Benzodiazepines

Prescription Benzodiazepines

 

Benzodiazepine medications can be effective when used in the short-term (less than two weeks) or intermittently to manage the symptoms of anxiety and insomnia.

 

The risks of using benzodiazepines for longer than four weeks outweigh the short-term benefits. The risk of harm also increases dramatically if benzodiazepines are combined with other sedatives such as prescription opioids or alcohol.

 

If you have sleep apnea, you use benzodiazepines with other opioids or alcohol, or you have history of anxiety or depression, you are more at risk of harm.

Getting to know benzodiazepines

 

Benzodiazepines explained

What are ‘benzos’?

 

Benzodiazepines or ‘benzos’ are sedatives or minor tranquilliser medications. They are often referred to as sleeping tablets or muscle relaxants and are usually prescribed for anxiety problems and insomnia. They often make your anxiety feel better in the short term because they reduce anxiety and make you feel relaxed.

 

There are many different types of benzodiazepines, and each type can also have a number of different brand names.

 

Common benzodiazepines include:

 

+ diazepam (brand names such as Valium or Diazepam Intensol)

+ temazapam (brand names such as Temaze or Normison), and

+ alprazolam (brand names such as Xanax, Ralozam or Kalma)

+ oxazepam (brand names such as Serepax, Murelax or Alepam)

 

It is important to also note that while so-called “Z” drugs such as

+ Zolpidem (with brand names such as Stilnox), and

+ Zopiclone (with brand names such as Imovane)

are hypnotics, they act in a similar way to benzodiazepines. These medications should also only be used in the short-term.

Benzodiazepines have a limited role for some short-term issues, but like opioids, are best to avoid as ongoing treatment.

 

Speak with your doctor or another health professional about your medication use and how to manage your health condition/s.

The role of benzodiazepines for anxiety, sleep and pain

Benzodiazepines and anxiety

 

Benzodiazepines are commonly prescribed to manage the symptoms of anxiety, particularly for those experiencing panic attacks or agoraphobia. However, benzodiazepines do not treat the underlying causes of anxiety and are the third-line treatment recommended for people seeking to manage anxiety and/or panic disorder.

 

Evidence shows that psychological therapies, such as Cognitive Behavioural Therapy (CBT), are the most effective ways to treat these conditions. These treatments address the underlying causes of anxiety, and help people to change their thought patterns and how they react to certain situations. If further treatment is required, anti-depressants are the next line of treatment recommended to reduce the symptoms of anxiety. These medications don’t have as high a risk of dependency.

 

Benzodiazepines should therefore only ideally play a short-term role in treating anxiety, and should be used infrequently or for less than 2 to 4 weeks. When used for longer than this, it is common for people to become dependent on their medication, and even experience increased anxiety due to withdrawal.

 

You can read more about benzodiazepines and anxiety on Beyond Blue’s website here.

Benzodiazepines and sleep

 

Similarly, benzodiazepines or ‘sleeping tablets’ are only recommended for occasional use to help you fall asleep.

 

Evidence has shown that behavioural treatment strategies are the most effective way to manage common sleep problems.

 

 

In fact, long-term use of sleeping tablets can lead to worse sleep patterns, lower quality sleep and waking up frequently in the night and increased insomnia due to withdrawal.

Benzodiazepines and pain

 

There is little scientific evidence that benzodiazepines play any role in the treatment of pain.

 

We do know, however, that chronic pain patients often experience anxiety due to their condition, or may have trouble falling asleep, and this may help explain why patients are sometimes prescribed benzodiazepines.

 

Your doctor or another health professional can help answer any questions you may have about your medications.

 

It is important to avoid using benzodiazepines in combination with pain medications such as opioids, or other central nervous system depressants such as alcohol. This can increase the risk of slowing down a person’s breathing, leading to overdose.

