I have been writing (and warning) about benzodiazepine drugs since the early 1970s. My book Life without Tranquillisers was published in 1985 and drew national attention for the first time to the size of the problem. In the 1970s and 1980s I made hundreds of TV and radio programmes about benzodiazepines – and wrote hundreds of columns and articles on the subject.
Sadly, benzodiazepine drugs are still overprescribed.
Benzodiazepines can cause anxiety, can cause depression, can cause sleeplessness, can make patients aggressive, can cause foetal abnormalities when taken by pregnant women, can make patients so drowsy that they are unsafe to drive motor cars or operate machinery and can cause a huge number of uncomfortable, unpleasant or dangerous side effects. Benzodiazepines are also extremely addictive.
Here is a small sample of the evidence that has been available to all doctors for decades. The journals from which the quotes are taken are named underneath each quotation.
Since habitual use is common it is wise to prescribe these drugs with care to review repeatedly the prescription of a benzodiazepine once it has been given for more than a few weeks. If intolerance to the effects of the drug appears to be developing, as shown by an increase in dosage, the dose should be reduced and the drug stopped as quickly as possible.
Rebound insomnia, a newly defined clinical entity characterised by a marked worsening of sleep, has been found to occur as a result of abrupt withdrawal of even a single nightly dose of certain benzodiazepine hypnotic drugs, regardless of the duration of use.
The Committee on the Review of Medicines concludes that on published evidence the dependence potential of benzodiazepines is low, but that withdrawal symptoms are liable to occur between one and ten days after treatment is stopped, usually after higher doses have been given for a long time...the Committee has to some extent fudged the issue of benzodiazepine dependence...if the CRM believes that benzodiazepines produce dependence, it should have said so more clearly...long term use should be avoided where possible because of the unwanted effects and the risk of dependence. If a benzodiazepine is being taken continuously and is to be withdrawn, this should be done gradually to minimise withdrawal symptoms.
Although geriatricians do not favour this group of drugs, they are still widely prescribed in general practice.
More recently, evidence has been accumulating that a specific physical withdrawal syndrome may follow the prolonged use of benzodiazepines even when given in normal therapeutic doses...Our findings, like those of other recent reports, show that patients taking benzodiazepines in therapeutic doses risk developing some form of dependence in that a mild to moderately severe syndrome is commonly experienced upon stopping long term benzodiazepine treatment. The demonstration of withdrawal problems in patients on normal, therapeutic doses and the psychological impairment associated with chronic sedative ingestion argues against regular daily medication for chronic anxiety other than of severe degree.
Reaction to benzodiazepine withdrawal was first noticed in 1961. Since then sporadic reports have drawn attention to a wide range of physical and emotional symptoms which can accompany the withdrawal of benzodiazepines...the Committee on Safety of Medicines advises that benzodiazepines should be prescribed for short periods only and that withdrawal symptoms, following administration, can be avoided by withdrawing medication slowly.
Recently a number of studies both in Britain and the USA have demonstrated that a true physical withdrawal syndrome exists on stopping benzodiazepines. This withdrawal syndrome is characterised by severe anxiety, often worse than the original symptoms for which the medication was prescribed. The symptoms become maximal about five days after medication is stopped and gradually resolve in about two weeks...Benzodiazepines are the most commonly prescribed drugs. They are effective in the treatment of anxiety and allied states. Not surprisingly, they can produce both physical and psychological dependence. Physical dependence can be hard to treat and can occasionally result in severe withdrawal symptoms. Its prevention and management are primarily the province of the community psychiatrist - the general practitioner.
Dr Jacob Norell, ex dean of studies at the Royal College of General Practitioners and editor of The Practitioner told a meeting of the Islington Community Health Council in North London that "Valium had become the opium if the people". Society was now using it as a "form of crowd control", he said, and GPs were the worst offenders. "These drugs do not offer true treatment and draw attention from real causes of illness. Their drawbacks rebound when the drugs are stopped.
Benzodiazepines withdrawal needs very careful handling.
In recent years...the pendulum of approval has swung dramatically against the benzodiazepines...several investigations have shown quite unequivocally that benzodiazepines may produce pharmacological dependence in therapeutic dosage...The best management for benzodiazepine dependence is far from clear. Treatment should not be stopped abruptly, for this is more likely to lead to serious withdrawal symptoms including epileptic seizures...In terms of public policy, now that benzodiazepines have been shown to cause drug dependence should their use be more closely controlled - or even banned?
