September 1, 2025 • 34 mins
Dr. Casey Grover explores the challenging world of benzodiazepines, explaining why these commonly prescribed medications can create more problems than they solve for patients struggling with anxiety and other conditions.
• Benzodiazepines work like alcohol in pill form, enhancing the brain's natural "downer" chemical GABA
• Long-term use leads to tolerance, dependence, and potentially Benzodiazepine-Induced Neurological Dysfunction (BIND)
• The four most commonly prescribed benzos are diazepam (Valium), lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax)
• Benzodiazepine withdrawal can cause seizures months after the last dose, making it particularly dangerous
• Unlike opioid addiction, there are no specialized medications to treat benzodiazepine addiction
• Tapering from benzodiazepines is extremely challenging, often taking months or years with patients experiencing severe rebound symptoms
• Modern medical understanding now recognizes benzos as inappropriate for long-term anxiety treatment
• Case studies demonstrate how patients prescribed benzos for anxiety often never learn proper coping skills and suffer increasingly worse symptoms
Thanks for listening and remember treating addiction saves lives.
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is onbenzodiazepines.
(00:43):
I am the medical director for adrug and alcohol treatment
program near me and as a part ofmy medical director duties,
every month I do an educationallecture for the staff of the
program and we choose adifferent topic each month.
This month I did an overview ofbenzodiazepines a very
challenging topic.
Here we go.
A very challenging topic herewe go.
(01:06):
Okay, so today we're going tobe talking about benzodiazepines
and before we start I just needto put in a little disclosure,
which is that benzodiazepinescan be prescribed and used by a
physician and a patient ifthat's the right decision for
that patient.
And I realized that when I'mspeaking to the audience,
(01:29):
someone in this audience mightbe taking benzodiazepines and I
don't mean to offend anyone, butin my opinion, given what I do
as an addiction medicine doctor,benzodiazepines are a really
bad problem and they cause quitea bit of harm.
And I'm going to be as honestas I can be.
I don't mean to offend anyoneand if anyone has a relationship
(01:51):
with their physician andthey're on benzodiazepines and
it's working, please realize I'mnot meaning to judge, I just
have my perspective, given whatI do as an addiction medicine
doctor.
So, as you can imagine, I'm notgoing to paint a very pretty
picture of benzodiazepines and Iwill share how I approach them
in my practice.
So benzodiazepines are a groupof medications that act like a
(02:14):
sedative or a downer.
So the way they work is theyincrease the effects of the
brain chemical GABA, and GABAstands for gamma-aminobutyric
acid and it's one of our brain'snatural downers.
And if you remember some of ourlectures on alcohol, gaba is
how alcohol acts like a downer.
(02:35):
Alcohol makes GABA work betterin the brain, so it takes the
brain's natural downer and makesit work better.
And benzodiazepines are thesame way.
In fact, many physicians oftentry to explain to patients that
benzodiazepines are basicallylike alcohol in a pill.
Why do we use them?
As I mentioned, they're downers, they're a sedative, and so we
(03:00):
used to use them for anxiety,and I'll explain why we're
reevaluating this.
We will often use it to makepeople sleepy around a medical
procedure, like if people areclaustrophobic to get into an
MRI.
When people are really agitatedin the hospital, we'll use them
to sedate people and they havea very profound downer effect.
(03:21):
And so when people haveseizures, actually we use
benzodiazepines.
They're really effective whensomeone is having a seizure, to
terminate the seizure.
And when someone is taking adowner and they're in withdrawal
from that downer, we sometimesuse benzodiazepines to suppress
the withdrawal and they'rereally the best medication we
(03:43):
have when someone has severealcohol withdrawal and as we
really the best medication wehave when someone has severe
alcohol withdrawal and as we'lltalk about, unfortunately we
don't have a lot of options totreat benzodiazepine addiction
or withdrawal or dependence.
So when people are onbenzodiazepines, we actually use
benzodiazepines to manage theirwithdrawal and we'll talk about
that in quite a bit of detailNow I'm going to show you a
(04:06):
chart here.
There's quite a few differentbenzodiazepines and we really
look at them in a couple of wayshow fast do they come on and
how long do they last, and dothey have metabolites that are
also active?
And so here are some namesalprazolam, clonazepam, diazepam
(04:27):
, lorazepam, medazolam.
You see they all end in pam orlam and you can see some of them
come on quickly like alprazolam, but it doesn't last very long.
Something like diazepam comeson quickly and lasts a long time
.
And the reason why thisunderstanding of how the
different benzodiazepines workmatters is because as physicians
(04:49):
we have to choose the rightbenzodiazepine for the patient
in the right circumstance.
So let's say, somebody is inalcohol withdrawal which can
last for several days.
We don't want a benzodiazepinethat's short-acting because when
it wears off we don't want abenzodiazepine that's
short-acting because when itwears off they're going to be in
withdrawal again.
So we usually use long-actingbenzodiazepines like diazepam or
(05:11):
chlorodiazepoxide to managewithdrawal, because they are
long-acting.
The other thing is traditionallywe used to think of
benzodiazepines as useful foranxiety, and when people are
anxious they want to feel betterquickly.
So we would use a fast onsetbenzodiazepine.
I'll talk quite a bit in detailabout how using benzodiazepines
(05:33):
for anxiety is really notconsidered good medicine anymore
, and so we really don't usealprazolam or clonazepam to
manage anxiety.
But you can see here that,based on how they work, because
they're fast acting, that waswhy they were chosen.
Now, as you can see, one, two,three, four, five, six, seven,
(05:53):
eight, nine, 10, 11, 12, 13, 14.
This chart has 14 differentbenzodiazepines.
The big four are the ones thatdoctors use the most and I'm
gonna try to use generic names.
I may slip up a little bit, butthere's diazepam, also known as
Valium.
There's lorazepam, also knownas Ativan, and there's
(06:14):
clonazepam, also known asKlonopin, and there's Alprazolam
, known as Xanax.
Those four medications are theones that are most commonly
prescribed in the outpatientsetting.
We do use some other ones inthe hospital, but again, these
are the big four that you'remostly going to see when
someone's getting a prescriptionfor them from a doctor.
(06:35):
Now, the other thing tounderstand about benzodiazepines
is that they are different intheir potency, and again we're
going to focus on the big fourdiazepam, clonazepam, alprazolam
and lorazepam.
And you can see they aredifferent in their potency.
