What do I need to know about benzodiazepines?
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Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Well, I remember when they were called Mother's Little Helpers. They've also been called Reds and Blues, Forget Me Pills. All of them are common nicknames for benzodiazepines. And what's interesting is that they kept in the zeitgeist. Recently, their use and misuse became a plot line in the popular TV series The White Lotus and also The Pit. And as an emergency physician, I have seen countless patients who take them

For therapeutic purposes and some who take them far longer than recommended, benzodiazepines are both addictive and are challenging to quit. And I've seen the implications of that in the emergency department as well. So this week we're asking, what do I need to know about benzodiazepines?

Hi Paxton, welcome to The Dose. Hi Brian, thanks for having me. Do you watch The White Lotus? I do. Are you aware that the third season has a major plot line? One of the main characters is a regular user of benzos and her husband begins to, I guess, divert them, pilfer them? I have seen that, yeah, and it certainly kind of resonated with me a little bit based on my professional life.

Yes, that's why we want to talk about it. But before we begin, can you give us a hi, my name is, tell us what you do and where you do it. Just ad lib. My name is Dr. Paxton Bach. I am an internal medicine specialist by training and I practice primarily in addiction medicine at St. Paul's Hospital in downtown Vancouver, British Columbia. I also serve as the co-medical director at the British Columbia Centre on Substance Use. Just the perfect person to talk to.

Let's start with the names of the benzodiazepines that doctors prescribe the most these days. So benzodiazepines, as a class, as you're aware, is an enormous class of medications. We've been using these for over 50 years as a prescribed sedative for a variety of reasons. And there are innumerable different benzodiazepines that are out there. Ones that are more commonly seen or used in Canada include things like lorazepam, also known as Ativan.

diazepam, also known as Valium, some of the more common ones, but there are certainly many others out there. Some of them come and go. I remember when I started practicing in the emergency department for alcohol withdrawal, there were chlorodiazepoxide. Clonazepam has become one of the more widely prescribed benzodiazepines these days, haven't they? Yes, certainly. Clonazepam is another commonly used one out there. It's often

Pretty cultural. They certainly have different properties. They have subtle differences in the way they act. They have different half-lives, so different durations of action. But oftentimes it ends up being kind of a cultural thing as to which one a physician might reach for. Yep. As I said, some of them have come and gone. I remember Halcyon, Triazolam. And you're right, depending on what they're being used for, some of them are more short-acting, more long-acting. Lorazepam is a fairly short-acting. Clonazepam is a more long-acting one.

For what conditions are doctors supposed to be prescribing them?

Yeah, so this is a medication we've been using for more than 50 years for a broad range of different indications or different purposes. And I want to be clear that benzodiazepines are really good at what they do and often have a role and can be really effective in medicine. More commonly, we see them used for a number of short-term indications, including everything from acute anxiety. They're very effective at managing anxiety in the very short term. Sometimes for insomnia or sleep disorders, again, in the very short term, they can be

we can see them being used. In my world, we use them very often to manage certain medical complications or medical scenarios in hospital, like acute alcohol withdrawal, where they're our gold standard in managing that situation. We use them in the ICU as a sedative. We use them in the operating room as a sedative. They're used as an anti-seizure medication. So they're used pretty broadly. And again, they're very effective at what they do, especially in those really short-term scenarios. It's when people start to use them longer term,

whether that's prescribed or non-prescribed, that they can start to have more complications.

In the emergency department, we prescribe or administer benzodiazepines for two or three purposes. One of them is to stop a seizure, an active seizure. We use them as sedating medications. Midazolam, for instance, we use quite a bit to sedate patients who are undergoing procedures. And of course, as with you, we prescribe benzodiazepines to help treat the symptoms of alcohol withdrawal.

Any idea how prevalent benzodiazepine use is in Canada? I imagine it must still be a lot.

