ILLEGAL v. LEGAL BENZODIAZEPINE ADDICTION
Colin Downes-Grainger
January 28, 2009
"Because those affected don't have to steal to fund their habit, but instead get the drugs from the health service, their plight goes largely unnoticed by society. But the social cost of family breakdowns and individual impairment is immense." Liberal Democrat MEP Chris Davies, 2004
In November 2000 at a conference in Croydon, Professor Heather Ashton described the illicit benzodiazepine scene in these words:
"The most recent and possibly the most menacing worm crawling out of the woodwork is that of so-called recreational benzodiazepine abuse. There are probably over 100,000 illicit benzodiazepine abusers in the UK and the number is still rising. Up to 90% of opiate, cocaine and amphetamine users report that benzodiazepines increase the "high" obtained from opiates and alleviate the withdrawal effects when supplies are limited. Users of stimulants such as cocaine, amphetamines and even ecstasy use benzodiazepines as "downers" to overcome the effects of their "uppers". Benzodiazepines have already crept into the "rave" scene. Benzodiazepines are already used by alcoholics attending for detoxification and are often obtained illegally. They are taken partly to alleviate the anxiety associated with alcohol use, but also because the mixture of alcohol and benzodiazepines produces a desirable effect. Temazepam and lager is a popular combination.
There are also some who use benzodiazepines alone or as their main drug because they have discovered that high doses can give them a kick. Just about all the benzodiazepines can be used and delivered orally, by injection or snorted as snuff. Temazepam is the most popular benzodiazepine in the UK and intravenous users in Liverpool reported injecting over 3000 mgs in one go. They said that such injections not only provide a "buzz" and relaxation, but also give confidence to engage in criminal activities.
Some street users have moved on to taking large amounts of oral benzodiazepines in combination with injected opiates such as buprenorphine. This combination, temazepam and Temgesic (Tem-Tem) causes about 100 deaths in Glasgow alone. A popular youth craze is to ride on the buses all day in gangs "wobbling" on oral temazepam fortified by high strength lager and cannabis. Needless to say these practices are not without adverse effects. Complications of IV injection included abscesses and venous and arterial thrombosis. When their arms are affected, users may progress to injecting in the groin and this has resulted in gangrene."
This is a dire picture of self-induced harm and it is not surprising that government would wish to do something about it, but to apply the motivations involved in illicit use to patients is grossly inappropriate and wrong. To understand illegal addiction - its nature and its problems gives no understanding of addiction produced by prescriptions from doctors. Campaigners for iatrogenic addicts are tragically caught between the needs and misunderstandings of media, between the raison d'κtre of illegal drug workers, groups and charities, and the long-standing indifference of the Department of Health.
On 14 December 2006, Rosie Winterton, Health minister wrote to Michael Meacher MP:
"As is the case for those people who misuse drugs, such as heroin and cocaine, we would expect those who misuse benzodiazepines to have access to a range of services both in the primary and secondary care settings to meet their needs.
Your constituent may be aware that drug treatment services, which expanded rapidly in the last few years, have been developed in a way that allows them to meet the needs of the drug misuser, irrespective of their addiction, rather than by developing drug specific services. Figures on numbers accessing and being retained in these services are all positive, which indicates this type of approach does meet the needs of individual drug misusers.
In terms of benzodiazepines, you will be aware that to minimise the risk of overdose and other negative effects of abuse of these drugs, we have changed the general medical service (GMS) regulations to allow for instalment dispensing of these drugs."
Although a DoH spokesperson subsequently back-pedalled from this statement, somebody in the department the adviser behind the letter, obviously believes that patients are drug misusers cut from the same cloth as those who buy the drugs on the street. Rather than control the cause of prescribed addiction doctors, the department introduced a scheme for doctors to dole out prescriptions to patients they had addicted.
These excerpts from several patients' stories illustrate the complete difference in motivation between the two groups of addicts prescribed and illegal. How anyone can believe and make the assertion that patients willingly addicted themselves is impossible to understand.
"I have been on this medication for 34 years, yes 34 years, and all because I had a small concern in 1967. All doctors told me was to keep taking the meds. One year ago I started to find out that I didn't need it. BUT to get off it is a serious job, people need help and advice. I nearly died of going into convulsions as I didn't know enough about how to withdraw. I'm still in a very serious condition called de-realization, the doctor said it was like stopping smoking! I nearly killed myself."
