Benzodiazepines

How do benzodiazepines work?

Benzodiazepines act on the brain and central nervous system by increasing the calming effect of the brain’s naturally-occurring chemical messengers. The sedative and calming effects of benzodiazepines will relieve the symptoms of anxiety and promote sleep for most people, with few side-effects in the short term. 

It’s important to remember that benzodiazepines treat the symptoms and not the cause of anxiety and insomnia. Once medication is stopped, symptoms may return if the underlying cause of the anxiety or insomnia has not been addressed.

Benzodiazepines can be useful as a short term treatment of insomnia or anxiety, but should be used as part of a broader treatment plan involving lifestyle measures, psychological strategies or other treatments, not as the first-line or only treatment.

Benzodiazepines can be helpful drugs when used intermittently or for a short period of time only (two to four weeks). If taken for a long period of time (months or years), benzodiazepines can become less effective and there is also a high risk of becoming physically dependent on these drugs. A person who has become dependent on benzodiazepines may experience withdrawal symptoms when trying to cut down or stop taking benzodiazepines. These symptoms include insomnia and anxiety – often the very reason that the benzodiazepines were prescribed for in the first place. 

Because of the high risk of dependency, prescribing guidelines for benzodiazepines recommend no longer than two to four weeks of continuous daily use.¹

Benzodiazepines and anxiety

Research shows that psychological therapies such as cognitive behaviour therapy (CBT) are the most effective in helping people with anxiety conditions.² Anxiety conditions include panic disorder, social phobia, post-traumatic stress disorder, generalised anxiety disorder, specific phobias and obsessive compulsive disorder.

CBT is one of the most-researched psychological therapies and there is a lot of evidence to support its effectiveness in treating people who have anxiety and/or depression. It involves teaching people about their condition, providing relaxation strategies, as well as helping people to think realistically about common difficulties. This helps them to change their thought patterns and the way they react to certain situations. Behavioural therapy approaches, such as exposure therapy, have also been shown to be very helpful for many anxiety conditions.

If medication is required, specific antidepressants can be more appropriate than benzodiazepines in helping reduce the symptoms of anxiety.

Antidepressants do not carry the same risk of dependency as benzodiazepines. However, they are only effective in some anxiety conditions and generally, are less effective than psychological treatments.

Benzodiazepines and older people

In addition to the risks of dependency, when older people take benzodiazepines long-term, they are vulnerable to problems including:

• over-sedation
• increased risk of falls
• impaired blood pressure regulation
• exacerbation of respiratory conditions
• nocturnal incontinence
• problems thinking clearly.

Because of these risks and the concern about interactions with other medications, benzodiazepines should rarely be used for older people (over 65 years). 

Benzodiazepines and sleep

Benzodiazepines can be useful, occasionally, to induce sleep, but they have a limited role in helping people with established sleep problems. People who have taken sleeping pills for long periods of time actually have worse sleep patterns, with less time spent in the deep phase of sleep and more frequent waking during the night.

People who have been taking sleeping pills for a long time can experience acute insomnia as a withdrawal or ‘rebound’ symptom, when they try to cut down or stop taking the pills. This ‘rebound’ insomnia can be misinterpreted as evidence that the sleep problem is still present, and the person may resume taking the benzodiazepines in the mistaken belief that they're unable to sleep without them.

Zolpidem and zopiclone are newer sleeping pills are available on prescription that are not benzodiazepines. Short-term use (no longer than two to three weeks) is also recommended for these drugs because of the risk of dependency. Over-the-counter sleeping pills should also be used only for a short period of time.

Benzodiazepines and other sleeping pills don’t address the reasons for insomnia. The cause of insomnia needs to be assessed accurately by a general practitioner (GP). Most chronic insomnia is the result of poor sleeping patterns that have developed over a number of years. Research shows that for common sleep problems, behavioural treatment strategies are more effective long-term than any sleep medication. For more information visit sleeping well.

Benzodiazepines and side effects

Benzodiazepines are generally safe to use. However, like all medications they can produce unwanted effects. Benzodiazepines can reduce alertness and affect coordination and reaction time, so the person may take longer to complete tasks or be at increased risk of falls or accidents. Benzodiazepines can also lower inhibitions and make some people more impulsive and likely to take risks, particularly if these medications are mixed with alcohol or drugs.

Pregnancy and breastfeeding

It's generally best to avoid or limit the use of benzodiazepines during pregnancy and while breastfeeding, and use them intermittently or for short periods under medical supervision if they're necessary – for example for the treatment of severe anxiety during pregnancy.