I couldn't put a number on it, but it's one of the most common classes of medications we prescribe. Again, we use these very, very commonly in the short term for a variety of reasons. And they can be very safe and effective when they are used appropriately. It's when they're used on a longer-term basis or when they're used in a non-prescribed basis that they start to have some concerning adverse effects. And we'll get to that in just a moment. But how do benzodiazepines work chemically in our brains? Yeah.

Sure. So benzodiazepines as a class, they're a class of sedative or a depressant medication. And they work as many of these classes do in the neurotransmitter system in our brain. So our brain communicates using neurotransmitter, using chemicals that help communicate between the neurons. And benzodiazepines in particular work in a specific way.

area in the brain where they enhance the signaling of a neurotransmitter known as GABA, which is a very kind of sedating, depressing neurotransmitter. So they sort of

They almost work as a sort of a blanket on the brain activity and just sort of bring things down a little bit. And again, when somebody is having a seizure, when somebody's experiencing withdrawal, when somebody's in an operating room, that's exactly the mechanism we're looking for. However, as you can imagine, over time, there can be consequences if that exposure is ongoing. Wow.

What do you see as the main side effects and the risks of benzodiazepine use? So I would say that by far the biggest side effect or the biggest concern around benzodiazepines, again, they're very effective at what they do in the short term, but they can cause a pretty profound physical dependence and that can start to show up quite early. So in as little as a week or two of regular exposure, your body can become quite attuned to them, quite used to them, and start to develop a physical tolerance that's

such that if they are then suddenly removed, you can experience benzodiazepine withdrawal. And that can range from mild anxiety, insomnia, restlessness, to very severe, including things like seizures, coma, and death.

Now, Paxton, certainly from my teaching, there's a difference between a medication like a benzodiazepine inducing tolerance, meaning that you have to keep taking a higher and higher dose to achieve the same effect and having withdrawal effects and addiction per se. And you're you're the addiction expert. Help us distinguish between the two. Correct. So so so physical dependence and tolerance is one aspect of.

potentially have an addiction, but it's certainly not synonymous with an addiction and it's not required. So when I see people presenting with benzodiazepine use, I tend to see it in

A couple of different presentations. So one may be somebody who's been prescribed benzodiazepines, who's taken them as prescribed for an extended period of time and who wants to come off of them because of decreasing benefit, because of side effects that accumulate over time. They can lead to things like increased risk of cognitive decline and falls and fractures over many years of use. And so if I see somebody like that who's been taking them as prescribed, that's somebody who has a physical dependence on

who certainly has a tolerance to the medication, but doesn't meet the other criteria of addiction, doesn't have compulsive use and cravings and lack of control around the use and consequences related to their use.

So that's somebody who I might help them in a careful and controlled way to slowly taper off these medications over time such that they can get off these medications in a safe way. But it is something that can take many weeks or even many months to do depending on what dose they've been on and how long they've been taking them for. The alternative is somebody who shows up and they've been using them in a non-prescribed way. So either using benzodiazepines that have been prescribed for them in greater amounts than have been prescribed or potentially taking

borrowing them from friends, buying them off the street or using non-prescribed benzos. And that's a potentially very dangerous situation, not only because, again, of the significant physical dependence that they cause and the risks of being cut off suddenly, but also just the unpredictability in general of the non-prescribed drug supply that's out there and people's risk of being exposed to something that they did not intend to be exposed to. I

And that's somebody who we would treat very carefully and cautiously, whether in our clinic or in hospital, to try and stabilize them on a prescribed dose of medication and again taper them

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So Paxson, it's an interesting thing. I don't want to be a spoiler, but those who are watching The White Lotus this season are actually seeing two different use patterns of lorazepam. So you have Victoria, who is a chronic user of benzodiazepines, and her husband, Tim, who was never a pill taker, has taken one, and we see him taking another and another and another and another. First of all, it wasn't prescribed for him. He's borrowing medication, and he's using it

what appears to be in an excess pattern that could be more consistent with addiction. I don't know if you've watched it, but have you seen that? Yeah, yeah, I have seen the show. And you're right, they do represent sort of two different dimensions of a patient that I might see, one being the one with the

the ongoing prescribed use and potentially physical dependence, which in and of itself may be concerning for some people, and the other being somebody with the non-prescribed use. I'll note that in his case, he's just started taking these. He doesn't necessarily meet the criteria for an actual use disorder at this point in time, but certainly...

