There are more than 15 different types of FDA-approved benzodiazepine medications, often called “benzos” for short, which are widely prescribed for the treatment of anxiety disorders and insomnia, as reported by the Center for Substance Abuse Research (CESAR).
To be considered a benzodiazepine medication, the drug must have hypnotic, muscle relaxant, anticonvulsant, or amnesiac properties, or provide anxiety relief. One such medication, Xanax, was the most prescribed psychiatric medication in the United States from 2005 to 2013, according to IMS Health and published by PsychCentral. Benzodiazepines are prescribed to treat the following:
- Generalized anxiety disorder (GAD)
- Social anxiety
- Panic disorder
- Alcohol withdrawal
- Sedation prior to surgery
- Acute agitation
These medications are intended to be used short-term for acute symptoms; they can lead to tolerance and dependency if taken regularly or for an extended amount of time. Benzodiazepines are most commonly prescribed for the treatment of insomnia and anxiety. According to the Drug Enforcement Administration (DEA), alprazolam, lorazepam, clonazepam, diazepam, and temazepam are the five most prescribed benzodiazepine medications in the US.
Types of Benzodiazepine MedicationsBenzodiazepines are short-, intermediate-, or long-acting, and they are generally dispensed either in tablet or capsule form, liquid syrup, or intravenously. Drugs with shorter half-lives usually work rapidly and leave the system faster, while longer-acting medications have longer half-lives, take longer to begin working, and stay effective for an extended length of time. Short-acting benzodiazepines usually start working within minutes, are out of the system in a few hours, and include:
- Triazolam (Halcion): sedative hypnotic medication used for the treatment of insomnia
- Midazolam (Versed): anesthesia adjunct medication used prior to surgery or medical procedures to relieve anxiety and produce sleepiness
- Clorazepate (Tranxene): anti-anxiety medication that treats anxiety, insomnia, and seizures
Intermediate-acting benzodiazepines take marginally longer to take effect and stay in the bloodstream for longer. They include:
- Alprazolam (Xanax): anti-anxiety medication used for treating anxiety and panic disorders
- Lorazepam (Ativan): anti-anxiety medication used for the treatment of anxiety, anxiety coupled with depression, and insomnia
- Temazepam (Restoril): sedative hypnotic medication that treats insomnia
- Oxazepam (Serax): anti-anxiety medication used for the treatment of anxiety, anxiety coupled with depression, and during alcohol withdrawal
- Estazolam (ProSom): sedative hypnotic medication that treats insomnia
Long-acting benzodiazepines take longer to begin working and are effective for the longest period of time. They include medications such as:
- Diazepam (Valium): anti-anxiety, muscle relaxant, and anticonvulsant medication that treats anxiety and muscle spasms; also used during alcohol withdrawal
- Chlordiazepoxide (Librium): anti-anxiety medication used to treat alcohol withdrawal, anxiety, and tremors
- Flurazepam (Dalmane): sedative hypnotic medication used to treat insomnia
- Quazepam (Doral): sedative hypnotic medication used to treat insomnia
- Clonazepam (Rivotril, Klonopin): anticonvulsant medication that treats anxiety, panic disorders, and epileptic seizures
All benzodiazepine medications are currently classified as Schedule IV depressants by the DEA with the exception of flunitrazepam, or Rohypnol, which is considered Schedule IV but has Schedule I penalties in some cases. This drug is often called the “date-rape drug,” and it is not approved for legal use in the United States.
Benzodiazepines and the Brain
Benzodiazepine medications are central nervous system depressants. The central nervous system is responsible for regulating heart rate, respiration, blood pressure, and body temperature. Benzos suppress these vital life functions to some extent, slowing them down.
The brain and central nervous system communicate with each other and the body by using chemical messengers, or neurotransmitters. Benzodiazepines work by stimulating the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), which acts as a natural tranquilizer, and binding to its receptors. By stimulating GABA production, benzodiazepines slow down brain activity, producing calming, sedative, and relaxing effects, working on either the anti-anxiety or sedative-eliciting receptors. This sedative effect can be pleasant, which may increase their potential for abuse. Stress has a stimulating effect on the brain, increasing the firing of certain neurons, and anxiety produces excessive activity of nerves in the brain, which benzodiazepines can dampen, much like water dousing flames.
