Benzodiazepine Related Problems: It’s Almost Never Addiction

It’s complicated.
Actually, it’s quite confusing.
But most of all and importantly, it’s mischaracterized. 

Benzodiazepine-related problems are often categorized as “addiction,” when in fact, for the vast majority of those who have difficulties, that diagnosis simply does not apply. Involved in family medicine for 36 years and addiction medicine for 31 years, I have only treated one patient – precisely one – with true benzodiazepine addiction. It’s rare. 

How do we make sense of this?
What is this thing called “addiction”?
And how does that differ from the challenges faced by most benzodiazepine survivors? 

The disease of addiction is a disease of the brain reward system characterized by the three “C’s” – all of which must occur together in order to make the diagnosis: 

1. Compusion to use for reasons other than for which they are prescribed
2. Loss of Control with amounts used significantly increased over time and more than intended by the prescriber and the patient 
3. Continued use despite adverse consequences which are recognized by the user as problematic 

Although non-addicted benzodiazepine survivors may experience the third criteria, they are not driven to do so by craving that leads to inappropriate and excessive overuse. On the contrary, it is physical dependence including overwhelming withdrawal symptoms that binds them to continued use, not addiction. They have what is probably better termed as a benzodiazepine brain injury – “benzo brain” – which results in the wide array of symptoms that differ from person to person and can be so devastating. 

Misapplying these criteria is compounded by a misunderstanding of how to use the detailed criteria found in the Diagnostic and Statistical Manual, version 5 (DSM-5) which are as follows: 

A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Sedatives, hypnotics, or anxiolytics is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.
3. A great deal of time is spent in activities necessary to obtain the sedative, hypnotic, or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.
4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor performance related to sedative, hypnotic, or anxiolytic use; sedative-, hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school; neglect of children or household).
6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).
7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.
8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).
9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.
10. Tolerance, as defined by either of the following:  a) A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of the sedative, hypnotic, or anxiolytic.
11. Withdrawal, as manifested by either of the following:  a) The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics. b) Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol) are taken to relieve or avoid withdrawal symptoms.

Tolerance and withdrawal (numbers 10 and 11) are criteria that are not to be used when benzodiazepines are prescribed because these are expected responses to normal prescribing and do not reflect non-medical use in that context. It is easy to see how a medical provider might view many of the other criteria (1, 2, 5, 6, 7, 9 especially) applicable to those with major benzodiazepine adverse reactions. However as above, for most of these patients, the reason for continued benzodiazepine use despite bad outcomes is not craving or non-medical use but rather the inability to discontinue use successfully – often because of the inability of the medical provider to assist in withdrawal. These criteria, therefore, should not be applied to these individuals.

We medical providers did not and generally still do not understand and act on this this for a number of reasons:

1. Absence of updated knowledge that overplay benefits, in particular wrongly believing for most people benzodiazepine use long term remains effective
2. Absence of updated knowledge that alternative treatments might work better and safer
3. Absence of patient requests to increase dosing which could suggest non-medical use
4. Insufficient recognition that important symptoms could be due to benzodiazepines, thinking rather they are related to: (a) Inadequate treatment of the medical condition treated (e.g., anxiety or insomnia), (b) Worsening of the medical condition treated (e.g., anxiety or insomnia, (c) Development of a new medical condition
5. Focus on other medical problems like opioid addiction or pain felt to be of higher priority
6. Focus on other medications like opioids felt to be of higher priority
7. Insufficient training, skills, and patience to assist in the benzodiazepine withdrawal process
8. Perception that withdrawal is more harmful and difficult than continued prescribing
9. Absence of guidance from guidelines and key opinion leaders to highlight the evidence-based research and provide direction for best clinical practices
10. Not listening at all or not listening closely enough to what patients are saying

Truly, we medical providers weren’t and aren’t listening,
and benzodiazepine survivors know this all too well. 

Persons with substance-related problems often feel stigmatized. For persons with a valid diagnosis of addiction, “addict” puts them in a box that implies that that is all they are, when, in fact they are so much more: a mother, a father, a daughter, a son with a life with a career, a family, interests, hopes, aspirations, and dreams. Though it should not be the case, “addict” can carry the tone of being weak-willed, inherently flawed, morally degenerate, even criminal – none of which is necessarily true. Persons with addiction should not be stigmatized, nor should they feel stigmatized. 

For non-addicted persons with benzodiazepine-related trouble, it goes beyond this. Helping them manage and treat benzodiazepine trauma is entirely different from addressing benzodiazepine addiction – a difference that makes difference. Wrong diagnosis translates to wrong treatment and will not lead to effective solutions. . 

To become benzowise we need to understand this difference and respond accordingly.
Poor prescribing practices are built around misconceptions like this and so much more.
We can and must do better. 

To all the benzodiazepine survivors who kept courage when we weren’t listening
and to all those who did not survive,
 I apologize.