Benzodiazepine Addiction

Benzodiazepines belong to a class of drugs called central nervous system depressants. They are prescription sedatives, hypnotics, tranquilizers, and anxiolytics. Benzos, as they are commonly called, promote calmness, induce sleep, and reduce anxiety. They are prescribed for a wide range of medical conditions, including insomnia, anxiety disorders, panic disorders, social phobia, seizure disorders, alcohol use disorders, and pre-treatment before certain procedures.

While they have legitimate medical uses, benzodiazepines are also widely abused. These drugs are habit-forming. Taking them without a prescription or for recreational purposes puts you at risk of developing a benzo addiction. Even if benzodiazepines have been prescribed by a healthcare provider, taking them in any way other than how they were prescribed can lead to a physical and psychological dependence.

If you or a loved one is struggling with benzo addiction, call our 24/7 helpline.

What are Benzodiazepines?

Benzodiazepines are central nervous system (CNS) depressants. CNS depressants are drugs that slow brain activity and nerve signal transmission between the brain and the body. Benzodiazepines increase the activity of a natural chemical called gamma-aminobutyric acid (GABA) in the brain. GABA promotes relaxation, and at larger doses, has sedating effects, causing drowsiness and calmness.

Benzodiazepines such as alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan) are commonly used to treat anxiety disorders. They are also sometimes prescribed to people with insomnia, seizures, and those going through alcohol withdrawal. In addition, benzodiazepines are used to relieve anxiety before certain medical procedures. These medications are typically prescribed for short-term use due to the risk of dependence.

In addition to legitimate medical uses, benzodiazepines are commonly misused and abused for their calming effects. They are sold on the street as benzos, sleepers, downers, xannies, tranks, moggies, normies, serras, and nerve pills. Some people swallow the pills whole while others crush and snort them. Misusing prescription benzodiazepines or abusing benzos obtained from drug dealers carries a high risk of serious and even fatal effects, including overdose and death. ^[1]

In the United States, central nervous system depressants such as benzodiazepines are classified as Schedule IV Controlled Substances by the Drug Enforcement Administration (DEA). This classification means these drugs have a known potential for abuse and addiction, but they are relatively less harmful than Schedule I drugs such as cocaine, heroin, LSD, and MDMA; Schedule II drugs such as prescription opioid pain killers; and Schedule III drugs such as anabolic steroids and testosterone. ^{[2] [3]}

Benzodiazepines: A Brief History

The first benzodiazepine, chlordiazepoxide (Librium), was developed incidentally by an Austrian scientist, Leo Sternbach, while working with Hoffmann–La Roche in New Jersey in 1956. He later went on to develop another benzodiazepine, diazepam (Valium), in 1963. ^[4]

Benzodiazepines thus first became available in the United States in the 1960s. They quickly became popular because of their improved safety profile compared to older drugs such as barbiturates. In particular, benzodiazepines were associated with a lower risk of respiratory depression (slowed breathing), a lower potential for abuse and addiction, and a lower suicide potential. ^[5] Diazepam, specifically, was widely prescribed between the late 1960s and early 1980s. At its peak in 1978, over 2.3 billion doses of diazepam were sold. ^[6]

Some two decades after benzodiazepines were first introduced, scientists began to better understand their mechanism of action. At the same time, clinicians began discovering the potential for benzodiazepine abuse and addiction. However, as prescription drug abuse in the United States grew, the focus largely remained on prescription opioid abuse, with benzodiazepines relegated to the back burner.

Nonetheless, given the growing concerns about benzo addiction, in 1975, benzodiazepines were placed on the FDA’s list of restricted drugs. ^[7] To this day, benzodiazepines remain one of the most frequently prescribed classes of medications in the United Sates despite the known risk of addiction and the availability of safer alternatives. ^[8]

In 2019, an estimated 92 million benzodiazepine prescriptions were dispensed in the US, with alprazolam being the most common (38%), followed by clonazepam (24%) and lorazepam (20%). In 2020, to improve the safe use of benzodiazepines, the FDA issued an update to the Boxed Warning, the agency’s most serious safety warning, requiring labeling changes on all drugs in this class to include the risks of misuse, abuse, addiction, physical dependence, and withdrawal effects. ^[9]

