The Benzodiazepine Evidence
Dr Vernon Coleman
I have a filing cabinet which is packed with scientific papers and medical journal articles showing the dangers of the benzodiazepines. Many of these articles, which have been published in the 1970s and the 1980s, describe specific problems associated with the drugs. There were, for example, papers published years ago showing that the benzodiazepines can cause anxiety, can cause depression, can cause sleeplessness, can make patients become aggressive, can cause foetal abnormalities when taken by pregnant women, can make patients so drowsy that they are unsafe to drive motor cars or operate machinery and can cause a huge number of uncomfortable, unpleasant or dangerous side effects. I have long been a campaigner against tobacco but when I wrote `Life Without Tranquillisers’ in the 1980s I wrote that: `I think that doctors would serve some patients better if they gave them prescriptions for filter cigarettes rather than benzodiazepines’. The book became a Sunday Times bestseller within days.
There isn't room here to describe all the side effects and problems associated with the benzodiazepines. So I am going to concentrate on the evidence showing that these drugs are addictive.
Remember, all the quotes which follow are taken from magazines and popular medical newspapers which are widely read by doctors.
The technical and specialist journals have for years been full of articles about the benzodiazepines. Psychiatrists, therefore, have absolutely no excuse for not knowing about the dangers associated with these drugs. Back in 1975, for example, the International Journal of the Addictions carried a major paper entitled `Misuse and Abuse of Diazepam: An increasingly Common Medical Problem.
Any psychiatrist or hospital specialist who has not been aware of this hazard is guilty of gross incompetence and dangerous ignorance.
Here, now, is the evidence that has been available to all general practitioners. The journals from which the quotes are taken are named underneath each quotation.
`Since habitual use is common it is wise to prescribe these drugs with care to review repeatedly the prescription of a benzodiazepine once it has been given for more than a few weeks. If intolerance to the effects of the drug appears to be developing, as shown by an increase in dosage, the dose should be reduced and the drug stopped as quickly as possible.’
Drug and Therapeutics Bulletin 1979
`Rebound insomnia, a newly defined clinical entity characterised by a marked worsening of sleep, has been found to occur as a result of abrupt withdrawal of even a single nightly dose of certain benzodiazepine hypnotic drugs, regardless of the duration of use.’
Modern Medicine 1979
`The Committee on the Review of Medicines concludes that on published evidence the dependence potential of benzodiazepines is low, but that withdrawal symptoms are liable to occur between one and ten days after treatment is stopped, usually after higher doses have been given for a long time...the Committee has to some extent fudged the issue of benzodiazepine dependence...if the CRM believes that benzodiazepines produce dependence, it should have said so more clearly...long term use should be avoided where possible because of the unwanted effects and the risk of dependence. If a benzodiazepine is being taken continuously and is to be withdrawn, this should be done gradually to minimise withdrawal symptoms.’
Drug and Therapeutics Bulletin, 1980
`More recently, evidence has been accumulating that a specific physical withdrawal syndrome may follow the prolonged use of benzodiazepines even when given in normal therapeutic doses...Our findings, like those of other recent reports, show that patients taking benzodiazepines in therapeutic doses risk developing some form of dependence in that a mild to moderately severe syndrome is commonly experienced upon stopping long term benzodiazepine treatment. The demonstration of withdrawal problems in patients on normal, therapeutic doses and the psychological impairment associated with chronic sedative ingestion argues against regular daily medication for chronic anxiety other than of severe degree.’
Psychiatry in Practice, 1982
`Reaction to benzodiazepine withdrawal was first noticed in 1961. Since then sporadic reports have drawn attention to a wide range of physical and emotional symptoms which can accompany the withdrawal of benzodiazepines...the Committee on Safety of Medicines advises that benzodiazepines should be prescribed for short periods only and that withdrawal symptoms, following administration, can be avoided by withdrawing medication slowly.’
Modern Medicine, 1982
`Recently a number of studies both in Britain and the USA have demonstrated that a true physical withdrawal syndrome exists on stopping benzodiazepines. This withdrawal syndrome is characterised by severe anxiety, often worse than the original symptoms for which the medication was prescribed. The symptoms become maximal about five days after medication is stopped and gradually resolve in about two weeks...Benzodiazepines are the most commonly prescribed drugs. They are effective in the treatment of anxiety and allied states. Not surprisingly, they can produce both physical and psychological dependence. Physical dependence can be hard to treat and can occasionally result in severe withdrawal symptoms. Its prevention and management are primarily the province of the community psychiatrist - the general practitioner.’
