Benzodiazepines and Withdrawal

The long search for substances that would relieve anxiety, tension, and insomnia has resulted in a progression from alcohol, to opiates, bromides,barbiturates, now Benzo’s short for benzodiazepines. Benzo’s are used for anxiety, agitation, and insomnia. They share a common structure, mechanism of action and differ in milligram potency, duration of action, type and frequency of side effects. A few examples of benzodiazepine medications are Clonazepam (Klonopin),Diazepam (Valium), Flurazepam (Dalmane), Lorazepam (Ativan), Temazepam (Restoril), Alprazolam (Xanax), widely seen in the KCMH Medications list.

Benzo’s are considered relatively safe when used judiciously and alone. Failure to monitor closely may endanger the patient and lead to other consequences, potential malpractice suits and loss of license. It is imperative for clinicians to be knowledgeable about basic pharmacology, clinical indications, dosage and duration of usage, as they lead to overuse, misuse, and abuse. There appears to be a distinction between benzo-abusers and therapeutic-dose users. Almost-exclusively, the former are reported to also abuse other prescription drugs, street drugs, or alcohol.

Ideally, Benzo treatment of anxiety, GAD or related disorders should be with the lowest possible dose for the shortest possible time, on a flexible dosing and scheduling basis. Recent studies show long-term users account for the bulk of benzo’s sold in the U.S. and worldwide. About 80% of benzo’s consumed is by individuals using daily over a 4 month or longer duration. The number of users increased in recent years though efficacy of long-term use has not been established.

Unfortunately, although needed, effective, and reasonably safe, long-term Benzo therapy for anxiety has problems associated specifically in the elderly as follows, daytime drowsiness, cognitive impairment, confusion, psychomotor impairments, falls, paradoxical reactions-like depression, intoxication, on therapeutic dosage, amnesia, breathing problems, abuse and dependence, break through withdrawals. To lessen these, U.S. researchers recommend use to 4 months or fewer. British guidelines are more stringent as use is not recommended past 2-4 weeks. Benzos are rarely fatal in overdose alone but in combination can be; especially with alcohol, or other narcotics; potentially causing coma and respiratory arrest. Benzo’s cause impairment in coordination and cognition, even single doses in normal subjects. Long-term users perform poorly on tasks involving visuospatial ability, sustained attention, affecting everyday activities; interestingly subjects are not aware of these reductions in ability. There are several phenomena associated with benzo’s.

BENZO WITHDRAWAL SYNDROME. Benzo’s are potential to produce dependency and thus withdrawal symptom, the longer the duration, the greater the reaction, specifically if stopped abruptly. Potential adverse reactions include gastrointestinal symptoms, shakes and tremors, lethargy, dizziness, headaches, increased sensitivity to sound, smell, and light. Also, insomnia, irritability, anxiety, tinnitus (ringing in ears) and depersonalization may be experienced. (I have encountered each and every symptom in my practice). For some individuals, abrupt discontinuation may evoke more distressing symptoms as follows: severe prolonged depression, hallucinations, protracted tinnitus, bizarre involuntary muscle movements, catatonia, panic attacks, and agoraphobia. I encounter individuals with these issues often in practice. Withdrawal can be very painful and protracted lasting 6 months to 1 year. Rebound anxiety can be so severe patients often resist weaning. This state of withdrawal is unlikely in less than 4 months of use.

BENZO DISCONTINUATION SYNDROME occurs in abrupt termination and resembles symptoms for which the benzos were prescribed, except they are more pronounced and emerge soon after termination. Symptoms are short-lived, a few days to a couple of weeks. To avoid this syndrome, user normally, restarts medications leading to long-term use and dependency (like nicotine). Most symptoms appear like withdrawal; however, in some cases seizures and psychosis can be life threatening. Seizures are virtually unknown when discontinuation is gradual.

PROTRACTED BENZO WITHDRAWAL SYNDROME is experienced by 10-15% of chronic benzodiazepine users. This syndrome may last from months to years and reflects the slow reversal of receptor changes in the brain induced by benzo’s. Patients generally report wavelike recurrences with periods of normalcy. Recovery may never be complete. Management is a therapeutic challenge and may require the assistance of other psychotropics including an antagonist.

BENZO POST WITHDRAWAL SYNDROME continues for years after discontinuation of use. Reinstatement of benzo therapy does not help patients. Characteristic symptoms are panic attacks and agoraphobia. Cognitive therapy is considered the treatment of choice because there is a risk of dependency in therapeutic dose range.

Listening to prescribers and advocates, an editorial in JAMA on benzodiazepine dependence and withdrawal has concluded that physicians doing the following can reduce fear about benzo’s and educate clients by publicizing the truth about these drugs.

• minimize risk of dependence by,

• restricting prescriptions to valid clinical indications

• prescribing lowest doses possible; shortest possible duration

• limit refills

• carefully monitor clients, specifically those with alcohol and drug abuse

• avoid risk of withdrawal symptoms by a gradual weaning in patients suspected of long-tern heavy benzo use.

Finally, be aware of our “clock-watching clients.” Clients on short-acting benzo’s like Xanax go through inter-dose anxiety and perform a “clock watching ritual” between dosing.

By Shreedevi Keni, M.D.