Benzodiazepine Prescription Statistics in the United States

Surveys conducted between 2014 and 2016 found that benzodiazepines were prescribed at 27 out of every 100 office visits with healthcare providers. ^[10] A study of more than 385,000 ambulatory care visits from 2003 to 2015 found that benzodiazepine prescriptions increased substantially from less than 4% to nearly 7.5%. Psychiatrist prescriptions accounted for roughly one third of these prescriptions. ^[11] Other studies have found that between 1996 and 2013, the percentage of American adults filling benzodiazepine prescriptions increased from roughly 4% to more than 5.5%. At the same time, the overdose death rate increased from about 0.6 per 100,000 to more than 3.0 per 100,000, although fortunately, this figure plateaued after 2010. Benzodiazepines were involved in around 7,000 overdose deaths per year as of 2013. ^[12]

Between 1996 and 2013, the number of benzodiazepines dispensed in the US increased by 67% to 135 million prescriptions per year. At the same time, the quantity prescribed per patient more than tripled. Fortunately, the trend in benzodiazepine prescriptions has been encouraging in more recent years. In 2019, approximately 92 million benzodiazepine prescriptions were dispensed from US pharmacies. ^[13]

Increasing Prevalence of Benzodiazepine Abuse and Overdose Deaths

Data from the National Survey on Drug Use and Health (NSDUH) 2022 showed that nearly 4 million people (1.5% of the population) reported past year misuse of prescription benzodiazepines, including approximately 200,000 adolescents between the ages of 12 and 17 years and approximately 800,000 young adults between the ages of 18 and 25 years. ^[14] Women are twice as likely as men to be prescribed benzodiazepines. Also, people who are prescribed opioids are significantly more likely to be prescribed benzodiazepines.

US data tracking of the total number of overdose deaths involving benzodiazepines from 1999 to 2021 shows that drug overdose deaths involving benzodiazepines increased steadily from 1,135 in 1999 to 11,537 in 2017, declined to 9,711 in 2019, and increased again to 12,499 between 2019 and 2021. ^[15] 

These numbers are disturbing because benzodiazepine addiction can develop quickly, over a matter of days to weeks in some cases. Withdrawal symptoms can make it difficult for a person to quit benzo use. In people misusing or abusing these drugs, benzodiazepine overdoses can be fatal.

What Is Benzodiazepine Addiction?

Although benzodiazepines have several legitimate medical uses, some people misuse them and develop an addiction (dependence) on these drugs. The term used by the mental health community to describe benzodiazepine addiction is hypnotic, sedative, or anxiolytic use disorder. Misuse of benzodiazepines means:

• Taking the medication in a manner or at a dose or frequency other than prescribed
• Taking someone else’s benzodiazepine medication
• Taking benzodiazepines for recreational purposes (to get high)

Nearly half of all people who misuse benzodiazepines say their motivation for prescription drug misuse is to relieve tension and relax. A substantial number (roughly 22%) misuse benzodiazepines to self-treat sleep problems. About 12% of drug abusers say they use benzodiazepines to “get high” or because they are “hooked”. About 10% of users take benzos to help with emotions. Just under 6% of benzo misusers say they take these drugs to experiment. The majority of people who abuse or misuse benzodiazepines get the drugs from friends or relatives. Only 20% or so get them from physicians. ^[16]

Recognizing Benzodiazepine Addiction

Some of the warning signs of benzodiazepine addiction include:

• Taking the drug at higher doses or more frequently or for a longer time than prescribed.
• Spending considerable time trying to obtain benzodiazepines, using them, and recovering from their effects.
• Experiencing withdrawal symptoms or cravings when benzodiazepines are not available.
• Needing larger quantities or higher doses of benzodiazepines to achieve the desired effects.
• Experiencing impaired performance at work/school or neglecting home and family responsibilities.

Commonly Prescribed Benzodiazepines

More than a dozen benzodiazepines are currently FDA-approved in the United States. Benzodiazepines are categorized according to the duration of their effects. ^[17]

• Short-acting benzodiazepines, for example, midazolam (Versed), clorazepate (Tranxene), and triazolam (Halcion) produce effects lasting for 3–8 hours.
• Intermediate-acting benzodiazepines, for example, alprazolam (Xanax), temazepam (Restoril), and lorazepam (Ativan) produce effects lasting for 10–20 hours.
• Long-acting benzodiazepines, for example, diazepam (Valium), clonazepam (Klonopin), and chlordiazepoxide (Librium) produce effects lasting for 1–3 days.

