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 host of medical conditions, such as insomnia, anxiety, and panic disorders. If you or a loved one is struggling from benzo addiction, call our 24/7 helpline.

Substance Overview: Benzos

Legality

Available under prescription

Cost

$5–$10 per pill on the street

Annual deaths

7,000

Side effects

Slurred speech, stuttering, slowed breathing, low blood pressure

Also known as

benzos, sleepers, downers, xannies, tranks, moggies, normies, serras, nerve pills

What are Benzodiazepines?

Benzodiazepines are central nervous system (CNS) depressants. This means they slow down brain activity and the transmission of messages between the brain and the body. That’s why benzos are useful for treating acute stress reactions, sleep disorders, anxiety, panic, and muscle spasms. Other substances that are also CNS depressants include sedative-hypnotics like zolpidem (Ambien), and barbiturates like phenobarbital (Luminal). 1 Taking benzodiazepines simultaneously with other CNS depressants can be particularly dangerous.

Benzodiazepines increase the activity of a chemical called gamma-aminobutyric acid (GABA) in the brain. This produces the drowsiness and calming effect of benzodiazepines. While there are many legitimate medical indications for benzodiazepine use, some people misuse these drugs and develop an addiction to them.

In the United States, central nervous system depressants such as benzodiazepines are classified as Schedule IV drugs by the Drug Enforcement Administration (DEA). Benzodiazepines have a lower potential for addiction compared to Schedule I, II, and III drugs, such as LSD, cocaine, heroin, and prescription opioids. 2However, benzodiazepines can be habit-forming and lead to dependence or addiction.

Benzodiazepines: A Brief History

The first benzodiazepine, chlordiazepoxide (Librium), was created by chance by an Austrian scientist, Leo Sternbach, who was working with Hoffmann-La Roche in New Jersey in 1956. He later went on to develop diazepam (Valium) in 1963. 3

Benzodiazepines were thus introduced in the United States in the 1960s and quickly became popular because of an improved safety profile compared to older drugs like barbiturates. In particular, benzodiazepines were associated with a lower risk of respiratory depression (slowed breathing), a lower potential for abuse and addiction, and lower suicide potential. 4Diazepam, specifically, was widely prescribed with over 2.3 billion doses sold per year at its peak in the late 1970s. 5

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

Nonetheless, in 1975, benzodiazepines were placed on the FDA’s list of restricted drugs, given the growing concerns about benzo addiction. 6Benzodiazepines remain one of the most frequently prescribed class of medications in the U.S. despite the known risk of addiction and the availability of safer alternatives. 7

Increasing Prevalence of Benzodiazepine Use

According to the US National Center for Health Statistics, surveys conducted between 2014 and 2016 found that benzodiazepines are prescribed at 27 out of every 100 office-based doctor visits. 8These numbers are disturbing because benzodiazepine addiction can develop quickly, over a matter of days in some cases. Withdrawal symptoms can make it difficult for a person to quit benzo use. Moreover, benzodiazepine overdoses are potentially fatal.

Data from the National Survey on Drug Use and Health 2016 showed that more than 30 million Americans (12.6% of the population) reported past-year use of benzodiazepines. 9Misuse accounted for more than 17% of overall use. 10

These disappointing trends are not new and have been on the rise for the last couple of decades. 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 to more than 3.0 per 100,000 adults, although fortunately, this figure plateaued after 2010. Benzodiazepine is involved in around 7,000 overdose deaths per year as of 2013. 11

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%. In particular, use among psychiatrists was high at roughly 30% but remained stable during the study duration. 12

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.

What is Benzodiazepine Addiction?

Although benzodiazepines have several legitimate uses, some people misuse them and develop an addiction to 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 other than prescribed
  • Taking someone else’s benzodiazepine medication
  • Taking benzodiazepines to get high

Nearly half of all people who misuse benzodiazepines say the motivation for their prescription drug misuse is to relieve tension and relax. A substantial number (roughly 22%) misuse benzodiazepines to self-treat sleep problems. Just under 6% of benzo misusers quote experimentation as the reason for their drug abuse. About 12% of drug abusers say they use benzodiazepines to “get high” or because they were “hooked.Most people who abuse benzodiazepines get the drugs from friends or relatives. Only 20% or so get them from physicians. 13

On the street, benzodiazepines are available as benzos, sleepers, downers, xannies, tranks, moggies, normies, serras, and nerve pills. Some people swallow the pills whole while others crush and snort them. 14

Recognizing Benzodiazepine Addiction

Some of the warning signs of benzodiazepine addiction include:

  • Taking the drug at higher doses 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 of benzodiazepines to achieve the desired effects.
  • Suffering from impaired performance at work/school and home.