Since benzodiazepines can work rather quickly, they are often used to help manage severe symptoms and get them under control. Also, since these drugs have a high rate of tolerance and dependency when used in large doses or long-term, they are often a first-course medication that is used in conjunction with other medications until they take effect. General anxiety disorder, for example, may be treated with antidepressants long-term after the initial symptoms of anxiety are managed with a short course of benzodiazepines.
Other disorders, such as social anxiety, may be managed with longer-acting benzodiazepines, which, in a study published by Current Psychiatry, showed a 73 percent recovery rate with the use of clonazepam for 10 weeks. Alcohol withdrawal symptoms may be managed with a long-acting benzodiazepine, such as diazepam, during detox and recovery to manage the potential seizures and anxiety symptoms that may crop up as well as help to induce sleep. Epileptic seizures and tremors are caused by excessive neural activity in the brain that benzodiazepines can slow down, stopping seizures from occurring.
Benzodiazepines also have amnesiac results, meaning that they can cause short-term memory lapses that may be desired during a medical procedure or surgery, making benzodiazepines useful medical tools in many hospital settings as adjunct medications. Many benzos are also used as short-term muscle relaxers, to relieve acute tension or as temporary sleep aids. Since they are habit-forming, benzodiazepines are not meant to provide a long-term solution for insomnia, although they can be very effective for short periods of time.
Side Effects of Benzodiazepine Use
As with any drug, benzodiazepine medications are not without side effects and risk factors. These side effects will vary from person to person, depending on some genetic factors, such as metabolism and tolerance levels, as well as the type of medication taken, dosage amount, duration of use, and method of ingestion. Short-term side effects may include headaches, drowsiness, dry mouth, depression, blurred vision, slurred speech, weak muscles, short-term memory loss, impaired cognition, dizziness, tremors, impaired motor skills and coordination, loss of appetite, nausea, confusion, fatigue, and diarrhea or constipation.
Over-sedation can occur if you take too much of a benzodiazepine too fast, which can lead to a potential overdose or toxic buildup of the drug in the system indicated by extreme sleepiness, mood swings, hostility or aggression, shallow breathing, irregular heart rate, sweats, psychosis, loss of consciousness, or even death. The Centers for Disease Control and Prevention (CDC) reports that 30.6 percent of the 22,767 pharmaceutical overdose fatalities in 2013 were related to benzodiazepine abuse. Flumazenil may be used to reverse any adverse benzodiazepine effects or overdose symptoms.
Benzodiazepine Abuse or Dependency
Any non-medical use of a prescription medication is considered abuse. The National Survey on Drug Use and Health (NSDUH) reported that 1.7 million Americans over the age of 12 abused a benzodiazepine medication in the month before the 2013 survey. Large doses of benzodiazepines may create a rush of euphoria or high that user’s desire.
Benzos are abused by crushing and snorting the pills, injecting them, ingesting higher-than-intended doses, or taking medications that are not medically necessary. Pills are often diverted. In fact, the NSDUH of 2013 found that more than half of Americans over the age of 12 who obtained and used prescription medications for non-medical purposes got them for free from a friend or relative. Some people may doctor shop, or seek multiple prescriptions from multiple doctors. Other methods of diversion include inventing symptoms in order to obtain a prescription that may not be medically necessary. Altering the drugs and snorting or injecting them can be highly dangerous as these methods send the drugs directly across the blood-brain barrier and may increase the odds of a potentially life-threatening overdose.
Dependence occurs when the brain relies on the benzodiazepine being present, and chemical changes are made in the brain’s circuitry. The reward pathway is altered, creating drug cravings and withdrawal symptoms when the drug leaves the bloodstream. Withdrawal from benzodiazepines can be uncomfortable and may be severe, depending on the level of dependency, type of drug abused, method of abuse, dosage, and duration of abuse. When benzodiazepines leave the system, the user may experience a rebound effect as the brain attempts to restore balance. This is what causes withdrawal symptoms that may include insomnia, restlessness, anxiety, irritability, muscle weakness, dizziness, difficulties concentrating, increased heart rate, sweats, and depression as well as drug cravings. More intense symptoms may occur such as delirium, hallucinations, seizures, altered sensory perceptions, and depersonalization. These symptoms may last for weeks or months if left untreated.
You should never attempt to stop taking benzodiazepines suddenly without medical supervision due to the potential severity of the withdrawal symptoms, but instead set up a tapering schedule overseen by a medical professional. Gradually decreasing the dosage over time in a controlled manner may be the safest method of detoxing from benzodiazepines.