Millions of Americans suffering from anxiety and insomnia are prescribed a class of sedatives known as benzodiazepines.
Known under the popular trade names Xanax, Valium and Ativan, these medications have been widely prescribed beginning in the 1970s. However, long-term treatment with these medications have also been associated with serious clinical risks, including falls, respiratory problems, cognitive impairments and harmful interactions with other medications.
Many physicians are now appropriately working with patients to taper these medications, but the tapers themselves often create a new set of problems: Severe physical withdrawal symptoms such as tremors and high blood pressure; dangerous psychiatric conditions such as depression and suicidal thoughts; and the recurrence of the underlying conditions of anxiety and insomnia that the medication was originally intended to treat. The underlying conditions often return much worse than before.
Now, a group of physician-scientists at Oregon Health & Science University and the VA Portland Health Care System have coined a new term for this phenomenon: Complex persistent benzodiazepine dependence, or CPBD.
“This is really a dangerous situation,” said Christopher K. Blazes, M.D., assistant professor of psychiatry in the OHSU School of medicine and the director of OHSU’s addiction psychiatry fellowship. “We now know that long-term benzodiazepine prescribing is rarely indicated, but we are still left with the problem of helping those who have been on these medications for years to safely get off them. The process of discontinuation can be very challenging and even dangerous. There may even be some circumstances, when attempts to discontinue fail, that restarting safe doses may be indicated.”
Blazes and co-authors Linda Peng, M.D., assistant professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine, and Thomas W. Meeks, M.D., assistant professor of psychiatry in the OHSU School of Medicine and the Portland VA, published a viewpoint in the journal JAMA Psychiatry establishing and clinically defining CPBD.
Prevalence of the condition will become clear as health care providers begin to recognize it in clinical practice, Blazes said.
“The opioid crisis has dominated headlines, yet benzodiazepines are an underrecognized and important contributor to the public health crisis of drug overdose deaths,” the authors write.
All patients who take benzodiazepines long term will develop physiologic dependence to the medications, which means they develop tolerance requiring escalating doses, and will experience withdrawal symptoms when they stop taking the drugs.
But dependence is different than addiction — the distinction identified by the new term, CPBD. Most of these patients don’t have addictions that result in sacrificing jobs, relationships or personal stability. Instead, CPBD defines a form of physiological dependence to benzodiazepines that sometimes includes behaviors consistent with addiction, but that only develop during the discontinuation process.
The distinction is important because treatment for addiction differs from treatment of dependence, Blazes said.
“You don’t want to diagnose addiction if people don’t have addiction,” he said. “People who don’t have addictions aren’t going to respond as well to psychological-social and behavioral interventions that work for addiction.”
Because benzodiazepines are associated with a large uptick in mortality, Blazes said he works with patients to taper off these medications. At the same time, he recognizes that many patients who have been prescribed benzodiazepines over months and even years will experience severe repercussions from de-prescribing.
“It’s a conundrum,” Blazes said. “You’re damned if you do and damned if you don’t.”