Managing anxiety, sleep problems and chronic pain

Managing anxiety

 

There are lots of different ways to manage both the underlying causes of anxiety and its symptoms. Find out more about managing your anxiety:

 

 + Speak with your GP or make an appointment to see a mental health professional such as a psychologist or counsellor

+ Your GP will also be able to speak with you about a Mental Health Care plan to subsidise your treatment through Medicare

+ Visit Beyond Blue’s website or call their helpline on 1300 22 4636

+ Call Lifeline on 13 11 14 or read their Tool Kit for Panic Attacks here

+ Visit the Centre for Clinical Intervention‘s website for information packages with modules to learn more about managing: Panic Attacks, Mastering your worries, and Coping with social anxiety

+ Visit the ‘This Way Up’ website to take an online course

Managing sleep problems

 

Most of us have had trouble sleeping at different times in our lives, and the quality of our sleep can have a big impact on our wellness. There are many resources to help you improve your sleep.

 

+ If you have trouble sleeping regularly, talk with your GP to find out the best treatment for you.

+ This might involve working with your GP to find out the underlying reason/s you can’t sleep, and could include filling out a questionnaire, keeping a sleep diary, and/or referral to a psychologist or sleep specialist

+ SA Health has provided an excellent ‘Insomnia Management Kit’ you can work through with your GP to determine how to improve your sleep

+ The Centre for Clinical Intervention also has some great resources to find out more about improving your sleep, including maintaining good ‘sleep hygiene’

+ Beyond Blue’s website also has some great tips and strategies

 

+ NPS MedicineWise also has some great resources on insomnia available here

Managing chronic pain

 

For more resources about managing chronic pain visit ScriptWise’s ‘Managing Chronic Pain’ information tab here.

 

Risks of using benzodiazepines long-term

Dependence

Benzodiazepine dependence

 

It is possible to become dependent on benzodiazepines without realising it. The brain develops a “tolerance” and adjusts to the medication so that it is no longer effective. This often means that more and more medication is needed to get the same effect.

 

Dependence can develop quickly, within a few weeks or months, and the risks of dependence increase the longer the medication is used.

 

Once you have developed a dependence on benzodiazepines, it means you will experience withdrawal symptoms when you try to reduce the amount of medication you are taking, or when you try to stop using it.

Benzodiazepine dependence symptoms

 

If you answer yes to any of the following questions, it is important to speak with the medical professional who has prescribed your medication (usually your GP) to discuss a plan to slowly reduce your medication to avoid the side-effects associated with dependence.

 

+ Have you been taking your benzodiazepine medication (a tranquilliser or sleeping pill) for longer than 2 to 4 weeks?

+ Do you feel you need your benzodiazepine medication to cope?

+ Do you feel sick and/or more anxious when you stop or take less of your benzodiazepine medication?

+ Do you have more trouble sleeping than when you first started taking your benzodiazepine?

+ Do you feel like your medication isn’t having the same effect that it used to?

+ Have you taken more medication to get the same effect? Particularly during stressful times?

+ Do you feel stressed or anxious when you don’t have your medication with you? Even if it’s just for a short time?

+ Do you go out of your way to make sure you always have your medication with you?

+ Is your medication use interfering with your daily life? Is it negatively affecting your work or family life? Your relationships?

+ Do you have trouble remembering things or feel like it’s harder to cope with everyday life?

 

These questions have been adapted from the Beyond Blue and Reconnexion factsheet available here.

Withdrawal

Withdrawal

 

Withdrawal symptoms occur when benzodiazepines are reduced or stopped. People can experience no symptoms or can be surprised by the variety of withdrawal symptoms which can last from a few days, to weeks or months.

 

Usually the longer a person uses benzodiazepines, and the higher their dose, the more likely they are to experience longer and more severe withdrawal symptoms.

 

Do not stop using your medications suddenly (go ‘cold turkey’). This can lead to severe withdrawal symptoms, including seizures or fits. Visit the ‘treatment options’ section below to find out more about next steps, or speak directly with your doctor.

‘Rebound’ withdrawal symptoms

 

 

Often when a person reduces or stops their benzodiazepines, they experience an increase in the original symptoms they took the medication for such as anxiety or insomnia.

 

These ‘rebound’ symptoms can cause people to mistakenly believe that their original issue has gotten worse. This might mean they think they need to increase their dose, when really, this is a symptom of benzodiazepine dependence.

