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Journal of Addiction and Mental Health
Toronto, Ontario Canada

March/April 2001
by Andrea Gordon

En français:
Questions courantes sur les risques associés aux benzodiazépines,
  Le Journal de toxicomanie et santé mentale, mars/avril 2001

What are benzodiazepines?

Benzodiazepines - often referred to as tranquillizers, sedatives or "downers" - are a group of medications that slow down the central nervous system. Though most commonly prescribed to treat anxiety, tension and insomnia, they are also used to treat symptoms of alcohol withdrawal, and certain panic and convulsive disorders; as well as to relax muscles and relieve muscle spasms. Different forms are available under a wide range of trade names, including Valium, Ativan, Dalmane and Serax.

How prevalent is their use?

Benzodiazepines are the most widely prescribed psychoactive drugs in the world. Recent statistics indicate that one in 10 Canadians report using a benzodiazepine at least once a year, and continue using them for at least a year. Joan E. Gadsby, author of Addiction by Prescription (2000), describes benzodiazepines as the best-selling drugs in the history of medicine, with annual worldwide sales of $21 billion.

Who are benzodiazepines primarily prescribed for?

Women and elderly patients are the principal users. This may stem from the fact that women are generally more willing than men to seek help for psychological problems. And elderly patients commonly suffer from conditions, such as insomnia and depression, which benzodiazepines may be used to treat.

What is the risk of becoming addicted?

David Marsh, clinical director of Addiction Medicine at the Centre for Addiction and Mental Health, says users can experience physical withdrawal symptoms after using benzodiazepines for as little as two weeks. However the amount of use required to develop a dependency varies according to dosage, symptoms before taking the drug, whether a patient is also taking other drugs, and individual variables such as addiction history.

Marsh says the best protection against abuse is not to rely on drugs to modulate normal emotions. At the same time, he warns against discontinuing medication too quickly, particularly after prolonged use, or of discontinuing without first consulting a doctor.

Signs of dependence often resemble the symptoms that initiated the treatment, such as irritability, nervousness and sleeplessness, as well as abdominal cramps, trembling or shaking. Benzodiazepines can also cause blurred vision, impairment of motor co-ordination, slurred speech, slowed reflexes, impaired thought and short-term memory, mood swings, and hostile or erratic behaviour. As well, the drugs can worsen dementia and put elderly patients at risk of falls and injury due to impaired co-ordination and motor function. Higher tolerance, which means the user needs higher doses to achieve the same desired effect, is also a signal of dependence, along with a strong desire to keep taking the drugs.

In her book, Addiction by Prescription, Joan Gadsby chronicles her own 23-year addiction, which began in 1966 following the death of her four-year-old son. While she has been off the drugs for 10 years, she says she still lives with long-term and residual effects ranging from sensitivity to light to co-ordination problems, emotional flatness and some cognitive-related difficulties. She writes that the inappropriate prescribing of benzodiazepines can not only affect people's quality of life, but result in significant health care costs - not only for drugs and physician fees, but expenses related to emergency care, detoxification, treatment centres and rehabilitation.

Is overdose a risk?

Benzodiazepines are the most commonly implicated substances in drug overdoses, accidental or otherwise. Often, an overdose occurs as a result of taking benzodiazepines in combination with other drugs, such as alcohol, which some people with substance use problems do to heighten the drugs' impact. An article in American Family Physician notes that 80 per cent of benzodiazepine abuse occurs by those using other drugs, most commonly opioids. Canadian statistics also indicate that anywhere from 30 to 75 per cent of people who abuse alcohol also use benzodiazepines. And cocaine abusers may use them to ease the "crash" following a cocaine high. These interactions could be lethal.

How has benzodiazepine use been affected by the growth in antidepressants to treat anxiety and depression?

Benzodiazepines became widely used in the 1960s as a safer alternative to barbiturates. But the development of selective serotonin reuptake inhibitors (SSRIs), such as Paxil or Prozac, are now the first choice for depression and anxiety because they are not addictive, says Marsh. "It seems to me a lot of physicians prescribe benzodiazepines freely," Marsh says. "It takes a long time to change people's practice."

In their article in the American Family Physician, authors Lance Longo and Brian Johnson warn that caution must be exercised in prescribing the drugs. "Their greatest asset is also their greatest liability: drugs that work immediately tend to be addictive. Compared with benzodiazepines, antidepressants have a longer onset of action but are the best agents for long-term treatment of anxiety disorders."

Determining the growth of benzodiazepine use relative to that of SSRIs is difficult. But statistics compiled by health care information provider IMS Health indicate that SSRIs are overwhelmingly the drug of choice for depression, which typically includes symptoms of anxiety and insomnia. According to IMS Health, the number of times Canadians visited their doctors for depression increased 22 per cent between 1996 and 2000. Seventy-six per cent of visits ended with drug recommendations, with 65 per cent of those for SSRIs and eight per cent for benzodiazepines, primarily Ativan.

Andrea Gordon

Sources: David Marsh, Clinical Director, Addiction Medicine, CAMH; Gadsby, Joan. Addiction by Prescription: One Woman's Triumph and Fight for Change, Toronto: Key Porter Books, 2000; IMS Health Canada, ; Longo, Lance P. and Brian Johnson, "Addiction: Part 1. Benzodiazepines - Side Effects, Abuse Risk and Alternatives," American Family Physician, April 1, 2000.

Original Article

Centre for Addiction and Mental Health
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Fax: (416) 595-6892

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