Introduction

Have you heard of anyone overdosing on Xanax and alcohol? Xanax is one of a class of medication called benzodiazepines. When taken as prescribed, benzodiazepines can be very helpful to people suffering from mental health or painful conditions. However, many people combine benzodiazepines with other substances, such as opioids or alcohol. When these drugs are combined, benzodiazepines become a very dangerous player with the risk of overdose and death. Treatment may be required if the drug use becomes an addiction.

What are Benzodiazepines?

Benzodiazepines are a class of medications that act as sedatives. They work to calm anxiety by raising the levels of gamma-aminobutyric acid (GABA) and promoting its ability to bind to receptors in the brain. GABA inhibits the signals in the brain that produce anxiety. Benzodiazepines, introduced to the United States in 1960, were considered to be a much safer alternative to the tranquilizers on the market at that time, especially when compared to barbiturates. 1

Because they were viewed as safe medications, benzodiazepine prescriptions rose in popularity. Between 1996 and 2013, the number of prescriptions filled for benzodiazepines rose from 8.1 million to 13.5 million – a 67% increase. 2 The prevalence of benzodiazepine use has remained steady at 4 to 5% of the general population since 2016. People who take benzodiazepines are more likely to be older, more likely to be female, and more likely to be taking other medications such as opioids. 3

Why are Benzodiazepines Used?

Benzodiazepines are used to treat many conditions, including:

Anxiety

Panic disorder/panic attacks

Alcohol withdrawal

Seizures

Muscle tightness or spasticity

Insomnia / sleep disorders

Benzodiazepines may also be used as a sedative before surgery.

When benzodiazepines are prescribed for reasons other than surgery, the dose must be increased gradually until the desired amount can be tolerated. This is called ramping. The same is true when benzodiazepine use ends. The dose must be gradually decreased or “ramped down” to minimize the effects of withdrawal.

Types

Benzodiazepines all work similarly, but they do differ in how they act on the receptors in the brain and how long they work. Here is a list of benzodiazepines commonly used in the United States, including their generic and brand names, whether they are short-acting, medium-acting or long-acting, and what conditions they are typically used to treat.4

Brand Name

  • Xanax, Xanax XR, Niveram, Alprazolam Intensol

Length of Effectiveness

  • Short acting

Conditions Treated

  • Anxiety, panic disorders

Brand Name

  • Librax

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Anxiety, alcohol withdrawal

Brand Name

  • Onfi

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Seizure disorders

Brand Name

  • Klonopin

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Seizure disorders, panic disorders, nerve pain

Brand Name

  • Tranxene T-Tab

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Anxiety, alcohol withdrawal, partial seizures

Brand Name

  • Valium

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Anxiety, alcohol withdrawal, muscle spasms, seizure disorders, sedation

Brand Name

  • ProSom

Length of Effectiveness

  • Medium-acting

Conditions Treated

  • Insomnia (short-term use)

Brand Name

  • Dalmane

Length of Effectiveness

  • Long-acting

Conditions Treated

  • Insomnia (short-term use)

Brand Name

  • Ativan

Length of Effectiveness

  • Medium-acting

Conditions Treated

  • Anxiety, seizure disorders, insomnia (short-term use), sedation

Brand Name

  • Versed

Length of Effectiveness

  • Short-acting

Conditions Treated

  • Sedation before surgery and when starting general anesthesia, seizure disorders

Brand Name

  • Serax

Length of Effectiveness

  • Short-acting

Conditions Treated

  • Anxiety, alcohol withdrawal

Brand Name

  • Restoril

Length of Effectiveness

  • Medium-acting

Conditions Treated

  • Insomnia (short-term use)

Brand Name

  • Halcion

Length of Effectiveness

  • Short-acting

Conditions Treated

  • Insomnia (short-term use)

The most common side effects of benzodiazepines are drowsiness, sleepiness, and dizziness. This is why benzodiazepines are effective short-term treatments for insomnia. This is also why people taking benzodiazepines are cautioned not to drive or operate machinery. Other common side effects of benzodiazepines include:

Amnesia

Confusion

Nausea

Constipation

Sexual dysfunction

Blurry or double vision

Stumbling, lack of coordination when walking

Slow, shallow breathing

When benzodiazepines are stopped abruptly, symptoms of withdrawal may occur, including:

Insomnia

Profuse sweating

Vomiting

Cramps

Convulsions

Tremors5

Overdose

While it is possible to take too much of a benzodiazepine medication, the effects of an overdose of benzodiazepine alone are not usually fatal. Symptoms of overdose from benzodiazepine include:

Slurred speech

Ataxia (decreased coordination)

Variable levels of consciousness, ranging from drowsiness to stupor

Slowed breathing

The danger of overdose becomes magnified when benzodiazepines are taken in combination with other drugs. Since benzodiazepines enhance the effects of other drugs, an overdose of benzodiazepines combined with opioids or alcohol can be fatal, and can lead to death more quickly than an overdose of opioids or alcohol alone.

