Download Benzodiazepines - Dr Anthony (Tony) Mander

Benzodiazepines
What are benzodiazepines?
They are a group of medications which have been used since the 1960s to
treat:
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anxiety
epileptic seizures
mania
alcohol withdrawal
sleeping problems
They replaced the barbiturates which had been commonly prescribed for 50
years around the 1950s, but which were addictive and very dangerous in
overdose.
They include:
Some benzodiazepines commonly used in the UK:
Trade Name
Valium
Ativan
Temaze
Librium
Mogadon
Proper name
Diazepam
Lorazepam
Temazepam
Chlordiazepoxide
Nitrazepam
Used for:
Anxiety
Anxiety
Sleep
Alcohol withdrawal
Restricted
Zolpidem
Zaleplon
Zopiclone
They all work in a similar way (see below). Those which have a short effect
have been marketed as sleeping tablets – the idea being that you don't get a
muzzy head the next day. Others with a longer effect have been marketed for
their use in controlling anxiety.
How do they work?
They boost the effect of a substance in the brain – GABA.
What is GABA?
GABA is a neuro transmitter – a chemical which is used in the brain to control
the passage of impulses from one cell to another. GABA has a generally
calming effect in the human brain.
What are the main side effects?
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Sleepiness
Unsteadiness
Memory problems.
But most people find they don’t have significant problems of this sort.
Aren't benzodiazepines addictive?
Yes. Around 4 in every 10 people who take them continuously for more than 6
weeks will get withdrawal symptoms. These include difficulty in sleeping,
feeling tense and agitated – rather like the return of the symptoms the
medication was originally prescribed for. You can also get dizziness, metallic
tastes, and disturbances of your vision.
They will usually start within 48 hours of stopping or reducing the dose of a
benzodiazepine. They can be mild and pass off within a few days.
For some people they may be so severe that they produce confusion,
hallucinations and epileptic fits.
Some people experience unpleasant symptoms for several months
afterwards.
Managing withdrawal
If you have been taking a benzodiazepine for more than a few weeks, talk it
over with your doctor – you should probably reduce the dose by just 1-2 mg
every 2 weeks. It may take a while, but nearly everyone can tolerate this very
slow rate of withdrawal.
Are blood tests necessary?
Benzodiazepines are very safe and no routine tests are needed before taking
them.
How effective are the benzodiazepines?
They are work well for the short term treatment of both anxiety and sleep.
They work particularly well in generalised anxiety disorder and social anxiety
disorder. They can also be helpful in panic and obsessive compulsive
disorders, but in these conditions antidepressants - especially the SSRIs seem to work better.
In all the conditions in which they are used, benzodiapines tend to produce
dependence and withdrawal reactions. They should really only be used for
periods of a few weeks or so.
How long does treatment last?
Just a few weeks, while other (often psychological) treatments have a chance
to work. A very few people may benefit from taking them long-term, but this
should only be carried out by a specialist unit after other treatments have been
tried and have failed.
How do the treatments compare and how does one choose between
treatments?
The main differences between the benzodiazepine type drugs are:
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how quickly they start to act
how long they stay in the body.
When they are used to help sleep, then a short-acting drug is better so that
you don't get a “hangover” effect the next day, which can make it dangerous to
drive or use machinery. The “z-drugs” were designed to fulfil this need and do
it well.
When anxiety is present all day long, then a longer acting benzodiazepine
such as valium or ativan is used.
If someone is both anxious and sleeping badly, the longer-acting
benzodiazepines can be taken at night - they will improve sleep but still be
present the next day to help with the anxiety.
What can I do to help myself ?
Self-help treatments for anxiety and insomnia are available from
psychologists, in books and over the internet. See the reading materials
section at the end of this leaflet and of our other leaflets:
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Sleeping Well
Cognitive behavioural therapy
What would happen without treatment?
Anxiety and insomnia can be short-lived, especially when they have started
because of a stress such as bereavement or a job loss. However, many
people have lasting anxiety and insomnia because of chronic stress or family
tendencies. These need attention if the person is to get better.
Are there any major differences of opinion about benzodiazepines?
Most health care professionals now accept that the benzodiazepines and zdrugs can be helpful in anxiety and insomnia. However, it is universally
acknowledged that they were overused in the 1960s and 1970s which led to
many people becoming dependent on them – see above.
It now seems safe to use them in the short term (less than 4 weeks).
Psychological therapies and/or antidepressants are needed in the longer term.
What are the main gaps in our knowledge about anxiety and
sleeplessness?
We do not know why some people are more anxious or sleep less well than
others. Brain scans suggest that they may not have enough GABA (see
above). This also happens in some forms of epilepsy and alcohol withdrawal.
The benzodiazepines increase the effects of GABA and so make up for this
shortage.
References
Baldwin DS, Anderson IM, Nutt DJ, Bandelow B, Bond A, Davidson J, Den
Boer JA, Fineberg NA, Knapp M, Scott J, Wittchen H-U [2005] Evidencebased guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology.
Journal of Psychopharmacology 2005; 19: 567-596.
Malizia AL, Cunningham VJ, Bell CJ, Liddle PF, Jones T, Nutt DJ (1998),
Decreased brain GABA(A)-benzodiazepine receptor binding in panic disorder:
preliminary results from a quantitative PET study, Arch.Gen.Psychiatry 55:
715-720.
Nutt DJ, Malizia AL (2001) New insights into the role of the GABA(A)benzodiazepine receptor in psychiatric disorder. Br.J.Psychiatry 179: 390-396.
Nutt DJ [2007] chapter on Medication, in The Mind – A Users Guide ed R
Persaud. Royal College of Psychiatrists.
Wilson SJ Nutt DJ [2007] Management of insomnia: treatments and
mechanisms. Brit J Psychiatry 191: 195-197.
Further Reading
Nutt, DJ & Ballenger, JC. (2003) Anxiety disorders. Blackwell Science Limited,
Oxford. I-xii, 1-542. ISBN 0-632-05938-9.
Doble A, Martin IL, Nutt DJ. (2004) Calming the brain: benzodiazepines and
related drugs from laboratory to clinic. Martin Dunitz Limited, London. i-vi, 1185. ISBN 1-84184-05201.
Wilson SJ and Nutt DJ (2008) Sleep Disorders; Oxford Psychiatry Library.
This factsheet was produced by the RCPsych's Public Education Editorial Board and
the Psychopharmacology Special Interest Group.
Series Editor: Dr Philip Timms.
© January 2009. Royal College of Psychiatrists. This factsheet may be downloaded,
printed out, photocopied and distributed free of charge as long as the RCPsych is
properly credited and no profit is gained from its use.
Addendum by TM
Taken from the above pamphlet
Aren't benzodiazepines addictive?
Yes. Around 4 in every 10 people who take them continuously for more than 6 weeks will get
withdrawal symptoms.
I am not allowed to change the pamphlet under the Colleges rules for allowing their distribution
freely. However there is a difference between addiction, tolerance and dependence. The latter two
occur and are responsible for the withdrawal effects described. Addiction, in the sense of seeking
drugs for a high, as with heroin or cocaine, does not occur. Drug seeking if it occurs is about
offsetting withdrawal phenomena