 

 

People who are using benzodiazepines for a long time can constantly be experiencing withdrawal symptoms, without ever reducing their dose. This can mean that people don’t realise that their health problems may be due to withdrawal, and not other underlying factors.

What are the symptoms of withdrawal?

 

According to Beyond Blue and Reconnexion, common benzodiazepine withdrawal symptoms include:

 

+ anxiety

+ insomnia

+ feeling detached from reality

+ heightened sensitivity to noise, light, smell and touch

+ muscle pain

+ headaches

+ shaking

+ dizziness

+ feeling depressed

+ nausea

+ loss of memory or appetite

+ seizures (may occur with sudden and complete stopping of benzodiazepines)

 

Read the full fact sheet here.

Overdose

Overdose involving benzodiazepines

 

Too many Australians are dying due to prescription medication overdose involving benzodiazepines. Prescription medications, not illicit drugs, are responsible for the highest number of drug-induced deaths in Australia. In 2016, prescription opioid and benzodiazepine related drug deaths outnumbered the road toll in Australia.

 

663 Australians died due to a benzodiazepine induced death and 784 due to a prescription opioid induced death (codeine, oxycodone, fentanyl, tramadol or pethidine).

 

When used alone, there is little risk of a benzodiazepine overdose. But when benzodiazepines are used with other central nervous system depressants such as opioids or alcohol, they increase the risk of an overdose.

What is an overdose?

 

 

When benzodiazepines are combined with other central nervous system depressants, they can act to slow down a person’s breathing and heart rate even more.

 

An overdose happens when these medications reduce the body’s natural urge to breath and stop someone from breathing. This can lead to brain damage or death.

 

According to the Penington Institute, signs of an overdose can include:

+ No response to stimuli

+ Shallow/stopped breathing

+ Can’t be woken up

+ Unusual snoring/gurgling sounds

+ Blue/grey lips or finger tips

+ Floppy arms and legs

 

If someone has overdosed due to a combination of benzodiazepines and prescription or illicit opioids, naloxone can be used to temporarily reverse the effects of the opioid overdose. To find out more about preventing an opioid overdose at www.scriptwise.org.au/prescription-opioids.

Getting effective treatment

Treatment options

Treatment options

Visit your GP

 

If you are concerned about your benzodiazepine use, it is important to first talk with your prescriber (usually your GP) to make a plan to reduce your medication by small amounts over time.

 

Do not stop using your medications suddenly (go ‘cold turkey’). This can lead to severe withdrawal symptoms, including seizures or fits.

 

Your prescriber can help you to gradually reduce your dose, giving your body time to adjust. Read more about reducing your dose in the next tab.

Counselling

 

It can also be really important to ensure that prior to reducing your medication, you feel comfortable and have the tools necessary to manage your anxiety and/or sleep issues.

 

When reducing benzodiazepine use, it is possible that the original problem the medication was used for could become more intense. This means it’s even more important to ensure you have the necessary tools to manage during what can be a difficult time.

 

You can visit your GP to get a referral and Mental Health Care Plan to see a mental health practitioner with a Medicare rebate, or you can choose to see a psychologist or counsellor privately.

 

Reconnexion also have some great resources to find out more about this process, and a free helpline in Victoria you can call to arrange counselling or a secondary consult with your GP should they need assistance. It is a free service and does not require a referral or mental health care plan. You can call Reconnexion on 1300 273 266.

Slowly reducing benzodiazepines

Tapering off benzodiazepines

Don’t stop your medication suddenly or without speaking with your health care professional. The withdrawal symptoms can be extremely uncomfortable, and in some cases dangerous.

 

If you are concerned that you have been using benzodiazepines long-term, speak to your prescriber (usually your GP).

 

Your doctor will likely talk with you about an individualised plan for you to slowly reduce and eventually stop your medication over time. This might involve slowing reducing your dose each month.

 

This process can take weeks or months depending on a number of different factors.

 

If you have been prescribed a high dose of benzodiazepines for a long time, your doctor may also recommend that you are admitted to hospital to help manage your withdrawal process.

