1. They prescribe benzodiazepines long-term without informed consent.
Informed consent is a foundation of medicine, both ethically and legally. When a prescriber writes a long-term (2-4 weeks or more) benzodiazepine prescription for a patient, they should also be providing informed consent. Prescribed benzodiazepines carry great risks, both in the short and long term. Studies past a few months of use are lacking, while evidences after long-term use of tolerance, physical dependence, withdrawal syndromes, and a worsening of the initial condition for which it was prescribed are known. All patients should have the right to receive this information and be allowed to inquire further about the recommended benzodiazepine prior to its prescription. Prescribers who do not inform patients of these common but major risks, while highlighting only the very short-term benefits of benzodiazepines, are skipping one of the greatest patient safeguards in medicine. This deprives patients of self-advocacy and shared decision-making that is a critical element of the provider-patient trust and relationship.
2. They think benzodiazepines help anxiety and sleep disorders long term.
There are no long-term studies on benzodiazepine safety, but a 14-week study conducted by Upjohn resulted in that the Xanax-exposed patients were much worse off than the placebo group; they were more anxious, had more panic, were doing worse on a “global scale” that assesses overall well-being, and forty-four percent had been unable to get off the drug. Also, benzodiazepines have been shown to impair the effectiveness of therapeutic interventions and are therefore contraindicated for use in PTSD. Hypnotics have also been found to be ineffective long term in aiding insomnia.
3. They only disclaim about addiction, not physical dependence.
Many prescribers do disclaim about addiction but very rarely about physical dependence. When initiating a short- or long-term benzodiazepine prescription, it is common for patients to be warned about the medication’s addictive potential. While benzodiazepines can be addictive, physical dependence is a more common outcome. A substantial percentage of compliant patients will experience physical dependence and a withdrawal reaction with attempts at discontinuing a benzodiazepine. For some patients, this withdrawal, mostly when done cold-turkey or too rapidly, can result in severe symptoms (psychosis, seizures, suicide), protracted disability, and even death. Disclaiming only about addiction and abuse provides a false sense of security, failing to inform patients of their very real risk for physical dependence just by way of taking the drug exactly as prescribed.
4. They tell patients they are on a “low dose”.
Another way that prescribers provide a false sense of security is by telling patients that they are on a “low dose.” This is a very misleading and often erroneous claim. Compliant benzodiazepine patients can become physically dependent and experience subsequent severe withdrawal and disability, sometimes protracted, after attempts at cessation from any dose, even comparatively (to other prescribed doses) “low” ones. Even the lowest available prescribed dosage for any commercially available benzodiazepine can subject a patient to physical dependence and a withdrawal syndrome, thus requiring careful and slow tapering. That aside, when prescribers make the “low dose” claim, they are often falling prey to clever marketing techniques, completely unaware that 0.5 milligrams of benzodiazepines like Ativan, Xanax, and Klonopin are equivalent to 5-10 milligrams of Valium (equivalency charts can vary, depending on source). The term “low dose” misleads patients into believing that so long as they stay below a certain non-existent threshold, they are safe.
5. They downplay or fail to recognize adverse effects.
If a prescriber minimizes or fails to recognize benzodiazepine adverse effects, it’s very likely that that they are not informing their patients about them prior to initiating a new prescription. Because many prescribers are unable to recognize the adverse effects of prescribed benzodiazepines, including tolerance and interdose withdrawal, patients can spend years suffering and chasing “mystery symptoms,” often resulting in unnecessary testing, medical expense, misdiagnosis, and sometimes polydrugging. In addition, during this time, because diagnostic testing will often come back negative, the patient is assumed histrionic, malingering, or anxious and, ironically, their benzodiazepine dose is sometimes increased as a result. This only further prolongs inaccurate diagnosis and patient suffering.
6. They don’t understand tolerance or interdose withdrawal.
Many prescribers fail to understand the significance of benzodiazepine half-lives and that prescribing guidelines call for short-term prescriptions, because the benzodiazepines quickly lose their effectiveness. As a result, patients especially those taking short half-life benzodiazepines,often end up experiencing interdose withdrawal, where they are actually withdrawing on a daily basis in between doses, and tolerance withdrawal, where they have become tolerant to the medication’s therapeutic effects at that dose and require higher dose to achieve the same effects as they did initially. Because interdose and/or tolerance withdrawal is often confused with “addiction” or “craving,” prescribers often refuse to increase the patients dose or frequency of dose, even when that can be the necessary solution to provide the patient more comfort and stability if the patient wishes to remain on benzodiazepines or prior to beginning a taper.
