Benzodiazepines are among the most prescribed tranquilizing drugs, and among the most misused and abused medications in the world. According to the DEA, their street names include “Benzos, Downers, Nerve Pills and Tranks”. Technically, they are classified as “sedative-hypnotic” drugs. Sedative-hypnotics produce a temporary reduction in your level of consciousness for the purpose of inducing sleep, feelings of calm, and feelings of tranquility.
Alcohol is widely considered the oldest sedative-hypnotic in existence, and coincidentally, alcohol works very similarly to benzodiazepines. Both are central nervous system (CNS) depressants, meaning they slow down brain activity. They also both bind to the GABA receptor in our brain and spinal cord, to open the chloride channel. What does that mean in real life? At minimum, rapid relief in anxiety and insomnia. While that sounds great in theory, it comes at a price. Similar to alcohol, if benzodiazepines are used too frequently or in the wrong population, their transient positive effects can be quickly outweighed by negative side effects and long term consequences.
The five most common benzodiazepines I see prescribed in clinical practice, with their brand names in parentheses, include: lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), and temazepam (Restoril). The DEA is in agreement with this benzodiazepines list, as they also cite these five as the most prescribed and most frequently encountered benzodiazepines in the illicit market. The first benzodiazepine, chlordiazepoxide (Librium) was discovered in 1955, and is still frequently used today. There are about thirty total types of benzodiazepines, and they are categorized according to their potency and half-life (speed at which they are eliminated from the body). Five (5) half-lives are generally needed for a drug to be eliminated from the body. Short acting benzodiazepines have a half life of 1-12 hours, intermediate is 12-40 hours, and long acting is 40-250 hours.
The benzodiazepines are also classified by their potency. The first benzodiazepines were low to medium potency. These include chlordiazepoxide (Librium) and temazepam (Restoril). Later, high-potency benzodiazepines were discovered, and were found to be more therapeutic in their effect, and have a faster onset of action. Here is a list of benzodiazepines medications according to potency and half life:
It may appear confusing that Librium is classified as having a “long half-life” at 5-30 hours, while Xanax is classified as having a short half-life at 6-27 hours. This is because some benzodiazepines (including Librium and Valium) get converted in the liver into “active metabolites”, whereas others (such as Xanax, Klonopin, Ativan) have no active metabolites. So while Librium may have a half life of up to 30 hours, one of its metabolites, “Desmethyldiazepam”, has a half life of up to 120 hours!
The strength of a benzodiazepine depends on the dose prescribed, how it is administered (by mouth or by injection) and how you define strength in “strongest benzodiazepine”. Although the benzodiazepines are classified based on potency and half-lives, a high dose, “low potency” benzodiazepine administered intravenously (through an IV in your arm) will have a much stronger effect than a low dose, high potency benzodiazepine that you take by mouth in pill form. The former may cause a previously agitated person to fall asleep within minutes; the latter may provide a mild reduction in anxiety after about one hour.
The benzodiazepines are most often prescribed for treatment of anxiety and insomnia. They produce almost immediate effects, and are ideal for short-term, intermittent, “as-needed” use for management of anxiety and insomnia. Although they won’t work quickly enough to extinguish a panic attack (a panic attack will generally peak within 10 minutes and resolve within 30 minutes), the short term effects of benzodiazepines are helpful when used prior to planned, anxiety provoking events (i.e., prior to an MRI for those with claustrophobia, or prior to a flight for those with phobia of flying).
The benzodiazepines are also widely prescribed for other reasons, such as muscle stiffness, sedation before surgery, detoxification from alcohol and other substances, and for rapid treatment of seizures. During my internship after medical school, I did several months of training in inpatient (hospital based) neurology. During this time, I gained plenty of experience in using benzodiazepines for seizures. If someone was suffering from a seizure on the medical floor, it was common for us to order an injection of several milligrams of lorazepam (Ativan) to quickly stop the seizure.
The adverse effects of benzodiazepines are similar to those of alcohol, since they both work very similarly. Risks of benzodiazepines include:
Daily, long term use of benzodiazepines is generally frowned upon in medicine. Long term benzodiazepines side effects include:
The withdrawal symptoms and timeline are similar to alcohol withdrawal. Short-term withdrawal symptoms include anxiety, increased heart rate, increased blood pressure, tremors, sweating, insomnia. The most serious acute benzodiazepine withdrawal symptoms include seizures and a phenomenon called delirium tremens, which can result in death. These more serious conditions occur if someone abruptly stops benzodiazepines after long term, high dosage use. These same conditions can occur if someone abruptly stops drinking alcohol after long-term, heavy use. Because alcohol and benzodiazepines are so similar, we actually prescribe benzodiazepines for alcohol withdrawal treatment and for benzodiazepine withdrawal treatment. The benzodiazepine withdrawal timeline corresponds to the half-life of the particular benzodiazepine being used; a shorter half-life leads to emergence of withdrawal symptoms far more quickly than a longer half-life.
The benzodiazepines are effective at quickly alleviating anxiety and insomnia. Because they are useful in the short-term and in a controlled environment, I frequently prescribe them in the hospital setting, where rapid reduction of anxiety, insomnia, and agitation are often needed. However, in the office setting, I rarely prescribe these medicines. They are too fraught with side effects–both short-term and long-term–that far outweigh their transient benefits. Situations in which I do prescribe benzodiazepines include:
If you have found that you are dependent or too reliant on benzodiazepines, and have realized that they are no longer as helpful as they once were, give us a call. I have extensive experience in comfortably and safely tapering people off of these drugs, both in the hospital and office setting. What do you have to lose? Call us for a consultation, and let us help you feel well again.