 

Further resources can also be found on Reconnexion’s website here

Personal stories

Merideth's Story

Merideth shares her story of recovery from benzodiazepine dependence (diazepam and temazepam).

 

*Please note Merideth is a pseudonym

 

If you’re concerned about your medication use, speak to your GP or another trusted health professional. Do not stop or reduce your medication without first speaking to a health professional as this can be potentially dangerous.

 

In 1994 I sought help from a psychiatrist to work through the abuse and torture I had experienced as a child.  I was against any medication however he said it was necessary.  He prescribed 10 mg Diazepam (Valium) and 10 mg Temazepam (The Temazepam was equivalent to 5 mg Diazepam) as well as 200mg Zoloft, an anti-depressant.

 

When I started taking the medication I was a healthy, fit forty-two-year-old. As a family, my husband and I, and our three children enjoyed bush walking and outdoor activities.  Within three years of starting that medication my coordination had deteriorated, and my GP suspected that I was either suffering from a brain tumour or Multiple Sclerosis (MS).  After an MRI and a neurological examination by a leading neurologist I was diagnosed with MS.

 

By 1997, I had worked through the trauma of the abuse and come to terms with it, however, the psychiatrist wanted me to remain on the medication because of the MS diagnosis.  Over the years that followed he incorrectly reassured me that I could safely remain on it for the rest of my life. Our life changed significantly because I became increasingly more disabled requiring a motorised scooter when out shopping and home help to do everyday tasks.  The active life that I had always enjoyed was no longer possible and instead I lived a restrictive, socially isolated, indoor lifestyle.

 

Eighteen years after starting the medication as I approached my sixtieth birthday, I decided to take stock of my rapidly declining health.  Around about this time my then 4-year-old grandson asked why I walked, talked and moved so slowly.  I explained to him about the MS.

 

I decided to reduce the medication in the hope that I would see some general improvement in my health.

 

Unfortunately, when I spoke to my GP about the withdrawal process he was extremely unhelpful. We contacted all support services in our area finally we were given the number of a rural withdrawal support worker who was extremely supportive and understanding. He said that it wasn’t going to be easy, and that I would have to work at it. He gave very practical advice such as keeping a diary of the withdrawal process from day 1 to day 14, to help me understand the patterns of my withdrawal symptoms, which gave me a good indication of what to expect in my future withdrawals. This helped to get rid of the feeling that I didn’t know what would happen to me. He said that it was important to go for a walk or swim every day.

 

Two thirds of the way through the tapering process I was informed by two separate neurologists that I did not have MS, it then became clear that the medication had caused the MS symptoms.

 

Regaining physical fitness became my focus after the completion of the withdrawal which took 2 years.   Gardening and farm work helped me regain upper body and arm strength while walking and gardening helped strengthen my legs.   I pushed myself even on bad days because I wanted to regain my former health.

 

The Irritable Bowel Syndrome symptoms which I had experienced for about 8 years had resulted from developing tolerance to the medication, this started improving 6 months after completion of the withdrawal.  I went from being very frail at 47 kilos to 64 kilos.  It took 2 years

 

Now over four years since the completion of my withdrawal from the benzodiazepines I am fitter than the average 65-year-old.  As an example of this transformation, compared with 6 years ago when I struggled to walk just 50 metres, this week I was able to catch 150 lambs when we were doing the docking and tagging of our lambs, last year I struggled to catch 60 lambs.

 

Unfortunately, the poor medical advice  I received while withdrawing has resulted in me developing a very severe form of Multiple Chemical Sensitivities according to the specialist.  Having MCS means that again I am forced to live in social isolation because all man-made chemicals affect me from fragrances to agricultural chemicals, essential oils to petrol and diesel.

 

It is now over four years since the final withdrawal.  My life while on Diazepam was just an existence which lacked any quality because I was so physically, emotionally and intellectually disabled by Diazepam.  I found that in the recovery phase I had to actively work at recovery even though I was tired and disillusioned.  It was also important to keep busy so as not to focus on the symptoms.

