Reprinted from "Women's" issue of Visions Journal, 2004, 2 (4), p. 8-11
What are benzodiazepines?
Benzodiazepines are a family of prescription drugs commonly known as tranquillizers and sleeping pills. These medications were originally designed for short-term relief of anxiety and/or sleeping problems. They are also used to ease withdrawal from other drugs.
About 16 different benzodiazepines are available in Canada today. In the 1960s when benzodiazepines were first prescribed, Valium (diazepam) and Librium (chlordiazepoxide) were the most common kinds. (The first word is the brand name; the second word is the generic name). Both drugs are still in use today. Other benzodiazepines prescribed by Canadian doctors are:
Imovane (zopiclone), a hypnotic similar to a benzodiazepine
Women and benzodiazepine use
Many women are prescribed benzodiazepines when they tell their doctor about being anxious or having panic attacks. Other women are given benzodiazepines because they are in emotional pain or grieving a loss. Others are given the drug because they are experiencing trauma, chronic illness, physical pain and/or sleep problems. It is also common for women to be offered benzodiazepines if they are going through a divorce or are in a period of physical change, such as adjusting to a new baby or menopause. Still other women use benzodiazepines to deal with long work hours or a stressful job.
More women than men are prescribed benzodiazepines. Indeed, women in British Columbia are prescribed benzodiazepines at a rate two times higher than men. This discrepancy is a sign of a serious social problem. Many people believe that women are over-prescribed benzodiazepines: offered a moodaltering drug rather than the human support they need to cope with difficult life circumstances.
Many women do have too much stress and anxiety in their lives. They may be taking care of children, elderly parents, husbands and jobs with very little assistance. Women often have no time to look after themselves, physically or emotionally. They are more likely than men to be living in poverty as single parents or as seniors. Yet these are social and economic problems that will not be solved by giving pills to women. The real solution is to provide women with services and community support.
How benzodiazepines are prescribed
Benzodiazepines were originally intended for short-term use only, seven to 10 days at most. However, many women are given prescriptions for much longer periods. A doctor will often prescribe benzodiazepines month after month without a follow-up visit to discuss the woman’s progress. Some doctors prescribe more than one type of benzodiazepine at the same time. Other doctors switch a woman from pill to pill if the old prescription stops being effective. A woman may be given a second benzodiazepine if she has negative side effects from the first.
Today, benzodiazepines are typically prescribed in four ways:
in a single dose to cope with a specific event (e.g., surgery, plane ride)
for short-term use up to four weeks (e.g., after a death in the family)
for a set period exceeding one month (e.g., during a stressful divorce)
for long-term use, with no end date
Many women slip from short-term use into longterm use. This often happens when the doctor fails to do any follow-up, or when the woman is not offered any community support or counselling.
The problem with benzodiazepines
Are benzodiazepines addictive? The answer is yes, if we listen to women’s stories. Prolonged use of tranquillizers and sleeping pills can result in physical and mental dependency. Some doctors and scientists disagree about the risk, claiming that benzodiazepine addiction is not a real possibility. The fact remains: many women find themselves hooked on benzodiazepines.
Every woman is vulnerable to addiction, regardless of her background, income, education and age. Some women find themselves dependent on benzodiazepines after their trusted family doctor prescribed the drug. As a result, they can feel angry, confused, afraid, isolated, betrayed or ashamed. Other women get benzodiazepines ‘on the street’ to manage the pain in their lives or to deal with withdrawal from illicit drugs. They too may find themselves feeling trapped and ashamed.
Every woman must evaluate the benefits of using benzodiazepines against the dangers of becoming addicted.
The signs of dependency
The signs of benzodiazepine dependency include:
feeling unable to cope without the drug
making unsuccessful attempts to quit or cut down on the number of pills you take
craving the drug
feeling extreme discomfort (mental or physical) if you miss a pill
going to great lengths to ensure your pills are always close by
monitoring your supply to make sure you don’t run out
taking ‘extra’ pills when a situation is stressful
taking more pills or trying different brands because the effects are wearing off
increasing your dose over time
noticing that the drug’s effects are wearing off
Benzodiazepine use is also associated with accidents. Women are advised not to drive when taking the drug. The risk of falling due to benzodiazepine use is a serious concern for seniors and people with certain medical conditions. For example, women with low bone density can easily break a hip during a fall.
Masking the real problem
The short-term use of tranquillizers and sleeping pills can be a helpful part of an overall plan to deal with anxiety or sleeplessness. But the drugs take care of symptoms only, not with the underlying problem. For true relief, a woman needs to get at the root cause of her distress.
It is easy to become dependent on benzodiazepines. For one thing, the pills ‘work well’ at the beginning. Many women find it easier to take pills for ‘just one more day’ rather than to tackle the root problems. This is very understandable given how little social support there is for women in crisis or emotional pain.
