therapies).
For more information about medicines consumers can call Medicines Line on 1300 888 763. This is a national hotline available Monday-Friday, 9am-6pm EST for the cost of a local call. This hotline is one of many services run by the National Prescribing Service Ltd (NPS). NPS is an independent organisation set up for consumers and health professionals to assist us all in using our medicines more wisely and achieving better health.
Treatment of benzodiazepine dependence, K. Jean Lennane, FRACP, DPM, 1986.
Benzodiazepine Dependence, Dr Andrew Byrne, 1997.
Benzodiazepines: the end of a dream, Dr Andrew Byrne, 1994.
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