Tag Archives: benzodiazepines

Klonopin and prozac withdrawal

This post was submitted by a reader.

 

 

 

 

 

It’s been almost 3 months since I have ingested any antidepressants or benzos. Almost died after drinking a large amount of vodka with the daily does of pills. Went to a rehab for a month and have been clean since. This is after over 27 years of benzos and prozac. I am 60 years old and am finally coming a awake. The Withdrawals, notably the restless leg and horrible cramping have been horrid at night, but I am totally committed to staying off the evil pills! Thanks for listening!

 

A Reader

Benzodiazepines: Miracle Drugs?

The first benzodiazepine – chlordiazepoxide – became available, from Hoffman-La Roche, in 1960, under the brand name Librium.  It was soon followed by:

diazepam (Valium) 1963;
nitrazepam (Mogadon) and oxazepam (Serax) in 1965;
temazepam (Restoril) 1969;
clorazepate (Tranxene) 1972;
flurazepam (Dalmane) 1973;
clonazepam (Klonopin) 1975;
lorazepam (Ativan) in 1977; and
alprazolam (Xanax) in 1981;
etc.

Benzodiazepines are categorized as sedative/hypnotics, which means that they have a relaxing, generally pleasant, sleep-inducing effect, and were embraced promptly by psychiatry for the “treatment” of anxiety, tension, worry, sleeplessness, etc.

In this respect, the benzodiazepines largely replaced the earlier barbiturates, which had received a great deal of negative publicity because of their much publicized role in lethal overdoses, both accidental and intentional.

. . . . . . . . . . . . . . . .

Initially, there was a good measure of skepticism among the general public with regards to benzos, and indeed, with regards to psychotropic drugs generally.  The dominant philosophy in those days was that transient, drug-induced states of consciousness were not only ineffective in addressing human problems, but were also dangerous. There were still lingering traces in the collective memory of the laudanum travesty, and, of course, there were daily reminders of the dangers of “drowning one’s sorrows” in alcohol.

But pharma-psychiatry systematically, deliberately, and self-servingly undermined this skepticism.  Pharma’s motivation in this regard is clear:  to make money.  Psychiatry’s motivation is more difficult to understand because the history, as is often the case, is largely forgotten.  At present, psychiatrists have come to be accepted as “real doctors” by the medical profession generally, and by the general public.  But in 1960, it would not be an exaggeration to say that they were considered something of a laughing stock among medical practitioners, and were regarded with bemused tolerance by the general public.

For these reasons, psychiatrists were highly motivated to accept something that would enhance their status, and create an appearance of medical authenticity.

Meanwhile, pharma was looking for ways to market their products.  It was a match – to mangle the usual phrase – made in Hell.  Psychiatrists – desperate for status and assurance, and smarting under the negative publicity of the barbiturate debacle – succumbed readily to pharma’s unctuous flattery and cajolery, and linked themselves whole-heartedly to the industry’s efforts to undermine the healthy skepticism of the general public, and incidentally, of a great many real doctors.

And the package sold like hot cakes.

By 1977, according to Wikipedia, “…benzodiazepines were globally the most prescribed medications.”  Sales dipped briefly in the late 70’s after their classification in the US as a Schedule IV drug, but benzos remained generally popular, and today, the drugs continue to grow in popularity.  According to IMS Health, a total of 76.7 million prescriptions for benzodiazepines were written in the US in 2005.  By 2009, that figure had risen to 87.9 million – an increase of 14.6%.  During the same period, the US population had gone from 295.52 million to 306.77 million, an increase of only 3.8%.

. . . . . . . . . . . . . . . . 

So what we have here is a success story.  Pharma sells billions of dollars worth of drugs, psychiatry takes its “rightful” place in the ranks of bona fide medical specialties, and vast numbers of people receive safe and effective “treatment” for “real” illnesses such as generalized anxiety disorder, social anxiety disorder, agoraphobia, etc…

So what’s the problem?  Well, there are lots of problems.

Firstly, the products, despite the long-insisted pharma-psychiatry hype, are addictive – a fact which is now well-known and need not be labored here.  Check the website Beyond Meds, or search Google for benzodiazepine addiction/dependence.

Secondly, it began to be clear early on, that the drugs did indeed have some serious adverse effects.  These included:  drowsiness and falls; skill impairment/traffic accidents; disinhibition/aggression; memory problems; etc.

Thirdly, more evidence of adverse effects emerges almost every year.  Most recently, it has been reported that benzodiazepine use is associated with an increased incidence of homicide and dementia.

HOMICIDE

In June 2015, Tiihonen et al published a study from Finland on the link between homicide and various drugs.  They found that the risk ratio for current use of benzodiazepines was 1.45, with a 95% confidence interval of 1.17-1.81.  In other words, current benzo users were about 45% more likely to commit a homicide than comparable non-users.

“Benzodiazepine…use was linked with a higher risk of homicidal offending, and the findings remained highly significant even after correction for multiple comparisons.”

DEMENTIA

In May 2015, Zhon et al published a meta-analysis from China which explored the association between long-term benzodiazepine use and the risk of developing dementia.  A meta-analysis is a study which combines the results of previous studies on the same topic.  Zhon et al combined the findings from six studies, involving a total of 45,391 participants, including 11,891 individuals with dementia, and found:

“Compared with never users, pooled adjusted risk ratios (RRs) for dementia were 1.49 (95% confidence interval (CI) 1.30–1.72) for ever users, 1.55 (95% CI 1.31–1.83) for recent users, and 1.55 (95% CI 1.17–2.03) for past users. The risk of dementia increased by 22% for every additional 20 defined daily dose per year (RR, 1.22, 95%CI 1.18–1.25). When we restricted our meta-analyses to unadjusted RRs, all initial significant associations persisted.”

And concluded:

“On the basis of either unadjusted or adjusted risk estimates, our study consistently indicates that long-term benzodiazepine use is associated with an increased risk of dementia.”

The authors point out that associations of this sort do not necessarily prove causality.  However, given the known neurotoxic effects of these products, a causative link seems likely.

Zhon et al conducted three separate investigations:  ever use vs. never use; recent use vs. never use; and past use vs. never use.  In all three cases, the association between benzo use and dementia was clear and substantial, which prompted the authors to write:

“…our findings regarding recent and past use of benzodiazepines may provide an important implication that stopping use of benzodiazepines cannot significantly reduce the risk of developing dementia.”

In other words, the damage is already done.  People who have used benzos in the past are at increased risk of developing dementia even if they haven’t used the drugs recently.

DISCUSSION

So there it is.  Pharma invents a dangerous drug, and with the enthusiastic help of psychiatry, markets it as “safe and effective” in the “treatment” of anxiety, which psychiatry has obligingly, conveniently, (and incidentally, fraudulently) transformed into an illness.

The reality is that anxiety is not an illness, but is, rather, the normal human response to anxiety-provoking situations.  And in our brave modern world, there is no end of anxiety-provoking situations.

Personally, I have not experienced a great deal of anxiety in my life, but I will readily acknowledge that in recent years, I have experienced a fair measure of anxiety while driving or riding in fast-moving, congested traffic.  My concerns in this regard are exacerbated when I notice the very large number of other drivers who are speaking on their cell phones (and even texting!) as they careen blithely through the narrow lanes of potential carnage.

I have resolved this problem by the simple expedient – and this is not Einsteinian stuff – of avoiding fast-moving, congested traffic!  The notion that a person could or should dissipate anxiety of this sort (or any sort) by ingesting a downer drug is a special kind of inanity found only in psychiatry.