"My doctor prescribed Librium continuously for 10 years in the 7080s after a minor bout of anxiety. My memory is permanently impaired over that period."
"I have been taking Nitrazepam for 20 years, I can't stop taking them. When I was given them by a hospital doctor I was told that they were to relax me so that I could sleep. I was not told anything about them being addictive. Obviously I have found out that they are highly addictive. If I do not take them my whole body shakes to such an extent that I cannot hold a cup of tea in my hand. I also get terrifying dreams, there is much more that I can tell you about them."
"I believe I am one of the longest addicts of Lorazepam, I started taking them in 1974 following a car accident and finished taking them in 2000 (26 years). I was 18 when I was first prescribed them and the effect upon my life has been devastating, like others I thought I was going out of my mind, a fact my doctor was only too willing to agree with...I am forty five and I can't remember what it was like when I was 18, I can't remember a time when my life was not governed by fear. I may function in society, but that does not mean I can lead a normal life. However I find that the medical profession believes that now I no longer take these drugs that I am back to full fitness...I was offered no support from anywhere and yet if I was a Heroin addict, I would have had masses of help and support."
"I started off on Valium in 1973 when I was 18." he says. "I had gone to the GP because I felt a bit shy and introverted. I was not a very outgoing fellow and there was some personal stuff in my childhood. I had anxiety, tension and stress. The doctor gave me Valium. I took it and felt that it was great. I felt very attached to it." So attached, that it was to dominate the next 14 years of his life. "For all that time, I was living in a haze. I lost my job and did not care. Once I had it I could float around. I stopped for a very short time and felt that the world was a frightening place...I did not realise that this was worse than a heroin addiction. It's very secretive as well. It's like putting on a mask. Behind it all you are a shell, dying inside."
"There are people out there...who are hooked, unknowingly, unwillingly, and they feel that society has 'chucked them overboard'. They feel they no longer belong anywhere."
Drug company experimentation in profit generation in the 1960s and 70s drew in huge numbers of people who were not mentally ill and who had no organic disease. Subsequently many of them became very ill, many losing homes, families, jobs and future - things which cannot be given back and remain unacknowledged to this day. No-one in the political or medical establishment has ever demonstrated any degree of passion regarding this assault on human rights and no-one it seems feels any sense of guilt. These days the latest version of the 'let's avoid any understanding of what has happened or do anything about it show' the purchase of drugs on the internet is emphasised. People do buy drugs on the internet but that is not the reason for the 1 million plus iatrogenic tranquilliser addicts in the UK. Buying drugs on the internet is a recent phenomenon and is not relevant to the historical benzodiazepine scandal.
Neither is the very latest attempt to lay responsibility at the door of patients - the wrong-headed but comfortable belief that prescribed drug victims are misusers just like illegal users.
In June 2008 a spokesman for the doctors' trade union the BMA said on the BBC Watch Politics Show West:
"The problem is people want to go on and on and therein lies the problem."
"I think the government should come out so that the public at large know it's not their right [...to ask for and become addicted to benzodiazepines]. It's not in their interests. We come back to smoking, alcohol and various other things which doctors speak out against."
So the whole problem of benzodiazepine addiction was emphatically NOT created by doctors, it was due to the fact that the government has failed to educate the public out of their ignorant desires for tranquillisers, that a foolish element purchase drugs from the internet, and doctors have been helpless, confronted as they are by waves of patients with addictive personalities - the equivalent of alcoholics. Sometimes the degree of ignorance within medicine is truly amazing. People want to go on and on? Of course they do, they have become addicted!
The passing on of prescription drugs illegally is not the cause of the 1 to 1.5 million existing iatrogenic addicts in the UK, though it does happen. We are talking about largely but not exclusively 30-70+ year old people who relied entirely on doctors and government drug regulators, people who did not seek addiction and who never bought drugs on the internet which did not exist when most of them were medically addicted without warnings.
