What are benzodiazepines?

Benzodiazepines are psychotropic drugs - drugs that affect the mind and are mood altering. They are commonly known as minor tranquillisers and are prescribed mainly for anxiety and sleeping problems. In the past benzodiazepines were thought to be harmless and non-addictive. However, many studies have reported that they are actually drugs of dependence and potentially lethal when taken in overdose quantities.

Benzodiazepines available in Australia
A large number of benzodiazepines are available on prescription in Australia. The most common ones are Valium, Serepax, Temazepam, Rohypnol and Xanax. Others are listed in the following table.

How do benzodiazepines work?

Benzodiazepines are:

• absorbed in the stomach and small intestine, and metabolised by the liver (when taken orally)
• highly fat soluble and accumulate in fatty tissue
• excreted through sweating, saliva, urine, faeces and breast milk.

The unwanted effects
Even though benzodiazepines relieve the symptoms of anxiety and insomnia in the short-term, they do not cure the problem and have a number of unwanted effects. They are strong drugs which in many instances produce either dramatic or long-term side effects which may render the individual incapable of functioning at a normal level.

The unwanted side effects include things such as:

• drug dependency
• impaired memory and concentration
• emotional ‘anaesthesia’ (being unable to respond normally and feeling isolated or ‘cut off’ from people and feelings)
• depression
• loss of balance
• impaired motor coordination
• mood swings
• irritability and outbursts of rage.

Benzodiazepines, pregnancy and the newborn child
Benzodiazepines freely cross the placenta and appear in the foetus. Although studies regarding foetal development risk are inconclusive, it is known that when moderate to large amounts of benzodiazepines are taken continuously during most of the pregnancy, withdrawal symptoms can be experienced by the baby. These withdrawal symptoms consist of respiratory distress, irritability, disturbed sleep patterns, sweating, feeding difficulties and fever.

High benzodiazepine use during the later stages of pregnancy can lead to floppy infant syndrome. A newborn child with floppy infant syndrome has poor muscle tone and sucking response. Continuous benzodiazepine use during pregnancy and administration of high doses during delivery should be avoided.

Pregnant women using benzodiazepines should withdraw slowly in consultation with expert, specialised medical assistance. Contact TRANX or the Chemical Dependency Unit of the Royal Women’s Hospital for specialist advice on pregnancy, birth and benzodiazepine withdrawal.

Combining benzodiazepines with other drugs

Alcohol
Using benzodiazepines and alcohol together can be dangerous. This is because alcohol:

• heightens the effects of benzodiazepines
• can cause amnesia if combined with benzodiazepines
• when combined with benzodiazepines, decreases the protective upper airway reflexes, which increases the risk of inhaling vomit.

Methadone
An estimated 30 percent of methadone users use benzodiazepines. Many people on methadone programs are using benzodiazepines long-term (which may have been prescribed or obtained without prescription) to alleviate symptoms of discomfort or heighten the effect of methadone. It is common for methadone users to be dependent on benzodiazepines.

The combination of using benzodiazepines and methadone increases the effects of the drugs and is dangerous because of the risk of overdose.

Other drugs
Benzodiazepines are sometimes prescribed for psychiatric disorders in conjunction with an antipsychotic drug, in order to enhance the effect of the antipsychotic.

The effect of benzodiazepines may be increased when combined with:

• antipsychotic drugs
• antidepressant drugs
• analgesics (pain relievers) containing Codeine
• anticonvulsants
• antihistamines
• oral contraception.

The effect of benzodiazepines is decreased when combined with appetite suppressers and asthma drugs because of the stimulant effect of these drugs.

References and resources
The information provided is general and more information can be obtained from the references and resources used to compile this chapter listed below:

References
Ashton, H.C. 1989, ‘Anything for a quiet life?’, New Scientist, 1663, 6 May.

Boyd, J.R. 1985, Drug facts and comparisons, J.B. Lippincott Company, Missouri, USA.

Brown, H. 1993, ‘Young people and the use of prescription pills’, Burdekin project, funded by Health and Community Services Department of Victoria.