And fast-moving, congested traffic is only one of the many anxiety-provoking situations in modern life.  Here are a few others:

Persistent inability to make financial ends meet
Not having medical insurance
Being concerned about losing one’s job
Driving an unreliable car
Living in tornado/hurricane areas
Being troubled by painful/distressing memories
Getting into the “right” school
Getting one’s children into the right school
Competing for college placement
Involvement in competitive sports
Living in big cities
Choosing the “right” food
Socializing with members of the opposite sex
Decision-making generally in everyday life
Concern about child-rearing
Worry about exposure to everyday toxins
Dealing with new job/city/people
Poor health
Feeling overwhelmed by the demands of one’s job
Having a chronically sick child
Caring for an aging parent
Involvement in a stressful relationship
Caring for an ailing partner
Tension surrounding the sale/purchase of a home
Fluctuations in the stock market
Forest fires
Noisy neighbors
Street violence
Floods
Drought
Blocked septic systems
Earthquakes
Failure to conceive
Unplanned pregnancy
Threat of domestic violence
Having little or no social/family support
Being alienated from one’s family
Etc., etc., etc…

I recognize, of course, that avoiding fast-moving, congested traffic is a great deal easier than dealing with most of the anxiety-provoking situations in the above list. But the general principles are the same.

Anxieties are normal.  In fact, they are adaptive.  They encourage us to be alert and ready for action, and also to take corrective actions with regards to the anxiety-provoking situations.  Extreme anxiety is the normal and adaptive response to extreme situations.

During my career as a psychologist, every client who came to me in extreme distress or anxiety was living in circumstances that were extremely distressful or anxiety-provoking.  Helping the individual ameliorate the distressing circumstances invariably ameliorated the feelings of distress.

Psychiatrists don’t see this obvious fact, or if they do, they ignore it, because they are conditioned by their training and by the exigencies of reimbursement, to pretend that the problem is – to quote the DSM phrase – “in the individual”.  The problem is fraudulently presented as an illness, because psychiatrists need illnesses to legitimize their drug-pushing, and for their continued survival as a profession.

Benzos “work” on these anxieties essentially by switching off neuronal activity.  Benzo users don’t feel anxiety, because the pills have impaired their ability to feel anxious.  To put it plainly, people who use benzos on a regular basis to dissipate anxiety are chronically intoxicated to the point of blissful apathy, all the while incurring an array of risks which often are far more serious than the initial problem.  (Some people, of course, use benzos to avoid withdrawals, but that’s a whole other issue.)

And psychiatrists actually have promoted, and continue to promote, the notion that this constitutes treating an illness!  It is noteworthy that at a time when real doctors are developing an increased recognition and respect for the body’s natural resources, warning systems, and defense mechanisms, psychiatry is going in the opposite direction.  All psychiatric drugs – including benzos – operate, not by correcting an abnormal state, but rather by suppressing/distorting normal function and creating a pathological state.  Chronic benzo intoxication is a pathological state.

Modern life offers unprecedented comforts and conveniences, but, in exchange, exacts a huge toll in terms of tension and anxiety.  The notion of dissipating these anxieties with neurotoxic, addictive drugs isn’t just ill-conceived, dangerous, and disempowering; it’s a dehumanizing obscenity.

Benzodiazepine Withdrawal: A Dilemma

On March 17, 2013, I wrote a post titled Withdrawal from Benzodiazepines.  In that post I wrote:

“Withdrawal from these drugs is potentially dangerous, incidentally, and medical supervision is a good idea, especially if the dependence is marked.  Try to find a physician other than the one who got you hooked on them in the first place.  In severe cases, hospitalization is required.”

On December 27, 2014, a reader (Nancy Rubenstein) left a comment which stated that this is dangerous advice in that  “…there are literally less than a handful of doctors nationwide who have proven they can handle this. There is no safe hospitalisation for people in psych drug withdrawal…”  Nancy also pointed out that when people do go to hospital for emergency withdrawal problems, they are often met with disbelief, and that this disbelief can result in further problems, e.g. diagnosis of a “mental illness”, further drugging, etc…

All of these points are well taken, and I appreciate Nancy’s feedback.  I received similar feedback from Monica Cassani (Beyond Meds) in March of 2013.

The great difficulty in all of this is that withdrawal from benzos can be life-threatening.  So people who have become addicted to these products are in a particularly difficult dilemma:  to seek medical care or not?  I would be very grateful for comments from people who have had to face this question, and from people who have experienced adverse consequences as a result of seeking medical care for this kind of withdrawal.

Benzodiazepines and Aggression

On November 19, 2014, the Australian and New Zealand Journal of Psychiatry published Benzodiazepine use and aggressive behaviour: A systematic review, by Bonnie Albrecht et al, from Deakin University, Melbourne, Australia.

Here are the authors’ conclusions:

“There appears to be a moderate association between some benzodiazepines and subsequent aggressive behaviour in humans. The circumstances under which aggressive responding may be more likely to follow benzodiazepine use remain unclear, although some evidence suggests dose and/or personality factors may influence this effect.”

In their opening paragraphs, the authors point out that benzos are commonly prescribed for anxiety, insomnia, agitation, and alcohol withdrawal.  They also write that although sedation and reduced anxiety are the most common effects of these products, “…there have been reports of some users experiencing behavioural disinhibition following consumption, which includes aggressive behaviour.”

They cite references to studies dating back to 1975 in which aggressive responding was reported following administration of these drugs.  “…it is estimated that anywhere between 1% and 20% of benzodiazepine users experience some form of increased anger or express aggression.”  These aggressive incidents occurred at both low and high doses, and by individuals with and without histories of this kind of behavior.

. . . . . . . . . . . . . . . .

Albrecht et al searched the literature for studies that addressed the question of a link between benzo use and aggression.  From 2492 candidate articles they found 46 in which this link was explicitly investigated.  All 46 articles are listed, with a brief description of each study’s parameters and outcome.  For the purposes of their study, Albrecht et al defined aggressive behavior as  “…physical behaviour directed toward another person with the goal of harming or injuring that person, who is motivated to avoid such behaviour.”

In the discussion section of the paper, the authors state:

“Although it was not feasible to conduct a meta-analysis, according to our review of these studies it appears that benzodiazepine use is moderately associated with subsequent aggressive behaviour.”

In the conclusions section, they state:

“Anecdotal evidence indicates that the benzodiazepine–aggression response is an urgent clinical issue with serious clinical and forensic implications. The reviewed literature suggests that although there appears to be a moderate association between some benzodiazepines and subsequent aggressive behaviour in humans, the circumstances under which aggressive behaviour is likely to follow benzodiazepine consumption remain poorly understood.”

The authors point out that this issue warrants further research:

“The evidence base requires high-quality and systematic investigation of the various benzodiazepines and doses.”

Given that these concerns have been finding expression since at least 1975, and given also the seriousness of the matter, it seems to me that a definitive piece of research is long overdue.

INCIDENTALLY

The FDA’s information sheet on Valium lists the following under Psychiatric and Paradoxical Reactions:

“stimulation, restlessness, acute hyperexcited states, anxiety, agitation, aggressiveness, irritability, rage…”

Wikipedia provides a list of paradoxical effects of benzodiazepines generally.  The list includes:

“…aggression, violence, impulsivity, irritability and suicidal behavior…”

. . . . . . . . . . . . . . . .

There are no psychiatrists among the authors of the present study.