So I usually, when I'm gettingpeople off of benzodiazepines,
(06:55):
convert everything to diazepam,kind of like how with opiates we
convert everything to morphineto understand their relative
potencies.
So alprazolam and clonazepamare 10 times stronger than
diazepam and lorazepam is fivetimes stronger than diazepam.
And what happens is people gettold oh, don't worry, you're
(07:17):
just on a milligram ofclonazepam and it's no big deal.
One milligram doesn't soundlike a lot, but when we actually
look at the potency ofbenzodiazepines because
clonazepam and alprazolam are sopotent people's tolerance and
dependence goes up fairlyquickly, even though it seems
like a small dosage.
And we'll talk about what I dowhen I get people off of
(07:40):
benzodiazepines.
Now, the reason I findbenzodiazepines so frustrating
is, like other medications andsubstances when people take them
chronically, the brain changesand we see the same things we
see with other substances.
They get tolerance where theyneed more to feel the same
(08:01):
effects.
They get dependence, so theyfeel sick or go into withdrawal
when they stop.
But there's actually more tothe story, specifically around
benzodiazepine use and one of mypatients I just talked to him
last night.
He is completely miserable aswe taper him off of
benzodiazepines and he actuallytaught me about this condition,
(08:24):
which is called BIND B-I-N-Dbenzodiazepine-induced
neurological dysfunction, andthis is why I was saying that we
used to prescribe them prettyregularly for anxiety.
But what we're learning isthey're not benign long-term.
So benzodiazepine-inducedneurological dysfunction
(08:45):
involves a lot of differentsymptoms that people get when
they're on benzodiazepineschronically and it's the worst
as they try to taper off ofbenzodiazepines.
Symptoms can include anxiety,fear, poor sleeping,
palpitations, nerve sensations,and it can be really
debilitating.
It can interfere withrelationships, work,
(09:07):
interpersonal functioning, and Ididn't actually know what this
was originally, but I would getreferred all of these patients
to me that were on chronicbenzodiazepines when their
physician retired or said oops,I've had you on Alprazolam for
five years.
I don't think it's a good ideaanymore and I just couldn't
(09:29):
figure out why people had noability to regulate their
emotions once they were onchronic benzodiazepines.
And I had come up with my ownterm they seem so emotionally
fragile that I called itbenzodiazepine-induced emotional
fragility.
And it turns out that'sactually not just my observation
(09:53):
, but that is something that weare now seeing is a side effect
of long-term benzodiazepine use,and I'm going to call it BIND
just for simplicity's sake as wego forward.
And again, that'sbenzodiazepine-induced
neurological dysfunction, andwe'll talk about why it makes
getting off of benzodiazepinesso difficult.
Now, as I mentioned, what wewere seeing with benzodiazepines
(10:17):
is people just were so unableto manage their emotions once
they were on chronicbenzodiazepines and in part,
that's a little bit about howaddiction works in general.
Right, I ask my patients whatdoes alcohol do for you?
Oh well, I got beat up horriblyas a child by my stepdad, and
(10:39):
when I drink alcohol, I don'thave to remember it.
I use it to numb out.
And so, in addition to theunique issues that
benzodiazepines cause in termsof changing our brain function,
long-term a benzodiazepineaddiction, or chronic
benzodiazepine use, is like anyother addiction.
People learn that the substanceis the only way that they can
(11:01):
manage anything, and that's partof what plays in to why it's so
hard to get people off of.
Benzodiazepines is, forgive me,they're very effective at
acting like a downer and calmingpeople down, but then people
don't actually ever learn how tomanage anxiety and I feel so
bad.
I have so many patients thathave been on benzos for longer
(11:22):
than I've been alive and they'rehorribly anxious and they don't
know how to manage it and theirdoctor never referred them for
mental health services and theirdoctor just kept giving them
more benzodiazepines.
It's actually really sad.
So let's go through someclinical cases and you can start
to see what this actually lookslike when someone comes to me
(11:43):
and they've been onbenzodiazepines for a long
period of time.
So this is my first case.
This is a 45-year-old femalewho came to my clinic and she
wanted to get off of clonazepam.
So she had a history of cancerand her oncologist started her
on benzodiazepines because shewas very anxious while she was
getting her cancer treatment.
(12:03):
And because she was onclonazepam chronically, her
brain adapted to it.
She developed tolerance and heroncologist just kept increasing
the dose of her clonazepam andso on my very first visit with
her, she was on two milligramsof clonazepam three times daily.
That's a total again, of sixmilligrams a day.
(12:25):
And she kept telling me like,oh, it's not that bad, it's only
six milligrams.
And I had to show her that it'sa really high dose.
She's on the equivalent of 60milligrams of diazepam or Valium
a day and insurance won'tactually cover that high of a
dose of diazepam.
(12:45):
It's felt to be unsafe.
And what was so challengingduring this visit is she
complained the entire visitabout how anxious she was and I
remember thinking like what'seven the point of being on
clonazepam?
She's just anxious and now wehave to worry about withdrawal.
So we're going to put a pin inher case and we're going to come
(13:09):
back to it because we need totalk about why we have to be
really careful when we getpeople off of benzodiazepines.
So you probably all know, aswe've talked about various
substances, that usuallysubstances have a withdrawal
syndrome.
Alcohol withdrawal we've talkedabout.
People get shaky, they getrestless, they can have seizures
(13:30):
.
Opiate withdrawal people havenausea and vomiting and diarrhea
.
They get restless.
Benzodiazepines are a downer andthe way I look at it is if the
drug takes you down, thewithdrawal syndrome is the
opposite You're up and soessentially what we see is
because the benzodiazepines actas a sedative, withdrawal
(13:52):
involves the opposite.
So mild withdrawal would justbe anxiety or insomnia or
restlessness.
But as people are on higherdoses and the withdrawal gets
worse, it can be very number oneunpleasant and number two
life-threatening.
So moderate withdrawal peopleget a lot more somatic symptoms
(14:14):
muscle tension, sweating,sensitivity to light and sound,
and they can also get somepsychiatric symptoms.
Beyond anxiety and insomnia.
They can get what's calleddepersonalization, where they
feel like they're having anout-of-body experience.
It can mess what's calleddepersonalization, where they
feel like they're having anout-of-body experience.
It can mess with their mood andthen again, because it's a
downer, you get some otherthings that come up, like you
can get a fast heart rate orpalpitations.
(14:36):
And what we really worry aboutis severe benzodiazepine
withdrawal.