Pronouncements on iatrogenic addiction seem these days to be coming from people concerned with illegal drug use (inside and outside government), hence the inappropriate belief that there is no difference between the illicit population and the prescribed population. These views are finding their way into the media. Steeped as they are in the culture and use of illegal drugs, groups such as DrugScope who provide the secretariat for the All Party Parliamentary Drugs Misuse Group (APPDMG), showed definitively in their contribution to that group's January 2009 report that they have no understanding and no expertise in the area of prescribed addiction.
On 10 February 2008, The Observer printed a report on the findings of the All Party Parliamentary Group on Drug Misuse under the headline "GPs have got Britain 'hooked on painkillers'".
The report highlighted key facts, none of which addicted patients would disagree with:
Some doctors (and the number is worryingly unknown) are 'mis-prescribing' drugs such as painkillers, sleeping tablets and anti-anxiety pills 'leading to addiction and dependence'.
They are fuelling the growth of the number of citizens hooked on prescription drugs by giving them dangerously high doses of medicines that can prove highly addictive. Among these drugs are benzodiazepines and 'Z' drugs.
GPs ignore the advice from the Committee on Safety of Medicines and subsequent advice that patients should take benzodiazepine tranquillisers and hypnotics for no more than four weeks. They issue repeat prescriptions without even seeing patients in their surgery.
Home Office figures suggest the misuse of benzodiazepines has caused 17,000 deaths since their introduction in the Sixties.
"It was extremely concerning for the inquiry to receive so many testimonials of people still being negligently prescribed these drugs by their GP. The guidelines now in place recommend that benzodiazepines are not taken continuously for longer than four weeks, but there were many cases of GPs continuing to prescribe the drug for a lot longer - sometimes even allowing repeat prescriptions without having the patient in for a consultation."
"Some GPs are addicting people by giving them repeat prescriptions without checking to see how long they've been on the drugs in the first place. They are not stopping patients from getting any more of them after the set amount of time." All Party Parliamentary Group on Drug Misuse, February 2008.
These quotes from the APPDMG are supportive on the face of it but in view of the misconceptions in the January 2009 report, it seems that there may be a sub-text which is saying that doctors are failing in their duty to protect patients from themselves rather than doctors are failing to safeguard patients from the impact of involuntary addiction.
Mick Behan clearly pointed out the misunderstandings and errors in the subsequent APPG for Involuntary Tranquilliser Addiction Alternative Report on the Inquiry carried out by the All Party Parliamentary Drug Misuse Group:
Involuntary Tranquilliser Addiction
"The APPDMG report's definition of involuntary addiction is wrong as far as Tranquilliser addiction is concerned:
'The term involuntary addiction has been coined by some experts and patient groups to describe the type of drug dependence which has occurred through medication taken initially to treat a medical condition (and often under medical supervision) but to which the patient has subsequently become dependent.'
Firstly, for involuntary Tranquilliser addiction in the U.K., addiction is always under the supervision of the doctors who prescribe the medication. Secondly, doctors do not always give Tranquillisers to treat a medical condition. They also give them for a variety of other inappropriate reasons, e.g. bereavement; toothache; divorce. Thirdly, and most importantly, the Tranquilliser is given without the patient's informed consent as the dangers associated with the Tranquilliser have not been explained by the prescriber to the patient.
The report claims to be 'setting the context' and 'defining the problem' but fails to do either.
Defining the problem properly and accurately is essential if correct solutions are ever to be introduced by government.
The report does not mention the bizarre, intense and painful side effects that people experience whilst on Tranquillisers. Over 200 have been listed, and addicts often suffer 30 or 40 of them.
The report does not mention the Tranquilliser post-withdrawal syndrome in which painful symptoms persist for many years and are sometimes permanent. Side-effects and post-withdrawal syndrome are common amongst Tranquilliser addicts and extremely debilitating to the extent that ex-addicts are unable to work. Both Barry Haslam and Michael Behan gave verbal evidence to the enquiry on this point and many others have produced written evidence e.g. Colin Downes-Grainger. The two Tranquilliser case studies paraphrased by the report contain no mention of side-effects or post-withdrawal; the Department of Health also refuses to acknowledge post withdrawal or permanent damage.