More on Benzos and Cognitive Damage

On September 9, 2014, the BMJ published an article by Sophie Billioti de Gage et al.  The article was titled Benzodiazepine use and risk of Alzheimer’s disease: case-control study, and concluded:

“Benzodiazepine use is associated with an increased risk of Alzheimer’s disease. The stronger association observed for long term exposures reinforces the suspicion of a possible direct association, even if benzodiazepine use might also be an early marker of a condition associated with an increased risk of dementia. Unwarranted long term use of these drugs should be considered as a public health concern.” [Emphasis added]

On October 17, I wrote a post on this topic.  In that post I noted that I had not been able to find an APA comment on the BMJ article.  In fact, on October 15, Psychiatric News, the APA’s online publication, had posted Long-Term Use of Benzodiazepines May Be Linked to Alzheimer’s, by Vabren Watts, PhD.  The article is pure damage control.

The problem for the APA is that the evidence implicating benzos as a causative factor in the development of Alzheimer’s disease is mounting.  The APA can’t ignore this reality, but at the same time they can’t afford to alienate either pharma, or their own members who are prescribing these products.  So they’re having to walk a tight line.

Here are some quotes from the Psychiatric News article, interspersed with my comments.

“Researchers caution physicians to take more care when prescribing benzodiazepines.”

Strictly speaking, this is accurate.  Dr. de Gage et al did indeed write:  “…treatments [with benzodiazepines] should be of short duration and not exceed three months.”  But they also wrote:

“Our study reinforces the suspicion of an increased risk of Alzheimer type dementia among benzodiazepine users, particularly long term users, and provides arguments for carefully evaluating the indications for use of this drug class.  Our findings are of major importance for public health, especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries. In such conditions, a risk increased by 43-51% in users would generate a huge number of excess cases, even in countries where the prevalence of use of these drugs is not high.” [Emphasis added]

“Carefully evaluating the indications for use” of a drug class, is light-years beyond taking “more care when prescribing.”  The former denotes a complete re-appraisal of the status quo.  The latter is little more than platitudinous encouragement.

. . . . . . . . . . . . . . . . 

“‘Prevalence of [benzodiazepines] use among elderly patients is consistently high in developed countries … [ranging] from 7 percent to 43 percent,’ noted the researchers.”

This is the first quote that Dr. Watts provides from the de Gage et al study, and although it provides an important demographic reality, it is not the main issue.  This is a nice example of the spin tactic known as deflection, and watch how skillfully Dr. Watts uses it.  His next sentence reads:

“International guidelines recommend short-term use of the drug, mainly because of withdrawal symptoms that make discontinuation problematic; however, the study noted, use of benzodiazepines is often long term in older people.”

The issue here is that benzodiazepines, for decades one of the mainstays of psychiatric prescribing, are almost certainly causing AZD in millions of victims world-wide.  But Dr. Watts has adroitly shifted to a discussion of the over-use of those drugs and the potential for addiction when used long-term.  Again, these are important issues, but they are not central to the de Gage findings.  It is also worth nothing that people can become thoroughly hooked on these products even with very short-term use, and that the overuse of these drugs was fuelled primarily by psychiatrists, who for years assured the public, and other medical practitioners, that these drugs were benign and non-addictive.

. . . . . . . . . . . . . . . .

Having found a safe angle, Dr. Watts stays with it.

“‘Somewhere along the way, the message got lost, and patients were allowed to use benzodiazepines for months and years,’ said Mohit P. Chopra, M.D., a member of APA’s Council on Geriatric Psychiatry. Chopra, who was not involved with the study, told Psychiatric News that guidelines recommend that the anxiolytic and insomnia medicines are to be used on a daily basis for no longer than four to six weeks.”

This is a slick rewriting of history.  In fact, the message didn’t get lost.  The original message, as propagated by psychiatrists, was that benzos were safe and non-addictive.  “Patients” weren’t just allowed to use benzos for months and years.  They were actively encouraged to do so, and in many cases were told the standard psychiatric lie that these products would correct non-existent anomalies in their brains.  The promotion of benzos by the psychiatry-pharma alliance is one of the great commercial success stories of this business.

And the APA continues to promote these drugs, albeit indirectly.  In their online section on anxiety disorders, under the heading “For more information” they give links to Anxiety Disorders Association of America (ADAA) and National Institutes of Mental Health (NIMH).  Here’s a quote from the ADAA site (under the heading Finding Help: Treatment):

Benzodiazepines
This class of drugs is frequently used for short-term management of anxiety. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are highly effective in promoting relaxation and reducing muscular tension and other physical symptoms of anxiety. Long-term use may require increased doses to achieve the same effect, which may lead to problems related to tolerance and dependence.”

And here’s a quote from the NIMH link:

“High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness.”

These quotes are in marked contrast to the statement of Eric Lenze, MD, a geriatric psychiatrist, et al:

“Benzodiazepine risks, whether short-term or chronic, include cognitive impairment, delirium, respiratory insufficiency, falls, fall-related injuries such as hip fractures, motor vehicle crashes, and death.  Most patients are not warned of these risks before starting these medications.  The main risk factor for chronic benzodiazepine use is any previous use, so an intended short-duration prescription of these habit-forming medication is likely to lead to their long-term use.” 

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Eventually, of course, Dr. Watts has to provide some information from the BMJ study.  He gives a very brief description of the research design and the results.  He mentions the finding that benzodiazepine use six years earlier was associated with an increased risk for AZD, and that this association was maintained after adjustment for anxiety, depression, and sleep disorders.

And then another PR gem:

“The researchers concluded that benzodiazepines are ‘indisputably valuable tools for managing anxiety disorders and transient insomnia,’ but warned that treatment with these medications should be used within the time parameters set by international guidelines.”

The researchers did indeed write this, but it was a sideline to the main issue, and the quote did not come from their conclusions section, which I have quoted in full above.  The primary conclusion is that the evidence for a direct causal link between benzo use and AZD is steadily mounting.

Dr. Watts’ primary concern throughout the article is to dispel any suggestion that benzos are inherently dangerous and damaging, and to promote the notion that they are only problematic when over-used.  To this end, he now introduces the very eminent psychiatrist Davangere Devanand, MD, director of geriatric psychiatry at Columbia University.

“‘These findings emphasize the importance of restricting the use of benzodiazepines in the elderly population,’ said Devanand in an interview with Psychiatric News.  ‘Benzodiazepines are known to be associated with an increased risk of worsening cognition … even in cognitively normal elderly subjects.’ Devanand said that in such situation, it would be best to taper and cease patients’ use of the benzodiazepine while reevaluating cognition functioning.”

And then, Dr. Devanand continues with a truly perfect piece of spin:

“‘If the cognitive decline is due to benzodiazepines, and the patient does not have an underlying dementia such as Alzheimer’s disease, the cognitive decline should reverse after stopping the treatment.'” [Emphasis added]

In other words, he is saying:  Yes, benzos can cause some cognitive impairment, but it’s temporary, and will clear up if the pills are stopped.

And if it doesn’t clear up, then the individual must already have had AZD or some other dementia.  The benzodiazepines couldn’t have caused permanent cognitive impairment.  Dr. Devanand provides no evidence or references to support this contention, but he’s an eminent psychiatrist, so I suppose his assertion should be evidence enough.  Besides, who ever heard of a psychiatric drug causing damage?

But then, wanting to have his cake and eat it too:

“Devanand stressed that in order to ensure that prescribers are not putting their patients at risk for the onset of neurocognitive disorders, ‘benzodiazepines should be prescribed sparingly and for short periods.'”

So benzos don’t cause permanent cognitive impairment, but to avoid putting patients at risk, they should be used  “…sparingly and for short periods”!