7. They think one benzodiazepine is unsafe but another is safe.
All benzodiazepines, despite sharing the same drug class, are not the same; they have different receptor binding affinities, half lives and durations of therapeutic effect, etc. which accounts for some of the disparate opinions on which of them is “more dangerous” or “unsafe.” That aside, the notion that the newer benzodiazepines or “anxiolytics,” like Klonopin and Ativan, for example, are “safe” and Valium “unsafe” is an old wives tale deriving from the original pharmaceutical marketing around the time Valium got a bad rap and was brought under scrutiny for the destruction it caused in the 1960s and 70s. Because of this, it is common for an ignorant prescriber to think of Valium as “dangerous” or “deadly,” but Klonopin as “safe.” But that wasn’t true then, and it isn’t true now. In fact, Valium is often recommended in renowned benzodiazepine tapering guidelines as the “gold standard” choice to cross patients over to from their current benzodiazepine. This is because of Valium’s long half-life and its availability in commercial liquid preparations and smaller doses which better facilitate tapering. While it is true that benzodiazepines with a shorter half-life, like Xanax or Ativan, can put patients at greater risk for interdose withdrawal than their longer half-life counterparts, all benzodiazepines carry the same potential for causing physical dependence, tolerance, withdrawal syndromes, disability, and sometimes death when prescribing guidelines are ignored and patients are maintained on them long term.
8. They think other drugs can alleviate benzodiazepine withdrawal.
While in some cases, adjuvant therapies are reported to assist with benzodiazepine withdrawal, many times they fail to offer relief and also subject patients to new or increased adverse effects from polydrugging, as well as physical dependence to a new medication and thus the potential for another (potentially difficult or severe) withdrawal syndrome down the line in addition to that of the benzodiazepine. The studies on adding medications to benzodiazepine withdrawal are paltry and unconvincing, perhaps explaining why the British National Formulary benzodiazepine guidance states, “the addition of beta-blockers, antidepressants and antipsychotics should be avoided where possible.” Anecdotally, too, adjuvant therapies, such as prescription and over-the-counter medications and supplements, are often reported to exacerbate benzodiazepine patients’ conditions, so this should be heavily considered when weighing risks versus benefits. Usually the severity of a patient’s withdrawal can be effectively managed and minimized through slow and proper tapering as opposed to complicating matters with the addition of more medications. That said, some patients may express a desire to try adjuvant therapies in hopes of a more tolerable withdrawal, in which case informed consent as to the risks of doing so is critical.
9. They don’t know how to safely withdraw a patient from benzodiazepines.
Many prescribers enter patients into the long-term benzodiazepine bargain with no exit plan. When it does come time to stop the medication, patients are often either over-rapidly tapered, cold turkeyed, or inappropriately sent to detox centers.. If a withdrawal is initiated or forced by a prescriber at a rate that is faster than removing 5-10% from the current dose every 2-4 weeks (or less, if this turns out to be intolerably fast for the specific patient), excluding special circumstances like paradoxical reactions, it is usually too fast. Where a prescriber can also go wrong with withdrawal is when a patient is crossed to a longer half-life benzodiazepine (like Valium) from their current benzodiazepine for the purpose of tapering and the prescriber underdoses the patient on the new, longer half-life benzodiazepine because they fail to know or understand the equivalents. Sometimes, too, patients are quickly crossed from a short half-life benzodiazepine to a long half-life one in one shot, as opposed to the slower and recommended stepwise crossover, causing severe withdrawal because the short half-life benzodiazepine is eliminated before the long half-life one has a chance to build up. Another point of contention is that prescribers may refuse to be flexible, digging in their heels when a patient reports requiring the slightly-higher (compared to some other sources) Ashton Manual Valium equivalence, insisting the lower equivalence dose of another source is adequate, leaving the patient underdosed, destabilized, and suffering from severe and intolerable withdrawal. In addition to the above, prescribers can have unreasonable timeline expectations for tapering (tapers have been reported to take many months and sometimes many years, depending on the patient) and the potential levels of disability that withdrawal can create are not disclaimed, or are often even outright denied.
10. They think all patients will have similar benzodiazepine experiences.
While a percentage of patients will have no problems with long-term benzodiazepine prescription, many prescribers live under the assumption that this applies across the board to all of their patients. As a result, prescribers often miss properly diagnosing benzodiazepine problems for what they are because the potential for them isn’t even on their radar or in their differential. There have been numerous reports of benzodiazepine-dependent patients who discovered their own iatrogenic issue and then tried educating their cognitively-dissonant prescriber on the topic, only to end with the patient being dismissed, written off, gaslit, or even fired because the prescriber refused to consult provided sources, investigate further, or challenge their current belief system. The end result of this is that many patients do not get the support, validation, recognition, or help they need around a very real and serious iatrogenic medication-induced illness. Also, aside from the FDA warnings against prescribing benzodiazepines to patients with an addiction history, which are frequently ignored, there is no way to predict in advance which patients will develop physical dependence or experience severe withdrawal reactions when coming off of benzodiazepines. Every patient’s benzodiazepine experience will be unique and should be treated as such. Ultimately, it is the patients, not their prescribers, that should be regarded as the “experts” when it comes to determining the speed of their tapers based on the severity of symptoms and signals from their body.
JC founded Benzodiazepine Information Coalition in 2016 after sustaining a multi year injury from prescription Ativan. Shocked with the widespread lack of knowledge within the medical community she decided to organize the injured and professionals together to form a coalition to facilitate information sharing, awareness and change. She is a USF graduate, and has attended law school and graduate school prior to her illness.