The report makes no mention of Tranquilliser deaths. Professor Ashton has calculated, from Home Office yearly figures that 17,000 Tranquilliser deaths have occurred during the last 50 years, including road traffic accidents and overdoses. The Department of Health have refused to acknowledge this figure.
The report acknowledges the withdrawal syndrome but does not mention the prolonged withdrawal period. The addiction created by Tranquillisers is so strong that safe and successful withdrawal can take from six months to two years. Again the Department of Health does not acknowledge safe withdrawal time frames.
In fact there is no real difference (except for the addiction associated with tranquillisers) between the Vioxx patient who going to a doctor with pain symptoms is told that a new drug on the market shows good promise only to be killed or injured later by its side-effects and the patient who going to a doctor with stress, life-related worries, sports injuries and many other conditions is told that a benzodiazepine offers a good possibility of improvement, only to become addicted and often suffer severe health, social and economic consequences as a result. Neither group of patients was drug-seeking - each group trusted what their doctor told them. They did not acquire drugs on the street or the internet - they were prescribed licensed drugs by the NHS.
Cannabis reclassification (reclassified to B on 26.10.09) is not so much a case of increasing scientific evidence of harm but more a case of pressure from a myriad of groups, individuals and the tabloid press. Iatrogenic benzodiazepine victims have no such support and in any case medicine is somehow largely exempt from the questions which surround illegal drugs, even if as is the case with benzodiazepines, the drugs are the same. Somehow the writing of a prescription is deemed to turn a dangerous drug on the street into a safe drug in the surgery. And it should be remembered that hundreds of thousands of patients have been taking these dangerous drugs, every day for decades and often in far larger quantities. But the majority, like doctors believe that they are taking medicine and there are no serious side-effects.
Basic questions can be asked about benzodiazepines in order to discover whether patients are in fact the same group of people as illegal users.
Are benzodiazepines addictive?
There is no doubt they are addictive and in this country apart from Professor David Nutt, chair of the Home Office drugs advisory body the ACMD and his disciples, all expert opinion appears to accept that they can addict quickly and that presumably is why the 1988 four week Guidelines are still in place.
"There's no scientific evidence to indicate that one particular tranquilliser is worse than another ... To act just against one would he wrong because there is a problem with the whole group." - Brass Tacks, BBC2, October 20, 1987. Professor Sir Michael Rawlins - Chair of CSM Subcommittee on Safety, Efficacy and Adverse Reactions. Vice Chair and then Chair of the CSM. Chair Advisory Council on the Misuse of Drugs. Chair National Institute of Health and Clinical Excellence (NICE)
"...And then the alarm bells started to ring, quietly at first and then louder and louder. [...] Doctors were not well equipped to deal with this. This was something new in their experience. They don't like dealing with chronic drug use or addiction anyway and here they were being confronted by hundreds in their practices - who they had put on the tranquillisers - and were now coming for help to come off. And I think they were bewildered by the numbers and severity of some of the reactions. [...] The main characteristic of these dependent people was that when they tried to stop they didn't just get their old symptoms back, they didn't just get their old symptoms back in an exaggerated form; they developed new symptoms which they had not experienced before." Professor Malcolm H Lader, Professor of Clinical Psychopharmacology, Institute of Psychiatry, University of London. In Pills We Trust, Discovery Channel, December 4-18, 2002.
"There's still a significant continuing problem with benzodiazepines in this country. We would have liked if it was solved 20 years ago, but it still exists. We continue to work as a College with prescribing groups around the country to try and continue to raise awareness of this issue and reduce the prescribing of these drugs to appropriate use, but it is a very long struggle. ... I think it should be a significant priority for this country. It's potentially a million people who are on drugs which only maybe is a tiny percentage of them need to be on, and that is not good for this country. It's also a waste of resource. We are ploughing money into these drugs and into support services for patients for a situation that we may have created ourselves." Dr Jim Kennedy, Royal College of General Practitioners, The Tranquilliser Trap, BBC Panorama, May 13, 2001.
"It is difficult to defend that we have such a huge problem of benzodiazepine prescription and long-term use and therefore dependence. Professor Louis Appleby, National Director for Mental Health, The Tranquilliser Trap, BBC Panorama, May 13, 2001.
How addictive are they?