Benzodiazepine Addiction Statistics in the United States

With more than 75 million prescriptions written in the United States each year (2008 figures), benzodiazepine addiction is a growing concern. Here are some worrisome statistics that reveal the seriousness of the problem.

  • Approximately 2.3% to 18% of Americans report misusing sedatives and tranquilizers at some point in their lifetime. Nearly 10% of these individuals develop an addiction. 15 16
  • In 2010, there were more than 185,000 new benzodiazepine abusers in the US. 17
  • More than 400,000 emergency department visits in 2010 were related to benzodiazepine use. 18
  • Between 1998 and 2008, admissions to all substance abuse treatment programs increased by 11%; however, what was more worrisome was that admissions to benzodiazepine addiction treatment programs tripled. 19
  • Admissions to treatment programs for combined opioid and benzodiazepine abuse skyrocketed by 570% between 2000 and 2010. 20

Commonly Prescribed Benzodiazepines

Thousands of benzodiazepines have been developed worldwide, but less than 15 are presently FDA-approved in the United States. Benzodiazepines are categorized according to the duration of their effects. 21

  • The effects of short-acting benzodiazepines, for example, midazolam (Versed), clorazepate (Tranxene), and triazolam (Halcion) last for 3-8 hours.
  • The effects of intermediate-acting benzodiazepines, for example, alprazolam (Xanax), temazepam (Restoril), and lorazepam (Ativan) last for 10-20 hours.
  • The effects of long-acting benzodiazepines, for example, diazepam (Valium), clonazepam (Klonopin), and chlordiazepoxide (Librium) last for 1-3 days.

Legitimate Uses of Benzodiazepines

Commercially available benzodiazepines in the United States are marketed as anti-anxiety drugs and sedative-hypnotics. However, it is worth noting that all benzodiazepines have both sedative and anti-anxiety properties. Some of the FDA-approved indications for benzodiazepine prescriptions include: 22

  • Anterograde amnesia in patients undergoing surgeries (patients cannot remember events while under the influence of the drug)
  • Anxiety disorders
  • Panic disorders
  • Insomnia
  • Muscle relaxant
  • Preoperative anxiety and apprehension
  • Seizure disorders and status epilepticus
  • Withdrawal from acute alcoholism

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

Effects of Benzodiazepine Abuse

People who are abusing CNS depressants like benzodiazepines or are addicted to them can display various physical and behavioral signs and symptoms. 23

Physical Symptoms of Benzodiazepine Abuse

  • Anxiety and depression
  • Confusion
  • Drowsiness
  • Dizziness
  • Impaired coordination
  • Tremors
  • Slurred speech, stuttering
  • Sleepiness, fatigue, weakness
  • Dry mouth
  • Double vision, 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, hostility, aggression
  • Lethargy, lack of motivation
  • Changes in sleeping habits, disturbing dreams
  • Poor decision-making

Risk Factors for Benzodiazepine Addiction

Most people take benzodiazepines as prescribed. However, a small percentage of individuals misuse CNS depressants like benzodiazepines 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. The unauthorized escalation of benzodiazepines to higher doses puts users at risk of developing a dependence or addiction to these drugs.

Clinicians should be vigilant for signs of self-medication with benzodiazepines. Repeated requests for early refills are a warning sign of benzodiazepine addiction. Even though the overall potential for addiction to benzodiazepines is low in the general population, certain subsets of the population are at higher risk for benzo abuse. Physicians should be particularly vigilant in:

  • People with a personal or family history of substance use disorders (history of substance abuse is a risk factor for benzo abuse and addiction).
  • People with co-occurring psychiatric illness (there is a strong association between comorbid psychiatric disorders and benzodiazepine misuse).
  • People with a history of alcohol use disorder and antisocial personality disorder (such individuals are at particularly high risk of developing benzodiazepine addiction).
  • Young adults 18 to 35 years old (this age group has the highest rates of benzodiazepine abuse).