People will seize, they willget delirious, where they get
acutely confused and then theycan even begin to hallucinate,
where they get psychosis.
And if any of you have heard ofdelirium tremens, that is the
absolute most severe form ofalcohol withdrawal and really
(14:59):
bad benzodiazepine withdrawalcan look like that and it can
put people in the intensive careunit.
We also need to specificallydiscuss seizures as it pertains
to benzodiazepine withdrawal.
Now, as I mentioned, weactually treat seizures with
benzodiazepines.
So let's say somebody hasepilepsy and 911 gets called
(15:23):
because they're having a seizure.
The paramedics will often givea dose of benzodiazepine to
terminate the seizure and it isa known side effect of coming
off of benzodiazepines that youcan get seizures.
Essentially, the way to thinkof it is because they're a
downer.
They turn down brain activityand as people are coming off of
(15:45):
it, the brain activity goes upand eventually the brain
activity can.
And as people are coming off ofit, the brain activity goes up
and eventually the brainactivity can get so intense that
a seizure gets triggered.
And with alcohol withdrawal,people only are at risk for
seizures within like the firstcouple of days of coming off of
alcohol.
Benzos are different.
People can randomly have aseizure for months as they're
coming off of benzodiazepinesand they might even, let's say,
(16:08):
take their last dose ofbenzodiazepine in July.
They could have a seizurerelated to benzosensation in
November or December, and it'sreally unfortunate because it
can be really unpredictable wehave to worry about.
Is it epilepsy?
Is it just coming off of benzos?
And the highest risk for aseizure coming off of
(16:28):
benzodiazepines is when someoneabruptly stops, and so usually
we put people on a long, slowtaper to try to get them off of
benzodiazepines safely.
But even then you can still getseizures when you're doing it
carefully and slowly with ataper, when you're doing it
carefully and slowly with ataper.
(16:49):
Okay, so I've been mostlytalking about people getting
benzodiazepines from a doctor,getting them prescribed.
We've talked about dependence,we've talked about bind, we've
talked about tolerance, we'vetalked about withdrawal.
Can you get addicted tobenzodiazepines?
And I think you all know theanswer is yes, and so you can
also get a benzodiazepine usedisorder.
(17:11):
And again, just to make sure weunderstand everything, anyone
who is prescribedbenzodiazepines regularly will
develop tolerance and dependenceand go through withdrawal.
A use disorder is an addiction.
It's the psychologicalphenomenon of cravings,
compulsive use and using despiteconsequences, and it's the same
(17:35):
criteria we use to diagnose anyaddiction.
There are 11 of them.
You can see them on the screen.
You're using more or for longerthan you wanted to.
You've tried to cut down.
You spend a lot of time tryingto get it.
Cravings for benzodiazepines.
Because of your use, you do notfulfill your major role
obligations.
(17:55):
You continue to use despitesocial or interpersonal problems
.
You're giving up hobbies andother activities.
You use when it's physicallydangerous.
You use despite havingpsychological harm to your body
and then, as we've talked about,because people tend to get
dependent because they're usingit so frequently, we also see
tolerance and withdrawal.
(18:16):
So, yes, we see, unfortunately,quite a few patients with
benzodiazepine use disorder inour practice.
Disorder in our practice.
Now, how do we treatbenzodiazepine addiction?
I'm going to try to be funnyhere.
The great news is we haveincredibly effective medications
for benzodiazepine addiction.
(18:37):
Kind of like we have methadonefor opioids we have methabenzone
, and like we have suboxone foropioids we have benzoboxone.
I'm completely kidding.
There are no effectivemedications to treat
benzodiazepine addiction.
It's horribly frustrating.
We don't have a methadone or asuboxone for benzodiazepines.
(19:01):
All we can really do is getpeople into counseling.
They might need to go toresidential and we're going to
want to get them to mutualsupport groups and then we just
very slowly wean them off ofbenzos.
Having discussed this with anumber of other addiction
medicine doctors, we all prettymuch agree that the hardest
(19:23):
addiction to treat isbenzodiazepines.
It's the most frustratingproblem I have as an addiction
medicine doctor.
Now we've talked about the factthat when people get dependent
on benzos whether it'sprescribed by a doctor or it's
because of their benzodiazepineuse disorder we have to get them
(19:44):
off of benzodiazepines safely.
How do we do this?
It's really weaning them off ofit over several months.
What I like to do, as Imentioned, is I put them on a
long-acting benzodiazepines mypreference is diazepam because
it's long-acting and if theymiss a dose they're not going to
(20:04):
be in really bad withdrawal andthen we just start dropping the
dose and it takes time.
So let's say somebody is buyingAlprazolam on the street and
they're taking two 2-milligramAlprazolam bars a day.
I'm going to convert so it's 10to 1.
So 4 milligrams of Alprazolamis going to be the same as 40
(20:26):
milligrams of diazepam.
I'm going to start them on 40milligrams of diazepam, let them
equilibrate and then I'm goingto drop the dose by about 10%
every few weeks.
So that's probably going tolook like something where we'd
go from 40 to 35, and then to 30, and then down to 25, etc.
And actually at the end of thetaper we might even go even
(20:47):
slower, like below 10 milligrams, we might drop by 2 milligrams.
So it's a very time-consumingprocess and I've got some more
cases where I can show you justhow long this takes.
Okay, so back to case one.
So this was my 45-year-oldpatient that was put on
clonazepam by her oncologist.
How has it been going?
(21:07):
Well, I've been seeing her forover a year and I've gotten her
down from six milligrams ofclonazepam a day to three and a
half milligrams a day.
I haven't even gotten 50% ofthe dose down yet, and the
reason why is she has horribleanxiety and insomnia that the
benzos have been masking foryears, and the problem is the
(21:30):
benzo didn't help anything, itjust masked it.
And one of the things that we'velearned and this may be bind, I
think we're still figuring itout is when people are coming
off of benzos, the originalsymptoms that the benzos were
prescribed to treat come back,even worse than before they were
on benzos.
So we call it rebound anxietyor rebound insomnia and so, as
(21:56):
we've brought her dose down,every time we dose drop she
can't sleep and she's even moreanxious than her usual.
And I got to be honest.
It looks really, reallyunpleasant to have to go through
this.
And what I'm also trying to dois add in non-addictive
medications to try to make thetapering less uncomfortable and
(22:19):
to treat those rebound symptomsof anxiety and insomnia.