The answer to that is very addictive indeed and it is that fact which is patently not understood in any statements seeking to justify long-term prescribing which say that patients 'like' benzodiazepines and benzodiazepines are 'well-received' by patients (this latter view was repeated in the January 2009 APPDMG report).
"[Benzodiazepines] have been prescribed for sports injuries, muscle spasms, premenstrual tension, exam nerves, depression, general malaise and much else. Because they make some people feel good at first...these prescriptions tend to be continued long-term." Bristol and District Tranquilliser Project AGM, October 2005
Patients are in fact trapped between the initial euphoria produced by the drugs and their highly addictive nature. Euphoria (an effect denied by Roche for decades), false gregariousness and unnatural confidence - deliberately induced by the administrators of benzodiazepines in date rape, are part of the picture of how benzodiazepine addicts, created by doctors, find that their lives have been made limited and harmed by over-prescription. Many former iatrogenic addicts find that as a consequence of the false picture of life that benzodiazepines produced in them, they are afterwards faced with financial burdens and a variety of other social and economic consequences, which were the direct result of inappropriate drug-induced decision making.
"When they first came out they were seen as some sort of panacea or universal remedy. But with constant use it was found they turned people into zombies in the end." Dr Ian Telfer, Consultant Psychiatrist, West Pennine Health Authority, UK.
"It is more difficult to withdraw people from benzodiazepines than it is from heroin. It just seems that the dependency is so ingrained and the withdrawal symptoms you get are so intolerable that people have a great deal of problem coming off. The other aspect is that with heroin, usually the withdrawal is over within a week or so. With benzodiazepines, a proportion of patients go on to long term withdrawal and they have very unpleasant symptoms for month after month, and I get letters from people saying you can go on for two years or more. Some of the tranquilliser groups can document people who still have symptoms ten years after stopping." Professor Malcolm H Lader, Royal Maudesley Hospital, BBC Radio 4, Face The Facts, March 16, 1999.
"It has been estimated that one in three patients prescribed benzodiazepines in normal therapeutic doses for six weeks would experience withdrawal symptoms if treatment were withdrawn abruptly. Even with gradual withdrawal, patients would request further prescriptions. Thus, there is a considerable risk of dependence even in comparatively short-term use." M.A. Cormack, R.G. Owens, M.E. Dewey, The effect of minimal interventions by general practitioners on long-term benzodiazepines use, J Roy Coll Gen Practitioners, October 1989, 39, 408-411.
"Physical and psychological dependence on tranquillisers can happen in an alarmingly short space of time. You reach a stage where you can't cope without tranquillisers and are terrified of trying to stop taking them... Suffering withdrawal from tranquillisers is no joke, but it can be done. Those who have gone through it say that it must be harder than coming off heroin." - Dr Miriam Stoppard.
"We have much more difficulty getting people off Ativan than we do heroin, mainly because with heroin ... within a couple of weeks they're off and then the problem is staying off. But with Ativan it's much more prolonged and they take up a lot more time in terms of treatment than do heroin users." Jim Corcoran, Torbay Drug Addiction Team, Brass Tacks, BBC2, October 20, 1987.
"Not only do benzos create a physical addiction, the drugs can alter how the brain processes neurotransmitters that calm a person down." Dr Harris Stratyner vice chairman of the National Council on Alcoholism and Drug Dependence, August 2008.
Have doctors over 50 years consistently failed to tell patients that benzodiazepines were addictive?
The widespread usage of the benzodiazepines has inevitably led to thousands of people becoming dependent, perhaps 500,000 in the UK and twice that number in the USA where long-term use is less common. Patients who have become dependent and have either been unable to withdraw or have only done so with great symptomatic distress justifiably feel aggrieved against their doctors and the benzodiazepine manufacturers for not warning them about the risk. Lader M. History of Benzodiazepine Dependence. Journal of Substance Abuse Treatment 1991; 8:53-59.
