What Are Benzodiazepines?
Benzodiazepines, a class of psychoactive drugs in the family of substances commonly known as minor tranquilizers, enhance the effect upon the central nervous system of a chemical known as gamma-aminobutyric acid (GABA).
Amongst the most frequently prescribed medications on Earth, benzodiazepines are used to treat a broad range of disorders thanks to their sedative, hypnotic and muscle relaxant properties. However, they are also amongst the most commonly abused drugs thanks to their superficially pleasurable effects and the relative ease with which they may be obtained. These medicaments have caused widespread damage as a result of their habit-forming qualities and their associated side effects. Benzodiazepine addiction is a significant problem in the UK, as elsewhere.
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Benzodiazepine Addiction Explained
Benzodiazepines have been proven to be effective in the treatment of a number of disorders, and their short-term consumption has been instrumental in improving countless lives around the world. However, longer-term usage can be extremely problematic thanks to their habit-forming qualities.
There is a significant psychological component to benzodiazepine addiction, with the pleasurable effects created by the drugs often driving repeated use even amongst individuals with no medical need for benzodiazepines, and such repeated consumption impacting the reward centres in the brain in a way which drives the desire for further use and the onset of psychological withdrawal symptoms if the affected individual ceases to take benzodiazepines.
However, benzodiazepines also create a very strong physical dependence in individuals consuming them over a period of time.
Patients taking benzodiazepines can develop tolerance – the state of becoming accustomed to certain levels of benzos in the system, consequently requiring more and more of the drugs to achieve the same effects – and dependence after as little as two weeks’ consumption, and the withdrawal symptoms associated with benzos are amongst the most distressing and dangerous of any such symptoms, with the danger of death if withdrawal is not correctly managed.
What are Benzodiazepines Used For?
Benzodiazepines were discovered in 1955, and first made available to the public in 1960, with perhaps the best-known benzodiazepine, diazepam (first marketed under the brand name Valium) hitting the market three years later. Their sedative, tranquilising effects immediately suggested their use in the treatment of a range of physical and psychological disorders. They have been most commonly prescribed to treat anxiety disorders (including panic disorder and generalised anxiety disorder), insomnia, agitation, seizures, muscle spasms, and alcohol withdrawal, as well as being used as a premedication for medical or dental procedures.
Benzodiazepines may also be used as sedation for patients receiving mechanical ventilation or those in extreme distress, to manage shortness of breath in patients with advanced diseases, to treat individuals suffering from acute panic following hallucinogen intoxication, in the treatment of many forms of parasomnia, restless legs syndrome and rapid eye movement behaviour disorder, as a treatment option in complex cases of obsessive compulsive disorder (OCD), to reduce the adverse effects of electroconvulsive therapy, and as a first-line treatment for delirium caused by sedative hypnotic withdrawal. Their use in many other situations has been and continues to be explored.
List of Popular Benzodiazepines
As benzodiazepines are some of the most commonly prescribed and most widely available drugs in the world, and because several of the most frequently encountered benzos now have generic status, they are found under a huge range of trade names, with the same substances often available under many different names depending on location.
Some of the most popular benzodiazepine varieties and brands include:
It is vital always to ask the official chemical name for any branded benzodiazepine you may be prescribed in order to know the identity of the substance you are taking.
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Factors in Benzodiazepine Addiction
There is no one single “roadmap” applicable to every case and every individual who develops a benzodiazepine addiction. The precise causes of addiction are not yet fully understood, though it is known that both genetic and environmental factors may play a role; one of the few things that can be said with certainty is that whilst taking benzodiazepines in the short term is unlikely to lead to any addiction-related challenges, the longer an individual takes them the greater the chance that that individual will go on to develop both a psychological addiction and physical dependence to benzodiazepines.
Those individuals most likely to develop substance use disorders and addictions are those with family histories of addiction, those associating with peer groups where substance abuse is commonplace, those who are going through or have experienced significant trauma including abuse, illness and bereavement, people experiencing difficulties in life such as divorce, unemployment, academic failure, people with pre-existing mental health conditions including depression and individuals with a low quality of life generally. Not everyone with such factors will go on to develop an addiction.
Risk factors for benzodiazepine addiction
Along with the general factors given above, a number of risk factors have been identified as being physically associated with benzodiazepine addiction:
- Long-term use beyond four weeks: while there is no hard and fast time limit beyond which benzodiazepine addiction is a certainty, and while it is important to recognise that some individuals may take benzodiazepines over a long period without developing either psychological addiction or physical dependence, it is recognised that taking them regularly for more than four weeks is very likely to result in the development of tolerance and dependence, and quite likely to cause a psychological addiction. It is also important to note that such results can manifest significantly more quickly than four weeks, with some individual patients developing dependence within a fortnight.