So I have her on gabapentin totry to help with anxiety and
restlessness.
She gets a lot of musclesymptoms, so I have her on
tizanidine, which is anon-addictive muscle relaxant,
and then we've tried somedifferent non-addictive sleep
medications and I'll probably bedoing this for another six to
(22:41):
nine months with her if it goeswell.
She has BIND.
She does not have a lot ofability to manage negative
emotions.
I'm trying to get her into atherapist.
It's really been challenging.
Okay.
Case two this is a 40-year-oldmale who came to the clinic and
(23:02):
he asked for help with multiplesubstances.
He used alcohol, cannabis,opioids and benzodiazepines.
We were able to get him onSuboxone to manage his opioids
and then he went to residentialand in residential we put him on
what we felt to be theequivalent dose of the benzos he
was getting on the street andthat was 60 milligrams of
diazepam a day and we startedvery slowly tapering him down.
(23:25):
I initially started droppinghis dose by about five
milligrams every two weeks.
I've been seeing him for 18months and he's still on
benzodiazepines and same thing.
He gets all these reboundsymptoms, insomnia, anxiety, and
he bargains with me every timeI tell him it's time to drop.
(23:46):
No doc, please, please, justanother two, three weeks and the
other addiction doctor and I inthe practice are actually going
to probably switch to doing aprotocolized taper where people
know what they're going to getand we don't have this like
please, can I drop the dose nexttime?
Because people really feelmiserable as they come off of
(24:06):
benzodiazepines and it's areally difficult question.
If I push them too hard, will Icause a relapse?
If I push them too hard, arethey gonna develop some
psychosis or have debilitatinganxiety and have to be
hospitalized in the mentalhealth unit?
There's not a good answer onwhat to do with this.
(24:27):
The American Society ofAddiction Medicine just released
some guidelines on benzotapering which, I will admit, I
am behind.
I haven't read them and I'mactually gonna interview a
psychiatrist on my podcast laterthis year to give some advice
on how to do this better.
I'm just trying to really keeppeople from relapse and keep
them engaged in treatment and,to this gentleman's credit, he's
(24:49):
been working hard.
We've dropped his dose.
We're almost down to zero.
I anticipate that we'reprobably going to get him off of
benzos in the next severalmonths, but it's been really
challenging.
Okay, so I think you guys knowthe answer to this question
based on what I've been saying.
But should we be usingbenzodiazepines for anxiety?
(25:10):
And I have to say what I wastaught in medical school is
anxiety equals benzos.
When people are anxious, givethem benzos.
And I remember, as a new doctorout of my residency training,
people would come into the ERfor anxiety attacks and we'd
send them home with like 20lorazepam.
And, based on what I know now,I personally believe this is my
(25:33):
opinion that it is medicalmalpractice to treat anxiety
with benzodiazepines because, asI've pointed out to you, it is
so miserable for the patient toget off of them and there's no
end game.
It's not like going to therapyand learning coping skills.
It's just basically taking asedative to not feel anxious.
So, in my humble opinion, Ithink using benzodiazepines for
(25:58):
anxiety is wrong.
Now, that being said, I am not apsychiatrist, and if a
psychiatrist wants to managetheir patient on benzodiazepines
, great.
They have the knowledge of whatthe potential consequences are.
And if somebody has reallysevere mental illness, like
schizophrenia or bipolar, andthey need benzodiazepines and
(26:20):
that psychiatrist thinks it'sthe right decision, I say go for
it.
But in my practice, given whatI see in the world of addiction,
putting people on benzos justresults in them being completely
miserable when they try totaper off of them.
And my heart goes out to mypatients because it's so
uncomfortable to watch.
They just feel so bad all thetime.
I was actually trying to find atext message.
(26:42):
One of my patients actually theone that taught me about BIND
will send me messages of like DrGrover, this is so bad, why do
doctors prescribe this?
And he's really trying, andit's just I'm trying my best to
support him.
Okay, case number three A65-year-old male was referred to
(27:03):
our clinic because he was onchronic alprazolam and his
doctor retired and his newdoctor didn't want to prescribe
them for him because she felt itwas inappropriate.
And so the patient had ahistory of anxiety and his
primary care doctor had put himon Alprazolam at four milligrams
a day.
Now you all know that's afairly high dose and what's
(27:24):
amazing is this primary caredoctor had been giving this
patient Alprazolam for years andhad never referred him for any
mental health services.
So he comes to me, I believe,health services.
So he comes to me.
I believe, given what I'mlecturing you about, that he has
BIND and he has panic disorderand an anxiety disorder.
(27:45):
I actually think he probablyhas some PTSD because he had a
bad accident that led to hisanxiety and panic disorder
starting in the first place.
And he was pretty clear.
I'm going to use the brand namehere Xanax is the only thing
that helps my anxiety.
I don't want anything else.
I've tried to refer him fortherapy services.
He declines, and I think this iswhere we see that chronic
(28:08):
benzodiazepine use is not asbenign as we were led to believe
years ago.
And you know his doctor 20years ago was probably doing
what we thought was goodmedicine then.
In fact, I just want to remindyou, in medical school I was
taught to treat benzos withanxiety and we didn't understand
how chronic benzo use couldlead to profound changes in the
(28:29):
brain.
My case continues His anxietythanks to his chronic benzo use
and bind has only worsenedbecause of the years he's been
on Alprazolam and the Alprazolamdidn't help his anxiety.
And I always try to tell himthis, you know, I'll tell him
like, if it really helped youranxiety, why are you on them 20
(28:51):
years later?
And he really will not workwith me on this.
And I keep trying to try to gethim some services and let's try
a non-addictive med.
He did, to his credit, accept anon-addictive sleep aid, but at
a certain point I'm going tohave to tell him like, look, I
think this is wrong, I'm goingto have to have you see someone
(29:13):
else or have you see apsychiatrist.
I just feel like I'm makingyour anxiety worse and it's
going to be a difficultconversation with him that I'm
going to have to have and again,I feel so bad for him.
Anxiety is really, reallyuncomfortable.
He actually does not have abenzodiazepine use disorder.
He is not addicted, he does notcrave it, he does not misuse it
, but because he's been onbenzos for so long, he has
(29:36):
tolerance, he is dependent andhe has benzodiazepine-induced
neurological dysfunction and hisanxiety has never been treated.
It's very frustrating.
Okay, as I mentioned, we talkedabout rebound symptoms.