Another overdose condition can occur when using diazepam or lorazepam (Valium or Atavan) to treat withdrawal symptoms from other sedatives or alcohol. This condition, called propylene glycol poisoning, happens when these medications are used for a prolonged period to treat withdrawal. Since benzodiazepines are suspended in a solution of propylene glycol, the body can ingest too much of this substance while receiving medications. This type of poisoning can be fatal.

Symptoms of propylene glycol poisoning include:

Tissue death of skin or soft tissues called necrosis

Destruction of red blood cells

Irregular heartbeat

Low blood pressure

Lactic acidosis

Seizures

Multiple organ failures6

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Mixing Benzodiazepines with Other Substances

Benzodiazepine abuse and overdose occurs primarily in combination with other drugs. People use benzodiazepines to enhance the euphoria that other drugs create. They can also use benzodiazepines to counteract the effects of other drugs. Three of the most common classes of drugs that benzodiazepines are combined with are opioids, alcohol, and stimulants.

Benzodiazepines and Opioids

Opioids are the most common class of drugs abused concurrently with benzodiazepines. This is partially because physicians routinely prescribe opioid and benzodiazepine medications together to treat certain conditions. When patients deviate from the medication instructions or when someone else obtains these medications for recreational use, the risk of overdose increases. Out of the total number of opioid overdose deaths occurring from January to June 2018, 32.5% involved a combination of opioids and benzodiazepines, more than any other non-opioid drug. 7

Because of the rate of overdose deaths involving opioids and benzodiazepines, the Centers for Disease Control (CDC) issued new guidelines to physicians regarding prescription opioids and benzodiazepines in 2016. The rates of co-prescribing these medications have decreased slightly since these new guidelines were released, but physicians continue to prescribe both types of medications together frequently, especially for chronic pain conditions. 8

32% of overdose deaths involved opioids and Benzodiazepines

January-June 2018

Benzodiazepines and Alcohol

Combining alcohol and benzodiazepine medications is particularly dangerous because both substances act on the GABA receptors, so they enhance the effects of each other. The combination can lead to significant central nervous system depression, which can lead to death. Out of all emergency room visits for benzodiazepine abuse, 25% involve alcohol. Also, 20% of benzodiazepine-related deaths involve alcohol.9

Another risk to consider when benzodiazepines and alcohol are combined is the effect on the ability to drive a motor vehicle. Since benzodiazepines enhance the effects of alcohol, a person who is taking both substances may end up driving in an impaired state, even though blood alcohol levels may be within legal limits. A study of unsafe driving actions revealed that people who tested positive for either medium- or long-acting benzodiazepines and alcohol (up to a blood level of .08 with medium-acting or .05 with long-acting) were 7 to 9% more likely to commit an unsafe driving action than those who tested positive for alcohol alone.10

Benzodiazepines and Stimulants

Unlike opioids or alcohol, stimulant substances have the opposite effect on the brain from benzodiazepines. While benzodiazepines depress the central nervous system, stimulants “wake up” the brain, increasing focus, attention, and perceived energy. When a benzodiazepine medication and a stimulant medication (such as Adderall) are used together, they counteract each other, making both medications less effective. This could result in a person taking more of both medications to increase the effectiveness, putting that person at risk of overdose.

Interestingly, benzodiazepines are sometimes used to counteract an overdose of recreational stimulant drugs, such as cocaine. Benzodiazepines may be used initially to reduce the stimulation effects of the stimulant drug, followed by other control measures to prevent heart failure and other fatal side effects.11

Misconceptions About Benzodiazepines

Benzodiazepines are so widely used that a few misconceptions have arisen over the years.

1. Myth: Benzodiazepines are safe

The primary misconception about benzodiazepines is that they are safe medications. Physicians have prescribed benzodiazepines for years, believing them to be a safer alternative to stronger tranquilizers such as barbiturates. However, benzodiazepines are not as safe as they may seem due to a couple of reasons:

  • To safely take benzodiazepine medications, the dose must be ramped up when beginning and ramped down when ending use. If this is not done correctly, severe side effects may occur.
  • Benzodiazepines enhance the effects of opioids and alcohol. This makes them dangerous medications to combine with these other substances.

2. Myth: Benzodiazepines can be safely used to come down from a stimulant high

One trend that is occurring among drug abusers is to use a stimulant (such as cocaine) for a high, followed by a “benzo” to come down off the high. The misconception is that benzodiazepines are safe to use for this purpose, but the use of benzodiazepines to counteract a cocaine high can lead to a dangerous drug intake pattern. This pattern may lead to overdose, more severe addiction, and accidents while under the influence of drugs.12

3. Myth: Benzodiazepines are not addictive

While benzodiazepines are not addictive in the same way as opioids, long-term use does result in chemical changes in the brain that cause physical dependence on the medication. Stopping benzodiazepines “cold turkey” results in serious side effects. People who end long-term use of benzodiazepines can end up with worse symptoms than when they started the medication unless proper medical intervention is provided.