And besides, there’s a beautiful little catch to the notion of prescribing benzos for short periods.  When discontinuation is attempted, the client, as often as not, experiences withdrawals, and becomes agitated.  And agitation, of course, calls for medication.  And what medication is remarkably effective for suppressing agitation?  Benzos!  Isn’t psychiatry just wonderful.  Not only can it damage people with its drugs, it can “treat” the damage with the very same drug – and do it all with a straight face!

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DISCUSSION

The gist of Dr. Watts’ article is:

  • Benzos are generally safe if used for short periods (i.e. up to 3 months);
  • If they are used for longer periods, they may cause some cognitive impairment, but it’s unlikely to be permanent

But there is no mention of what, at least in my view, is the most important point in the de Gage et al report:

“Our findings are congruent with those of five previous studies, two of which explored the modifying effect of the dose used.  In four studies, the role of a putative protopathic bias could not be ruled out because an insufficient duration of follow-up; a lack of statistical power in subgroup analyses; and no consideration of the most relevant time window for exposure and ascertainment of confounders.  The most recent study found a similar 50% increased risk within the 15 years after the start of benzodiazepine use (average length of follow-up 6.2 years).  This excess risk was delayed and thus not indicative of a reverse causality bias. Another study found a positive association, though lacked significance because of its limited sample size.”

In other words, there is mounting evidence that benzodiazepines are causing AZD.  I cannot imagine any genuine medical specialty ignoring or downplaying information of this sort.  But psychiatry, with the perennial defensiveness of those with something to hide, promotes the idea that they are safe when used for short periods, knowing full well that a huge percentage of users become “hooked” after a week or two, and stay on the drugs indefinitely.

In the 80’s, I knew a psychiatrist who used to quip:  “The difference between Xanax and true love is that Xanax is forever.  You don’t take people off Xanax.”  I wonder how many of his “patients” have Alzheimer’s disease today?  And remember, Alzheimer’s is a truly devastating disease.

. . . . . . . . . . . . . . . . 

In addition, the notion that the drugs are safe if used for 3 months or less is questionable.  There is no magic dividing line between three months and four months.  If a drug causes damage when used for four months, then it is reasonable to infer that it causes damage when used for three months.  The degree and scope of the damage for most people will probably be less, but it won’t be zero.

The relevant figures from the de Gage study are:

Relative Risk of AZD:  Benzodiazepine Users vs. Non-Users

Benzos and AZD.

 

 

 

The point about the 1.08 risk ratio for the 1-90 days individuals is that, given the sample size, it is too close to 1 to say definitively that it represents a real increase in risk.  There is a 95% probability that the risk for all 1-90 day users lies between 0.92 and 1.27.  So it could be just a random fluctuation in the data.

But when all these risk ratios are considered together, the most obvious interpretation of the table is that the risk is trending upwards as the cumulative dosage increases.  And bear in mind that the 1.08 ratio represents an average of people who have taken the pills for just a few days as well as people who took them for the full three months.  For the latter, the risk will almost certainly be considerably higher than 1.08.  The only thing we can say for sure about the 1-90 day users is that we can’t say anything for sure.  There is nothing in the de Gage et al data to suggest that the drugs are safe for use up to three months, and in fact, strong grounds for thinking otherwise.

Designing a randomized controlled trial to check for a causal link poses enormous problems, not the least of which is that almost all participants will be able to tell if they’ve received a benzo or a placebo.  In addition, an RCT has to be done prospectively.  So we wouldn’t have the results for another 10 or 15 years!  By all means this study should be undertaken, but meanwhile, shouldn’t we go with the best data that we’ve got?

The overall picture here is a steady accumulation of evidence that the drugs are causing AZD in some people, that the risk is dose-contingent, and that for people who have taken the drugs for 6 months or longer, the risk is approaching two-fold.  It is also particularly noteworthy that of the 894 study participants who used benzos, 66% took them for 6 months or more.

Certainly, less use is better than more use, but promoting the message that use up to 3 months is safe strikes me as irresponsible.  Given the numbers of people taking benzos and the number of people contracting AZD, risk ratios as low as 1.1 or even 1.05 represent an enormous additional burden of preventable disease. This is particularly relevant in that neither anxiety nor depression is an illness, and although popping a benzo may provide a temporary sense of relief, there are better ways to cope with these problems, that don’t entail any increased risk of AZD.

AND INCIDENTALLY

Vabren Watts’ specialty is cardiology research.  He has a PhD in biomedical sciences from Meharry Medical College, and he completed his training in cardiology research at Johns Hopkins.  He has worked as a Science Expert Ambassador and as a Health Science Leader and Spokesperson for the American Heart Association.  He is the founder of The Science Journalist, where he provides freelance science/health reporting and technical writing services to various media outlets.  Since 2013, he has worked for the APA as a Senior Staff Writer on Clinical and Research News for the APA.

On his bio summary, he describes himself as a:

“Biomedical researcher and health science communicator dedicated to making scientific findings and policies more comprehensible to medical experts, stakeholders, and lay audiences.”

Two things strike me as noteworthy:  firstly that the APA has hired a professional writer (rather than a psychiatrist) to broadcast the de Gage result; and secondly, that the writer’s specialty is biomedical research.  So much for psychiatry’s recent attempts to persuade us that they have always espoused a biopsychosocial approach.

Also, I am reminded of a paragraph in Jeffrey Lieberman’s final Psychiatric News article as APA President.

“Mindful of the continuing stigma associated with mental illness and psychiatric treatment, we retained an outside consultant agency (Porter Novelli) to review APA’s communications capabilities, needs, and opportunities. Based on its report, we are now moving forward with an initiative to enact a sophisticated and proactive communications plan that will be directed both internally to APA members and externally to the media, mental health stakeholder groups, and the general public.”

So, to counteract stigma (which, incidentally, is largely a product of psychiatry’s spurious medicalization of human problems), the APA, with the help of a prestigious PR firm, has set up “a sophisticated and proactive communications plan.”  And presumably the hiring of Vabren Watts, and other talented young writers, is an integral part of this plan.

So here’s my question:  If everything one is doing is honest, above-board, and clearly beneficial, why would one need “a sophisticated and proactive communications plan” to communicate with one’s own members, the media, and the general public?

And why does the APA need to re-package the eminently clear message of the de Gage et al report?

Benzodiazepine Use and Risk of Alzheimer’s Disease

On September 9, 2014, the BMJ published an article by Sophie Billioti de Gage et al.  The article is titled Benzodiazepine use and risk of Alzheimer’s disease: case-control study  The research was a study based on data from the Quebec health insurance program database.

Here are the authors’ conclusion:

“Benzodiazepine use is associated with an increased risk of Alzheimer’s disease. The stronger association observed for long term exposures reinforces the suspicion of a possible direct association, even if benzodiazepine use might also be an early marker of a condition associated with an increased risk of dementia. Unwarranted long term use of these drugs should be considered as a public health concern.”

Here’s how the study was conducted:

Individuals were selected as “cases” for the study if they met the following criteria:

1.  “a first diagnosis (index date) of Alzheimer’s disease…recorded during the study period without any record of another type of dementia at the index date or before”
2.  “absence of any anti-dementia treatment before index”
3.  “at least six years of follow-up before the index date”

Each person with Alzheimer’s was matched on gender, age group, and duration of follow-up (6, 7, 8, 9, or 10 years) at the index date with four controls.  Both cases and controls were randomly selected from people over age 66 living in the community in 2000-2009.