Other High-Risk Groups for Benzodiazepine Abuse

A population that is at particularly high risk of benzodiazepine abuse and addiction is individuals 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 individuals 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.

Benzodiazepines are generally not recommended in women who are pregnant or breastfeeding as they can lead to pre-term delivery, low birth weight, and possible birth defects.

Benzodiazepines can be particularly dangerous in people with respiratory conditions such as asthma, sleep apnea, and emphysema or advanced liver or kidney disease. In elderly individuals, 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 abuse. 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, or 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.

The most common drugs with which benzodiazepines are abused include opioids (55%) and alcohol (25%). 24These are worrisome numbers because the risks of health complications and death multiply with polydrug use.

Approximately 1 in 5 people with alcohol use disorder also abuse benzodiazepines. Alcohol is involved in 1 in 4 ED visits related to benzodiazepine abuse. Individuals 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.

What makes polydrug abuse involving benzodiazepines so dangerous? By themselves, benzodiazepines are weak depressants of the respiratory system. However, in polydrug abusers, when benzodiazepines are used in combination with alcohol, opioids, or other CNS depressants, significant and potentially life-threatening or fatal respiratory depression can occur.

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). For example, benzodiazepines with a shorter half-life (duration of action) appear to have a greater potential for abuse and addiction. 25 26 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

People who have been prescribed benzodiazepines for valid medical reasons are at risk of developing an addiction to these drugs if they are not taken exactly as prescribed. To obtain the benefit of benzodiazepines without becoming addicted to them, patients should:

  • Follow their doctor’s directions regarding the dose and method of use.
  • Inform their doctor about the use of other prescription medicines, over-the-counter medicines, herbal supplements, and any illegal drugs or alcohol.
  • Refrain from making dose changes on their own.
  • Never use someone else’s benzodiazepines, even if they have similar symptoms.
  • Never order benzodiazepines from unauthorized sources (for example, online pharmacies in countries outside the US) since the drugs could be counterfeit and may cause harm.

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 should carefully identify and monitor benzodiazepine use in high-risk individuals, such as those with a personal or family history of substance abuse. The risk of benzodiazepine addiction can be reduced or prevented by issuing prescriptions for 1-2 weeks supply and monitoring for signs of abuse. Pharmacy shoppers and doctor shoppers are at 4-5 times higher risk of escalation of doses, benzodiazepine addiction, and overdose deaths. Prescription monitoring programs can help ensure patients do not obtain benzos from multiple sources (doctor-shopping or pharmacy-diversion).

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. 27

Benzodiazepine Withdrawal

Benzodiazepines are effective short-term treatment for many medical conditions. However, any individual who uses benzodiazepines for more than 3-4 weeks is likely to suffer from withdrawal symptoms if the dose is reduced or the use of the drug is stopped abruptly. Withdrawal symptoms and severe cravings also occur in individuals who have developed 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. Also, the 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

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. Many patients are arousable and can even provide a medical history. Some of the typical symptoms of benzodiazepine overdose include: 28

  • 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)

A benzodiazepine overdose can be intentional or unintentional. Most intentional overdoses of benzodiazepines involve other substances, commonly alcohol, which can lead to severe respiratory compromise.

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.

Benzodiazepine Addiction: A Pressing Concern

Benzodiazepines 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. Benzodiazepine addiction is a pressing concern because roughly 60-100% of people who are prescribed these drugs become inadvertently addicted to them. 29

Physical dependence on benzodiazepines is characterized by the presence of tolerance and withdrawal. Tolerance is the need for higher doses to achieve the desired effects. As tolerance to benzos develops, patients gradually increase the frequency of doses beyond what has been recommended by the prescribing physician. Many patients do not realize that this dose escalation is inappropriate or habit-forming.

Withdrawal is the presence of distressing symptoms in the absence of the benzodiazepine drug. Even patients who recognize the potential for benzo addiction often continue using the drug to stave off uncomfortable withdrawal symptoms. With continued and increased use, tolerance and withdrawal worsen. And when such a person combines benzodiazepines with other CNS depressants, such as alcohol or opioids, the results can be lethal.

Last updated: August 17, 2020

References

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