Churchill, A. 1993, ‘Sleep and benzodiazepines in the elderly’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

Closser, M.H. 1991, ‘Benzodiazepines for the elderly: a review of potential problems’, Journal of Substance Abuse Treatment, vol. 8, pp. 35-41.

Cumming, R.G., Klineberg, R.J. 1993, ‘Psychotropics, Thiazide, Diuretics, and Hip Fractures in the Elderly’, Medical Journal of Australia, vol.158.

Drake, S., Swift, W., Hall, W. & Ross, M. 1993, ‘Drug use, HIV risk-tasking and psychological correlates of benzodiazepine use among methadone clients’, Drug and Alcohol Dependence, vol. 34, pp. 67-70.

Faust, B. 1991, ‘Doctors and detailers: the benzodiazepine scandal’, The Australian Nurses’ Journal, no. 20, p. 9.

Gill, A., Pead, J. & Mellor, N. 1992, Methadone Prescribers Manuel, Drug Services Victoria, September

Higgins, G. 1993, ‘Prescribing benzodiazepines for older people’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

Laegreid, L., Olegara, R., Wahlstrom, J., Conrad, N. 1987, ‘Abnormalities in children exposed to benzodiazepine in utero’, Lancet, January.

Mant, A. 1991, ‘Prescribing and use of psychotropic drugs: ideal, ideology and rationality’, paper presented at National Conference on Benzodiazepines (minor tranquilliser) use, Melbourne.

Mant, A., Whicker, S., McManus, P., Birkett, D., Edmonds, D. & Dumbrek, D. 1993, ‘Benzodiazepine utilisation in Australia: Report from a new pharmacoedidemological database’, Australian Journal of Public Health, vol. 17, no. 4, pp. 345-349.

Moulds, R. 1991, ‘The Pharmacology and Administration of Minor Tranquillisors’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

National Health and Medical Research Council (NHRMC)m ‘Guidelines for the prevention and management of benzodiazepine dependency’, Monograph Series, No. 3.

Pleasant View Study, 1994, Managing Methadone clients with benzodiazepine use, paper presented at Methadone Conference, Melbourne, November.

Powell, J. 1992, ‘Drugs and the elderly’, Connexions, vol. 12, no. 6, Nov/Dec.

Ray, W.A., Griffin, M.R., Schaffner, W.B., David, K. & Melton, J. 1987, ‘Psychotropic drug use and the risk of hip fracture’, The New England Journal of Medicine, vol. 316, no. 7, pp. 363-369.

Resources

MIMS Australian, MediMedia Australia Pty Ltd, NSW.
Published bi-monthly, this publication lists all currently available prescription drugs in Australia. Note that this publication contains drug company information and differs in some instances to standard pharmacological texts.

Be wise with medicines.
A campaign the Federal Department of Health, Housing and Community Services released in 1992.

Alcohol, Other Drugs and Pregnancy booklet, Eastern Metropolitan Alcohol and Drug Network.
This booklet provides information on the effects of all drugs of dependence on the developing baby. The booklet includes suggestions to help pregnant women, who are using drugs, to decrease the harm to their babies. This booklet is available from TRANX or the Maroondah Social and Community Health Service, 75 Patterson Street, Ringwood, Victoria, (03) 9879 3933.

Be alert!
Benzodiazepines are very addictive. At least half of the people regularly taking low doses of benzodiazepines on a long-term basis will develop a physical tolerance to the drug and become dependent.

As the lack of recognition of this dependency is common, it often goes undetected or is misdiagnosed. Be alert for dependency, even though it may not be initially identified as a problem.

Dependency
Drug dependence usually has physical and psychological elements. People who are dependent on benzodiazepines will:

• crave for the drug
• feel unable to cope without the drug
• find it extremely difficult to stop taking the drug
• find that the drug no longer has the same effect and will increase the dose or drink alcohol to achieve the same effect
• need the drug to function normally
• have withdrawal symptoms if the drug is not cut down or stopped.

What causes dependency?
Benzodiazepine dependence and tolerance can occur very quickly and can be caused by:

• any drug in the benzodiazepine group
• continuous use (as little as two weeks)
• low doses taken continuously
• intermittent but regular use (every three to four days).