`...no one would doubt that the benzodiazepines are valuable drugs in the short term management of acute anxiety reactions and sleep disturbance, as well as in other specific indications. What is disturbing is their prolonged use. In many cases there seems to be little clinical justification for this. It simply creates addicts from whom subsequent withdrawal is extremely difficult. Regrettably, doctors, both as a result of their prescribing habits as well as their willingness to allow themselves to be manipulated by `hooked’ patients are very much to blame. In this context the repeat prescription, a mechanism which often allows us to avoid confrontation with chronically emotionally disturbed patients, has much to answer for. Nor are hospitals blameless. The indiscriminate nightly distribution of sleeping tablets starts many a patient on the rocky road to addiction.’
Psychiatry in Practice, 1982
`Benzodiazepines have a well-established role in conditions such as status epilepticus, but it is emerging that there are distinct disadvantages in using them for symptoms such as anxiety or depression. Most hypnotics tend to lose their sleep promoting properties within 14 days of continuous use, and there is no evidence that they are effective in the treatment of anxiety after four months' continuous use...Patients taking benzodiazepines for four months or more may develop a psychological and physical withdrawal syndrome on stopping them.’
Modern Medicine, 1982
`It is increasingly being realised that patients can become dependent (both in a psychological and a physical sense) on benzodiazepines. There is also evidence to suggest that the chances of a patient who starts on a course of psychotropic drug treatment becoming a long term consumer are increasing. There is no doubt that benzodiazepines and other mild tranquillisers afford considerable short term symptomatic relief from anxiety. There is, however, little or no evidence that they are beneficial in the long term. Patients who are started on these drugs should be kept under regular review so as to minimise the chances of patients becoming long term consumers by default.’
Medical Digest, 1983
`In recent years...the pendulum of approval has swung dramatically against the benzodiazepines...several investigations have shown quite unequivocally that benzodiazepines may produce pharmacological dependence in therapeutic dosage...The best management for benzodiazepine dependence is far from clear. Treatment should not be stopped abruptly, for this is more likely to lead to serious withdrawal symptoms including epileptic seizures...In terms of public policy, now that benzodiazepines have been shown to cause drug dependence should their use be more closely controlled - or even banned?’
British Medical Journal, 1984
`Irresponsible prescribing by doctors often leads to psychotropic drug addiction, a specialist has claimed. Professor Griffith Edwards...told the meeting: `When the media give us yet another heading on `Britain overrun by drugs’ you can wager that they are referring to illicit drugs such as heroin. Too easily lost from sight, though, is a problem which seldom makes the front page - the social significance of illicit prescribing of mind-acting drugs.’ Professor Edwards said benzodiazepines was one example of a drug which was overprescribed. And the central question was why this boom had occurred.’
`Doctors were urged last week to be more cautious in their prescribing of benzodiazepines because of the huge withdrawal problems in a significant number of patients...Certain benzodiazepines pose more dependency and tolerance problems than others. Lorazepam (Ativan) and triazolam (Halcion) were particularly likely to induce dependence.’
`A report by MIND, the National Association for Mental Health, stating that benzodiazepine drugs are being prescribed by GPs for periods that far exceed their usefulness, was described as fair comment by a professor of general practice.’
`Long term use of minor tranquillisers can lead to physical dependence, with the development of a withdrawal reaction if the drug is stopped suddenly...As awareness of this fact increases, so concern is growing amongst doctors and patients alike.’
Medical News, 1984
`Large numbers of people take benzodiazepines to control anxiety and often continue to do so for months or years, despite the recommendation of the Committee on the Review of Medicines that they should be prescribed only for short term use.’
Medical Digest, 1983
`...these findings show very clearly that benzodiazepine withdrawal is a severe illness. The patients were usually frightened, often in intense pain, and genuinely prostrated. The severity and duration of the illness are easily underestimated by medical and nursing staff, who tend to dismiss the symptoms as `neurotic’. In fact, through no fault of their own, the patients suffer considerable physical as well as mental distress.’