- Use of high doses: the greater the quantities of benzodiazepines consumed, the more likely it is that dependence will result. Taking benzodiazepines in strict accordance with the instructions of your prescribing doctor should mitigate against the consumption of excessively high doses; however, for individuals taking benzos recreationally, without such instructions at hand, the risk of taking too much for too long is significant.
- Use of potent short-acting benzodiazepines: not all benzodiazepines have the same potency or duration of effect. More potent, shorter-lived benzodiazepines are significantly more likely to lead to tolerance, dependence and addiction if taken over a longer period than recommended – partly because their effects are more pronounced, and often considerable more pleasurable, therefore driving the desire to repeat consumption, and partly because they wear off more quickly, often prompting the user to take more to keep up the desired effects.
- Proclivity for drug abuse: individuals who have already demonstrated a tendency to engage in substance abuse, and/or who have been identified as having dependent personalities, are significantly more likely than the average to develop benzodiazepine addictions if they consume benzodiazepines regularly for more than a very short period. Again, the precise psychological mechanisms which drive substance abuse are not completely understood, but individuals who have already experienced substance abuse are more likely than others to consume benzodiazepines recreationally and to take them for longer and in higher doses than prescribed.
Benzodiazepines work in a similar way to various other sedative substances which act upon the GABA receptor in the brain, and because of this their consumption can lead to a phenomenon known as cross tolerance, whereby the consumption of one drug will alleviate the withdrawal effects of another, similar substance. It is for this reason that benzos are often used to treat very severe alcohol withdrawal symptoms including delirium tremens.
However, cross tolerance also means that an individual who has developed tolerance for one specific drug will also be very likely to have a tolerance to other similarly acting substances. Cross tolerance has been identified between benzodiazepines, alcohol, the nonbenzodiazepine class of drugs, barbiturates and corticosteroids.
The Stages of Benzodiazepine Addiction
Whilst bearing in mind that every case of addiction is unique, it is possible to suggest a series of stages by which benzodiazepine addiction can develop.
the first contact with benzodiazepines can create notably enjoyable effects – partly because of the possible beginnings of the alleviation of conditions for which benzos may be prescribed, but even in cases of purely recreational use, the drugs can have pleasurable effects. The user may quickly feel the desire to take more benzodiazepines to replicate and/or sustain such effects.
whether or not in accordance with a prescription, benzodiazepine consumption may become regular very quickly, with initial use leading to daily consumption. At this point, benzodiazepines are already becoming an aspect of daily life, and it is therefore vital to respect the instructions of any prescribing physician and to cease taking benzodiazepines at the end of the course – or, if consuming benzodiazepines recreationally, to avoid doing so for more than a few days in succession.
a psychological addiction to benzodiazepines can begin to develop even before physical dependence manifests, but once the latter is present it is almost invariably accompanied by the former. The addicted individual will need to take benzodiazepines regularly in order to avoid withdrawal symptoms – which by this point may be quite distressing and even dangerous – and their drug use will have become the single dominant factor in their daily life, potentially having extremely deleterious effects on their personal and professional life. Ceasing to take benzodiazepines at this point can lead to perilous side-effects and professional help should be sought by any benzodiazepine addict wishing to stop abusing the drugs.
Development of tolerance and dependence:
if such warnings are not heeded, tolerance to benzodiazepines can develop relatively quickly, with the user feeling the need to take higher doses to achieve the same effects as previously experienced. As tolerance sets in, the user’s system will become dependent upon benzodiazepines: they will need to take benzos in order to feel “normal” and to stave off unpleasant withdrawal symptoms. Obtaining and consuming benzodiazepines will take on a higher and higher priority in the user’s daily life and may start to impact upon their activities and relationships with others.
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Neurochemistry of Benzodiazepine Addiction
Benzodiazepine consumption lowers the levels in the brain of certain neurotransmitters – specifically norepinephrine (noradrenaline), serotonin, acetylcholine and dopamine – regulating mood, muscle tone and coordination, emotional response and other activities. Over time, once tolerance and dependence develop, the withdrawal of benzodiazepines from the system can result in the abnormal behaviour of certain of the systems associated with these neurotransmitters, causing physical and psychological withdrawal symptoms which persists until the nervous system is able to overcome the physical dependence which is manifested (via detoxification and withdrawal).