While recent studies have found no evidence of an increase in birth defects resulting from the use of benzodiazepines during pregnancy, no conclusions have been drawn regarding long-term brain development of the baby. Furthermore, the use of benzodiazepines during pregnancy may increase the risk of pre-term birth and low birth weight.

Babies of mothers who have taken moderate to large doses of benzodiazepines during pregnancy may have withdrawal symptoms following birth. Pregnant women using benzodiazepines are advised to withdraw slowly before delivery, in consultation with a specialist health professional. Most maternity hospitals have special units which can provide assistance.

Breastfeeding while taking benzodiazepines may cause lethargy and poor feeding in the infant. Mothers taking benzodiazepines and planning to breastfeed are advised to consult their doctor or maternal and child health nurse. 

Benzodiazepine dependency

Benzodiazepines are potentially addictive drugs. Not all people taking benzodiazepines long-term develop a dependency, but the risk increases the longer a person has been taking the drug. Dependence can develop within a few weeks to months of continuous use. Dependence means that people will experience withdrawal symptoms when cutting down or stopping their benzodiazepine dose.^3,4

How can you tell if someone is dependent on benzodiazepines?

People may be dependent on benzodiazepines if:

• they have taken a tranquilliser or sleeping pill for four months or longer 
• they feel they cannot cope without taking benzodiazepines
• they have cut down or stopped taking benzodiazepines and have felt ill, anxious or experienced unusual symptoms as a result
• they feel the medication is not having the same effect as when they first started taking it
• they take an extra pill during a stressful time
• they experience increasing discomfort close to the time of their next pill
• they have tried to cut down or stop taking benzodiazepines and could not sleep
• they have increased their dose
• they have increased their alcohol intake
• they always make sure they never run out of benzodiazepines
• they carry their benzodiazepines with them ‘just in case’
• the benzodiazepines are interfering with their lives in some way, for example, time off work, family or relationship problems, difficulty coping, difficulty remembering things.

If two or more of these statements apply to a person, he or she can seek further information from a GP, another health professional or contact Reconnexion. (Reconnexion is a not-for-profit organisation providing counselling and support for people dependent on benzodiazepines.)

Withdrawal from benzodiazepines

People who have been taking benzodiazepines for many years can have symptoms of withdrawal most of the time, even when they have not reduced the dose. Often they are unaware that their poor physical and mental health is related to their long-term use of benzodiazepines.

Not everyone who cuts down or stops taking benzodiazepines has withdrawal symptoms and the experience of withdrawal varies from person to person. Some people have a few weeks of discomfort only, while others experience severe symptoms, often for months on end. The range and severity of symptoms can often take people by surprise and for many, the intensity of benzodiazepine withdrawal can be overwhelming.

What are the symptoms of withdrawal?

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
• loss of appetite
• seizures (may occur with sudden and complete stopping of benzodiazepines).

How long does withdrawal last?

Usually, the length of time a person has been taking benzodiazepines, or the amount he or she has been taking, will determine the time it takes for withdrawal symptoms to pass. Slowly reducing the dose of the drug minimises the severity of withdrawal symptoms. Improvement occurs gradually, with more symptom-free days occurring and symptoms reducing in severity and number. Once through the withdrawal period, most people recover completely.

How to come off benzodiazepines

For a variety of reasons, many people find that they have been taking benzodiazepines for a lot longer than the period recommended as being safe.

In consultation with a GP, a reduction program can be developed to reduce the benzodiazepine dose by small amounts, thus minimising withdrawal symptoms.

It is strongly recommended that people don’t go ‘cold turkey’ (i.e. stopping benzodiazepines immediately and altogether). It's possible to have a withdrawal seizure or fit as a result of doing so. If a person stops taking benzodiazepines suddenly, they can be overwhelmed with severe withdrawal symptoms.

Stopping medication should only be done gradually, on a doctor’s recommendation and under supervision. It is generally recommended that people who are taking benzodiazepines and who wish to come off the drug should reduce the dose by small amounts on a weekly or fortnightly basis, on the advice of their doctor – even if after only a few weeks of benzodiazepine use.

Sticking to a plan to reduce benzodiazepines slowly allows the body and mind to adjust to each level and gradually return to normal.

References

1 Rossi, S. (Ed.) (2009). Australian Medicines Handbook 2009. Adelaide: Australian Medicines Handbook

2 Andrews, G. (2003). The treatment of anxiety disorders: clinician guides and patient manuals. 2nd ed. Cambridge, UK: Cambridge University Press.

3 Woods, J., Katz, J. & Winger, G. (1992) Benzodiazepine: use, abuse and consequences, Pharmacological review, 44, vol.2:151-347.

4 Ashton H (2005) The diagnosis and management of benzodiazepine dependence. Current Opinion in Psychiatry 18:249–255