Legitimate Uses of Benzodiazepines

Commercially available benzodiazepines in the United States are marketed as anti-anxiety drugs and sedative-hypnotics. It is worth noting, however, that all benzodiazepines have both sedative and anti-anxiety properties. Some of the FDA-approved indications for benzodiazepine prescriptions include: ^[18]

• Anterograde amnesia in patients undergoing surgery (such that patients do not remember events while under the influence of the drug)
• Preoperative anxiety and apprehension
• Anxiety disorders
• Panic disorders
• Insomnia
• Muscle spasms
• Seizure disorders and status epilepticus
• Withdrawal from acute alcoholism

Alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan) are commonly prescribed for anxiety disorders. Estazolam (ProSom), flurazepam (Dalmane), temazepam (Restoril), and triazolam (Halcion) are used to treat insomnia. Midazolam (Versed) is used for sedation, anxiety, and amnesia in critical care
settings. Midazolam (Versed) and diazepam (Valium) are used in anesthesia. Clonazepam (Klonopin) and clorazepate (Tranxene) are used to treat seizure disorders. Diazepam (Valium) is used as a muscle relaxant. Chlordiazepoxide (Librium) is used in patients undergoing alcohol withdrawal.

Effects of Benzodiazepine Abuse

People who misuse or abuse CNS depressants such as benzodiazepines or are addicted to them can develop a range of physical and behavioral signs and symptoms. ^[19]

Physical Symptoms of Benzodiazepine Abuse

• Anxiety and depression
• Confusion
• Drowsiness
• Dizziness
• Impaired coordination
• Tremors
• Slurred speech, stuttering
• Sleepiness
• Fatigue
• Weakness
• Dry mouth
• Vision problems such as double vision or blurred vision
• Poor concentration, memory problems, impaired thinking
• Slowed breathing
• Low blood pressure
• Diarrhea, constipation, nausea, loss of appetite

Behavioral Signs of Benzodiazepine Addiction

• Personality changes
• Mood swings, such as hostility or aggression
• Lethargy
• Lack of motivation
• Changes in sleeping habits, unusual or disturbing dreams
• Poor decision-making

Risk Factors for Benzodiazepine Addiction

Most people take benzodiazepines as prescribed. However, a small percentage of people misuse CNS depressants like benzodiazepines by taking them in a way that is not authorized by the prescribing physician. For example, someone may use a larger dose of benzos to cope with the symptoms of anxiety or insomnia. Any unauthorized escalation of benzodiazepines to higher doses puts users at risk of developing a dependence or addiction to these drugs.

Clinicians are aware of these risks and remain vigilant for signs of self-medication with benzodiazepines. Repeated requests for early refills are a warning sign of benzodiazepine addiction and will raise suspicion.

The overall potential for addiction to benzodiazepines is low in the general population. However, certain subsets of the population are at higher risk for benzo abuse. There is no single cause for benzo addiction. A number of factors can increase the likelihood of developing an addiction. These include:

• People with a personal or family history of substance use disorders
• Having another mental health condition (especially untreated)
• People with a history of alcohol use disorder and antisocial personality disorder
• Young adults 18 to 35 years old
• Being socially isolated, lonely, or having no social support system
• Relying on the medication to cope, relax, or numb emotions
• Experiencing high levels of stress or a traumatic life event

Other High-Risk Groups for Benzodiazepine Abuse

One group of individuals that is at a particularly high risk of benzodiazepine abuse and addiction is people receiving opioid replacement therapy with buprenorphine or methadone. In methadone replacement patients, for example, the prevalence of benzodiazepine abuse is as high as 66% (lifetime) and 50% (current). Similarly, 67% of buprenorphine patients report concurrently taking benzodiazepines. Experts believe that the psychological distress, sleep disturbances, and withdrawal symptoms experienced by people receiving opioid addiction treatment makes them vulnerable to high rates of benzodiazepine abuse and addiction. What’s more, many people are under the misconception that benzodiazepines are not dangerous.

