With benzos, a doctor discovers ease of dependency, ordeal of withdrawal


For the Gazette

Published: 01-02-2018 11:05 AM

Editor’s note: This is Part 2 of a four-part series on the role of sedatives known as benzodiazepines in the nation’s opioid crisis.

Dr. Christy Huff, a Texas cardiologist, was prescribed Xanax after a dry-eye syndrome caused her eyes to “feel like sandpaper,” disrupting her ability to sleep. She began taking the small dose, 0.25 mg, at night as a sleep aid.

Two years later, she’s still trying to taper off the drug, and still suffering through severe withdrawal symptoms. Her experience prompted her to offer testimony on legislation halfway across the country in Massachusetts that seeks to increase warning labels and warn patients of the dangers of benzodiazepine use.

She said the drug has seriously disrupted her life.

“At first I was blindsided; I had no idea this could happen,” she said. “Still it’s completely unreal, and if it didn’t happen to me, I wouldn’t believe it.”

Xanax is among a class of prescription drugs called benzodiazepines often prescribed for anxiety, panic disorders, seizures and sleeplessness. Commonly known as benzos, they are sedatives that act on the central nervous system, slowing the brain and causing drowsiness.

Medical practitioners generally agree that when used for specific, severe symptoms, benzos are effective at controlling acute anxiety, PTSD and insomnia. However, there is a rising debate about the side effects and withdrawal symptoms that can develop when these drugs are used for longer than a few weeks.

More troubling are studies linking opioid overdoses to benzo use. Some opioid users take benzodiazepines to treat withdrawal symptoms or to intensify the high from less potent forms of opioids. Since both classes of drugs act on the central nervous system, combining the two can slow the heart and lungs with fatal results.

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A 2016 study by the American Journal of Public Health concluded that benzos were involved in 31 percent of all fatal overdoses between 1996 and 2013 nationwide. The study also found that the number of adults filling benzo prescriptions in that period increased by 67 percent from 8.1 million people to 13.5 million.

State prescribing rules

In Massachusetts, doctors and psychiatrists must report new benzodiazepine prescriptions — classified as Schedule IV controlled substances — to the Massachusetts Prescription Monitoring Program.

There are two other Schedule IV classes of drugs. Barbiturates, known to be physically and physiologically addictive, were widely abused in the 1960s and ’70s. They were phased out in favor of drugs with a lower potential for overdose, but are still sometimes used as pre-surgical anesthesia despite the FDA classification of “considerable abuse potential.”

The other is dextropropoxyphenes, a class of synthetic opioids that carry an FDA black box label similar to benzodiazepines.

According to state prescribing guidelines, a Schedule IV classification means the drugs are less likely to be abused than drugs like ketamine, often used as a horse tranquilizer, or Suboxone, used to stave off withdrawal in opioid users. However, the guidelines note they may “still lead to physical or psychological dependence.”

It is this dependence that prompted Huff to submit testimony supporting a bill that would change benzodiazepine labeling and prescribing to better inform patients of long-term side effects and withdrawal.

Advocates say such steps are important not just because of benzos’ increasing use and their deadly impact on the opioid crisis, but also because of the severe problems they can cause after just a few weeks of prescribed use.

Tremors, panic

After a few weeks of taking Xanax as a sleep aid, Huff began to feel anxious during the day with difficulty breathing, chest tightness and an inability to swallow. She developed a tremor and would wake in the night in a panic. The symptoms, she said, were eased by more Xanax.

Soon she took a prescribed dose every six hours to stave off the symptoms. She went to multiple specialists, who concluded she was experiencing inter-dose withdrawal from the Xanax, which can occur between regular doses of benzodiazepines.

Through her residency in internal medicine, Huff knew that benzos could cause chemical dependency and weren’t meant for long-term use.

“But I was never taught about how bad the withdrawal could be,” she said. “I just thought if you became dependent, you could just taper off.”

Her attempt to taper off in the two to four weeks recommended by her doctor brought on new symptoms: severe nausea, low appetite, insomnia, muscle spasms, severe acid reflux, severe constipation, confusion, anxiety, and depression. Her short-term memory, she said, “is shot.”