Norepinephrine (more commonly known in the UK as noradrenaline) is a hormone and neurotransmitter most prominently identified with the mobilisation of the brain and body for action. It increases arousal, alertness and vigilance; improves the performance of memory; focuses attention; increases blood pressure and heart rate; and performs a range of other physiological functions.
Acetylcholine is a neurotransmitter released by motor neurons in the nervous system in order to activate muscles – specifically skeletal muscles, which are muscles used for every type of voluntary movement. It is also used to mobilise the body for action via its effects upon the autonomic nervous system, connected with the “fight or flight” and “feed and breed” impulses.
Dopamine is a hormone and neurotransmitter which plays a number of crucial roles in the brain and body. It plays a major role in the development of reward-motivated behaviour, fundamentally linked with addiction. Whilst in popular culture dopamine is often thought of as a “pleasure chemical” along with serotonin, current pharmacological science considers the dopamine to confer motivational salience – that is, to drive behaviour towards or away from desirable or undesirable outcomes.
Serotonin is commonly thought of by the general public to be the chemical most responsible for feelings of pleasure and happiness, though its actual full function is significantly more complex. Serotonin regulates mood, appetite, temperature and sleep; modulates our awareness of resources, including food and sexual partners; and has been thought to affect cognition, anxiety levels and a wide array of other activities and phenomena in body and mind.
Difference Between Benzodiazepine Addiction, Benzodiazepine Physical Dependence, and Benzodiazepine Tolerance
Despite its familiarity, addiction is actually a somewhat nebulous concept, often used to describe different physiological and psychological phenomena. Fundamentally, addiction can describe a brain disorder characterised by the psychological compulsion to engage in rewarding (often pleasurable) stimuli despite the awareness of adverse consequences of doing so. Whilst theoretically any such stimuli could be a factor in addiction, in benzodiazepine addiction specifically the problematic behaviour is the consumption of benzodiazepines and the experience of their effects, driving the desire to take more benzodiazepines to sustain or replicate those effects.
Benzodiazepine dependence can develop with or without psychological addiction: it is the phenomenon by which the system of an individual taking benzodiazepines over a period of time becomes accustomed to certain levels of benzodiazepines, requiring them in order to function normally. The sudden cessation of use and absence of benzodiazepines in the system of a dependent individual will lead to the abnormal functioning of that system – and the manifestation of often distressing symptoms comprising withdrawal syndrome – until and unless the individual is able to go through a period of detoxification and renormalisation.
Benzodiazepine tolerance is a phenomenon by which someone taking benzodiazepines over time needs to take higher and higher doses of benzodiazepines in order to achieve the same desired results and effects. Similar to dependence, it is a function of that individual’s system becoming accustomed to certain levels of benzodiazepines and adjusting activity accordingly; following that adjustment, greater quantities of benzodiazepines are required in order to achieve the same neurochemical effects as were achieved previously by lower doses.
Co-Occurring Disorders: Mental Health Issues & Benzodiazepine Addiction
Although this is not always the case, addiction (to any substance) is often closely related to other mental health issues (which may preexist the addiction, result from it, or both). Many mental disorders are known to be significant contributing factors to substance abuse and thence to addiction; meanwhile, both the direct effects of drugs themselves and secondary factors arising from addiction (such as decreased quality of life, alienation and sadness) can themselves lead to mental health issues, including some very serious ones.
In the case of benzodiazepines specifically, the situation is complicated by virtue of the fact that benzos are often prescribed to treat certain mental disorders, especially anxiety disorders; and that those disorders may also be accompanied by other mental health issues which may not be immediately obvious and diagnosable, but which nevertheless may be exacerbated by benzodiazepine use and abuse. The long-term use of benzodiazepines has also been associated with permanent brain damage which itself can cause numerous mental health issues.
The treatment of benzodiazepine addicts also suffering from co-occurring mental health issues is necessary more complex than that of those “merely” suffering from addiction, with challenges relating to the type of medication which may be used to assist with withdrawal and the nature of therapy which might be provided. Specialist care is recommended for individuals suffering from both benzodiazepine addiction and any other mental health issue (“dual diagnosis”).
Medications and Interactions with Benzodiazepines
As a class of drugs, benzodiazepines pose various risks associated with interactions with other drugs; however, particular benzodiazepines may interact differently with different substances. Roughly speaking, benzodiazepines can be divided into two groups in terms of their potential for such interactions: those metabolised by cytochrome P450 enzymes (the largest group, with the greatest potential for interaction); and those metabolised by glucuronidation, which generally has fewer interactions.