Rebound symptoms are the ideathat when people try to come off
(29:56):
of benzodiazepines, thesymptoms that they were
originally treated for emergeworse than before.
And he gets this a lot.
His anxiety gets worse overtime.
I've been seeing him for abouta year.
I can tell, even in the yearthat I've been seeing him, that
his anxiety only continues toworsen.
And a little bit of levity here,this was a meme.
(30:17):
I don't always make baddecisions, but when I do, I make
sure to repeat them over andover again, and this is a lot of
what we see in patients thathave been managed with
benzodiazepines for years andyears and years is, to some
extent, no one really knows whatto do with them, except just to
try to continue to taper off ofthem, get them on better, safer
medications.
But some of these patients havebeen on benzodiazepines for
(30:39):
like 60 years and the changes intheir brains are just profound.
Okay, so what do I do?
In my practice, a single dose ofa benzodiazepine before a
medical procedure is not mypreferred medication.
But if someone hasclaustrophobia and they need to
(31:04):
get an MRI, a single dose ofdiazepam isn't really going to
hurt anything.
Given how much frustrationbenzodiazepines cause my
patients and I I just I reallystruggle to even sign the
prescription if I have to writethem.
I've had a number of patientsthat were put on benzodiazepines
before they came to me and asI'm working on tapering with
them, I'll continue them ifthey're not dependent on just a
(31:26):
few doses a week.
So I had one patient come to me.
Her primary care doctor put heron lorazepam for anxiety and she
came to me basically saying Iwant to get off of them but I
don't know what to do with myanxiety.
And she is amazing.
She has worked so hard on heranxiety, believe it or not.
She went on YouTube and watchedvideo after video on how to
(31:49):
treat anxiety and she on her own, along with her therapist, has
come up with all these greatcoping strategies.
She'll use really cold water onher neck to distract her when
she's got a really bad anxietyattack and she's now completely
benzodiazepine free.
But there was a point where Iwas only giving her basically
four doses of lorazepam a week.
As she was building her skills,I needed her to start triaging
(32:13):
her anxiety.
Oh, I'm anxious, but it's onlya little bit.
I'm going to do some breathingexercises or I'm going to
meditate.
But when she was just losing itshe had a little bit of
lorazepam that she could take aswe were building her mental
health skill set.
And then, unfortunately for thechronic benzodiazepine patients,
it's just tapering over severalmonths and it's a really
(32:33):
frustrating problem.
Again, if one of my patientscomes to me and says, dr Grover,
I want you to get me onSuboxone for my opioid use
disorder and they've got apsychiatrist who's managing them
on benzos, that's between themand the other doctor.
If they want me to take it over, I tell them the only way I can
offer you benzodiazepines is totaper you off of them.
(32:54):
And I've had patients fire me.
They don't want to come off ofthem.
And what's really frustratingfor me as a doctor is, let's say
, somebody is sober and theirdrug of choice is opiates.
When they have a slip-up we canstabilize them on suboxone or
methadone or, if it's alcohol,we'll do a quick course of
medications to manage theirwithdrawal.
(33:14):
Getting people off of benzostakes so long and it's so
uncomfortable for the patient.
If people relapse and they tellme they relapse on benzos, I
just know it's going to bemonths of work for the patient
and I.
And then again, just becauseweaning involves dropping the
dose.
People feel benzodiazepinewithdrawal pretty regularly
throughout the weaning process.
It's a really frustratingproblem.
(33:38):
Okay, I don't know if anyonegets my joke from Saturday Night
Live, but let's stop here andwe will do some questions Before
we wrap up.
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenonprofit Central Coast Overdose
(33:59):
Prevention for teaming up withme on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(34:19):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is onbenzodiazepines.
(00:43):
I am the medical director for adrug and alcohol treatment
program near me and as a part ofmy medical director duties,
every month I do an educationallecture for the staff of the
program and we choose adifferent topic each month.
This month I did an overview ofbenzodiazepines a very
challenging topic.
Here we go.
A very challenging topic herewe go.
(01:06):
Okay, so today we're going tobe talking about benzodiazepines
and before we start I just needto put in a little disclosure,
which is that benzodiazepinescan be prescribed and used by a
physician and a patient ifthat's the right decision for
that patient.
And I realized that when I'mspeaking to the audience,
(01:29):
someone in this audience mightbe taking benzodiazepines and I
don't mean to offend anyone, butin my opinion, given what I do
as an addiction medicine doctor,benzodiazepines are a really
bad problem and they cause quitea bit of harm.
And I'm going to be as honestas I can be.
I don't mean to offend anyoneand if anyone has a relationship
(01:51):
with their physician andthey're on benzodiazepines and
it's working, please realize I'mnot meaning to judge, I just
have my perspective, given whatI do as an addiction medicine
doctor.
So, as you can imagine, I'm notgoing to paint a very pretty
picture of benzodiazepines and Iwill share how I approach them
in my practice.
So benzodiazepines are a groupof medications that act like a
(02:14):
sedative or a downer.
So the way they work is theyincrease the effects of the
brain chemical GABA, and GABAstands for gamma-aminobutyric
acid and it's one of our brain'snatural downers.
And if you remember some of ourlectures on alcohol, gaba is
how alcohol acts like a downer.
(02:35):
Alcohol makes GABA work betterin the brain, so it takes the
brain's natural downer and makesit work better.
And benzodiazepines are thesame way.
In fact, many physicians oftentry to explain to patients that
benzodiazepines are basicallylike alcohol in a pill.
Why do we use them?
As I mentioned, they're downers, they're a sedative, and so we
(03:00):
used to use them for anxiety,and I'll explain why we're
reevaluating this.
We will often use it to makepeople sleepy around a medical
procedure, like if people areclaustrophobic to get into an
MRI.
When people are really agitatedin the hospital, we'll use them
to sedate people and they havea very profound downer effect.
(03:21):
And so when people haveseizures, actually we use
benzodiazepines.
They're really effective whensomeone is having a seizure, to
terminate the seizure.
And when someone is taking adowner and they're in withdrawal
from that downer, we sometimesuse benzodiazepines to suppress
the withdrawal and they'rereally the best medication we
(03:43):
have when someone has severealcohol withdrawal and as we
really the best medication wehave when someone has severe
alcohol withdrawal and as we'lltalk about, unfortunately we
don't have a lot of options totreat benzodiazepine addiction
or withdrawal or dependence.