Tackling the problem
Many women reach the point where the negative effects of taking benzodiazepines outweigh the original benefits. They no longer want to cover up the reasons for their anxiety or sleeplessness. This is an important, life-altering stage, but any changes in benzodiazepine use must be made slowly and in consultation with medical professionals.
Do not suddenly stop taking benzodiazepines. ‘Cold turkey’ withdrawal is extremely dangerous and can cause lifelong, negative side effects.
If you have decided to cut back or stop using benzodiazepines, try to find a supportive doctor and other health care providers who are knowledgeable about the issue.
The process of withdrawal is different for each woman depending on how long she has used the drug, the amount she uses, and her personal circumstances. The process can be difficult if she has used benzodiazepines for a long time. Withdrawal must go very slowly and gradually. Women should be under informed medical supervision during this process.
Benzodiazepine withdrawal has many symptoms. Some lucky people do not feel any negative effects. But most women will experience some, or all, of the following symptoms (the list is partial):
increased anxiety and panic attacks
hypersensitivity to light
depression or “the blues”
excitability, jumpiness, restlessness
poor memory and concentration
dizziness and light-headedness
weakness, tremours or shaking
heart palpitations, sweating
nausea, indigestion, bodily pains
changes in sight, hearing and other perceptions
Less common symptoms
tightness, like a band around the head
feelings of depersonalization (the loss of one’s sense of identity)
suicidal thoughts, paranoia
outbursts of rage and aggression
pins and needles, other skin sensations
hypersensitivity to sound or touch
increased saliva, difficulty swallowing
The recovery process
The recovery process includes withdrawal, healing, finding personal supports and learning new coping mechanisms.
Recovery begins when a woman makes a commitment to herself to stop using benzodiazepines. Her goal is often to replace them with more positive coping skills.
Although each person’s experience of withdrawal from benzodiazepines is unique, women also have many common experiences. Support is an essential part of recovery. Every woman benefits from having a safe, confidential place to talk and listen. This basic support makes a world of difference to dayto-day survival and longterm success. By learning positive coping skills and seeking support, women find it easier to deal with life’s many difficulties, from grief, pain, chronic illness, insomnia, cultural changes and divorce, to aging and death.
Benzodiazepines: rates and trends
Although the benefits and risk of benzodiazepine use should be carefully measured in all populations, the biological, psychological, and social factors in certain populations call for further special considerations when using benzodiazepines.
Women make up to 65% of all adults who are taking benzodiazepines. Some studies suggest that women are prescribed benzodiazepines at twice the rate of men1,2 and for longer periods of time than men.1,3 Several factors may contribute to this phenomenon, including the higher incidence of anxiety and mood disorders in women4, 5 and the possibility of increased anxiety and sleep problems related to the reproductive processes of menstrual cycles, pregnancy, postpartum and menopause. Other conditions that affect women more commonly than men like sexual assault, domestic violence, poverty, and single parenting may increase their vulnerability to anxiety, panic, mood, and sleep disorders. All of these factors can result in significant stress, but not all will lead to a clinical syndrome warranting a medication. Thus, a careful diagnostic assessment is essential and non-pharmacological solutions and interventions should first be utilized in women presenting with some of the above factors.
Pregnancy and Lactation: benzodiazepines and their metabolites freely cross the placenta and are excreted into breast milk. Prolonged use of benzodiazepines is not recommended in breastfeeding and in pregnancy.7 As the newborn’s ability to metabolize benzodiazepines is limited, they may accumulate in the baby’s blood when breastfed. If given in the first trimester, there is an increased risk of congenital malformation (the most common being a 0.4% risk of cleft palate with the use of diazepam7). In addition, ongoing use of benzodiazepines in pregnancy can result in withdrawal symptoms in the newborn.
In general, the developing brain of childhood and adolescence is more sensitive to the central nervous system effects of most medications. Younger individuals on benzodiazepines often encounter enhanced sedation, cognitive and motor effects. In addition, benzodiazepine side effects of agitation and irritability are more common in children—particularly those who are mentally challenged.
Barriers to getting help
The stigma of drug addiction
For most women, the biggest barrier to getting help is the stigma of drug addiction. Women often suffer in silence and isolation because they feel ashamed of their dependency on benzodiazepines. This is particularly true for a woman who trusted her family doctor and unknowingly became addicted to a prescription drug. She may fear the judgement of friends and family who discover she is hooked on a pill that was supposed to help her.
Lack of treatment programs
Another barrier is the lack of treatment programs specifically designed for women. For example, women with children or other dependants need programs that take account of their caregiving responsibilities. There are also very few programs that understand the particular features of benzodiazepine addiction and withdrawal.
New options are gradually becoming available to women who want to deal with their benzodiazepine use. Among the most promising are self-help circles: groups in which women can tell their story and get support from women in similar situations. In the circle, women share information about what helped them to recover and where they got stuck. The circles are a safe place for women to talk without being judged, go at their own pace, and just listen if they wish.