A broad range of drugs including oral contraceptives, some antidepressants, some antibiotics and certain antifungal agents act as inhibitors of cytochrome enzymes in the liver, which has the effect of reducing the speed with which benzodiazepines are eliminated from the system; in turn, this leads to the potentially excessive accumulation of benzodiazepines in the system, and potentially dangerous side effects. On the other hand, drugs which enhance the action of cytochrome enzymes, including St John’s wort, some antibiotics, and a range of anticonvulsants, accelerate the removal of benzodiazepines decrease their action, which can lead to the desire to consume more and more benzodiazepines to achieve the desired effects.
Using benzodiazepines alongside alcohol, opioids and various other central nervous system depressants can enhance the effects of all those drugs resulting in notably increased sedation, impaired motor control, suppressed breathing and other potentially catastrophic adverse effects. In the West – and especially in the USA, currently experiencing an opioid crisis – the majority of deaths associated with benzodiazepines also feature opioid consumption.
Signs and Symptoms of Benzodiazepines Addiction and Withdrawal
It is important to note that because of the stigma associated with addiction and the desire felt by the great majority of addicts to hide their condition, it may not be possible to identify addiction even in someone who has struggled with the condition for a long time.
Any addiction can have an extremely damaging effect on an individual’s life prospects which may be evident by numerous signs, including (but not limited to): frequent intoxication; changes in behaviour and character; changed peer groups, habits and preoccupations; worsened financial and living circumstances; decreased professional and academic opportunities; impaired relationships with friends and loved ones; secrecy and deceit; physical and mental health issues including depression; alienation and isolation; criminal activity; altered sleeping and dietary patterns; reduced levels of hygiene and care in appearance; loss of interest in previously enjoyed activities; general apathy regarding future prospects.
In the case of addiction benzodiazepines specifically, signs to look out for include: frequent intoxication including drowsiness, slurred speech, dizziness, blurred vision, and impaired motor control; preoccupation with obtaining and consuming benzodiazepines specifically; “doctor shopping” (visiting several doctors to obtain benzodiazepine prescriptions); greatly enhanced intoxication when consuming other substances, especially including alcohol; long-term symptoms including anxiety, insomnia, anorexia, weakness, cognitive impairment and brain damage; and the manifestation of withdrawal symptoms upon cessation of use.
Symptoms of gradual withdrawal from benzodiazepines
Individuals who have developed a physical dependence to benzodiazepines, and who withdraw gradually from their consumption, are likely to develop at least some of the following symptoms:
- Agitation and anxiety, possible terror and panic attacks
- Blurred vision
- Chest pain
- Depression (can be severe, with possible suicidal ideation)
- Dilated pupils
- Dry mouth
- Elevation in blood pressure
- Fatigue and weakness
- Gastrointestinal disturbance (including nausea, diarrhoea, vomiting)
- Hearing disturbance
- Hot and cold spells
- Hypnagogic hallucinations
- Increased sensitivity to touch
- Loss of appetite and weight loss
- Mild to moderate aphasia
- Mood swings
- Muscular spasms, cramps, discomfort or fasciculations
- Obsessive compulsive disorder
- Postural hypotension
- REM sleep rebound
- Restless legs syndrome
- Taste and smell disturbances
- Visual disturbances
- Increased urinary frequency
- Impaired memory and concentration
Thus, it is important to always withdraw only under the supervision of a medical professional.
Symptoms of rapid withdrawal from benzodiazepines
Meanwhile, individuals dependent upon benzodiazepines who cease taking them suddenly expose themselves to the risk of the following withdrawal symptoms:
- Catatonia, which may result in death
- Convulsions, which may result in death
- Coma (rare)
- Delirium tremens
- Neuroleptic malignant syndrome-like event (rare)
- Organic brain syndrome
- Post-traumatic stress disorder
- Suicidal ideation or suicide
- Violence and aggression
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How to Prevent Benzodiazepine Addiction when Taking Benzodiazepines
As with any prescription medication, it is vital that you follow as closely as possible the instructions of the prescribing doctor with regards to the duration of the course and dosages consumed. Doing so should prevent the development of dependence and addiction. However, it is possible that you may be more susceptible than the average user to benzodiazepine addiction, so even when following your doctor’s instructions it is vital that you report any unpleasant side-effects, and especially any symptoms which may be associated with withdrawal, to your doctor immediately.
Never consume benzodiazepines other than in accordance with a doctor’s instructions. If however you do choose to abuse benzodiazepines recreationally, doing so regularly over a period of more than a few days greatly increases the likelihood that you will develop dependence and addiction.
