The benzodiazepines (or “benzos”, for short) are a class of medicines that have been quite popular and widely used to treat anxiety and sleep problems for many years. Examples include Librium (chlordiazepoxide), first marketed in the U.S. in 1960, Valium (diazepam) in 1963, Klonopin (clonazepam) in 1975, Ativan (lorazepam) in 1977, and Xanax (alprazolam) in 1981. They work quickly and work well for many people, and tend to be pretty “clean” in terms of short term side effects compared to other psych meds- they typically don’t cause weight gain, for example.

Yet the medical profession has turned against these meds, and it’s getting more and more challenging for patients to find doctors who prescribe them- why?

As time has gone on, we have become increasingly concerned about the short and long term side effects of the benzos.

First and foremost, they carry abuse and dependence potential. Benzos affect the GABA (gamma-amino-butyric acid) receptors in the brain- the same receptors alcohol affects. I’ve heard benzos described as “freeze-dried alcohol.” Most people drink alcohol socially without problems, just like most people take benzos without issues- but a significant number of people have trouble restraining the use of both substances.

Just like alcohol, benzos can impair balance and coordination. Research definitively shows older patients on benzos are more likely to fall and have hip fractures. Benzos can impair alertness and memory. There is even some research suggesting that long term (more than 90 days) use of benzos can increase the risk of dementia.

In 2016 the FDA came out with a “black box” warning about combining opiate pain medicines with benzos- the combination increases the risk of overdose, respiratory suppression, and death. Many pain doctors will no longer prescribe opiates if a patient is on benzos.

In 2018, the state of Indiana passed a law requiring over the next couple of years that all physicians in the state run an “Inspect report” on controlled substance prescriptions on a patient before prescribing benzos. I predict that this additional hoop to jump through will lead many primary care docs to stop prescribing benzos entirely- just like the hoops put into place around opiate prescribing caused most PCP’s to stop prescribing opiate pain meds a few years ago.

What’s my take on benzos? I think they can be very useful meds when used judiciously and appropriately. Just like the opiates for pain, they tend to work better when used short-term and on an as needed basis for anxiety. Chronic daily benzo use is like chronic daily opiate use- usually the patient is left with their chronic anxiety (or pain) but now they have a drug addiction to deal with on top of it.

Pretty much every week, I see at least one new patient or more with some variation of the story, “I’ve been taking Xanax 1 mg three times a day for 20 years. My primary care doc retired, and my new doc said she won’t prescribe it for me on an ongoing basis. It works for me! Can I stay on it?”

In that situation, I will continue your Xanax- for a while, while discussing with you alternatives and trying to work the dose down. The older you are, the more dangerous the benzos are, and the quicker I’ll work to get you off of them. That’s the story on benzos.