Some people taking benzodiazepines don’t realise that they are dependent until they stop a dose or try to cut down and experience withdrawal symptoms.

Not everyone who takes benzodiazepines on a daily and long-term basis, will become physically dependent. People who don’t become dependent won’t have withdrawal symptoms when reducing or stopping their benzodiazepine use. Dependence cannot occur if benzodiazepines are taken infrequently (less than once or twice per month).

References and resources
It is crucial the previous information is not applied to other drugs. Further details about benzodiazepine dependency can be obtained from the resources and references listed below:

References
Ashton, H.C. 1989, ‘Adverse effects of prolonged benzodiazepine use’, Adverse Drug Reaction Bulletin, no. 118, pp. 440-443.

Ashton, H.C. 1987, ‘Benzodiazepine withdrawal: Outcome in 50 patients’, British Journal of Addiction, vol. 82, pp. 665-667.

Ashton, H.C. 1989, ‘Risk of dependence on benzodiazepine use: A major problem of long-term treatment’, British Medical Journal, no. 298, pp. 103-105.

Foy, A. 1991, ‘Drug withdrawal: A selective review’, Drug and Alcohol Review, vol. 10, pp. 203-214.

Lader, M. 1991, ‘History of benzodiazepine dependence’, Journal of Substance Abuse and Treatment, no. 8, pp. 53-59.

Lennane, K.J. 1986, ‘Treatment of benzodiazepine dependence’, Medical Journal of Australia, vol. 144, pp. 594-597.

Lockwood, A. & Bercatis, C.G. 1990, ‘Benzodiazepine drugs in Australia: Associated mortality and morbidity’, Drug and Alcohol Review, pp. 277-286.

Mant, A. 1996, ‘Benzodiazepine dependence: Strategies for prevention and withdrawal’, Current Therapies, February Ed.

Miller, N.S., & Gold, M.S. 1990, ‘Benzodiazepines: A major problem’, Journal of Substance Abuse and Treatment, no. 8, p. 307.

Miller, N.S., & Gold, M.S. 1990, Benzodiazepines: Tolerance, dependence, abuse and addiction’, Journal of Psychoactive Drugs, no. 22, vol. 1, pp. 22-33.

Woods, J.H., Katz, J.L. & Winger, G. 1992, ‘Benzodiazepines: Use, abuse and consequences’, Pharmacological review, no. 44, vol. 2, pp. 151-347.

Information
People often express a strong need for detailed information about withdrawal. Providing information usually allows people to make informed decisions about pill reductions. In particular, make sure you provide an overview of recovery possibilities - this does not mean providing a program and insisting adherence to it, it means encouraging the person undergoing withdrawal to take control of decision making.

Alcohol
People reducing their benzodiazepine intake should be encouraged to totally abstain from alcohol. The key concerns for people drinking alcohol whilst taking benzodiazepines are:

• the combined effect when alcohol and benzodiazepines are used together increases the sedative effect on the person
• the fact that it has been reported by people that drinking alcohol during benzodiazepine withdrawal worsens the withdrawal symptoms
• the danger of the alcohol intake increasing as benzodiazepine intake decreases.

If a person is unable to abstain from alcohol and appears to be dependent on alcohol, you may need to refer him or her to an alcohol and drug counselling agency.

Exercise
Gentle exercise, such as walking or swimming, should be undertaken daily when someone is reducing his or her benzodiazepine intake. Encouraging a person suffering from agoraphobia (a common withdrawal symptom) to get out for a walk will help prevent a fear of leaving the house developing. People who are usually very active and use sport as their preferred method of relaxation need to be aware that muscle spasms are common during withdrawal and that they mat feel exceptionally sore or tired after their usual sporting activity.

Finding the balance is important for each individual. Exercise has been shown to lift depression and induces a relaxed state of body and mind. This can be useful for people who find it difficult to use other types of relaxation techniques. Exercise helps to increase the circulation which assists in the elimination of the drug from the body.