Protracted Withdrawal Syndrome from Benzodiazepines Addiction
Whilst most cases of benzodiazepine withdrawal last for a matter of weeks at most, some users go on to develop a condition known as protracted – or post-acute – withdrawal syndrome, during which symptoms including psychotic depression, poor concentration, decreased appetite, insomnia, anhedonia, low levels of energy, and psychomotor impairment, along with paranoid ideation, hallucinations, depersonalisation, anxiety and dizziness may all manifest for a period of months or even years. Protracted withdrawal syndrome may be treated with a combination of medication and therapy.
Getting Help for Benzodiazepines Addiction
An addiction to benzodiazepines can have extremely damaging effects on your physical and mental health and many other aspects of your life. Fortunately, however, in recent years the medical understanding of the condition has grown significantly more sophisticated, and there are now numerous treatment options available across the UK for anyone suffering from a benzodiazepine addiction.
When to seek medical care
If you feel that your benzodiazepine habit is having a damaging effect on any aspect of your life – especially upon your health – it is important to seek help sooner rather than later to avoid doing more damage. Speak with your GP and/or an addiction specialist about your situation and what help may be available to you.
Regardless of whether or not you feel able to ask for help, it is vital that you report any negative health consequences of your benzodiazepine consumption before they worsen and place your greater risk.
Exams and tests
Your GP or another doctor may wish to conduct various examinations and tests to determine the extent of your benzodiazepine addiction; it is crucial to answer all their questions as openly and honestly as possible.
Types of Benzodiazepine Addiction Treatment
A range of options exist for the treatment of benzodiazepine addiction, provided either by the NHS or privately. In general, however, treatment consists of two main phases: detoxification and withdrawal (potentially assisted with medication) and therapy.
Benzodiazepine addiction withdrawal and detox
The first phase of overcoming a benzodiazepine addiction is detoxification: the removal of benzodiazepines from the system over time, during which withdrawal symptoms may manifest. Because of the danger of death associated with benzodiazepine withdrawal specifically, it is vital that you do not attempt to detox from benzodiazepines independently; instead, your detoxification needs to be managed by medical professionals, who can potentially prescribe certain medications to ease withdrawal.
Benzodiazepines addiction treatment and rehab
Once the immediate pressures of physical dependence have been overcome via detoxification, the more profound challenge of tackling the psychological addiction to benzodiazepines is taken on by the provision of therapy (in various formats and methods). Only therapy can tackle the root causes of addiction and assist the addict to change their behaviour in order to avoid relapse and the resumption of addiction. Both the detoxification and therapy phases may be provided during a stay in residential rehabilitation (rehab) which can also provide other aspects of a coordinated addiction treatment programme including dietary and fitness plans, group therapy and a range of other elements and activities.
Medications used in benzodiazepine addiction treatment
Because of benzodiazepines’ potential for interactions and their cross tolerance with other substances, the list of medications which can be used in the treatment of benzodiazepine addiction is somewhat constricted. Some of the most prominent medications which are used include phenobarbital, carbamazepine, flumazenil and imipramine.
Always consult a doctor before consuming any medication related to treating withdrawal symptoms, and never embark upon an independent medically assisted detoxification.
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Helping Someone with a Benzodiazepine Addiction
If someone you know is struggling with benzodiazepine addiction, it is important to recognise that your first priority is to protect yourself. Rather than confronting them directly to voice your suspicions and concerns, first speak with an addiction specialist about your situation; they will be able to give you advice about the best way to proceed, which may include how to organise an intervention and what facilities and treatment options may be appropriate.
Benzodiazepines Addiction Support Groups in the UK
Numerous support groups including Narcotics Anonymous (NA) are active across the UK providing help to those addicted to substances of abuse including benzodiazepines.
Benzodiazepine Addiction Statistics
A record 406 people died from benzodiazepine abuse in England and Wales in 2016.
Today, over a quarter of a million people in the UK have been taking benzodiazepines for longer than advised by their doctors.
- In the UK, the most frequently prescribed benzodiazepine is diazepam, often better known by its brand name Valium.
- In 2015, over 12,000,000 benzodiazepine prescriptions were issued in the UK – costing the NHS over £50 million.
- In 2017 there were over 800 seizures by UK police of illegal alprazolam (Xanax).
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If you have been struggling with a benzodiazepine, the sooner you can get help the better.
However, you could soon be in treatment and working towards overcoming addiction and resuming a happy and healthy life.
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There are a broad range of facilities active across the UK treating benzodiazepine addiction, including numerous inpatient rehab facilities.
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