Benzodiazepine tranquillisers - facts every patient should know

'The world's biggest addiction problem is not teenagers taking hash but middle-agers taking sedatives. The tranquilliser is replacing tobacco. It will, perhaps, give us an even bigger problem. It may prove even more dangerous. Already Valium is said to be taken by 14% of the population of Britain.'

'The habit usually starts insidiously. The patient may have a good excuse for taking a few tablets. A close friend or relative has died or there is a rush on at work. And the doctor finds it difficult to refuse the request for a little help.'

'The drugs which people take to help relieve their pressures vary. If he is young the addict may take drugs from a pusher. If he is older he may take drugs from a medical adviser.'


Quote taken from 'The Medicine Men' by Dr Vernon Coleman, 1975

During the 1950s and 1960s the type of problem being discussed in the doctor's consulting room changed and family doctors found that they were expected to deal with mental and psychological problems as well as physical problems. They were, for the first time, consulted by patients who wanted comfort, support, encouragement and help with social and personal problems. As the link between stress and disease become better and better known so more and more patients went to their doctors wanting help with dealing with the stress in their lives.

But there was a big problem. Doctors had never been trained to cope with psychological or stress induced problems. Most physicians had been taught more about tropical diseases than they had about anxiety or depression.

So, when the benzodiazepines were introduced and described as safe and effective drugs for the treatment of anxiety and a wide range of stress related disorders doctors welcomed the new pills with open arms and prescribed them in huge quantities.

The result is that for years now the biggest drug addiction problem in the world today has involved legally prescribed benzodiazepine tranquillisers and sleeping tablets which are widely and regularly prescribed for long periods for men, women and children suffering from stress and stress related symptoms.

It seems hard to believe but I first wrote about the dangers of tranquilliser addiction back in 1973. Over the decades that I have been campaigning to get these drugs controlled more effectively - and to persuade doctors to prescribe them more carefully - I have received tens of thousands of letters from tranquilliser addicts all over the world. In one month alone I counted over 6,000 letters.

After hundreds of articles and TV programmes my campaign to warn patients and doctors about the dangers of these drugs eventually forced the politicians to take action in Britain.

In 1988 - after 15 years of campaigning - doctors were warned of the hazards of handing out drugs such as diazepam, lorazepam, nitrazepam and temazepam for long term use.


(`Dr Vernon Coleman's articles, to which I refer with approval, raised concern about these important matters,' said Edwina Currie, Parliamentary Secretary for Health, in the House of Commons in 1988. She was referring to the introduction of new controls relating to the prescribing of benzodiazepine tranquillisers.)

The simple truth is that the benzodiazepine tranquillisers can cause all sorts of problems if they are taken for more than two weeks or so. Long term use can cause all sorts of very real problems. And patients who have been taking the drugs for more than a week or two need to cut down slowly if they are to avoid withdrawal symptoms.

Here are some of the warnings given by the manufacturers of a well known benzodiazepine:

* Symptoms such as anxiety, depression, headache, insomnia, tension and sweating have been reported following abrupt discontinuation of benzodiazepines. Other reported symptoms include tinnitus, involuntary movements, confusion, convulsions, muscle cramps, abdominal cramps and vomiting.

* Patients taking the drug may become dizzy or drowsy and should be warned against driving or operating machinery.

* Elderly patients may need to be given smaller doses. They may be more sensitive to the drug.

* The use of benzodiazepines may release suicidal impulses in depressed patients.

* Behavioural effects of the drug include excitement, aggressive outbursts and confusion. Loss of memory may occur.

* Other reported side effects may include: hangover, headache on waking, dizziness, blurred vision, nausea, depression, changes in appetite, sleep disturbance, blood problems, visual disturbances, low blood pressure, intestinal disturbances and skin rashes.

For well over twenty years now I have repeatedly warned that drugs in the benzodiazepine group are being wildly overprescribed and can cause tremendous problems. (For most of that time I was abused and attacked by many members of the medical establishment who maintained that there were no problems).

And I have on many occasions warned that drug abuse experts have told me that getting patients off these drugs is frequently more difficult than getting patients off heroin.

Sadly, it seems that although some doctors now accept that these drugs can cause problems there are still doctors in practise who do not understand the problems the benzodiazepines can produce.