Diary
A diary can be a useful tool for understanding the withdrawal process. Keeping a diary of progress gives people a sense of a goal to reach. It is also a useful vehicle for expressing and working through emotional issues. Because short-term memory loss is a common problem in withdrawal, many people find a diary useful to help remember what medication they take, symptom changes and other important things.

Massage
Massage is beneficial for people going through the withdrawal process because it relaxes the muscles which, during withdrawal, become very tense and sometimes spasm. Massage also improves the circulation which assists in eliminating the drug from the body. Additionally, massage is a useful relaxation technique. Counsellors should be able to offer to massage the head, neck and hands of people attending the centre for benzodiazepine withdrawal support.

Overcoming the challenges to recovery
During the recovery process people will face a variety of challenges. These include;

• fear
• a loss of identity
• family and intimate relationship issues or tensions
• coping with the memory and ramifications of incest and sexual assault
• anger
• a poor self esteem or self image
• other illnesses and conditions.

In order for you to successfully help people through the recovery process, it is necessary for you to understand these challenges and to know the strategies to help people to overcome them.

Fear
Fear can be an overwhelming emotion for the person going through benzodiazepine withdrawal. People may experience different fears at various stages of the withdrawal and recovery process, and it will therefore be necessary for you to work with the various fears as they arise during the different stages of withdrawal.

Fear of change
initially, people fear change. People are often frightened about what their life will be like when they are benzodiazepine-free and if they will cope.

It is not uncommon for people going through the withdrawal process to be frightened of changes in behaviour. Usually they are concerned if they will be able to predict theses changes and if they will be able to cope with them.

Fear of withdrawal symptoms
it is quite common for people to fear withdrawal symptoms during the recovery process. Lack of information, misinformation or doubts about managing the physical stress of symptoms can cause fear. Once people have understood their own pattern of withdrawal and how to mange symptoms, the fear usually disappears. It is important to address the fear of symptoms because withdrawal may become more severe if the fear of its symptoms isn’t dealt with.

‘Who am I?’
Many people who have used benzodiazepines for many years and are going through the recovery process, have lost their sense of identity.

Changes in mood and behaviour are common during withdrawal. Some people talk about not knowing who they are because their physical and mental states are so dramatically altered. Many people talk about forgetting the large parts of their lives.

People going through the recovery process may also find it difficult to relate to the person they used to be when they were taking benzodiazepines, and may question their relationships with their partners or family members. The years of taking benzodiazepines are often described as ‘the lost years’ or ‘the wasted years.’ People will need support while coming to terms with these realisations, which are usually very distressing.

People usually change during the recovery process. It is important to help people going through the recovery process to accept changes, to encourage positive development and to reassure them that the identity confusion they are experiencing can be resolved.

Family and intimate relationships
The effect of long-term benzodiazepine use on close relationships can be devastating. During the recovery process people may become irritated, depressed, aggressive, moody and generally difficult to get along with.

People suffering the effects of benzodiazepine withdrawal may be unwell a lot of the time, may not participate in family life and may feel uncomfortable and panicky when socialising. It is not uncommon for children to kept home from school because their parent is too fearful to be left alone.

Incest and sexual assault
As with most drug dependence, there is a significant correlation between long-term benzodiazepine use and past experience of incest or sexual assault.

For some people, memories begin to surface for the first time during benzodiazepine reduction. This may be due in part to the memory suppressing effects of the drugs. It is important that if forgotten memories are coming back, the reduction of the benzodiazepine is slowed down or halted and intensive support provided.

Anger
Anger, especially towards doctors who have prescribed the benzodiazepines is a common response. It is not surprising that people feel very angry and betrayed when they have been encouraged to take benzodiazepines, are reassured by the prescriber that they are taking a safe drug and then discover at a later stage that they are dependent on this drug.

It is important to validate this anger. Acknowledge the anger exists will reduce the likelihood of someone being immobilised by it. Information about the historical context for benzodiazepine prescribing will help people come to terms with their current situation. A good strategy for dealing with people’s anger is to:

• listen to what they have to say
• express your understanding and inform them of the historical context
• help them to move on.