So when people are onbenzodiazepines, we actually use
benzodiazepines to manage theirwithdrawal and we'll talk about
that in quite a bit of detailNow I'm going to show you a
(04:06):
chart here.
There's quite a few differentbenzodiazepines and we really
look at them in a couple of wayshow fast do they come on and
how long do they last, and dothey have metabolites that are
also active?
And so here are some namesalprazolam, clonazepam, diazepam
(04:27):
, lorazepam, medazolam.
You see they all end in pam orlam and you can see some of them
come on quickly like alprazolam, but it doesn't last very long.
Something like diazepam comeson quickly and lasts a long time
.
And the reason why thisunderstanding of how the
different benzodiazepines workmatters is because as physicians
(04:49):
we have to choose the rightbenzodiazepine for the patient
in the right circumstance.
So let's say, somebody is inalcohol withdrawal which can
last for several days.
We don't want a benzodiazepinethat's short-acting because when
it wears off we don't want abenzodiazepine that's
short-acting because when itwears off they're going to be in
withdrawal again.
So we usually use long-actingbenzodiazepines like diazepam or
(05:11):
chlorodiazepoxide to managewithdrawal, because they are
long-acting.
The other thing is traditionallywe used to think of
benzodiazepines as useful foranxiety, and when people are
anxious they want to feel betterquickly.
So we would use a fast onsetbenzodiazepine.
I'll talk quite a bit in detailabout how using benzodiazepines
(05:33):
for anxiety is really notconsidered good medicine anymore
, and so we really don't usealprazolam or clonazepam to
manage anxiety.
But you can see here that,based on how they work, because
they're fast acting, that waswhy they were chosen.
Now, as you can see, one, two,three, four, five, six, seven,
(05:53):
eight, nine, 10, 11, 12, 13, 14.
This chart has 14 differentbenzodiazepines.
The big four are the ones thatdoctors use the most and I'm
gonna try to use generic names.
I may slip up a little bit, butthere's diazepam, also known as
Valium.
There's lorazepam, also knownas Ativan, and there's
(06:14):
clonazepam, also known asKlonopin, and there's Alprazolam
, known as Xanax.
Those four medications are theones that are most commonly
prescribed in the outpatientsetting.
We do use some other ones inthe hospital, but again, these
are the big four that you'remostly going to see when
someone's getting a prescriptionfor them from a doctor.
(06:35):
Now, the other thing tounderstand about benzodiazepines
is that they are different intheir potency, and again we're
going to focus on the big fourdiazepam, clonazepam, alprazolam
and lorazepam.
And you can see they aredifferent in their potency.
So I usually, when I'm gettingpeople off of benzodiazepines,
(06:55):
convert everything to diazepam,kind of like how with opiates we
convert everything to morphineto understand their relative
potencies.
So alprazolam and clonazepamare 10 times stronger than
diazepam and lorazepam is fivetimes stronger than diazepam.
And what happens is people gettold oh, don't worry, you're
(07:17):
just on a milligram ofclonazepam and it's no big deal.
One milligram doesn't soundlike a lot, but when we actually
look at the potency ofbenzodiazepines because
clonazepam and alprazolam are sopotent people's tolerance and
dependence goes up fairlyquickly, even though it seems
like a small dosage.
And we'll talk about what I dowhen I get people off of
(07:40):
benzodiazepines.
Now, the reason I findbenzodiazepines so frustrating
is, like other medications andsubstances when people take them
chronically, the brain changesand we see the same things we
see with other substances.
They get tolerance where theyneed more to feel the same
(08:01):
effects.
They get dependence, so theyfeel sick or go into withdrawal
when they stop.
But there's actually more tothe story, specifically around
benzodiazepine use and one of mypatients I just talked to him
last night.
He is completely miserable aswe taper him off of
benzodiazepines and he actuallytaught me about this condition,
(08:24):
which is called BIND B-I-N-Dbenzodiazepine-induced
neurological dysfunction, andthis is why I was saying that we
used to prescribe them prettyregularly for anxiety.
But what we're learning isthey're not benign long-term.
So benzodiazepine-inducedneurological dysfunction
(08:45):
involves a lot of differentsymptoms that people get when
they're on benzodiazepineschronically and it's the worst
as they try to taper off ofbenzodiazepines.
Symptoms can include anxiety,fear, poor sleeping,
palpitations, nerve sensations,and it can be really
debilitating.
It can interfere withrelationships, work,
(09:07):
interpersonal functioning, and Ididn't actually know what this
was originally, but I would getreferred all of these patients
to me that were on chronicbenzodiazepines when their
physician retired or said oops,I've had you on Alprazolam for
five years.
I don't think it's a good ideaanymore and I just couldn't
(09:29):
figure out why people had noability to regulate their
emotions once they were onchronic benzodiazepines.
And I had come up with my ownterm they seem so emotionally
fragile that I called itbenzodiazepine-induced emotional
fragility.
And it turns out that'sactually not just my observation
(09:53):
, but that is something that weare now seeing is a side effect
of long-term benzodiazepine use,and I'm going to call it BIND
just for simplicity's sake as wego forward.
And again, that'sbenzodiazepine-induced
neurological dysfunction, andwe'll talk about why it makes
getting off of benzodiazepinesso difficult.
Now, as I mentioned, what wewere seeing with benzodiazepines
(10:17):
is people just were so unableto manage their emotions once
they were on chronicbenzodiazepines and in part,
that's a little bit about howaddiction works in general.
Right, I ask my patients whatdoes alcohol do for you?
Oh well, I got beat up horriblyas a child by my stepdad, and
(10:39):
when I drink alcohol, I don'thave to remember it.
I use it to numb out.
And so, in addition to theunique issues that
benzodiazepines cause in termsof changing our brain function,
long-term a benzodiazepineaddiction, or chronic
benzodiazepine use, is like anyother addiction.
People learn that the substanceis the only way that they can
(11:01):
manage anything, and that's partof what plays in to why it's so
hard to get people off of.
Benzodiazepines is, forgive me,they're very effective at
acting like a downer and calmingpeople down, but then people
don't actually ever learn how tomanage anxiety and I feel so
bad.
I have so many patients thathave been on benzos for longer
(11:22):
than I've been alive and they'rehorribly anxious and they don't
know how to manage it and theirdoctor never referred them for
mental health services and theirdoctor just kept giving them
more benzodiazepines.
It's actually really sad.