Data on benzodiazepine use was collected for each case and four controls for the period 5-10 years before the index date.  The following data was collected:

1.  any use of a benzodiazepine during the stated time frame
2.  cumulative dose
3.  whether the benzodiazepine used was long (> 20 hours) or short (< 20 hours) elimination half-life.

The specific benzodiazepines identified in the study were:

Long-acting:  bromazepam; chlordiazepoxide; clobazam; diazepam; flurazepam; nitrazepam; clonazepam.
Short acting:  alprazolam; lorazepam; oxazepam; midazolam; temazepam; triazolam.

Here are the results:

Billioti Table 3 highlighted

In summary:  Use of benzos was significantly associated with an increased risk of AZD. The odds ratios are:  1.52 for any use; 1.85 for long-term use (6 months or more); and 1.72 for use of benzos with a long half-life.  The corresponding odds ratios, after adjustment for potential confounders including anxiety, depression, and insomnia, were 1.43, 1.74, and 1.59 respectively.  The 95% confidence limits for each of these ratios are shown in the table.

Here are some quotes from the discussion section of the paper:

“Risk increased with density of exposure and when long acting benzodiazepines were used. Further adjustment on symptoms thought to be potential prodromes for dementia—such as depression, anxiety, or sleep disorders—did not meaningfully alter the results.”

“Our findings are congruent with those of five previous studies…”

Limitations:  This was a case-control study; not a randomized, controlled trial.  Therefore it is not possible to say with absolute certainty that the benzodiazepine use caused the excess incidence of AZD.  It could be argued, for instance, that the benzos were being prescribed to treat early (prodromal) signs of AZD.  This would be an instance of what’s called reverse causation bias.  However, the authors took particular pains to inoculate the study from this bias:

1.  They did not count as “cases” people who received benzos in the five years prior to the AZD diagnosis date. So if the finding is an instance of reverse causation, it has to be acknowledged that the AZD had an extremely slow and, incidentally, unrecognized onset.

2.  They measured cumulative dose and found a direct association between the magnitude of the dose and the risk of contracting AZD.

3.  They noted whether the benzos used were long or short acting and found the association stronger in the former. This is essentially another cumulative dose measure.  A person taking a 20-hour benzo daily is always effectively “dosed”, whereas a person taking a 2 hour compound daily will have significant breaks from the drug every day.

4.  They calculated the odds ratios after adjusting for the presence of anxiety, depression, and insomnia. These are the kinds of problems for which benzos are often prescribed, and could conceivably also indicate the early stages of AZD.  The fact that the association was still strong after adjusting for these factors makes the possibility of reverse causation bias even less likely.

Some more quotes from the study:

“Dementia is currently the main cause of dependency in older people and a major public health concern affecting about 36 million people worldwide.  Because of population growth and demographic ageing, this number is expected to double every 20 years and to reach 115 million in 2050.”

“Prevalence of use [of benzodiazepines] among elderly patients is consistently high in developed countries and ranges from 7% to 43%.”

“Although the long term effectiveness of benzodiazepines remains unproved for insomnia…and questionable for anxiety…their use is predominantly chronic in older people.”

“Our study reinforces the suspicion of an increased risk of Alzheimer type dementia among benzodiazepine users, particularly long term users, and provides arguments for carefully evaluating the indications for use of this drug class.  Our findings are of major importance for public health, especially considering the prevalence and chronicity of benzodiazepine use in older people and the high and increasing incidence of dementia in developed countries.” [Emphasis added]

PSYCHIATRY’S REACTION TO THE STUDY

In general there has been little reaction from psychiatry to the study.  I was unable to find any comment from the APA or from the Royal College of Psychiatrists.  I have found a small number of comments from individual psychiatrists.

Guy Goodwin, MD, is a professor of psychiatry at Oxford University in the UK.  He is also president of the European College of Neuropsychopharmacology.  In a BBC article dated September 9, he is quoted as saying that the findings:

“…could mean that the drugs cause the disease, but is more likely to mean that the drugs are being given to people who are already ill.” [Emphasis added]

There’s no indication in the BBC article that Dr. Goodwin cited any evidence for this assertion, or that he made any reference to the steps that the authors took to counteract precisely this kind of reverse causation bias.

. . . . . . . . . . . . . . . .

I also found a comment from Abbot Granoff, MD, a psychiatrist practicing in Norfolk, Virginia.  His comment was in response to a CBS article.  Here are some quotes from his comment.

“I am a Board Certified Psychiatrist…”

“I have been successfully prescribing benzodiazepines for the past 35 plus years in my private practice.”

“…anxiety, depression or insomnia might be early symptoms of dementia whatever the cause. Prescribing a benzodiazepine to treat these symptoms does not cause the illness.”

“Because of age, liver function (which breaks down medications) or brain function might already be compromised and cause the side effects of sedation and memory loss to become more severe. These side effects are dose related. Reducing the dose eliminates the side effects. They are not permanent.”

Again, there is no evidence, and no serious acknowledgement of, the issues – just the comforting (?) assertion that “prescribing a benzodiazepine to treat these symptoms does not cause the illness.”

. . . . . . . . . . . . . . . .

By way of contrast, I found an interesting comment in the BMJ’s rapid response section.  The comment is from Eric Lenze, MD, geriatric psychiatrist, et al, of Washington University School of Medicine, St. Louis, Missouri.  Here are some quotes:

“A mass of evidence suggests that the benefits of benzodiazepines in older adults rarely, if ever outweigh their risks.”

“Benzodiazepine risks, whether short-term or chronic, include cognitive impairment, delirium, respiratory insufficiency, falls, fall-related injuries such as hip fractures, motor vehicle crashes, and death.”

The main risk factor for chronic benzodiazepine use is any previous use, so an intended short-duration prescription of these habit-forming medication is likely to lead to their long-term use.” [Emphasis added]

“Benzodiazepines’ benefits for anxiety disorders are questionable, especially as they are commonly used in clinical practice. First, the dose of benzodiazepines necessary to provide a clinical response is far higher than that needed to cause harms in older adults – for example, 6-10mg daily of alprazolam is needed to bring about remission from panic disorder, and 30-60mg daily of oxazepam was needed for response in (to our knowledge) the only controlled study of benzodiazepines for anxiety disorder in older adults.  Second, there is growing evidence in anxiety disorders that benzodiazepine use reduces the efficacy of exposure-based cognitive behavior therapy, probably by interfering with learning and memory and preventing habituation to the anxiety.  Hence, benzodiazepine use may actually perpetuate (rather than treat) many anxiety disorders by preventing naturalistic recovery from them.”

“The evidence for benefits of benzodiazepines in insomnia is equally poor. In a meta-analysis, benzodiazepine use resulted in a mean nightly improvement of 25.2 minutes sleep. The number needed to treat for improvement of insomnia was 13, while the number needed to harm was 6.”

“For occasional insomnia or transient anxiety, watchful waiting or other low-intensity intervention are superior to initiating a dangerous and habit-forming medication.”

“To conclude, Billioti De Gage and colleagues provide more evidence still that deleterious consequences of benzodiazepines in older adults are a large and growing public health problem, given their high rates of use in this age group.  It is time for their use to be limited, for example to palliative and hospice care or specific treatment-refractory cases, and as a start we recommend the following:

1.  Clinicians prescribing these medications to older adults should warn them that their use is not considered best practice.

2.  These medications should come with a warning (like that found on cigarette packages) such as “If you are older than 60, use of this medication will increase your risk of cognitive impairment, falls, hip fractures, and death.”

3.  Educate health care providers regarding (a) risks of short-term and long-term benzodiazepine use and (b) safe alternatives for the management of anxiety and insomnia.”

