Treatment of Panic and Anxiety Disorders: Benzodiazepines

 

What are Benzodiazepines?

Benzodiazepines, or “benzos,” are a commonly prescribed class of medications known for their calming and relaxing effects. An estimated one in eight adults in the United States took benzodiazepines in 2018, which is 12.6% of the population.1 Benzodiazepines are most commonly prescribed to treat anxiety and panic disorders. They are also prescribed for short-term treatment of insomnia. Other uses for benzodiazepines include treatment of seizures, muscle spasms, pre-surgical sedation, and relief of alcohol withdrawal (“detox”) symptoms.

Benzodiazepines work by increasing the effect of a naturally-occurring brain chemical called GABA (gamma-aminobutyric acid). GABA blocks certain brain signals, which slows down the activity of the brain and nervous system. Benzodiazepines are effective in swiftly producing a calm, relaxed state. The quick results from benzodiazepines make them unique from most anti-anxiety medications, such as SSRIs, which take several weeks of treatment to reach full effectiveness.  

There are many varieties of benzodiazepine medications. They each differ in how quickly they start working (onset) and how long they take to wear off. They also vary in the size of the dose required to take effect (potency). For example, only a small dose of 0.25 milligrams (mg) of a high potency medicine has to be taken to get the intended effects. As opposed to a low potency medicine, which requires a relatively high dose of 30 mg to get the expected effects. These properties determine whether a particular benzodiazepine is more useful as an anxiety treatment or as a sleep-inducing treatment.       

The ten most common benzodiazepines are listed alphabetically in the table below, along with their characteristics and most prevalent uses.

xanax box

Commonly Prescribed Benzodiazepines in the United States

Generic (Brand)

Length of Effects

Potency

Common Uses

Alprazolam
(Xanax)

Short-acting

High potency

Anxiety, panic

Chlordiazepoxide
(Librium)

Long-acting

Low potency

Anxiety, alcohol withdrawal

Clonazepam
(Klonopin)

Long-acting

High potency

Anxiety, insomnia, panic, seizures

Clorazepate
(Tranxene)

Long-acting

Low potency

Anxiety, alcohol withdrawal, seizures

Diazepam
(Valium)

Long-acting

Low potency

Anxiety, seizures, muscle spasm

Flurazepam
(Dalmane)

Long-acting

Low potency

Insomnia

Lorazepam
(Ativan)

Short-acting

High potency

Anxiety, insomnia, panic, seizures

Oxazepam
(Serax)

Short-acting

Low potency

Anxiety, alcohol withdrawal

Temazepam
(Restoril)

Long-acting

Low potency

Insomnia

Triazolam
(Halcion)

Short-acting

High potency

Insomnia

Are Benzodiazepines Safe?

All medications have risks that should be discussed with a doctor or healthcare professional to determine if the potential benefits outweigh the risks. The most common side effects of benzodiazepines are drowsiness and dizziness. Confusion, blurred vision, incoordination, nausea, and memory impairment are also possible. Next-day grogginess or “hangover effect” is common with long-acting benzodiazepines, which limits their usefulness for treating insomnia. Older adults are more sensitive to all of these side effects and should not be prescribed long-acting benzodiazepines. Doctors are cautious about prescribing benzodiazepines for pregnant women because they may carry some risk of congenital disabilities.   

When taken alone, benzodiazepine treatment is considered relatively safe. However, benzodiazepines can be deadly when taken in combination with other substances that slow brain functions, such as alcohol and prescription painkillers (opioids). In 2018, more than 115 Americans died each day from opioid overdoses, and more than 30 percent of opioid overdoses involved benzodiazepines.2 The Centers for Disease Control and Prevention (CDC) recommend that physicians avoid prescribing benzodiazepines along with opioids whenever possible. Both benzodiazepines and opioids now carry “black box warnings” on the label, highlighting the dangers of combining these medications. Also, concurrent alcohol use is not recommended because it intensifies the effects of benzodiazepines, and benzodiazepines increase the effects of alcohol.   

Benzodiazepines are “controlled substances” which means they are regulated by the Drug Enforcement Agency (DEA) in the Controlled Substances Act laws. All controlled substances have some inherent risk of abuse and addiction. Physical dependence can happen quickly, sometimes within two weeks of daily use, especially with high doses of short-acting, high potency benzodiazepines like alprazolam or lorazepam.  

Benzodiazepines should not be stopped suddenly, or withdrawal symptoms may occur. Withdrawal symptoms usually include the return of anxiety symptoms, irritability, insomnia, headache, and blurred vision. Hallucinations or seizures are rare but possible, especially after suddenly stopping long-term high dose or short-acting therapy. The dose should be reduced gradually, under physician direction, over at least four weeks to ensure safety when stopping benzodiazepines.

Use of Benzodiazepines with Antidepressants for Anxiety and Panic Disorders

Benzodiazepines are regularly prescribed along with antidepressants to treat the symptoms of anxiety and panic disorders. The first choice antidepressants for generalized anxiety and panic disorder are selective serotonin reuptake inhibitors (SSRIs, such as sertraline or escitalopram) or serotonin-norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine). Their downside, however, is that they take two to four weeks to start working, and up to eight weeks for full effects. Also, SSRIs and SNRIs can cause a temporary increase in anxiety in the first few weeks. To manage this side effect, a benzodiazepine is frequently prescribed along with the antidepressant, to be taken “as needed” for anxiety or on a scheduled regimen to prevent panic attacks. For most people, as the antidepressant takes effect, the benzodiazepine dose can be gradually reduced or taken less often.  

Antidepressants are equally effective as benzodiazepines for the long-term treatment of generalized anxiety and panic disorder. Still, they will not provide immediate relief of intense anxiety or stop a panic attack. Benzodiazepines are safe when taken as directed and are effective at quickly relieving panic symptoms.  

Emotional dependence can occur with long-term use of benzodiazepines for anxiety or panic disorders. People may become reliant on their benzodiazepine, and may be reluctant to stop because of their understandable fear that anxiety or panic attacks may return. The risk of physical or psychological dependence is another reason why medication should not be the only tool for managing anxiety and panic disorders. Working through underlying issues through talk therapy or cognitive behavioral therapy with a licensed psychologist, as well as having a supportive network is essential for managing anxiety and panic disorders. With assistance, the right treatment, and a solid understanding of the disorder, the vast majority of people with anxiety and panic disorders continue to have full, rewarding lives.  

Citations

Maust, Donovan T. (2018, Dec 17) Benzodiazepine Use and Misuse Among Adults in the United States. Retrieved from https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201800321

National Institute on Drug Abuse. (2018, March) Benzodiazepines and Opioids. Retrieved from
https://www.drugabuse.gov/drugs-abuse/opioids/benzodiazepines-opioids

Harvard Health Publishing. (2014, March) Benzodiazepines (and the alternatives).   Retrieved from
https://www.health.harvard.edu/mind-and-mood/benzodiazepines_and_the_alternatives

Longo, Lance P. and Johnson, Brian. (2000, Apr 1) Addiction: Part I. Benzodiazepines—Side Effects, Abuse Risk and Alternatives.  Retrieved from https://www.aafp.org/afp/2000/0401/p2121.html

American Psychiatric Association. (2009, Jan) Treating Panic Disorder: A Quick Reference Guide. Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder-guide.pdf

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