So let's go through someclinical cases and you can start
to see what this actually lookslike when someone comes to me
(11:43):
and they've been onbenzodiazepines for a long
period of time.
So this is my first case.
This is a 45-year-old femalewho came to my clinic and she
wanted to get off of clonazepam.
So she had a history of cancerand her oncologist started her
on benzodiazepines because shewas very anxious while she was
getting her cancer treatment.
(12:03):
And because she was onclonazepam chronically, her
brain adapted to it.
She developed tolerance and heroncologist just kept increasing
the dose of her clonazepam andso on my very first visit with
her, she was on two milligramsof clonazepam three times daily.
That's a total again, of sixmilligrams a day.
(12:25):
And she kept telling me like,oh, it's not that bad, it's only
six milligrams.
And I had to show her that it'sa really high dose.
She's on the equivalent of 60milligrams of diazepam or Valium
a day and insurance won'tactually cover that high of a
dose of diazepam.
(12:45):
It's felt to be unsafe.
And what was so challengingduring this visit is she
complained the entire visitabout how anxious she was and I
remember thinking like what'seven the point of being on
clonazepam?
She's just anxious and now wehave to worry about withdrawal.
So we're going to put a pin inher case and we're going to come
(13:09):
back to it because we need totalk about why we have to be
really careful when we getpeople off of benzodiazepines.
So you probably all know, aswe've talked about various
substances, that usuallysubstances have a withdrawal
syndrome.
Alcohol withdrawal we've talkedabout.
People get shaky, they getrestless, they can have seizures
(13:30):
.
Opiate withdrawal people havenausea and vomiting and diarrhea
.
They get restless.
Benzodiazepines are a downer andthe way I look at it is if the
drug takes you down, thewithdrawal syndrome is the
opposite You're up and soessentially what we see is
because the benzodiazepines actas a sedative, withdrawal
(13:52):
involves the opposite.
So mild withdrawal would justbe anxiety or insomnia or
restlessness.
But as people are on higherdoses and the withdrawal gets
worse, it can be very number oneunpleasant and number two
life-threatening.
So moderate withdrawal peopleget a lot more somatic symptoms
(14:14):
muscle tension, sweating,sensitivity to light and sound,
and they can also get somepsychiatric symptoms.
Beyond anxiety and insomnia.
They can get what's calleddepersonalization, where they
feel like they're having anout-of-body experience.
It can mess what's calleddepersonalization, where they
feel like they're having anout-of-body experience.
It can mess with their mood andthen again, because it's a
downer, you get some otherthings that come up, like you
can get a fast heart rate orpalpitations.
(14:36):
And what we really worry aboutis severe benzodiazepine
withdrawal.
People will seize, they willget delirious, where they get
acutely confused and then theycan even begin to hallucinate,
where they get psychosis.
And if any of you have heard ofdelirium tremens, that is the
absolute most severe form ofalcohol withdrawal and really
(14:59):
bad benzodiazepine withdrawalcan look like that and it can
put people in the intensive careunit.
We also need to specificallydiscuss seizures as it pertains
to benzodiazepine withdrawal.
Now, as I mentioned, weactually treat seizures with
benzodiazepines.
So let's say somebody hasepilepsy and 911 gets called
(15:23):
because they're having a seizure.
The paramedics will often givea dose of benzodiazepine to
terminate the seizure and it isa known side effect of coming
off of benzodiazepines that youcan get seizures.
Essentially, the way to thinkof it is because they're a
downer.
They turn down brain activityand as people are coming off of
(15:45):
it, the brain activity goes upand eventually the brain
activity can.
And as people are coming off ofit, the brain activity goes up
and eventually the brainactivity can get so intense that
a seizure gets triggered.
And with alcohol withdrawal,people only are at risk for
seizures within like the firstcouple of days of coming off of
alcohol.
Benzos are different.
People can randomly have aseizure for months as they're
coming off of benzodiazepinesand they might even, let's say,
(16:08):
take their last dose ofbenzodiazepine in July.
They could have a seizurerelated to benzosensation in
November or December, and it'sreally unfortunate because it
can be really unpredictable wehave to worry about.
Is it epilepsy?
Is it just coming off of benzos?
And the highest risk for aseizure coming off of
(16:28):
benzodiazepines is when someoneabruptly stops, and so usually
we put people on a long, slowtaper to try to get them off of
benzodiazepines safely.
But even then you can still getseizures when you're doing it
carefully and slowly with ataper, when you're doing it
carefully and slowly with ataper.
(16:49):
Okay, so I've been mostlytalking about people getting
benzodiazepines from a doctor,getting them prescribed.
We've talked about dependence,we've talked about bind, we've
talked about tolerance, we'vetalked about withdrawal.
Can you get addicted tobenzodiazepines?
And I think you all know theanswer is yes, and so you can
also get a benzodiazepine usedisorder.
(17:11):
And again, just to make sure weunderstand everything, anyone
who is prescribedbenzodiazepines regularly will
develop tolerance and dependenceand go through withdrawal.
A use disorder is an addiction.
It's the psychologicalphenomenon of cravings,
compulsive use and using despiteconsequences, and it's the same
(17:35):
criteria we use to diagnose anyaddiction.
There are 11 of them.
You can see them on the screen.
You're using more or for longerthan you wanted to.
You've tried to cut down.
You spend a lot of time tryingto get it.
Cravings for benzodiazepines.
Because of your use, you do notfulfill your major role
obligations.
(17:55):
You continue to use despitesocial or interpersonal problems
.
You're giving up hobbies andother activities.
You use when it's physicallydangerous.
You use despite havingpsychological harm to your body
and then, as we've talked about,because people tend to get
dependent because they're usingit so frequently, we also see
tolerance and withdrawal.
(18:16):
So, yes, we see, unfortunately,quite a few patients with
benzodiazepine use disorder inour practice.
Disorder in our practice.
Now, how do we treatbenzodiazepine addiction?
I'm going to try to be funnyhere.
The great news is we haveincredibly effective medications
for benzodiazepine addiction.
(18:37):
Kind of like we have methadonefor opioids we have methabenzone
, and like we have suboxone foropioids we have benzoboxone.
I'm completely kidding.
There are no effectivemedications to treat
benzodiazepine addiction.
It's horribly frustrating.
We don't have a methadone or asuboxone for benzodiazepines.
(19:01):
All we can really do is getpeople into counseling.
They might need to go toresidential and we're going to
want to get them to mutualsupport groups and then we just
very slowly wean them off ofbenzos.