A low self-esteem and poor self-image
Given that many people have lost their self-confidence through the experience of benzodiazepine dependence and have often been labelled and given forecasts by other health professionals, you should aim to encourage belief in themselves and confidence in their own abilities and experiences.

• People’s experiences of withdrawal need to validated - reinforce that their experience is the most important
• Guilt and shame are common emotions during drug use and withdrawal. Guilt often seems from lack of confidence in dealing with stress by resorting to medication. Shame can result from perceived negative self-image and not wanting others to know that they cope in this way. Information about the prevalence of use of these drugs will usually help an individual place their experience in context. Prescribing benzodiazepines as a solution to stress or insomnia is a common practice, and not something the person need feel stigmatised about.

Schizophrenia
Unless you have experience and are competent in treating people with schizophrenia, it is most likely your involvement would be as a consultant in benzodiazepine withdrawal only. You may be useful in offering supportive counselling and information regarding the use of benzodiazepines and symptom management.

Sometimes benzodiazepines are prescribed to enhance the effect of antipsychotic drugs treating schizophrenia. Benzodiazepines are often used as additional therapy for the treatment of severe anxiety which can sometimes be present in these disorders. Sometimes long-term benzodiazepine use can be justified as it can improve quality of life and level of functioning without the severe side-effects associated with some of the antipsychotic drugs. Ideally, this usage should be kept to a minium and can often be reduced over time. Increased dosages and inappropriate use of the benzodiazepines is, however not uncommon. In this situation coming off the benzodiazepines will most likely improve the person’s quality of life.

Treatment
It is crucial that you seek the opinion of the specialist or treating psychiatrist before making any recommendations about management of benzodiazepine use.

References and resources
This information has been compiled using the following references and resources.

References
Ashton, H.C. 1991, ‘Chronic low dose benzodiazepine usage: Adverse effects, dependence and withdrawal’, paper presented at the National Conference on Benzodiazepine (minor tranquilliser) use, Melbourne.

Ashton, H.C. 1991, ‘Benzodiazepine withdrawal: an unfinished story’, British Medical Journal, vol. 288.

Cannard, G. 1996, ‘The benzodiazepine withdrawal syndrome’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

Churchill, A. 1993, ‘Sleep and benzodiazepines in the elderly’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

Codd, G. 1990, ‘A natural therapies approach to minor tranquilliser withdrawal’, Healthright, vol. 9.

Gilbert, A., Innes, L., Owen, N., Sansom, J.W. 1993, ‘Trial of an intervention to reduce chronic benzodiazepine use among residents of aged care accommodation’, Australian and New Zealand Journal of Medicine, vol. 23, pp. 343-347.

Golombok, S., Higgit, A., Fonagy, P., Dodds, S., Saper, J. & Lader, M.A. 1987, ‘A follow up study of patients treated for benzodiazepine dependency’, British Journal of Medical Psychology, vol. 60, pp. 141-149.

Higgins, G. 1993, ‘Prescribing benzodiazepines for older people’, paper presented at the Autumn School of Studies on Alcohol and Drugs, St Vincent’s Hospital, Melbourne, May.

McDermott, F., & Pyett, P. Not welcome anywhere, Victorian Community Managed Mental Health Services Inc., Melbourne, 1993.

McLellan, B. Overcoming Anxiety, Anen & Unwin, Sydney, 1992.

Porritt, D. & Russell, D. 1994, The Accidental Addict, Pan McMillan.

Schweiser, E., Case, W.G. & Rickels, K. 1989, ‘Benzodiazepine dependence and withdrawal in elderly patients’, American Journal of Psychiatry, vol. 146, pp. 529-531.

Trickett, S. Irritable bowel syndrome and diverticulosis - a self-help plan, Thorsons, London, 1990.

Weeks, C. Self-help for you nerves, Angus and Robertson, Melbourne, 1977.

Resources

Tranquillisers and your brain
An understanding of drug dependence is one step towards helping people break free to make a new beginning. A detailed account of the mechanisms involved is available in Dr Robert A Cummins’ article Tranquillisers and your brain. Robert Cummins is a senior lecturer in psychology and a copy of his article is available from TRANX.