If you see a doctor who tells you that the benzodiazepines never cause problems, don't cause addiction and can be stopped suddenly without danger my advice is simple: change doctors fast.

***

Here, for the record, are some facts about tranquillisers which many doctors still don't seem to know. Look at the dates carefully.

Fact One
In 1961, just a short time after chlordiazepoxide (the first widely prescribed benzodiazepine) had been introduced into clinical practice a report was written by three physicians from a hospital in California. Entitled 'Withdrawal Reactions from Chlordiazepoxide' the paper described very dramatically how patients who had been taking the drug suffered from withdrawal symptoms when the drug was stopped. The authors described how eleven patients who had been taking fairly high doses of chlordiazepoxide for up to six months were quite suddenly taken off the drug and given sugar tablets instead. Ten of the eleven patients experienced new symptoms or signs after the withdrawal of the chlordiazepoxide. Six patients became depressed, five were agitated and unable to sleep, two had major fits.

Fact Two
Testifying to a US Senate Health sub committee in Washington in 1979 a psychiatrist claimed that patients could get hooked on diazepam in as little as six weeks. The same committee heard testimony that it is harder to kick the tranquilliser habit than it is to get off heroin.

Fact Three
In 1975 three doctors from the Drug Dependence Treatment Center at the Philadelphia VA Hospital and University of Pennsylvania, Philadelphia, published a paper in the International Journal of the Addictions entitled 'Misuse and Abuse of Diazepam: An Increasingly Common Medical Problem'. The three authors of the paper referred to papers published as far back as 1970 which had documented instances of physical addiction to chlordiazepoxide and diazepam and reported that since the end of 1972 they had noticed an increasing amount of diazepam misuse and abuse. Their paper concluded: 'All physicians should know that diazepam abuse and misuse is occurring and careful attention should be given to prescribing, transporting and storing this drug.'

Fact Four
In 1972 the American Journal of Psychiatry published a paper in which two doctors described how patients on diazepam had exhibited a cluster of symptoms which included tremulousness, apprehension, insomnia and depression. The patients had all been previously emotionally stable and the symptoms, which started suddenly, were quite severe. When these patients were taken off their diazepam their symptoms disappeared.

Fact Five
In 1968 the Journal of the American Medical Association described a series of eight patients who had been given diazepam. The patients became so depressed that seven of them had suicidal thoughts and impulses and two of them made serious attempts to commit suicide.

Fact Six
Several reports published in the 1960s and 1970s showed that the benzodiazepines seemed to increase hostility, aggressiveness and irritability. The benzodiazepines have also been associated with baby battering.

Fact Seven
In a paper published in 1979 researchers found a 'highly significant association between the use of minor tranquillisers and the risk of a serious road accident'. The conclusion was that a patient's risk of being involved in a serious accident was increased five fold if he or she was taking a benzodiazepine.

Fact Eight
Back in 1982 the Committee on Safety of Medicines advised doctors that the benzodiazepines should be prescribed for short periods only and that withdrawal symptoms could be avoided by withdrawing medication slowly.

Fact Nine
When a 75-year-old lady was admitted to a British hospital in the early 1970s she was unable to walk or speak clearly and was confused and incontinent. She had been taking a benzodiazepine sleeping tablet for a year. When her pills were stopped she made a physical recovery in three days.

The sad truth is that for years any doctor who has studied the medical journals has known that the benzodiazepines cause problems.

But doctors are still prescribing these damned pills by the lorry load.

If you are hooked on a benzodiazepine tranquilliser or sleeping tablet you will need to wean yourself off your drug with care.

Here are some vital tips to help you.

1. Before doing anything visit your doctor and ask for his or her help. If he is unhelpful, if he tells you to cope by yourself or if he insists that you don't need to worry and that withdrawal is easy then I suggest that you find yourself a new doctor. There are plenty of good doctors around who understand the problem and who are prepared to help. Talk to friends and neighbours to find the name of a good local doctor.

2. You may experience unpleasant symptoms (see list). The most common withdrawal symptoms include: tremor and shaking, intense anxiety, panic attacks, dizziness and giddiness, feeling faint, an inability to get to sleep and an inability to sleep through the night, an inability to concentrate, nausea, a metallic taste in your mouth, depression, headaches, clumsiness and poor coordination, sensitivity to light, noise and touch, tiredness and lethargy, a feeling of being 'outside your body', blurred vision, hot and cold feelings and a burning on your face, aching muscles, an inability to speak normally, hallucinations, sweating and fits.