The fact that there are today somewhere between one million and one and a half million prescribed tranquilliser addicts in the UK says a lot about this question. Dr Vernon Coleman described it like this:
"The biggest drug-addiction problem in the world doesn't involve heroin, cocaine or marijuana. In fact, it doesn't involve an illegal drug at all. The world's biggest drug-addiction problem is posed by a group of drugs, the benzodiazepines, which are widely prescribed by doctors and taken by countless millions of perfectly ordinary people around the world... Drug-addiction experts claim that getting people off the benzodiazepines is more difficult than getting addicts off heroin... For several years now pressure-groups have been fighting to help addicted individuals break free from their pharmacological chains. But the fight has been a forlorn one. As fast as one individual breaks free from one of the benzodiazepines another patient somewhere else becomes addicted. I believe that the main reason for this is that doctors are addicted to prescribing benzodiazepines just as much as patients are hooked on taking them. I don't think that the problem can ever be solved by gentle persuasion or by trying to wean patients off these drugs. I think that the only genuine long-term solution is to be aware of these drugs and to avoid them like the plague. The uses of the benzodiazepines are modest and relatively insignificant. We can do without them. I don't think that the benzodiazepine problem will be solved until patients around the world unite and make it clear that they are not prepared to accept prescriptions for these dangerous products." Life Without Tranquillisers, 1985.
Professor Nutt in a Newcastle lecture recently said that benzodiazepines can safely be prescribed long-term. He asserts that this is acceptable medical practice provided there is informed consent. Informed consent means that the patient is made aware of the consequences of treatment and gives assent to it. This is as far as benzodiazepines are concerned, is a case of the Emperor has no clothes. Not only do some doctors fail to consider the need for informed consent and others argue they have no time to do it but informed consent can only take place if the patient is made aware of all the possible consequences of the treatment. If doctors themselves are not aware of possible consequences because pharmaceutical companies have not told them, regulators have not told them and patient evidence is seen by both as hearsay, there can neither be valid clinical judgement nor informed consent.
It wasn't until 1988 that the drugs' agency the Committee on the Safety of Medicines (by issuing the advice on short-term prescribing) implicitly accepted how addictive and damaging benzodiazepines could be. There had been hundreds of millions of prescriptions issue by then and many of the addicts created then are still addicts today. They had received no warnings not least because warnings were seen as unnecessary. Many today still receive no warnings and much of the list of side-effects is not accepted. Patient leaflets do not mention addiction. Where is informed consent? Do doctors tell patients they may end up on a whole range of drugs due to the side-effects of the first benzodiazepine? They do not because inexplicably they seem unaware of the connection. Do doctors tell patients that though they may still give the appearance of free-willed people, their thoughts and actions may be steadily altered by the drug? They do not, being seemingly unaware of the action of benzodiazepines and their impact on thought and decision-making.
Do patients need help to withdraw?
Professor Heather Ashton who is a world-recognised expert on iatrogenic tranquilliser addiction has said:
"In primary care the waiting list for "counselling, advice and/or psychological therapy" is up to two years, by which time it is too late for the long-term patient to benefit from it, especially since the therapists are ignorant about the effects of benzodiazepines and withdrawal. Secondary health care services are usually not available for prescribed benzodiazepine users; they are regularly turned down because they are not also using opiates or other "hard drugs". Mental health centres and specialised drug services are in any case inappropriate, and often disastrous, for prescribed benzodiazepine users who are a quite different population from illicit drug users. The "instalment dispensing facility" is a gross insult to prescribed users and reflects the hard-headed ignorance of the Department of Health who seem to be concerned only with illicit drug abusers..."
Professor Malcolm Lader made these comments over the years:
"We found that patients who had been put on Valium were getting withdrawal symptoms when it was stopped. Some of these were similar to alcohol withdrawal. They included mild delirium tremens, sleeplessness, jumpiness, everything seeming loud and bright - some people said they felt as though they were going mad." Professor Malcolm Lader, Sunday Express Magazine, 1999.
"The risks of the benzodiazepines are well-documented and comprise psychological and physical effects. Among the former are subjective sedation, paradoxical release of anxiety and/or hostility, psychomotor impairment, memory disruption, and risks of accidents." Professor Malcolm H Lader. Limitations on the use of benzodiazepines in anxiety and insomnia: are they justified? Eur Neuropsychopharmacol 1999 Dec;9 Suppl 6:S399-405.