Certain groups of people are at a higher risk of the negative consequences of benzo abuse. Benzodiazepines are generally not recommended in women who are pregnant or breastfeeding, as they can lead to pre-term delivery, low birth weight, and birth defects.

In addition, benzodiazepines can be particularly dangerous in people with respiratory conditions such as asthma, sleep apnea, and emphysema as well as advanced liver disease or kidney disease. In elderly people, benzodiazepines should be prescribed with caution, as they can increase the risk of falls and injury.

Benzodiazepines and Polydrug Use

Prescription drugs like benzodiazepines are especially dangerous when they are misused in combination with other substances, such as other prescription drugs, over-the-counter medications, alcohol, or illegal street drugs.

It is very common for benzodiazepines to be abused in conjunction with other drugs. A relatively small number of drug users report benzodiazepines as the primary drug of abuse. For the majority of drug users, benzodiazepines are a secondary drug of choice. In other words, benzodiazepines are often used to enhance the euphoric effects of other drugs. Sometimes, benzodiazepines are used to reduce the unwanted effects of other drugs, for example, insomnia due to stimulant abuse. They may also be used to alleviate withdrawal symptoms. Studies show that people who abuse benzodiazepines in combination with other drugs tend to use much higher doses compared to people who abuse benzodiazepines alone. This is worrisome because the risks of health complications and death multiply with polydrug use.

The most common drugs with which benzodiazepines are abused include opioids (55%) and alcohol (25%). ^[20]

Approximately 1 in 5 people with alcohol use disorder also abuse benzodiazepines. Alcohol is involved in 1 in 4 emergency department visits related to benzodiazepine abuse. People who use benzodiazepines in addition to opioids have a 15 times higher risk of drug-related death compared to people who do not use either drug. Opioids and benzodiazepines are the two most common prescription drugs involved in overdose deaths.

Polydrug abuse involving benzodiazepines is extremely dangerous. Benzodiazepines themselves are weak depressants of the respiratory system. However, significant and potentially life-threatening or fatal respiratory depression can occur in polydrug abusers who take benzodiazepines in combination with alcohol, opioids, or other CNS depressants.

Addiction Potential of Different Benzodiazepines

More than a dozen different benzodiazepines are FDA-approved in the United States. Each of these drugs has a variable risk of abuse and addiction based on differences in pharmacokinetics (how the drugs move through the body). In general, benzodiazepines with a shorter half-life (duration of action) appear to have greater potential for abuse and addiction. ^{[21] [22]} Based on research studies, the experience of medical professionals, and testimonies of drug abusers, diazepam has the highest abuse liability among the various benzodiazepines.

Moreover, among drug users who use benzodiazepines recreationally, i.e., to “get high,” diazepam, lorazepam, and alprazolam are rated higher than other benzos. Among these three, diazepam is rated higher than lorazepam and alprazolam. However, alprazolam (Xanax) is the most highly prescribed benzodiazepine in the US and also the most commonly involved benzodiazepine in ED visits related to drug abuse.

Safe Use of Benzodiazepines

Because of the high risk of abuse and addiction, benzodiazepines are not usually recommended for long-term or regular use. They are effective drugs for the short-term treatment of generalized anxiety disorder, panic disorder, and insomnia, but their long-term use carries a risk of physical dependence and addiction. These medications can be helpful in reducing acute anxiety (for example, occasional panic attacks, fear of flying, or dentistry procedures) but they are not recommended for long-term treatment of chronic anxiety.

People with anxiety can quickly become reliant on benzos because they work quickly and effectively, seeming to offer a ”magic” cure for anxiety. Unfortunately, the benefits decrease with repeated and regular use. A person overusing these medications to treat anxiety also does not gain the skills or confidence to manage their anxiety. This can even lead to an increased dependence on medication. Benzodiazepine treatment of anxiety is therefore always recommended in conjunction with psychotherapy to help people develop the skills they need to manage their condition long-term.