An increasing number of organizations that provide health services to women are becoming better informed about benzodiazepine use. They are learning to provide specialized services to women with benzodiazepine problems; some are offering recovery services to addicted women.
Outpatient withdrawal management options are also being developed. These programs provide a woman with a safe withdrawal process adapted to her individual medical and personal needs, without requiring that she stay in a hospital or treatment facility. Unfortunately, these programs are scarce and often underfunded.
Some women are using personal computers to connect with other women in recovery. They can email each other about their histories of using and withdrawing from benzodiazepines. Women can find this a safe, comfortable way to get information and support because they need not identify themselves. There are also a growing number of websites with up-to-date information on benzodiazepines.
The elderly commonly experience health problems such as insomnia, anxiety, and depression that can lead to prescription benzodiazepine use. Some factors that may result in increased benzodiazepine side effects and toxicity in the elderly include:
a) benzodiazepine accumulation as liver metabolism slows down with age.
b) increased brain sensitivity to adverse effect.
c) increase in general medical problems.
d) increased likelihood of being on more than one medication, with certain medication combinations possibly interfering with metabolism and/ or enhancing central nervous system effect.
The cumulative result of the above factors may include more sedation, confusion, behaviour problems, and impairment in memory, balance and coordination in the elderly. There is a higher risk of motor vehicle accidents and falls in the elderly.6 Some current data suggest that the use of benzodiazepines by older persons increases their risk of hip fracture by at least 50%.2 Those using higher doses and/or those who had recently started benzodiazepines were at the highest risk of hip fracture.
Are prescriptions increasing?
Here is a look at the issue in context.
British Columbia context
BC is well below the average Canadian rate for benzodiazepine tablet dispensing per capita. The Mental Health and Addictions Branch of the BC Ministry of Health Services recently reviewed the Pharmanet database for benzodiazepine utilization in BC from the fiscal years 2000-2003. Their analysis showed no significant change in the number of persons receiving benzodiazepine over those three years and benzodiazepine use was less than the prevalence of anxiety disorders (7.5% vs. 10%). BC psychiatrists prescribe more benzodiazepines than general practitioners (GPs), but GPs on average prescribe to a larger number of patients. The vast majority of benzodiazepine users (>80%) receive only one type of benzodiazepine, however about 30% receive prescriptions that would last six months in duration, indicating long-term use. The elderly are particularly vulnerable to longer-term benzodiazepine use, more so than younger populations in BC.
Benzodiazepines are widely used in Canada. Information from the Centre for Addiction and Mental Health indicates that about 10% of Canadians report using a benzodiazepine at least once a year, and continue using them for at least a year. Since each province is responsible for monitoring its own use of prescription medications, there is limited data on national trends for benzodiazepine use. Based on data from Canadian retail pharmacies on the number of benzodiazepine tablets dispensed per capita per province, there is not an overall increase in the use of benzodiazepines per capita from the years 1997–2001. The Eastern provinces of New Brunswick, Nova Scotia, and Quebec have the highest rates compared to the western provinces of BC, Alberta, and Saskatchewan with the lowest rates.
About the Author
Frances is a certified personal and executive coach, educator and community researcher. She has over 20 years experience working with women on lifestyle management, gender and development, and social justice issues
Frances prepared this article in 2002 based on the results of a community-based research project developed by principal investigator Nancy Hall, PhD, and funded by the BC Health Research Foundation and supported by the BC Division of the Canadian Mental Health Association and the BC Women’s Hospital and Health Centre. Reprinted with permission from the Women’s Addiction Foundation
Anderson, J.F. & Scott, D. (2004). Overview of Pharmanet Benzodiazepine Utilization Data to Inform Decision-Making Regarding Interventions Targeting Long-term Utilization of Benzodiazepines. Victoria, BC: BC Ministry of Health Services, Mental Health and Addictions.
Cumming, R.G. & Le Couteur, D.G. (2003). Benzodiazepines and risk of hip fractures in older people: A review of the evidence. CNS Drugs, 17(11),825-837.
Jorm, A.F., Grayson, D., Creasey, H. et al. (2000). Long-term benzodiazepine use by elderly people living in the community. Australian and New Zealand Journal of Public Health, 24(1), 7-10.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: APA.
National Institute of Mental Health. (2001). The Numbers Count: Mental Disorders in America. Retrieved November 15, 2004, from www.nimh.nih.gov/ publicat/numbers.cfm
Canadian Pharmacists Association. (2002). Compendium of Pharmaceuticals and Specialties: The Canadian Drug Reference for Health Professionals. Toronto, ON: Webcom Ltd.
IMS Health Canada. (2002). Canadian Compuscript Audit: Estimated Number of Benzodiazepine Tablets Dispensed per Capita in Canadian Retail Pharmacy. Pointe-Claire, QC: IMS Health Canada.