“Competing interests: none to report”

There are 20 references attached to this comment, so it’s a good source document for anyone wanting to research the facts about these dangerous drugs.

A CONSUMER’S REACTION TO THE STUDY

Here’s another comment from the BMJ’s rapid response thread:

“I have been prescribed generic Xanax for about 9 years, at dosage between 5mg and 1mg/day. I am 45.  This study is clearly alarming, and honestly terrifying.

How are my odds of being diagnosed with Alzheimer’s figured?  I can only imagine that I am in increased likelihood of about 8,000%.  Based on the 3-6 month likelihood rates.

My doctor says, ‘Just keep taking it. Benefits outweigh the risks.’ Clearly, they do not! I have not slept nor eaten well since I read the study.  Can anyone explain the likelihood ratios that are mentioned?  And is there evidence of the disease showing up in younger people after taking benzos for years?

Any help, and perspective at all would be so very much appreciated!”

DISCUSSION

So, if a person in mid-life is feeling anxious, or depressed, or can’t sleep?  No problem.  No need to figure out the source of these concerns.  No need to work towards solutions in the old time-honored way of our ancestors.  Today, psychiatrists have pills.  Pop a benzo!  And by the way, you’ll have a 40% increased risk of AZD in your late sixties.  And if that makes you anxious, don’t worry; psychiatrists have neuroleptics and electric shock “treatment” to “manage” dementia.

All psychiatric drugs exert their effect by distorting normal brain function.  They all cause damage, especially when ingested for prolonged periods. The present study simply confirms and quantifies this phenomenon.  Psychiatry’s usual response to this is to assert that the benefits of their “treatments” outweigh the risks.  But by  what Faustian calculus can one compare the short-term chemical dissipation of anxiety with the medium-term risk of AZD?

There is truly no human problem that psychiatry can’t make ten times worse.  The notion that all the great trials of life, and particularly aging, can be resolved by dispensing addictive drugs is fundamentally spurious, disempowering, and insulting.  The notion that such activity would masquerade as a legitimate medical specialty is a travesty, to which our descendents will one day hold psychiatry accountable.

Anxiety and depression are not illnesses.  They are normal human responses to various kinds of problems that are an integral part of what it means to be human.  The only effective way to cope with anxiety or depression is to confront, and resolve, the underlying causes, either by one’s own efforts, or with the help of others.  Taking psychiatric drugs to “treat” these feelings is no different than “drowning one’s sorrows” in a bottle of whiskey.  Both products are highly addictive, and the long-term results are comparable.

DETOXING FROM BENZOS

Detoxing from benzos, even after relatively short-term use, can be extremely difficult and fraught with problems.  These drugs should never be stopped abruptly.  For information on withdrawal from benzos, see Monica Cassani’s site Beyond Meds.

Benzodiazepines: Disempowering and Dangerous

I recently read an article by Fredric Neuman, MD, Director of the Anxiety and Phobia Center at White Plains Hospital, NY.  The article is titled The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium, and was published in June 2012 by Psychology Today.  Thanks to Medicalskeptic for the link.

Dr. Neuman opens by telling us that benzodiazepines are “…very commonly prescribed for any sort of discomfort.”

“They are called anxiolytics, and they are prescribed for any level of anxiety and more or less to anyone who asks for them.”

Dr. Neuman has been working at the Anxiety and Phobia Center for 41 years, first as Associate Director and then as Director.  So when he says that benzos are routinely given to “anyone who asks for them,” it’s probably safe to say that he’s being accurate.

He tells us that the benzos have a “modest tranquilizing effect” in the doses at which they are “usually prescribed.”  But –

“…I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills.”

and

“…I think these individuals suffer a loss of self-confidence. Their ability to rely on themselves has been undermined by their reliance on these drugs.”

Dr. Neuman asserts that benzos

“…are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.”

He provides a list of those adverse effects that concern him most.

  1. They are addicting.
  2. They effect coordination, particularly in the elderly.
  3. They compound the effect of other drugs and alcohol.
  4. They interfere to some extent with memory. 

And to this list he adds the dangers of abrupt discontinuation and

“…the fact that I think something is lost, as I indicated above, when someone relies on something make-believe to get through the day.”

Dr. Neuman concludes:

“…these drugs are sometimes helpful a little, and in some ways hurtful a little.  But I don’t wish to give the impression that they are really bad. If a patient demands them, I will usually acquiesce, assuming the dose is small. I always encourage patients to take less as time goes on.  If they won’t, I don’t usually argue with them.”

and

“I know most doctors give these drugs much more readily than I do.”

 DISCUSSION

In the article Dr. Neuman comes across as a reasonable and helpful person.  He prescribes benzos, but he recognizes and articulates the disempowering aspect of relying on drugs, and I think it is reasonable to assume that in his practice he encourages people to pursue genuine resolution of fears and anxieties rather than chemical masking.  But what struck me most forcibly in the article was the sentence:

“If a patient demands them, I will usually acquiesce, assuming the dose is small.”

Dr. Neuman is to be commended for his honesty, but it is a truly amazing admission – particularly his use of the word “demand.”  It has long been my contention that there is very little essential difference between psychiatric “prescribing” of psychoactive drugs and the illegal selling of drugs on the street.  Dr. Neuman’s use of the word “demand,” his admission that he usually acquiesces, and his credible assertion that most doctors prescribe these drugs more readily than he does, lends support to this contention, at least as far as benzos are concerned.  It is difficult to reconcile his statements with the notion that these drugs, when used in a psychiatric context, are medications being prescribed to treat illnesses.

MORTALITY HAZARD

The same day that I read Dr. Neuman’s piece, I also read an article in the BMJ:  Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study, by Weich et al.  Here are the conclusions:

“In this large cohort of patients [34,727 participants and 69,418 matched controls]  attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality [hazard ratio: 3.3] over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.”

The increased risk for those participants who had taken only benzodiazepines was slightly higher at 3.68.  Risk ratios were adjusted for age, gender, and the following health problems:  “arthritis, asthma, cancer, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, gastrointestinal disorders, hypertension, musculoskeletal disorders, anxiety disorders, sleep disorders, other (non-anxiety), psychiatric disorders, and prescriptions for non-study drugs.”  The association followed a dose-response pattern.  Participants who had taken benzos at the highest doses had a hazard ratio of 5.1.

Even allowing for the standard disclaimer, the study raises serious doubts as to the oft-claimed safety of these products, especially as other studies have produced similar findings.  It should also prompt us to question Dr. Neuman’s somewhat cavalier approach to these products – an approach which in my experience is widespread in psychiatry.  A three-fold increase in mortality rate over seven years is not a trivial matter.

Benzodiazepines: Dangerous Drugs

On February 25, Kristina Fiore published an article on MedPage today.  It’s titled Killing Pain: Xanax Tops Charts

The article is based on a study conducted by Jann M et al, and published in the February 2014 issue of the Journal of Pharmacy Practice.  The study is titled Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics.  Here’s a quote:

“During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression.”

Alprazolam is a benzodiazepine.  It was marketed as Xanax in 1981, and has been available in generic form since 1993.  It is used by psychiatrists as an anti-anxiety agent.

When the benzodiazepines were first introduced, it was widely claimed, both by psychiatrists and by pharma, that they were non-addictive.  This claim was subsequently abandoned in the face of overwhelming evidence to the contrary, and the addictive potential of these products is now recognized and generally accepted.  Incidentally, you can find some interesting history on the promotion of tranquilizers, including benzos, on a Medpage timeline published last month.  The timeline presents ads gathered from the New England Journal of Medicine and from the Journal of the American Medical Association.  It’s tawdry stuff.  Thanks to Laura Delano for the link.