"The withdrawal syndrome has been carefully described and comprises physical and psychological features. In particular, perceptual symptoms such as photophobia, hyperacusis and feelings of unsteadiness may predominate. The syndrome may come on during dosage reduction but generally starts 2-10 days after cessation of the benzodiazepine, depending on its elimination half-life." Professor Malcolm H Lader. Anxiolytic drugs: dependence, addiction and abuse, Eur Neuropsychopharmacol 1994 Jun; 4(2):85-91.
"In a few unfortunate patients symptoms may persist and include feelings of unsteadiness, neck tension, a "bursting" head, perceptual distortions and muscle spasm. The strange nature of these symptoms distresses the patient, perplexes the doctor and may lead to the patient being regarded as a hopeless neurotic or even a malingerer. We believe this to be a genuine part of a protracted withdrawal syndrome as the symptoms are identical with those seen earlier in withdrawal." (p828) Lader M. Benzodiazepine Problems. British Journal of Addiction 1991; 86:823-828.
"My estimate is that there's something between a quarter and half a million people in this country, at this moment, who would have problems trying to stop their tranquillisers. They would need help to do so, and there's been a sense that they're difficult to treat, difficult to deal with and a lot of these patients are just kept on their medication indefinitely. No real attempt is made to help them come off ... The Government should tackle this problem face on. There are thousands of people out there who are not receiving treatment, hundreds of GPs who don't know really how to treat these patients. There are self-help groups who are crying out for funding just to keep going at a very low level. I think the Government should now acknowledge the problem and set funds aside, because if the Government doesn't do that, these people will go to their graves with their tranquilliser bottles beside them." BBC Radio 4, Face The Facts, 1991.
This is what the British National Formulary has to say on the subject of withdrawal in January 2009:
Withdrawal of a benzodiazepine should be gradual because abrupt withdrawal may produce confusion, toxic psychosis, convulsions, or a condition resembling delirium tremens. Abrupt withdrawal of a barbiturate (section 4.1.3) is even more likely to have serious effects.
The benzodiazepine withdrawal syndrome may develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one. It is characterised by insomnia, anxiety, loss of appetite and of body-weight, tremor, perspiration, tinnitus, and perceptual disturbances. Some symptoms may be similar to the original complaint and encourage further prescribing; some symptoms may continue for weeks or months after stopping benzodiazepines. Time needed for withdrawal can vary from about 4 weeks to a year or more Counselling may help; beta-blockers should only be tried if other measures fail; antidepressants should be used only where depression or panic disorder co-exist or emerge; avoid antipsychotics (which may aggravate withdrawal symptoms).
The UK parliament Health Select Committee in March 2005 pointed out that not a single benzodiazepine withdrawal clinic existed - Fourth Report
It is well known and often pointed out that doctors generally have neither the time or inclination to deal with what they see as difficult patients.
In February 1994, David Blunkett, opposition Labour MP, who became Home Secretary in the Blair government and who then described the benzodiazepine situation as a 'national scandal', said:
"Dawn Primarolo and myself have been taking up cases and have advised on how best the groups involved might organise a parliamentary lobby and keep attention on these issues. We have also tried to assist through both Parliamentary Questions and raising the matter on the floor of the House, in pushing the Government to accept its own responsibilities and to take action now to ensure that it does not happen again."
Dawn Primarolo is a health minister in 2008. Here are two of her answers to questions asked in parliament on the subject of prescribed benzodiazepine addiction showing how her deep concern has not continued once in office:
3 March 2008
Jim Dobbin: To ask the Secretary of State for Health how many of those previously addicted to prescribed tranquillisers have suffered long-term impairment as a consequence of their addiction.Dawn Primarolo: The Department does not currently collect information that enables us to provide an estimate of the number of patients who are addicted to prescription drugs.
11 March 2008
Jim Dobbin: To ask the Secretary of State for Health
How many and what proportion of babies born with a tranquilliser addiction have a permanent impairment as a consequence of their addiction; [190209]
How many babies were born with an addiction to tranquillisers in each year from 1999 to 2006; [190273]
What treatment the NHS provides to babies born with an addiction to tranquillisers. [190275]
Dawn Primarolo: Information is not collected centrally about the number of patients with a prescription drug addiction, nor is information available either about the number of individuals with a permanent impairment as a consequence of their addiction.
