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Benzos: The Calm Before The Storm

Benzodiazepines, commonly known as “benzos”, include prescription drugs like alprazolam (Xanax), clonazepam (Rivotril or Klonopin), diazepam (Valium), and lorazepam (Ativan). These medications are used to treat anxiety and for sleep, among other things.




How common are they?


The use of benzodiazepines is pretty common. One study showed that 5.5% of ALL Ontario residents received a prescription for a benzo in 2019. (That’s approximately 1 in 18 residents!) The rates are even higher in the US, with one study showing 12.6% of adults (or 30.6 MILLION people!!) reported using benzos in the past year.


Benzos come with a lot of risk (...more on that later) and, thankfully, prescribing rates are going down overall. However, in the Ontario study, we saw that rates are actually rising among young people. Yikes!!


How do they work?


One of the biggest problems with benzodiazepines is that they work and they work quickly… initially, at least.


These medicines work to decrease your nervous system activity. The nervous system uses chemical messages, known as neurotransmitters, to send and relay messages through the body. One of these messengers is gamma-aminobutyric acid (it’s a mouthful!), also known as GABA. Benzos tell your brain to release more GABA which helps to make your nervous system less active.


Ok, what does all this do? It helps to calm your brain and body down! It reduces anxiety, makes you sleepy, and has an overall “quieting” effect. Makes sense why it is used for anxiety and sleep, right?! And, yes, because it works relatively quickly, (typically 15-30 mins when you take a pill by mouth), people get immediate relief.



What are the risks?


Firstly, it’s important to acknowledge they can be habit-forming and misused or abused. This is why they are a controlled substance and prescriptions are carefully monitored in most places.


But, even when used prescribed by a doctor at therapeutic doses, benzodiazepines carry risks, such as:

  • Confusion, cognitive impairment, poor concentration, forgetfulness

  • Low daytime energy and sedation, dizziness, disinhibition

  • Falls, fractures, increased risk of vehicle accidents

  • Increase in all-cause mortality (death!)


All of these risks increase as you age because of the way your body processes the drug.


So, why not just stop?


Oh, if only it were that easy!


Benzos are notoriously one of the most difficult meds for people who use them regularly to stop. There are a few reasons for this:


  • Rebound:if you reduce the dose or stop and get a re-emergence of symptoms, like anxiety or insomnia. This is not because the underlying issue is still there, but because your body got "used to" having the drug around. Your symptoms can even be worse than before you started it! It often leads you (or your doctor) to believe you still need the medication, when it's possible you don’t (if you tapered down more slowly).

  • Tolerance: Your body gets used to having it and they don’t work as well as they once did. This starts to develop after as little as 2-4 weeks of regular use. Often people need to go up in dose to have the same effect (which makes it harder to come off)

  • Dependence: Your body gets used to having it. If you miss a pill, try to reduce the dose or stop, you can experience withdrawal symptoms. This does not mean you are addicted to the medicine (...more on that here LINK OTHER BLOG)


Being physically dependent on the drug, your body can experience withdrawal symptoms when missing a pill, reducing the dose, or stopping the drug.


Possible withdrawal symptoms include:

  • Sleep disturbance

  • Nausea, vomiting, abdominal cramps

  • Tremor, twitching

  • Irritability, anxiety, panic attacks

  • Low mood

  • Nightmares

  • Heart palpitations

  • Headache

  • Muscular pain, stiffness

  • Perceptual changes (i.e. tingling in the hands and feet, ringing in your ears)

  • Delirium

  • Seizures

  • Etc.

….this list is NOT exhaustive.


Certain factors can be predictive of more severe withdrawal symptoms, like:

  • Taking if for a longer period of time (e.g. 5 years vs. 2 months)

  • Higher dose

  • Short half life drug

  • Older age

  • Poor physical health

  • Baseline mental state


However, it is a very individual experience. Two people can have been on the same drug at the same dose for the same amount of time and have a very different experience.


Getting off for good


I personally believe, and it has been my professional experience, that many people get “stuck” on benzodiazepines because of that dependence and withdrawal and not necessarily because they still need the drug.


What I’ve come to know is that there are three factors that are critically important for success in getting off benzos:

  1. Tapering down SLOWLY with a personalized plan

  2. Setting up your life for success without the drug

  3. Professional guidance and support every step of the way


This approach can help mitigate and reduce severity of withdrawal symptoms, as well as help manage any symptoms that do come up, whether that means adjusting the plan or adding an intervention to help in the short term.




Switching from a short acting to a long acting benzodiazepines is one strategy and is recommended in the “Ashton protocol”. However it has not shown to be more effective than slowly lowering the dose of a short-acting drug and some people have trouble switching between benzos. It is a very individual decision and your protocol should be created based on your own personal circumstance.


As you continue down the taper and the dose gets smaller, the percentage dose reduction should also get smaller. This is referred to as a hyperbolic taper.


Alongside the actual medication taper, it is important to incorporate other strategies to set up your life for success without the meds. This involves strategic and individualized changes to improve your physical and mental health. This can help to build up resilience against any withdrawal symptoms, as well as work on what brought you to needing the drug in the first place. This may involve lifestyle strategies, nutrition, movement, or supplements.


This is what we specialize in at Your Simple Health. We create a personalized plan for you, advocate with your own healthcare team, and are there to support you every step of the way.


Interested to learn more? Book a free discovery call .




Disclaimer: this is for information and education only and should not be construed as personal medical advice. It is important to speak with a licensed healthcare provider to help guide you through tapering off a benzodiazepine.



References.

  1. Ontario Drug Policy Research Network on behalf of the ODPRN Citizens’ Panel. Characterizing Prescription Benzodiazepine Use Among Community-Dwelling Residents of Ontario, Canada. Toronto. Ontario Drug Policy Research Network. April 2021. doi: 10.31027/ODPRN.2021.01.Accessed at https://odprn.ca/wp-content/uploads/2021/04/Trends-and-Patterns-in-the-Use-of-Benzodiazepines-in-Ontario.pdf

  2. Maust DT, Lin LA, Blow FC. Benzodiazepine Use and Misuse Among Adults in the United States. Psychiatr Serv. 2019 Feb 1;70(2):97-106. doi: 10.1176/appi.ps.201800321. Epub 2018 Dec 17. PMID: 30554562; PMCID: PMC6358464. Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358464/#:~:text=Benzodiazepines%20are%20prescribed%20to%20over,at%208.6%25%20(1)

  3. Deprescribing benzodiazepine receptor agonists

  4. Kevin Pottie, Wade Thompson, Simon Davies, Jean Grenier, Cheryl A. Sadowski, Vivian Welch, Anne Holbrook, Cynthia Boyd, Robert Swenson, Andy Ma, Barbara Farrell

  5. Canadian Family Physician May 2018, 64 (5) 339-351; https://www.cfp.ca/content/cfp/64/5/339.full.pdf

  6. Cleveland Clinic. Benzodiazepines (Benzos). https://my.clevelandclinic.org/health/treatments/24570-benzodiazepines-benzos

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