Back to Ms. Fiore’s article.

“When a patient comes in with complaints about anxiety, it’s easy to write a prescription for Xanax, Jann said.  Like other benzodiazepines, it’s cheap and it’s perceived to be safe.”

She also quotes Daniel Carlat, MD, professor of psychiatry at Tufts:

“Xanax really is a tried and true medication…When patients take it, they feel its effect quickly.”

 And

 “It also goes to work fast, which may be a reason why patients show a preference for it…”

 Miss Fiore has also interviewed Allen Frances, MD, former psychiatric chair at Duke and architect of DSM-IV:

“And the drug is an easy solution for primary care doctors who are pressed for time, said Allen Frances, MD, a professor emeritus and former chair of psychiatry at Duke University.

Indeed, the majority of benzodiazepine prescriptions in 2013 were written by family practice or internal medicine doctors, totaling some 44 million prescriptions. That’s vastly more than the 13 million written by psychiatrists.

Frances said that if the FDA were to conduct a thorough review of Xanax, it might not be so widely prescribed.

‘The effects of Xanax are much more subtle and dangerous,’ he said. ‘In combination it can be deadly, and for many people it creates an addiction problem that’s worse than the original condition.’

‘I think if there was a careful review of its risks and benefits, it would be taken off the market,’ he added, ‘or it would at least have much more restricted use.'”

Dr. Frances has reinvented himself in recent years as an outspoken critic of DSM-5 and of psychiatric excesses generally.  His points are usually cogent and well made, but he remains unreceptive to the fact that his own brainchild, DSM-IV, was an integral step in psychiatry’s spurious and self-serving medicalization of non-medical problems.

The fact is that anxiety is not an illness, and drugs that dissipate anxiety are not medications – they are drugs.

Benzodiazepines have a legitimate use in general medicine, and in that context are indeed medicines in the proper sense of the term.  But when prescribed for anxiety on a routine, daily basis, they are drugs.  They fall into the class of drugs that addictionologists call sedative-hypnotics, and are similar in their general effects to alcohol and opiates.  I worked in the chemical dependency field in the late 80’s – early 90’s, and even then we were admitting large numbers of people addicted to benzos.  It was, and is, an extremely difficult addiction to overcome.  Withdrawals are typically difficult, protracted, and sometimes dangerous.  Monica’s Cassani’s website Beyond Meds goes into this in great detail.

Dr. Frances makes the point – undoubtedly true – that general practitioners prescribe more benzodiazepines than psychiatrists.  This is a common cry from psychiatry when confronted with the damage that their products are causing.  But the argument is specious, because no practitioners could prescribe these drugs as a daily “treatment” for anxiety if psychiatry had not, in the first place, promoted the false message that anxiety is an illness.  No doctor could prescribe these products for these purposes if psychiatry had not invented, packaged, and sold their various anxiety “diagnoses.”  When psychiatry embarked on its great mission to medicalize every conceivable human problem, they basically drove the bus off the cliff .  Mental health today is still in a state of uncontrolled free fall.  And every time we hit an outcropping, or the bus turns end over end, psychiatry says: “Oh dear!  How did that happen?”  Well it happened because organized psychiatry put money and prestige above intellectual and moral integrity.  The damage this has done, and continues to do, is beyond reckoning. 

Psychiatry has damaged and killed human beings who came to them for help.  They have routinely disempowered people, and have spuriously equated all human distress to their confidently-touted, but fictitious, chemical imbalances, and, more recently to the twitching of aberrant neural circuits.  They have arrogantly promoted themselves as the arbiters of normalcy and the healers of emotional pain.  They have systematically undermined the notion of self-improvement through effort, and through natural social support networks.  They have enslaved millions to their toxic psychotropic chemicals.  And we haven’t hit bottom yet.

Anxiety is not an illness.  It is a normal human response to ambiguous or potentially challenging or dangerous situations.  I’ve written more on this in my post Anxiety Disorders.  Modern life is fraught with anxiety-arousing situations.    If psychiatry had had the slightest interest in truly helping people, it would have focused on this reality, and developed genuinely helpful concepts and practices in this area.  But there isn’t much money in that.

So instead, intoxicated by its customary delusion of infallibility, it did what it always does:  issued the self-serving decree that anxiety is an illness best treated by “medications.”

Dr. Frances is correct:  benzodiazepines should be taken off the market – not only because they are dangerous, but also because the notion of washing away people’s anxieties and concerns in a drug-induced haze of semi-euphoria is fundamentally disempowering, and makes a mockery of the practice of medicine.  The only possible honest response from a physician who is asked to treat anxiety, is to point out that anxiety is not a medical matter.

People who take these drugs as a routine measure to insulate themselves from life’s multi-variate challenges and vicissitudes are not medicated.  They are stoned.

And the great irony here is that everybody knows this.  The individuals know it; their family members know it; their friends and co-workers know it; the psychiatrists themselves know it.  And the street pushers who obtain benzos illegally know it.

But the great fiction has to be maintained.  Here’s a quote from Benzodiazepines:  A versatile clinical tool, by Bostwick et al in Current Psychiatry, April 2012

“Since the discovery of chlordiazepoxide [Librium] in the 1950s, benzodiazepines have revolutionized the treatment of anxiety and insomnia, largely because of their improved safety profile compared with barbiturates, formerly the preferred sedative-hypnotic.”

And psychiatry and pharma go on making a killing.  According to the Kristina Fiore article mentioned earlier, there were 94 million prescriptions for benzos written in the US in 2013.  Psychiatry is out of control.

Benzodiazepine Withdrawal

On November 28, I put up a post on the adverse effects of benzodiazepines, including the potential for protracted and serious withdrawal problems.

Since then I’ve become aware of a helpful and interesting resource in this area.  It’s called Benzo Info, and is on Monica Cassani’s blog, BeyondMeds.

Monica has first-hand experience of benzodiazepine withdrawal, and her comments and suggestions are always helpful, supportive, and insightful.  She also provides a comprehensive list of links to other materials dealing with specific aspects of this problem, including forums and support groups.

Withdrawing from benzodiazepines can be dangerous, and in my view should entail medical supervision.  Monica makes the point that some physicians are not as knowledgeable in this area as they might be.  She writes:

“Sometimes the best we can do is find a doctor who is willing to learn with us. I was blessed with such a prescriber while I came off my cocktail.”

If you, or someone you know, is in this plight, or if you’re just interested in this particular aspect of psycho-pharmaceutical destructiveness, this is a good site to peruse.

Benzodiazepines – Adverse Effects

On November 25, Mad in America posted a link to an article in the Journal of Neurological Sciences.  The article is by Harnod et al, and is titled An Association between Benzodiazepine Use and Occurrence of Benign Brain Tumors.  The authors studied the records of  62,186 individuals in Taiwan  who had been prescribed a benzodiazepine for at least 2 months between 2000 and 2009.  They compared the incidence of brain tumors in these patients with the incidence in patients in a matched-pairs control group.  The hazard ratio for benign brain tumors (benzo group vs non-benzo group) was 3.15 (95% confidence interval: 2.37-4.20).  The hazard ratio for malignant brain tumors was 1.21 (95% confidence interval: 0.52-2.81).  What this means essentially is that one can be 95% confident that the benign tumor association is real, but that the malignant tumor result might have arisen by chance.