3. Remember that you can minimise your symptoms by reducing your dose slowly. The rate at which you reduce your pills will depend upon the size of the dosage you have been taking and the length of time for which you have been on the pills. As a rule of thumb you should not go faster than to halve your dose every two weeks until it can no longer be halved. Some patients insist that this is much too fast. Others say it is too slow. Many seem to think it works well. For example, if you are taking six tablets a day then reduce to five a day for four days then to four a day for another four days, then to three a day for four days. That will mean that you will have halved your initial dose in your first two weeks.

4. Remember that the benzodiazepines cure nothing. But they do cover symptoms up. If you originally took your tablets for anxiety then the chances are that your original symptoms will return when you stop taking the tablets. Be prepared for this.

5. Warn your family and friends that you are likely to be going through a difficult time. Tell them what to expect and explain that you would welcome a little extra support, guidance, sympathy and patience. If you know someone else who wants to kick the habit then plan to do it together. Ring one another up, keep in touch, share your problems and keep your determination alive.

6. Do not try to give up these pills if you are going through a tricky patch at home or at work. Wait until things are more settled before you try to give up your pills.

7. Do not be tempted to try carving your tablets into tiny pieces. Break them into half by all means. But carving pills into fractions tends to make the whole procedure more difficult. It also makes everything more dramatic. Ask your doctor to prescribe the lowest dose of pills available so that you have the maximum amount of flexibility.

8. Do not despair if you reach a plateau and have difficulty in reducing your pills any more. Do not even despair if you have to increase your pills temporarily. You must stop these drugs at a rate that you find comfortable.

9. If you are taking a drug like lorazepam (which many experts believe is particularly difficult to come off) then your doctor may recommend that you substitute diazepam for part of the lorazepam and then cut down both drugs gradually. This MUST be done under medical supervision. Some people find that this helps cut down the withdrawal symptoms.

10. If you want to try a really gradual cutting down technique your doctor may suggest that you try the 'staging' technique. If, for example, you were taking three tablets a day to start with your routine would look something like this:

day one: three tablets
day two: two tablets
days three to seven: three tablets
day eight: two tablets
days nine to twelve: three tablets
day thirteen: two tablets
days fourteen to sixteen: three tablets
day seventeen: two tablets
days eighteen and nineteen: three tablets
day twenty: two tablets
day twenty one: three tablets
days twenty two to twenty six: two tablets
day twenty seven: one tablet
days twenty eight to thirty one: two tablets
day thirty two: one tablet
days thirty three to thirty five: two tablets
day thirty six: one tablet
days thirty seven and thirty eight: two tablets
day thirty nine: one tablet
day forty: two tablets
days forty one to forty five: one tablet
day forty six: no tablet
days forty seven to fifty: one tablet
day fifty one: no tablet
days fifty two to fifty four: one tablet
day fifty five: no tablet
days fifty six and fifty seven: one tablet
day fifty eight: no tablet
day fifty nine: one tablet
day sixty: no tablet

The procedure can then be continued in the same way with a reduction to half a tablet. The advantage of this system is that it gives your body plenty of time to get used to each new step down. Obviously, the same technique can be adapted to suit any patient on any starting dose.

The question tranquilliser addicts ask most often is: `How long does withdrawal last?'. And it is the question that causes most controversy.,

Some experts claim that withdrawal should take no more than a few weeks. One expert I know says that it can last for 10% of the time for which pills were taken. Some former addicts claim that it has taken them years to get off their pills.

The truth is that there is no fixed time for withdrawal. Some people can do it in days. Some take months.

But one reason for some of the confusion is that doctors and patients are sometimes talking about two quite separate things when they talk about withdrawal.

When drug addiction experts talk about the length of time it takes to come off tranquillisers they are talking about the period of time over which physical withdrawal needs to be spread. To keep physical withdrawal - the symptoms produced by the body being deprived of the drug - to an absolute minimum, the drug needs to be cut down slowly.

