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Key points
- Benzodiazepines are often prescribed for anxiety and sleep, but have numerous side effects and risks.
- Short-term use is usually safe, but tolerance, physical dependence, and addiction can set in fast—and once they do, they are hard to stop.
- With psychological support, people are twice as likely to succeed, and counseling may work better than add-on medication.
Benzodiazepines are some of the more commonly prescribed medications in the world. Lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax) are examples of medications classified as benzodiazepines. Z-drugs are similar in their pharmacology—they also bind to and activate the brain’s benzodiazepine receptors±and include zolpidem (Ambien) and eszopiclone (Lunesta).
Although benzodiazepines and Z-drugs are useful therapeutic agents, often prescribed for sleep disorders, muscle spasms, anxiety, and seizure, they are ideally used only on a short-term basis because they are notoriously habit-forming. Unfortunately, many people end up on them long-term—up to 15 percent of people, studies say.
After as little as two weeks after someone starts using them daily, tolerance and potential for withdrawal set in. With tolerance, the medication's therapeutic effect weakens, and people need to take higher and higher doses to achieve relief. If people stop these medications suddenly, withdrawal can occur, and symptoms include anxiety, panic, and insomnia.
In severe cases, benzodiazepine and Z-drug withdrawal can be life-threatening, causing seizures and hallucinations. It’s no wonder that many people who make an attempt to stop quickly give up the fight, resigning themselves to being on them long-term.
About Benzodiazepines and Z-Drugs: The Good and the Bad
These medications work by activating benzodiazepine receptors in the brain. If they are used for brief time periods, they can be very helpful for the problems they are designed to treat, like insomnia or panic.
However, they can also come with a whole host of problems. Common side effects include slurred speech, memory loss, confusion, sleepiness, and increased fall risk. Car accidents from slowed reaction time or over-sedation can occur. If people become tolerant, and as the dose is increased to get more therapeutic benefit, the side effects get worse, too. Some people even start to crave these medications and use more than prescribed or develop an addiction to them.
In the elderly, these medications can be downright dangerous. Several major psychiatric and medical organizations have put out society guidelines advising against their use in older adults, because they increase the risk of hip fracture, worsen the risk of dementia, and increase confusion, to name a few.
In people with co-occurring substance use disorders, they are also very risky. Benzodiazepines and Z-drugs interact with opioids and other sedating drugs, and their combination perpetuates overdose and death.
There are many reasons long-term benzodiazepine or Z-drug users are counseled to stop. Because of the risk of side effects in aging brains, anyone over 65 should do what they can to stop these medications. If people develop an addiction to alcohol, illicit drugs, or the benzodiazepine itself, they may also be instructed to taper off, even if they've been on them long-term and still suffer from the condition that prompted them to start the treatment.
But here's the rub—by nature of the fact that they cause tolerance, withdrawal, and addiction, stopping is often much easier said than done. Success rates of getting off are low: less than a sixth of people were able to stop in patients getting usual care in a UK study, where people were simply given instructions by their primary care doctor on how to slowly taper off.
Study Findings
Clearly, we need to know more about how to make the stopping process, also called "deprescribing," easier. Slowing the rate of the off-taper, with dose reductions as slow as 10 to 25 percent of the dose every two to three weeks; medication-based support by prescribing alternate medications; and psychological support, such as cognitive-behavioral or supportive therapy, are all being explored.
A new study wanted to find out whether supportive therapies, on the whole, would improve the success rates of stopping long-standing (more than four weeks), daily benzodiazepine or Z-drug use—something that hadn’t yet been measured. To do so, researchers pooled results from several published clinical trials and performed a metanalysis.
What they found was that adding supportive therapy to a slow taper (in this study, 10 to 50 percent dose reduction at a time over four to 12 weeks) doubled people’s chance of stopping by four weeks (risk ratio of 2) and tripled their chances at longer than four weeks (risk ratio 3). Three-quarters of the group getting support were able to stop at four weeks, and almost half of the sample was still off the medications at long-term follow-up.
Surprisingly, medication-based support—with melatonin, paroxetine, and/or switching to a different benzodiazepine—was helpful in the short-term for getting people off, but did not have a significant effect at long-term follow-up compared to standard care.
What Psychological Support Looks Like
So what was the nature of the psychological support? Several of the studies utilized cognitive-behavioral therapy-based interventions (Gosselin 2006, Voshaar 2003, Baillargeon 2003), whereas two others used a more simple intervention involving education, reassurance, and an individualized taper plan administered by trained providers plus (Vincens 2006) or minus (Vincens 2014) bi-weekly followup. In summary: The support techniques were straightforward.
One weakness of the study was that most of the patients included did not have other mental health comorbidities like dementia, severe psychiatric disorder, or substance use disorder, nor did most patients use other psychoactive medications. People with mental health problems may end up needing more intensive treatment, but as of now their rates of successful stopping with or without psychological support are not known.
Takeaways
For those of us working in the mental health field, it may not be surprising to hear that psychological support makes a big difference. However, studies like these are important as they establish that what we do works. People wanting or needing to stop benzodiazepines can do it with appropriate help—and it may just take a handful of visits with a trained primary care provider or mental health provider.
As a culture, we need to be careful to minimize our use and prescription of benzodiazepines and Z-drugs, using them only when absolutely necessary. Doing so will save lives, reduce morbidity, and lessen costs to healthcare systems.