Certainly high risk use. He's using medications that are not prescribed for him. He's using them in amounts that are exceeding what is prescribed. And I'll also point out in the show, he's combining with other sedating substances such as alcohol, which again can have really unpredictable and potentially dangerous effects.

Let's turn back then to what is probably the more common pattern, particularly if you think in Canada, when you think of the prevalence of chronic use, people who started taking benzodiazepines at one point and now years later are still taking them at the same steady dose. What's the risk if they quit suddenly taking their benzodiazepine if they've been using them chronically?

So any patient who's been on one of these medications long term, I hope has been communicating with their prescriber about the risks and benefits of being on the medication. There are certainly times when longer term use of benzodiazepines may be indicated, but in general, these are medications that are primarily intended for very short term use.

Over time, as mentioned, the brain gets very used to that exposure to the benzodiazepines. And if that's withdrawn suddenly, your brain is suddenly exposed to a very different

milieu, a different environment of neurotransmitters, such that it can end up being overexcited. And there's a number of different complications that can come from that. So if you think of benzodiazepines as sort of a blanket or a brake on the brain activity, and that's withdrawn very suddenly, you can imagine things kind of kick into overdrive. And again, benzodiazepine withdrawal can be characterized from

as mild of symptom category as anxiety and insomnia and restlessness and sort of general unease up to as significant of a pattern as seizures, delirium, coma, or even death or anywhere in between. Much similar to alcohol withdrawal. It sort of follows a similar spectrum and similar mechanism to alcohol withdrawal. You're experienced in this subject. What are some of the safe ways to get off benzodiazepines? So really...

it's not rocket science. And really, it's about a really slow and kind of thoughtful taper or slow and thoughtful incremental decreases over time. And it's something that people tend to work pretty carefully and closely with their prescriber on. And again, it may take a matter of weeks. It may take a matter of months. And the way that I frame it for patients is that it doesn't matter to me. It shouldn't matter to anyone whether they get off this medication in months

six weeks or 12 weeks or 20 weeks. That's not the concern. The important thing is that five years from now, somebody who's taking this medication and wants to come off it is no longer on it in five years because many of those adverse effects, those consequences that we're talking about related to long-term use, it really is a long game. It really is related to years of exposure to these medications. And that's when people start to

potentially be at risk for things like cognitive impairment, risk of falls, risk of fractures, risk of motor vehicle accidents, and a number of other undesirable consequences related to long-term use.

Paxton, can you say more about that long-term risk? Because those sound serious. Yeah. So, again, these medications can be very effective in the short term. And there are some scenarios where people might stay on them for a longer period of time. And if somebody's on a medication like this and they have concerns, they should talk to their prescriber about the risks and benefits.

but they are a medication that does affect the neurotransmitters of the brain. And over time, over many years of exposure, much like other sedating medications or sedating substances that we see, like alcohol, there can be permanent effects related to that. And those may be, again, those are going to depend on an individual, their other medical conditions, their age, what medication they're taking specifically and what dose they're on. But

There's certainly, it's well described that over many years of exposure, there can be some significant long-term consequences. And for most people, I'd suggest those are things that we want to try and avoid. Paxton, I'm going to frame this question as a question to both people who are listening to this, who've been taking benzodiazepines for a long period of time, and to prescribers, primarily primary care physicians. What's your take on this?

What do you say to those people who have said, I've taken benzodiazepines for years and you're not going to be able to get me to quit. I know I won't be able to quit. What do you say to them? I would say the same thing to a patient as I would to a provider is that if somebody wants to get off one of these medications because they're concerned about either decreasing benefit or potentially those adverse consequences, we can get anyone off of this one of these medications if we just take our time in doing it.