Prevention of Benzodiazepine Addiction

People who are abusing benzodiazepines and are addicted to these drugs obtain them from various sources. The most common sources of benzodiazepines include:

• Friends and relatives
• Regular physicians
• Script doctors (healthcare providers who sell prescriptions)
• Doctor shopping (going to multiple providers to obtain multiple prescriptions)
• Pharmacy diversion (employee theft, undercounting of pills by pharmacy staff)

Doctors carefully monitor benzodiazepine use in high-risk individuals, such as those with a personal or family history of substance abuse. To reduce the risk of benzodiazepine addiction, healthcare providers issue prescriptions for 1–2 weeks’ supply and offer refills only at follow up visits. They also monitor patients for signs of benzo abuse. Prescription monitoring programs are in place to ensure patients do not obtain benzos from multiple sources (doctor-shopping or pharmacy-diversion). Pharmacy shoppers and doctor shoppers are at 4–5 times higher risk of escalation of doses, benzodiazepine addiction, and overdose deaths.

Urine drug screening for benzodiazepines is complex because one benzo is often the metabolite of another. For example, temazepam is a metabolite of diazepam. Therefore, the presence of temazepam in the urine could lead to the (wrong) conclusion that a patient has been using other benzodiazepines during diazepam treatment. ^[23]

Benzodiazepine Withdrawal

Benzodiazepines are an effective short-term treatment for many medical conditions. However, anyone who uses benzodiazepines for more than 3–4 weeks has a high likelihood of developing withdrawal symptoms if the dose is reduced too quickly or use of the drug is stopped abruptly. Withdrawal symptoms and severe cravings also occur in people who have developed a physical dependence or addiction to benzodiazepines.

Benzodiazepine withdrawal symptoms include both physical and psychological effects. These effects can begin within a few hours of the last dose and tend to be similar to the person’s original problems. For example, a person who was prescribed benzodiazepines for anxiety may experience a return of anxiety symptoms. Additional clinical features of benzodiazepine withdrawal syndrome can include:

• Headache
• Sweating
• Palpitations
• Tremor
• Nausea
• Loss of appetite
• Diarrhea
• Muscle pain and stiffness
• Dizziness, lightheadedness, unsteadiness
• Shooting pains in the neck and spine
• Blurred vision, double vision
• Ringing in the ears
• Confusion, disorientation
• Delirium
• Delusions, paranoia, hallucinations
• Seizures
• Poor memory
• Irritability, agitation, restlessness

To prevent or reduce benzodiazepine withdrawal symptoms, it is important to gradually taper the dose of the drug over several weeks, rather than stopping it all of a sudden. Medically supervised withdrawal allows people to come off benzos safely and comfortably. Medications, such as flumazenil, can help patients rapidly withdraw from benzodiazepines to lower doses and ultimately to abstinence. However, these treatments can be associated with side effects and should only be undertaken in specialized addiction treatment units.

Benzodiazepine Overdose

A benzodiazepine overdose can be intentional or unintentional. The risk for overdose greatly increases when these medications are combined with other drugs with sedative properties, including opioids, barbiturates, and alcohol.

Benzodiazepines are relatively safer in that when they are taken at toxic doses without other drugs, they rarely cause significant effects. Patients with a classic single-drug benzodiazepine overdose typically present with central nervous system depression and near-normal vital signs. Some of the typical symptoms of benzodiazepine overdose include: ^[24]

• Slurred speech
• Ataxia (stumbling, falling, incoordination)
• Altered mental status
• Slowed breathing (common when benzodiazepines are combined with other CNS depressants)
• Coma and death (in cases of severe toxicity)

If you suspect someone has overdosed on benzodiazepines, call 911 immediately. Drug overdoses are medical emergencies. Prompt medical attention is necessary to prevent health complications, permanent damage, and death.

Getting Help for a Benzodiazepine Addiction

Any addiction disorder can cause pain, suffering, health problems, and even life-threatening complications. It is important to know that no matter how severe your addiction, there are ways to reverse the course of the disease.

Seeking professional help greatly increases your likelihood of successfully stopping benzo use. Call our helpline today for more information on available treatments, or even just to discuss your current challenges with addiction.

Remember, if you believe you are addicted to benzodiazepines, do not abruptly stop using them on your own, as doing so could be dangerous and even life-threatening. Contact a doctor, addiction treatment center, or inpatient hospital for help if you are experiencing signs of benzodiazepine withdrawal.

Last updated: February 29, 2024