British Medical Journal, 1984
`Benzodiazepine withdrawal seems to induce a minor transient rebound anxiety state in addition to minor physical symptoms, which might deter some patients from discontinuing their medication.’
Medical News, 1984
`Benzodiazepines have now become the most widely prescribed group of drugs, and their indiscriminate use is a cause for concern. In the UK approximately 14% of adults now receive a benzodiazepine during the course of a year...High doses given for long periods of time will almost invariably cause problems on abrupt withdrawal. Continuous treatment for longer than four months with anxiolytic benzodiazepines carries a significant risk of withdrawal effects.’
MIMS Magazine, 1984
`Tranquillising drugs are among those most commonly prescribed, and in view of their widespread use the incidence od dependence causes concern...The size of the problem is unknown but one must note the recent finding that normal dose dependence can and does occur frequently, especially in patients taking benzodiazepines for several months or more."
`Repeat prescribing accounts for up to half of all drugs issued. In the survey, which covered three group practices, 30% of all repeat prescriptions were for psychotropics...’
`GPs may be responding to public pressure against benzodiazepines by taking patients off the drugs too rapidly and without giving adequate support...’
`Early experience with benzodiazepines suggested that drug dependence was rare. It has since become clear, however, that dependence occurs readily and quickly in some patients and is not uncommon. Such patients develop a reliance on the drug to maintain psychological comfort and experience withdrawal symptoms if the drug is stopped or the dosage reduced. It has been estimated that about one third of patients taking benzodiazepines for six months become dependent, and some do so after only a few weeks of treatment...Present estimates suggest that perhaps half a million people in the United Kingdom and 2-3 million in the world are now dependent on benzodiazepines...Since dependence takes time to develop, it is best prevented by limiting the duration of benzodiazepine use. Severe withdrawal effects are uncommon if the drugs have been used for less than 2 weeks and it would seem advisable to restrict regular benzodiazepine administration periods to 7-14 days.’
Adverse Drug Reaction Bulletin, 1986
`Repeat prescribing is to blame for the "enormous" problem of benzodiazepine addiction, warned Dr Brenda Davies, consultant psychiatrist from Ticehurst House Hospital in East Sussex. She said benzodiazepines had become the most commonly prescribed of all drugs. One in five women and one in ten men in the UK used them at some time each year. Of these patients 25% may become dependent after only three months of regular use at the standard dose.’
`As far back as 1980 the Committee on the Review of Medicines pointed out...that `there was little convincing evidence that benzodiazepines were efficacious in the treatment of anxiety after four months' continuous treatment’. Despite this authoritative statement, and widespread corroborating evidence, there are still substantial numbers of patients receiving benzodiazepines for a year or more. Apart from exceptional cases there is no point in continuing to prescribe benzodiazepines for prolonged periods because they do not help the patient. What may arise, however, is a dependence on the drug among some patients. The symptoms they experience on withdrawal can be very similar to the symptoms which brought them to the surgery in the first place.’
`There is no doubt that benzodiazepines are effective initially but they should generally be prescribed for no more than a fortnight, and rarely for four weeks."
MIMS Magazine, 1987
`Excessive growth in prescriptions for benzodiazepines in the 1970s led to concern over their use. The concern was reinforced by evidence that they were being prescribed for excessively long periods. Subsequent studies have shown that about two fifths of regular users of benzodiazepines develop pharmacological dependence and have withdrawal symptoms when the dosage of their drugs is reduced or treatment is stopped.’
British Medical Journal, 1988
`At the 28th sitting of Standing Committee A on the `Health and Medicines Bill’ at the House of Commons Mrs Edwina Currie, replying to questions about lorazepam said: `We have taken action because I have been worried about the problem. Dr Vernon Coleman's articles, to which I refer with approval, raised concern about these important matters, and I sent them on to the appropriate bodies. I do not agree with everything that Dr Coleman says, but much of it is good plain common sense. I always read his column with the greatest interest.’
1st March 1988
My book `Life Without Tranquillisers’ was first published in 1985 and has been reprinted as a paperback.
The full history of the benzodiazepines (together with many references and quotes) is available in my paperback: `The Benzos Story’.
Copyright Vernon Coleman July 2023