 

When I started withdrawing from Temazepam and Diazepam in October 2012 I never envisaged that I would go from being frail with wasted muscles to being fitter than the average 65 year old, nor did I envisage that I would regain the ability to think and talk normally after so many years thinking and talking so slowly.  It is also wonderful to get back to being able to be organised and efficient rather than muddling through life.

Louise's Story

Louise shares her story of recovery from benzodiazepine dependence (oxazepam and temazepam).

 

*Please note Louise is a pseudonym

 

If you’re concerned about your medication use, speak to your GP or another trusted health professional. Do not stop or reduce your medication without first speaking to a health professional as this can be potentially dangerous.

 

Not many stories begin, “I’m an 82 old recovering drug addict!”

 

This story does, but it’s really for you of any age taking medication of the class ‘benzodiazepine’. With luck, sharing my experience might help change a life or two.

 

Eight years ago I had hip replacement surgery and the discharge meds were Serepax and Normison. Prescribed for sleep. Dosage was 15mg Serepax an hour before bed and 15mg Normison on retiring. Those drugs seemed the absolute ant’s pants and my sleep was wonderful.

 

‘Serepax’ and ‘Normison’ are brand names; not a chemical. Serepax is oxazepam while Normison is temazepam. Note the name-ending ‘zepam’, which is a marker that a drug is of the class ‘benzodiazepine’.

 

There are many brand-name benzodiazepines on the Australian market and the best known is Valium (diazepam). Then there’s Euhypnos (temazepam), Murelax (oxazepam), Ativan (lorazepam) for starters.

 

I soon began to need more than a 15mg Serepax to achieve sleep, meaning that I required fresh prescriptions at shorter intervals. My GP doubled the tablet strength to 30mg and ordered double packs. No questions asked; no advice or caution offered.

 

Fast-forward six years and by an insidious process I don’t recall in detail I’m now taking 45mg of Serepax a day. And not only for sleep…I had begun to use the med in waking hours too. Facing any stress; long haul flights, SHORT haul flights, painful recovery from a fracture, sitting with gravely ill relatives, tutoring my literacy class, negotiating a messy legal matter, medical appointments…

 

Ordinary, bog-standard life-requirements made me antsy…a quiver of low-grade anxiety…but Serepax sorted that like magic. No trouble getting the tablets though as my GP wrote scripts for the asking.

 

Then in June 2016 I crashed. Hard. Following routine cataract surgery my anxiety levels went ballistic and in two weeks I developed the blackest of depression; the memory of which terrifies me to this day. I would not have believed such profound suffering possible…merciless despair that made me desperate not to draw even my next breath. I was admitted to hospital and prescribed two powerful psychotropics.

 

In an effort to discover what was behind the depression I consulted a psychologist. She helped me identify a slew of major life traumas in the months preceding my breakdown and was of the opinion that I had suffered stress overload. ‘A perfect storm’ she called it.

 

Some independent research I did uncovered another factor…benzodiazepines are a depressant. I’m now convinced that the Serepax I was medicating it with was actually driving my increasing anxiety and furthermore, that same benzo was also a catalyst for my life-threatening crash.

 

I’d been advised not to try getting off the Serepax until I was free of the others and when that time came, faced the prospect with little trepidation. How wrong I was.

 

Even though I’m now confident my benzo whacked brain is in sight of complete healing there’s no point sugar-coating the early agony. It’s said that getting off a benzo is way harder than quitting heroin and I believe it. I was lucky enough to have expert advice and good support but the early days of my taper off were pure hell. No other word for it. There are about 40 benzo withdrawal symptoms listed and although I only copped a half a dozen it was a battle to survive the early mental and physical distress even from one minute to the next.

 

I’m now 13 months into my taper and a few weeks off taking the last benzo crumb I’ll ever put in my mouth. It hasn’t been a linear recovery and there are still down times but lately the overall trajectory is UP. I’m even accepting of the warning that for a while even after you’re completely ‘off’, symptoms can stick around for a while. So be it.

 

It’s daunting to safely taper and allow yourself time to recover but the good news is that tens of thousands before you have already done it. People from 19 to 87 and who have been on benzos for six months or 40 years. You can do it too and like them, you will get your life back. The joy of that will surprise you.