The Benzodiazepines

I get lots of questions regarding the benzodiazepine class of antianxiety drugs. So here’s an article addressing benzodiazepine actions, clinical uses, advantages, disadvantages, side effects, withdrawal and new information regarding onset parameters associated with physical dependence.

anxiety-discussionBenzodiazepines act throughout the central nervous system and have muscle relaxation, sedative, anxiolytic and anticonvulsant effects. As a class, they enhance the actions of GABA (gamma-aminobutyric acid), which blocks the rapid release of stress hormones associated with anxiety and panic, providing a dissociative or numbing effect on anxiety. The issue of what a user wants these drugs to do and for how long is particularly paramount because psychological or physical dependence concerns lurk in the shadows. Benzodiazepines are more similar than they are different. Prescriber decisions about which benzodiazepine to use are typically based on the anxiety disorder being treated, as well as on the onset of action and rate of elimination of the agent. For example, in the treatment of generalized anxiety disorder, longer half-life benzodiazepines, such as Valium (diazepam) and Klonopin (clonazepam), are often the drugs of choice due to their longer duration of action.

Librium (chlordiazepoxide) was the first benzodiazepine to reach the U.S. market. Three years later it was followed by Valium (diazepam). Today, benzodiazepines like Xanax (alprazolam) and Ativan (lorazepam) are frequently the drugs of choice for the treatment of panic disorders. That’s because they work fast enough to manage the acute symptoms of panic – such as racing pulse and shortness of breath – yet long enough to control the residual anxiety symptoms that typically fuel the concern and worry about future attacks. Benzodiazepines, when used short term, can be particularly effective in managing adjustment disorders with anxious mood, such as a recent job loss, death of a close friend or family member, or a recent divorce. These medications also treat insomnia and have anticonvulsant properties, relax skeletal muscle, treat alcohol withdrawal and sometimes treat the side effects of antipsychotics.

Whether or not benzodiazepines cause cognitive side effects (verbal learning, speed of thinking, etc.) is controversial. A meta-analysis has concluded that these agents do influence cognitive dysfunction during treatment, and that although cognitive function improved upon discontinuation of the benzodiazepine, it did not return to the level of functioning observed in the control groups not taking benzodiazepines.

pros-consBenzodiazepine Advantages:

  1. Very safe in overdose.
  2. Generally, onset of action is quick.
  3. Users are quite compliant with taking them.

Benzodiazepine Disadvantages:

  1. All of them influence tolerance and dependence.
  2. Sedative effects can be dangerous when combined with other anxiolytics or central nervous system depressants like alcohol.
  3. Can cause impairment similar to intoxication (slurred speech, poor judgment resulting from inhibition).

Rapid Onset Agents:

  1. Valium (diazepam)
  2. Tranxene (clorazepate)
  3. Dalmane (flurazepam)

Intermediate Onset Agents:

  1. Librium (chlordiazepoxide)
  2. Xanax (alprazolam)
  3. Ativan (lorazepam)
  4. Halcion (triazolam)

Slow Onset Agents:

  1. Klonopin (clonazepam)

Physical Dependence Onset Parameters:

  1. Valium (diazepam): 15mg daily for 90 days
  2. Xanax (alprazolam): 1.5mg daily for 45 days
  3. Ativan (lorazepam): 6mg daily for 60 days

Withdrawal symptoms of benzodiazepines include: marked anxiety; poor concentration; muscle pain; perceptual disturbances (“a body disconnected from mind” type of experience) and seizures.

Dependence is linked to a marked preoccupation with procuring the drug, concomitant craving, compulsive use tendencies and frequent relapse in spite of repeated, often adverse consequences.

Successful tapering of benzodiazepines should be done very slowly. Those following a slow, steady withdrawal sequence — extending over a period of 3-4 months — have the best chance of discontinuing these drugs altogether. Each stage in the tapering process is accompanied by its own attendant challenges with users often reporting that they feel worse each time dosing is decreased.

Many believe that when the taper is finally complete they will feel just awful and unable to function. In truth, just the opposite happens, in that virtually everyone feels better upon discontinuation — free from the constraints of turning over control to a drug to manage anxiety that only they themselves could get under control, and free from feeling sedated and having cloudy thought processes.

Benzodiazepines have helped millions of people navigate their way through short or intermediate-term anxiety, and they’re not to be feared if taken responsibly.


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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

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