'But,' say these experts, 'it is important not to spread the physical withdrawal over too long a period.' If the pills are cut down too slowly then the patient will be taking the drug for longer than is necessary. 'The quicker you stop the pills,' the argument goes, 'the quicker you will recover. Spread the withdrawal over too long and your recovery will be slow.'

Patients sometimes respond to this by pointing out that although they cut down their pills in a matter of weeks they are still getting side effects months later.

But this does not necessarily mean that these side effects are withdrawal effects.The whole picture is confused by several other factors.

First, it is important to remember that the benzodiazepines do not cure anything. If you were put on a tranquilliser ten years ago because you were feeling anxious and unhappy then the pills will have numbed your mind for ten years - but they will not have stopped your initial problem. When you stop the pills your anxiety will still be there. While you were taking the pills you may not have noticed the anxiety symptoms.

If you were given your pills fifteen years ago to cover up the unhappiness of a bereavement then you will once more have to endure the unhappiness of that bereavement. The benzodiazepines will have put your emotions into a sort of pharmacological 'deep freeze'.

Second, although the benzodiazepines do not cure anything they do numb the mind. They seal you off from the world and prevent you from experiencing the normal highs and lows of everyday life. Taking these drugs is like having your brain wrapped in a thick layer of cotton wool. While taking the drug you are immune to many of the pressures of everyday living; the world will be uniformly grey; you will be permanently anaethetised.

Once you stop your pills your mind will suddenly be exposed to a whole range of stimuli. The anaesthetic will 'wear off' and you will 'wake up'. It can be a frightening experience. The world will suddenly appear a good deal brighter. Noises will seem louder and joys and sorrows will seem more acute. So, in addition to having to cope with old, half forgotten emotions you will find that your nerve endings are raw and easily stimulated.

Since all these symptoms occur immediately after stopping or cutting down the pills you will probably assume that the symptoms have developed because you have stopped your drug too quickly. I don't think that this is necessarily the case. The symptoms are an inevitable part of coming off tranquillisers but they will be there however slowly you reduce the dose. Extending the withdrawal period doesn't always affect the end result at all - it may merely prolongs the agony.

Finally, it is essential that anyone planning to give up tranquillisers should spend a lot of time and effort learning how to relax and how to deal with stress.

What withdrawal symptoms should tranquilliser addicts expect?

Some people are lucky. They can stop taking one of these drugs with relatively few - or even no - side effects. Others are less fortunate. Here is a fairly comprehensive list of the side effects that patients have complained of while coming off benzodiazepine tranquillisers and sleeping tablets.


sleeplessness
loss of appetite
thirst
weight loss
vomiting
nausea
sore tongue
difficulty in swallowing
metallic taste in the mouth
stomach cramps
diarrhoea
constipation
difficulty in breathing
irregular breathing
tight chest
rapid breathing
dry cough
irregular pulse
altered blood pressure
palpitations
swollen hands, face or feet
tremors and shakes
hair loss
cracked lips
corners of mouth cracked
sexual desire changed (reduced or increased)
changes in menstruation
increased vaginal secretion
swollen vulva
fits
incontinence
difficulty in passing urine
poor concentration
lack of drive
lack of initiative
anxiety
panic
guilt
sadness, despair and depression
wanting to commit suicide
lack of confidence
irritability
a fear of going insane
aggression and rage
restlessness
volatile emotions
lack of a sense of humour
attention seeking
being demanding and giving other people a hard time
being quarrelsome
having destructive thoughts
tension in the head, neck and shoulders
backache
slurred speech
stuttering
word confusion
pins and needles
hot and cold shivers
difficulty in swallowing
shivering
fatigue and exhaustion
feeling of having a tight band around the head
numb hands and feet
unsteadiness
hallucinations
paranoia
nightmares
reliving the past
pains around the mouth
hypersensitivity to touch, smell, light or noise
noises in the ears (tinnitus)
a feeling of unreality
depersonalisation (a feeling of being unreal in one's own body)
visual disturbances - objects seeming smaller or larger
blurred vision and other visual problems


WARNING
Using tranquillisers or sleeping tablets to combat the effects of stress is like wrapping a blanket round a fire alarm because you don't like the noise. But do not stop taking tranquillisers or sleeping tablets or try cutting down without getting professional help from your doctor.


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