I suspect that many people, including my wife, become dependent unwittingly. None of the five or so people involved in her treatment told my wife anything about the possible problems with long-term use. Our GP at the time provided repeat prescriptions without question or review. It is no co-incidence that the All Party Parliamentary Group on Involuntary Tranquilliser Addiction uses the word involuntary and that the Department of Health prefers to use the word misuse and holds that benzodiazepine addiction can be treated by similar means to addiction to heroin or alcohol, although it is patently obvious that this is not true. Some people taking illegal drugs also take benzodiazepines. These people’s addiction is clearly not involuntary. The drugs are also used to help people recover from illegal drug use.
When taken regularly people become tolerant of the drug and then dependent on them. By contrast taken intermittently for specific purposes does not necessarily lead to dependence. In fact when my wife was prescribed Lorazepam for a few months some years ago, she was able to drop them overnight with no discernable effect.
Tolerance
Tolerance occurs when the Central Nervous System adjusts itself so that the combined effect of the benzodiazepine and the GABA is reduced to pre-treatment levels. The result is that as soon as the benzodiazepine is withdrawn, the GABA receptor by itself is less effective and the excitatory neurotransmitters become more active, hence the symptoms which accompany withdrawal. The onset of tolerance is the predecessor to becoming dependent, and the sign that withdrawal is called for. Tolerance can occur in a few weeks or take several months. As with so much in benzodiazepine withdrawal it depends on the individual’s chemistry.
When tolerance is reached, the drug has less effect on the original condition, which can then lead to the need for an increased dose to produce the same effect. To a doctor unaware of this it may appear that the condition for which the drug was originally prescribed is getting worse rather than tolerance setting in. He would then be likely to prescribe a bigger dose which would seem to alleviate the problem but would only last until tolerance set in again.
Tolerance varies depending on the reason for its original prescription. Sleep, for example, may return to its pre-treatment state during tolerance, although anxiety probably won't, and may actually get worse with time. So the drug may appear to be efficacious for the former but not so much so for the latter. This probably explains why although my wife was taking the prescribed dose, she experienced some of the same anxiety symptoms as she had later when actually tapering off the drug.
When withdrawing, each cut (see Tapering below) is likely to result in withdrawal symptoms, and the CNS will attempt to readjust once more. At some point, in my wife’s case 3-4 weeks after the cut, the symptoms tend to stabilise and people then make their next cut. If the gap between cuts is very long, there is the risk that symptoms will re-appear although no further cut has been made. This is usually known as tolerance withdrawal and there is very little a person can do about it. It does mean that there needs to be a careful balance between cutting too quickly, which risks more unpleasant symptoms and cutting too slowly which risks tolerance withdrawal.
Dependence
By the time she had been taking Lorazepam for nearly two years, my wife was clearly dependent. Our GP at the time suggested she had been on the drug for too long and should come off it. He suggested replacing the 1-1.5mg of Lorazepam she took daily with 2mg of Diazepam to allow her to eventually withdraw. As we now know the conversion is sound in principle, since tapering from Lorazepam is very difficult for reasons which I shall cover later, but he prescribed entirely the wrong equivalent dose, and no gradual taper. The results were disastrous, and it was some months before we found out how to taper, and concocted a schedule with help from a voluntary group with considerable expertise. None of our subsequent help has come from the medical profession. They simply do not appear to know enough. The latest version – November 2013 - of the British National Formulary (BNF), the doctor’s “bible”, includes tapering advice for the first time.
The most important aspect of the dependence is that it happens while the sufferer is taking a therapeutic dose, one that is nominally safe. In my wife’s case she was advised that she could take up to 4mg of Lorazepam a day without any potential ill effects, but never took more than 2mg a day. Yet she became dependent just the same. Some of the withdrawal symptoms with which we became familiar later had already become apparent before she started to withdraw. Driving became difficult because she lost the concentration and co-ordination needed. Panic began to set in, so on one occasion we could only go into a local pub for lunch after she took 0.5mg of Lorazepam. We had to cancel a holiday. Needing an extra dose to cope with a specific event is not uncommon apparently. We heard of one person who needed 0.5mg of Lorazepam to allow her to go to the local supermarket.
Although dependent my wife was not addicted. Addiction is not just a neurological effect, as is dependence, but has a psychosocial component as well. Her daily dose was slowly increasing albeit very slowly, and well within the therapeutic limits. Since it was clear that the quality of her life was deteriorating, she decided to withdraw from the drug, which proved to be a difficult experience.
Many people keep taking the drugs because they have tried to give up and found it too painful, and they find that their life is easier while taking the drug. In effect the drug is serving to avoid the withdrawal symptoms which are difficult to cope with. Others having given up and then had to re-instate them. People on short-acting benzodiazepines can also get withdrawal symptoms between doses.
Benzodiazepine Dependence Compared
Benzodiazepine dependence is much worse than heroin or cocaine addiction for three reasons:
- Firstly, it is involuntary. People take street drugs knowingly, but doctors prescribe benzodiazepines for longer than is safe, without warning the sufferer of the consequences. After a few months the drug will become ineffective and the sufferer will need to go on taking it, not for its therapeutic value, but because stopping can produce intensely unpleasant withdrawal symptoms. This will deter many people from giving up, particularly because they are likely to mistake the withdrawal symptoms for a recurrence of whatever illness for which they were being treated.
- Secondly it takes much longer to recover fully from benzodiazepine addiction than street drug addiction. Unlike the latter, which can take just weeks, benzodiazepine recovery can take many months or years. Giving up the drug is difficult enough but is not the end of it, because the nervous system then has to repair the damage caused by the benzodiazepine, which takes time.
- Thirdly, there is virtually no official informed support for withdrawal. Campaigns over decades have failed to persuade the medical authorities to provide the sort of support facilities available to street drug addicts. The Department of Health has recently promised local support through commissioning groups and local drug teams. However willing or concerned, these teams are unlikely to have the special knowledge required for benzodiazepine withdrawal. Involuntary addicts are not abusing benzodiazepines, and they need a different psychological approach. Support for involuntary addicts has been promised for nearly a quarter of a century and so far has failed to materialise. There seems to be no reason for optimism.
No one knows the precise number of benzodiazepine addicts in the UK, and the resources required to find out accurately are not made available. Estimates vary between 1 and 1.5 million people. The number of people in withdrawal and recovery is not known. By contrast the National Drug Treatment Monitoring System, which monitors street drug use, recorded just under 200,000 clients in treatment in 2012. They are supported by a nationwide network of drug and alcohol treatment centres. No such facilities exist for benzodiazepine addicts.
But there is good news. Much of the damage caused to the nervous system is temporary, and people recover. They often find this very difficult to believe and are convinced that their minds are going. But this is effect of the drugs temporarily distorting their rational minds which are still there and will recover. They need courage, belief and support to do so, and it takes time, but people who have recovered say that it is the best thing they have ever done, and is wholly worth the effort.