If you've been on a medication for five or 10 years and we try and taper you off over two weeks, it's going to be somewhere between unpleasant and potentially dangerous. But if we're, if we take weeks to months and we slowly and incrementally decrease the dose over, over time, in my experience,

Anyone and everyone can taper off these medications eventually if that's their intention. It's just about making sure we take the time and provide that level of engagement to do so in a careful and thoughtful way such that we minimize that risk and maximize the chance of success. And finally, what advice do you have for someone who might be watching, for instance, The White Lotus and seeing a husband pilfering medications from his wife and taking benzodiazepines without a prescription?

I think it's just a reminder that taking these kind of medications, if they're not being prescribed to you, is potentially a really risky situation. Not only, as mentioned, because we see him taking them in increasing amounts and combining them with alcohol, so the potential for short-term consequences like overdose are very real, but also because very quickly that physical dependence can develop and problems can ensue from that. I would really just

more than anything, caution people about taking medications that are not prescribed to them. And the other thing that I need to mention, especially in the current era, that they are taking pills that are not prescribed to you is a very risky scenario and you don't know what is necessarily in them. In the case of this TV show, obviously, his wife is the one with the prescription, but I can't impress enough upon the audience how unpredictable the non-prescribed drug supply is in Canada, how unpredictable

difficult it can be to distinguish prescribed pills that have been sold or diverted versus those that have been pressed or made outside of pharmacies, and how risky it is to take pills that have not been prescribed to you in terms of things like exposure to fentanyl and other really dangerous substances that are out there that I unfortunately, again, see on a daily basis. So more than anything, it's just about caution and about

communicating with your family physician or your primary care provider if you do have needs that are not being met and you're wondering whether this might be an appropriate medication for you in the short term. Dr. Paxton-Bach, thank you so much for adding that little bit and for talking about the use and the misuse and long-term consequences of using benzodiazepines here on The Dose. Thanks for having me, Brian. I appreciate it.

Dr. Paxton Bock is a clinical assistant professor in the Department of Medicine at the University of British Columbia and an addictions medicine specialist at St. Paul's Hospital.

Here's your dose of smart advice. Benzodiazepines are a class of sedative medications. They work in the brain to cause drowsiness and induce a feeling of calm. In general, doctors prescribe them on a short-term basis as a sleep aid to relieve anxiety and panic attacks, to treat alcohol withdrawal, and to sedate patients who are agitated. In hospital, we administer intravenous benzodiazepines to treat epileptic seizures and to sedate patients who are undergoing short-term procedures such as endoscopies and minor surgery.

Common benzodiazepines used by patients include diazepam or Valium, lorazepam or Ativan, alprazolam or Xanax, and clonazepam or Klonopin. There are many others. The most common short-term side effects include dizziness, confusion, drowsiness, memory gaps, slurred speech, muscle weakness, and loss of coordination and balance. Mixing benzodiazepines with alcohol or opioids increases drowsiness and can be dangerous.

Benzodiazepines are generally prescribed for two to four weeks. However, many people take them for years, long after the therapeutic benefits have decreased. The long-term adverse consequences of benzodiazepines can include problems learning or concentrating. In older people, they can increase symptoms of dementia.

Long-term use also generally leads to tolerance, which means that over time you need more of the medication to get the same effect. When you stop taking the medication suddenly, you can develop restlessness, trouble sleeping, confusion, and even seizures. Benzodiazepines can also be addictive and lead to craving the medication, taking more than prescribed, and being overly focused on obtaining a supply.

If you use benzodiazepines for years and want to get off of them, see your health care provider. Do not stop the medication suddenly on your own as that can lead to seizures. A health care provider can help you get off the medication by tapering the dosage over months. If you have topics you'd like discussed or questions answered, our email address is thedoseatcbc.ca. If you liked this episode, please give us a rating and review wherever you listen.

This edition of The Dose was produced by Samir Chhabra and Prapti Bhamania, our senior producers, Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose. For more CBC podcasts, go to cbc.ca slash podcasts.