In 2018, about 5.4 million people age 12 and older misused prescription benzodiazepines in some fashion. This equals about 2% of the population in the United States. The number is similar to past years.

Benzodiazepine Abuse

This data shows that adults ages 18 to 25 abuse benzodiazepines at over twice the rate of other adults. Benzodiazepine abuse in this age group decreased in 2018 as compared to previous years, while abuse in other age groups remained unchanged.

Substance addiction typically occurs when a person takes benzodiazepines:

More frequently or in larger quantities than prescribed

As a recreational “downer”

In combination with opioids or alcohol to enhance the effects

To counteract the effects of stimulants like cocaine

Treatment

When a person needs to end the use of prescription benzodiazepine use, the dose is gradually decreased to make the symptoms of withdrawal tolerable. This is done under the supervision of a physician. People who attempt to stop benzodiazepine use on their own at home risk experiencing the serious symptoms of withdrawal mentioned above. If a person must undergo treatment for benzodiazepine use combined with opioid or alcohol use, they must undergo detoxification for those other substances as well as ending benzodiazepine use. This is best completed in a medical facility due to the complications that can occur. Detox for opioids and alcohol are addressed in other articles, so please refer to these topics for detox methods.

Withdrawal

Withdrawal from stronger, short-acting benzodiazepines may be managed by using longer-acting benzodiazepines at lower doses to lessen the withdrawal effects. The benzodiazepine most commonly used for this purpose is clonazepam, due to its long half-life. Clonazepam is frequently used to treat the symptoms of alprazolam withdrawal. Anti-seizure medications and blood pressure medications may also be used to treat the possible seizures and cardiac symptoms that may occur with benzodiazepine withdrawal.

Psychological Therapy

Once detox is completed, a person may undergo counseling to address the psychological reasons for benzodiazepine addiction. These may include:

Cognitive Behavioral Therapy:

This treatment, commonly used to treat addiction to benzodiazepines, involves one-on-one counseling to identify the thought patterns associated with benzodiazepine use. The counselor works with the person to help develop strategies that can change those thought patterns.

Cue Exposure Therapy:

During this type of therapy, a person is exposed to situations that trigger drug use in a controlled environment. This allows the person to think about and use alternative strategies to cope with those trigger while avoiding substance use.

Self-Control Training:

Treatment that involves learning strategies to control the behaviors associated with drug use. Self-control therapy overlaps with cognitive behavioral therapy and cue exposure therapy.

Marital and Family Counseling:

Group therapy that includes the person’s spouse and other family members. This type of therapy helps to repair relationships damaged before or during addiction.

Benzodiazepines Can Be Dangerous When Combined

Contrary to popular misconceptions, benzodiazepines can be dangerous when prescription instructions are ignored or when combined with other substances. People who are abusing benzodiazepines, especially in combination with opioids or alcohol, should seek help as soon as possible.

Resources

  1. Schmitz, Allison. “Benzodiazepine Use, Misuse, and Abuse: A Review.” The Mental Health Clinician, CPNP: The College of Psychiatric and Neurologic Pharmacists, May 2016
  2. National Institute on Drug Abuse. “Benzodiazepines and Opioids.” NIDA, National Institute of Health, 15 Mar. 2018
  3. Schmitz, Allison. “Benzodiazepine Use, Misuse, and Abuse: A Review.” The Mental Health Clinician, CPNP: The College of Psychiatric and Neurologic Pharmacists, May 2016
  4. List of Common Benzodiazepines Uses & Side Effects.” Drugs.com, 1 Oct. 2019
  5. Ibid.
  6. Kang, Michael. “Benzodiazepine Toxicity.” StatPearls [Internet]., U.S. National Library of Medicine, 8 Mar. 2019
  7. Gladden, R. Matt, et al. “Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine – 25 States, July–December 2017 to January–June 2018 | MMWR.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Aug. 2019
  8. Jeffery, Molly M., et al. “Opioid and Benzodiazepine Coprescription Rates After 2016 Release of CDC Guidelines.” JAMA Network American Medical Association, 2 Aug. 2019
  9. Schmitz, Allison. “Benzodiazepine Use, Misuse, and Abuse: A Review.” The Mental Health Clinician, CPNP: The College of Psychiatric and Neurologic Pharmacists, May 2016,
  10. Maxwell, Hillary G., et al. “The Additive Effects of Alcohol and Benzodiazepines on Driving” PDF. Canadian Journal of Public Health, September/October 2010.
  11. Burnett, Lynn Barkley. “Cocaine Toxicity Medication: Benzodiazepines, Cardiovascular Agents, GI Agents, Nutrients.” Medscape, WebMD, 3 Feb. 2019
  12. Motta-Ochoa, Rossio, et al. “I Love Having Benzos after My Coke Shot’: The Use of Psychotropic Medication among Cocaine Users in Downtown Montreal.” The International Journal on Drug Policy, U.S. National Library of Medicine, Nov. 2017,
  13. Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19 5068, NSDUH Series H 54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from