The authors also discovered that dosage is an important factor.  The hazard ratios for benign brain tumors increased with dose.  At doses between 36 and 150 mg/year the hazard ratio was 2.12 (1.45-3.10); at doses above 150 mg per year, the hazard ratio was 7.03 (5.19-9.51).

The study in question is a matched-pairs cohort study, rather than a randomized controlled trial, so one can’t state with absolute certainty that the drugs caused the tumors, but given the large number of participants, the meticulous control of confounding factors, and the magnitude of the hazard ratio (three-fold), the results need to be taken very seriously.

There might also be a tendency to dismiss these results on the grounds that the tumors are benign.  But benign tumors can have serious implications..  Here’s what the American Brain Tumor Association says:

“…the location of a benign brain tumor can have a significant impact on treatment options and be as serious and life-threatening as a malignant tumor.”

HISTORY

The first benzodiazepine, Librium, was introduced in 1960, followed in 1963 by Valium.  Today there are dozens of benzodiazepine-class drugs in regular use.

The Harnod et al study is by no means the first time that researchers have drawn attention to the dangers of long-term benzodiazepine use.

Here is a short list of studies that found significant adverse effects for benzodiazepines:

Lader MH, Petursson H, 1981: Benzodiazepine derivatives–side effects and dangers.

“A range of paradoxical effects can occur of which release of aggressive and hostile feelings has excited most attention.”

Lader MH, Petursson H, 1984: Computed axial brain tomography in long-term benzodiazepine users. 

“The mean ventricular/brain area measured by planimetry was increased over mean values in an age- and sex-matched group of control subjects but was less than that in a group of alcoholics.” [Benzo users had more brain shrinkage than controls, but less than alcoholics]

Tata PR, et al, 1994: Lack of cognitive recovery following withdrawal from long-term benzodiazepine use.

“Despite practice effects, no evidence of immediate recovery of cognitive function following BZ withdrawal was found. Modest recovery of certain deficits emerged at 6 months follow-up in the BZ group, but this remained significantly below the equivalent control performance.”

Burke, KC et al, 1995: Medical services use by patients before and after detoxification from benzodiazepine dependence.

“Although a retrospective record review suffers from a range of limitations, the findings suggest that detoxification from benzodiazepines may be effective in reducing use of outpatient medical and mental health services and presumably in reducing costs of care.”

Cohen, SI, 1995: Alcohol and benzodiazepines generate anxiety, panic and phobias.

“In almost half the patients seeking advice for anxiety, panic and phobias the cause was alcohol or benzodiazepines.”

Barker MJ et al, 2004: Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis.

“Results of the meta-analyses indicated that long-term benzodiazepine users do show recovery of function in many areas after withdrawal. However, there remains a significant impairment in most areas of cognition in comparison to controls or normative data.”

Stewart SA, 2005: The effects of benzodiazepines on cognition.

“In an attempt to settle this debate, meta-analyses of peer-reviewed studies were conducted and found that cognitive dysfunction did in fact occur in patients treated long term with benzodiazepines, and although cognitive dysfunction improved after benzodiazepines were withdrawn, patients did not return to levels of functioning that matched benzodiazepine-free controls.”

Berger A et al: 2012: Change in healthcare utilization and costs following initiation of benzodiazepine therapy for long-term treatment of generalized anxiety disorder: a retrospective cohort study.

“Healthcare costs increase in patients with GAD beginning long-term (≥90 days) treatment with a benzodiazepine anxiolytic; a substantial proportion of this increase is attributable to care associated with accidents and other known sequelae of long-term benzodiazepine use.”

Kao CH et al, 2012: Benzodiazepine Use Possibly Increases Cancer Risk: A Population-Based Retrospective Cohort Study in Taiwan. 

“In the group with benzodiazepine use, the overall risk of developing cancer was 19% higher than in the group without benzodiazepine exposure…”

Other studies can be found that dispute details of the adverse effects spectrum, but there is general agreement that these effects are wide ranging and, in many cases, serious.

DRUG DEPENDENCE

Benzodiazepines were initially promoted as non-habit-forming, but in fact reports of dependence for each of the various products emerged, usually within a few years of its launch.  Withdrawal reactions from Librium were noted in a 1961 article (Withdrawal reactions from chlordiazepoxide (Librium), in the journal Psychopharmacologia 1961, 2: 63-68).  Reports of addiction to Valium were noted in a letter to the BMJ in 1967 (Addiction to diazepam (Valium), Br Med J 1967;1:112.1).  In 1976, a report of withdrawal symptoms in newborns who were exposed to benzodiazepines in utero appeared in the American Journal of Obstetrics and Gynecology.  In 1977, a similar report appeared in the Journal of Pediatrics.  In 1986, Professor Heather Ashton, DM FRCP, of the University of Newcastle, UK, wrote a comprehensive account of the benzodiazepine withdrawal syndrome in an article titled Adverse Effects of Prolonged Benzodiazepine Use.  Here are some quotes:

“The syndrome can be of considerable severity and has similarities to abstinence syndromes associated with alcohol, opiates, and barbiturates.”

“Agoraphobia, other phobias, and depression are common during withdrawal…”

“Perceptual distortions (sometimes hallucinations) and feelings of depersonalisation and unreality are characteristic. Acute psychotic episodes occur occasionally, but obsessions, intrusive thoughts and memories, and paranoid feelings are not uncommon. Irritability, rage, and aggression are also frequent…”

“Neurological symptoms include episodes of paraesthesiae and numbness, tremor, muscle pains, stiffness, weakness and fasciculation, ataxia, and blurred or double vision…”

“Major convulsions or temporal lobe seizures sometimes occur on abrupt withdrawal.”

“Gastrointestinal symptoms are very common…”

“Cardiovascular symptoms (palpitations, flushing, chest pain), hyperventilation, urinary symptoms (frequency, urgency, incontinence), and loss of libido are similar to those seen in anxiety states. An influenza-like syndrome with prostration and increased upper respiratory tract secretion may occur and resembles that seen after narcotic withdrawal, although it is more protracted.”

In an American Journal of Psychiatry editorial in 1991, Carl Salzman, MD, Chair of the APA Task Force on Benzodiazepine Dependence, Toxicity, and Abuse, acknowledged that:

“True physical dependence can arise from chronic therapeutic use, defined by the appearance of a constellation of discontinuance symptoms following abrupt withdrawal.”

Some individuals withdrawing from benzodiazepines experience protraction of withdrawal symptoms for months, and in some cases more than a year.  Lader M et al (2009), in Withdrawing Benzodiazepines in Primary Care, state:

“No clear evidence suggests the optimum rate of tapering, and schedules vary from 4 weeks to several years.”

Prescriptions for benzodiazepines continue to rise.  Alprazolam (generic Xanax) is the most prescribed psycho-pharmaceutical product in the US today.  The number of prescriptions written for this drug increased 9% from 2009 to 2011 (PsychCentral).

Psychiatrists claim that anxiety is an illness, and that the prescription of benzodiazepines is a legitimate medical intervention.  The reality is that anxiety is the natural consequence of the relentless, stressful, isolative, unfulfilling kind of lifestyle that is becoming increasingly common in the US and other industrialized countries.  Benzodiazepines are a fast-acting, addictive drug that dulls the pain, but often at enormous cost.  Their effects, including long-term adverse reactions, are similar to alcohol, but they can be used discreetly in situations where alcohol use would attract disapproval (workplace) or even legal consequences (public places).

Popping a benzo to cope with life’s difficulties and challenges is essentially on a par with taking a nip from a hip flask filled with whisky.  It might get one through the day, but it’s not an effective or personally fulfilling way to tackle life’s problems, and the adverse consequences can be truly horrendous.