Now, she is on a strict taper, slowly taking smaller and smaller doses to wean her body off the drug. She said she has good days and bad days.

“It’s hard to feel hope for the future when you’re dealing with these hellacious symptoms day in and day out,” she said. “I’ve accepted the process at this point. I’m going to see it through to the end.”

As she tries to get off benzos completely, she wants to make sure others are aware of the side effects and painful withdrawal she experienced. She is now the director of the Benzodiazepine Information Coalition in Houston, which is committed to spreading awareness of the problems with benzos.

Huff’s testimony was in support of H.3594, a bill now in the state Legislature’s Committee on Mental Health, Substance Abuse and Recovery.

The legislation would require prescribers to obtain written informed consent from patients acknowledging the risks of dependency and addiction associated with long-term benzodiazepine use. It would also add warning labels.

Dr. James Berry, who worked on benzodiazepine prescription guidelines for Maine, testified that such information is critical, as is the understanding of what constitutes “long-term use.”

“Patients who are given an initial prescription for benzos need to understand that if taken for longer than one to two weeks they can be difficult to discontinue,” he said.

‘Coming out of my skin’

Patients like Sonja Styblo, a mental health specialist at McLean Hospital’s Dual Diagnosis Drug & Alcohol Detox Program in Belmont, know how difficult that discontinuation can be.

“I was prescribed a small dose of Klonopin as needed to help with sleep difficulties related to post-traumatic stress. I took less than prescribed and not on a daily basis,” she wrote in her testimony, “I began to have brief transient moments where I would feel either oddly disconnected from my environment or I would wake up and frighteningly feel like I was coming out of my skin.”

But opponents of the bill said its restrictions would create more stigma around the drugs, making them less accessible to those who need them.

Dr. Edward Silberman, an attending psychiatrist and professor at Tufts University School of Medicine, testified against the bill at a hearing in September. Two other people, a professor of psychiatry at Harvard and the professor’s patient, also testified in opposition.

In an interview, Silberman said negative side effects and withdrawal symptoms affect only a small portion of the population.

“Benzodiazepines by themselves are really very safe. They’re among the safer drugs that we prescribe,” he said.

Silberman acknowledged that people particularly sensitive to benzodiazepine withdrawal can suffer “rebound anxiety,” with symptoms worse than the initial problem.

Overall, he said, patients using benzodiazepines do show a decline in cognitive function during neurological testing. However, he said that in most cases he’s seen, “the impairment of general anxiety is much worse than the impairment of the medication.”

He also acknowledged other side effects such as drowsiness, slowing of the reflexes and memory problems, but asserted that in young people these effects “aren’t something they notice.”

Tragic consequences

In November, a 19-year-old South Hadley man, Ryan Brunelle, was sentenced to a year in prison for motor vehicle homicide under the influence of drugs after he fell asleep at the wheel in 2016, killing the driver of another vehicle, Thomas Flanagan, 29 of Westfield.

Brunelle had taken “a substantial amount” of Xanax the day before, his lawyer said in court; a blood sample showed he still had the drug in his system at the time of the accident. The judge ruled the blood sample could be used in trial, indicating the drug played a significant role in the crash.

In court, his lawyer told the judge that Brunelle did not have a prescription for Xanax, but had begun using it to cope with depression.

Like Brunelle, many people find benzos “off the street,” or from friends or family and discover they can offer quick relief. What many casual users don’t know is the potential for painful withdrawal, dependence and the other serious side effects.

But others, like Huff and singer Stevie Nicks of Fleetwood Mac, say having a prescription didn’t help them avoid those problems.

“The biggest mistake I ever made was giving in to my friends and going to see a psychiatrist,” Nicks wrote in a Newsweek post. The psychiatrist prescribed Klonopin, “And the next eight years of my life were destroyed.”

Coming Wednesday: Benzodiazepine use among youth.

M.J. Tidwell writes for the Gazette from the Boston University Statehouse Program.