Irresponsible prescribing by doctors often leads to psychotropic drug addiction, a specialist has claimed. Professor Griffith Edwards...told the meeting: `When the media give us yet another heading on `Britain overrun by drugs’ you can wager that they are referring to illicit drugs such as heroin. Too easily lost from sight, though, is a problem which seldom makes the front page - the social significance of illicit prescribing of mind-acting drugs.’ Professor Edwards said benzodiazepines was one example of a drug which was overprescribed. And the central question was why this boom had occurred.
Doctors were urged last week to be more cautious in their prescribing of benzodiazepines because of the huge withdrawal problems in a significant number of patients...Certain benzodiazepines pose more dependency and tolerance problems than others. Lorazepam (Ativan) and triazolam (Halcion) were particularly likely to induce dependence.
Long term use of minor tranquillisers can lead to physical dependence, with the development of a withdrawal reaction if the drug is stopped suddenly...As awareness of this fact increases, so concern is growing amongst doctors and patients alike.
Large numbers of people take benzodiazepines to control anxiety and often continue to do so for months or years, despite the recommendation of the Committee on the Review of Medicines that they should be prescribed only for short term use.
...these findings show very clearly that benzodiazepine withdrawal is a severe illness. The patients were usually frightened, often in intense pain, and genuinely prostrated. The severity and duration of the illness are easily underestimated by medical and nursing staff, who tend to dismiss the symptoms as `neurotic’. In fact, through no fault of their own, the patients suffer considerable physical as well as mental distress.
Benzodiazepines have now become the most widely prescribed group of drugs, and their indiscriminate use is a cause for concern. In the UK approximately 14% of adults now receive a benzodiazepine during the course of a year...High doses given for long periods of time will almost invariably cause problems on abrupt withdrawal. Continuous treatment for longer than four months with anxiolytic benzodiazepines carries a significant risk of withdrawal effects.
Repeat prescribing is to blame for the "enormous" problem of benzodiazepine addiction, warned Dr Brenda Davies, consultant psychiatrist from Ticehurst House Hospital in East Sussex. She said benzodiazepines had become the most commonly prescribed of all drugs. One in five women and one in ten men in the UK used them at some time each year. Of these patients 25% may become dependent after only three months of regular use at the standard dose.
As far back as 1980 the Committee on the Review of Medicines pointed out...that `there was little convincing evidence that benzodiazepines were efficacious in the treatment of anxiety after four months' continuous treatment’. Despite this authoritative statement, and widespread corroborating evidence, there are still substantial numbers of patients receiving benzodiazepines for a year or more. Apart from exceptional cases there is no point in continuing to prescribe benzodiazepines for prolonged periods because they do not help the patient. What may arise, however, is a dependence on the drug among some patients. The symptoms they experience on withdrawal can be very similar to the symptoms which brought them to the surgery in the first place.
There is no doubt that benzodiazepines are effective initially but they should generally be prescribed for no more than a fortnight, and rarely for four weeks.
Clinicians must now recognise the need for extreme caution in benzodiazepine prescribing. In particular, repeat prescriptions should be avoided because the unused tablets are being sold on the black market and young people are abusing and becoming dependent on this class of drug.
Excessive growth in prescriptions for benzodiazepines in the 1970s led to concern over their use. The concern was reinforced by evidence that they were being prescribed for excessively long periods. Subsequent studies have shown that about two fifths of regular users of benzodiazepines develop pharmacological dependence and have withdrawal symptoms when the dosage of their drugs is reduced or treatment is stopped.
On 1st March, 1988 at the 28th sitting of Standing Committee A on the "Health and Medicines Bill" at the House of Commons Mrs Edwina Currie, replying to questions about lorazepam said: "We have taken action because I have been worried about the problem. Dr Vernon Coleman's articles, to which I refer with approval, raised concern about these important matters, and I sent them on to the appropriate bodies. I do not agree with everything that Dr Coleman says, but much of it is good plain common sense. I always read his column with the greatest interest."
This article is adapted from The Benzos Story – 1960s-1980s by Vernon Coleman. The Benzos Story is available as a paperback.