Prescription figures over the years. All figures are in Millions.
Benzodiazepines 19802006 in UK:
1980 29.1
1981 29.5
1982 29.7
1983 28.7
1984 28.0
1985 25.7
1986 25.3
1987 25.5
1988 23.2
1989 22.1
1992 15.8
1995 14.027
2002 12.7
2005 11.252
2006 10.769
Latest figures from NHS Prescription Services
ENGLAND ONLY DIAZEPAM ONLY
2007 4,553,584
2008 January September 3,510,830
If the figures for temazepam, nitrazepam, lorazepam and others plus the Z drugs are added on, it certainly seems clear that prescriptions for addiction are not on the decrease as the DoH and the APPDMG assert. It is worth noting that in Scotland prescriptions of diazepam have increased by 60% in the past decade, from just in excess of half a million per year in 1996 to more than 800,000 in 2007.
"The side-effects of zolpidem, zopiclone, zaleplon and eszopiclone are the same as those of benzodiazepines, as recognised by the National Institute of Clinical Excellence (NICE)." Professor C.H. Ashton
Conclusion:
Prescribed tranquilliser addicts have few advocates and some former advocates have inexplicably fallen by the wayside, though Professor C.H. Ashton has been steadfast in her criticisms of the way the drugs have been prescribed and is clear on the damage they do to patients.
Belief systems are part of people's lives and they find it difficult if not impossible to change those beliefs. To be told that medicine has needlessly and avoidably destroyed, uncounted numbers of healthy people over fifty years through the unfettered prescribing of tranquilliser drugs is not something most people want to think about. But if benzodiazepines on the street are to be regarded as illegal - presumably because they do harm, then in logic it follows that they do equal if not greater harm when prescribed to patients (often in larger quantities than on the street) for inordinate lengths of time. In defence of the contradiction, the myth is always maintained that if a tranquilliser or hypnotic is prescribed as a medicine then it must have been safely done for positive benefit and it must have been prescribed out of necessity. All the benzodiazepine drugs are available from a private or NHS doctor. They all work in the same way. They are a controlled substance when used illegally, but doctors who use them legally but without the knowledge of their social, economic and health effects are in practice uncontrolled.
The Department of Health and those involved in the illegal drugs world seemingly find it impossible to transfer their knowledge of the workings of addiction from the illegal scene into medicine. They admit that tranquillisers are addictive and then put forward the view that patients, who over the years had no warnings about the potential for dependence, are abusing prescriptions. At the same time while hundreds of millions of pounds are spent on illegal drug addiction, iatrogenic tranquilliser addiction receives little acknowledgement and even less help. Local Primary Care Trusts, the National Treatment Agency and drug action teams do not spend their drug treatment budget on involuntary tranquilliser addicts, it being argued that there is treatment available through GPs and in psychiatric hospitals.
If patient leaflets said clearly tranquillisers were addictive and should be taken with extreme caution and patients ignored that information, then they could be reasonably and logically blamed for their condition. But the leaflets don't contain that warning. Addiction is easily understood by government and the medical profession when the subject is illegal ingestion but medical addiction is a story of decades of rejection and inaction. That people have sought addiction and destroyed themselves in defiance of doctors is a completely indefensible message.
The benzodiazepine scandal has been treated as a game by the DoH in particular. It is a game in which those who know nothing of benzodiazepines reply on behalf of those who do. Those who do know about benzodiazepines stay well away from any involvement in the real situation. The DoH admits that tranquillisers are addictive but neither confirms nor denies details of what that addiction means. The same formulaic response is sent whatever the points being made. The DoH believes it cannot directly control the prescribing habits of doctors but insists that the situation is controlled and employs a variety of ultimately meaningless assertions to show that things are improving. In the background is always the message that science has rigorously investigated the drugs, though the truth is that science has mainly concentrated on whether the drugs are addictive, how addictive, and how long the addiction takes to set in. Patient reports of a variety of injuries are not researched and the socio-economic effects of the addiction remain completely unrecognised as far as prescribed addiction is concerned. Detailed collection of data on the use of the drugs and their impact on life is not collected. It is a 50 year game of trump the patient and use a stacked deck.
Colin Downes-Grainger
28 January 2009
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