Having discussed this with anumber of other addiction
medicine doctors, we all prettymuch agree that the hardest
(19:23):
addiction to treat isbenzodiazepines.
It's the most frustratingproblem I have as an addiction
medicine doctor.
Now we've talked about the factthat when people get dependent
on benzos whether it'sprescribed by a doctor or it's
because of their benzodiazepineuse disorder we have to get them
(19:44):
off of benzodiazepines safely.
How do we do this?
It's really weaning them off ofit over several months.
What I like to do, as Imentioned, is I put them on a
long-acting benzodiazepines mypreference is diazepam because
it's long-acting and if theymiss a dose they're not going to
(20:04):
be in really bad withdrawal andthen we just start dropping the
dose and it takes time.
So let's say somebody is buyingAlprazolam on the street and
they're taking two 2-milligramAlprazolam bars a day.
I'm going to convert so it's 10to 1.
So 4 milligrams of Alprazolamis going to be the same as 40
(20:26):
milligrams of diazepam.
I'm going to start them on 40milligrams of diazepam, let them
equilibrate and then I'm goingto drop the dose by about 10%
every few weeks.
So that's probably going tolook like something where we'd
go from 40 to 35, and then to 30, and then down to 25, etc.
And actually at the end of thetaper we might even go even
(20:47):
slower, like below 10 milligrams, we might drop by 2 milligrams.
So it's a very time-consumingprocess and I've got some more
cases where I can show you justhow long this takes.
Okay, so back to case one.
So this was my 45-year-oldpatient that was put on
clonazepam by her oncologist.
How has it been going?
(21:07):
Well, I've been seeing her forover a year and I've gotten her
down from six milligrams ofclonazepam a day to three and a
half milligrams a day.
I haven't even gotten 50% ofthe dose down yet, and the
reason why is she has horribleanxiety and insomnia that the
benzos have been masking foryears, and the problem is the
(21:30):
benzo didn't help anything, itjust masked it.
And one of the things that we'velearned and this may be bind, I
think we're still figuring itout is when people are coming
off of benzos, the originalsymptoms that the benzos were
prescribed to treat come back,even worse than before they were
on benzos.
So we call it rebound anxietyor rebound insomnia and so, as
(21:56):
we've brought her dose down,every time we dose drop she
can't sleep and she's even moreanxious than her usual.
And I got to be honest.
It looks really, reallyunpleasant to have to go through
this.
And what I'm also trying to dois add in non-addictive
medications to try to make thetapering less uncomfortable and
(22:19):
to treat those rebound symptomsof anxiety and insomnia.
So I have her on gabapentin totry to help with anxiety and
restlessness.
She gets a lot of musclesymptoms, so I have her on
tizanidine, which is anon-addictive muscle relaxant,
and then we've tried somedifferent non-addictive sleep
medications and I'll probably bedoing this for another six to
(22:41):
nine months with her if it goeswell.
She has BIND.
She does not have a lot ofability to manage negative
emotions.
I'm trying to get her into atherapist.
It's really been challenging.
Okay.
Case two this is a 40-year-oldmale who came to the clinic and
(23:02):
he asked for help with multiplesubstances.
He used alcohol, cannabis,opioids and benzodiazepines.
We were able to get him onSuboxone to manage his opioids
and then he went to residentialand in residential we put him on
what we felt to be theequivalent dose of the benzos he
was getting on the street andthat was 60 milligrams of
diazepam a day and we startedvery slowly tapering him down.
(23:25):
I initially started droppinghis dose by about five
milligrams every two weeks.
I've been seeing him for 18months and he's still on
benzodiazepines and same thing.
He gets all these reboundsymptoms, insomnia, anxiety, and
he bargains with me every timeI tell him it's time to drop.
(23:46):
No doc, please, please, justanother two, three weeks and the
other addiction doctor and I inthe practice are actually going
to probably switch to doing aprotocolized taper where people
know what they're going to getand we don't have this like
please, can I drop the dose nexttime?
Because people really feelmiserable as they come off of
(24:06):
benzodiazepines and it's areally difficult question.
If I push them too hard, will Icause a relapse?
If I push them too hard, arethey gonna develop some
psychosis or have debilitatinganxiety and have to be
hospitalized in the mentalhealth unit?
There's not a good answer onwhat to do with this.
(24:27):
The American Society ofAddiction Medicine just released
some guidelines on benzotapering which, I will admit, I
am behind.
I haven't read them and I'mactually gonna interview a
psychiatrist on my podcast laterthis year to give some advice
on how to do this better.
I'm just trying to really keeppeople from relapse and keep
them engaged in treatment and,to this gentleman's credit, he's
(24:49):
been working hard.
We've dropped his dose.
We're almost down to zero.
I anticipate that we'reprobably going to get him off of
benzos in the next severalmonths, but it's been really
challenging.
Okay, so I think you guys knowthe answer to this question
based on what I've been saying.
But should we be usingbenzodiazepines for anxiety?
(25:10):
And I have to say what I wastaught in medical school is
anxiety equals benzos.
When people are anxious, givethem benzos.
And I remember, as a new doctorout of my residency training,
people would come into the ERfor anxiety attacks and we'd
send them home with like 20lorazepam.
And, based on what I know now,I personally believe this is my
(25:33):
opinion that it is medicalmalpractice to treat anxiety
with benzodiazepines because, asI've pointed out to you, it is
so miserable for the patient toget off of them and there's no
end game.
It's not like going to therapyand learning coping skills.
It's just basically taking asedative to not feel anxious.
So, in my humble opinion, Ithink using benzodiazepines for
(25:58):
anxiety is wrong.
Now, that being said, I am not apsychiatrist, and if a
psychiatrist wants to managetheir patient on benzodiazepines
, great.
They have the knowledge of whatthe potential consequences are.
And if somebody has reallysevere mental illness, like
schizophrenia or bipolar, andthey need benzodiazepines and
(26:20):
that psychiatrist thinks it'sthe right decision, I say go for
it.
But in my practice, given whatI see in the world of addiction,
putting people on benzos justresults in them being completely
miserable when they try totaper off of them.
And my heart goes out to mypatients because it's so
uncomfortable to watch.
They just feel so bad all thetime.
I was actually trying to find atext message.
(26:42):
One of my patients actually theone that taught me about BIND
will send me messages of like DrGrover, this is so bad, why do
doctors prescribe this?
And he's really trying, andit's just I'm trying my best to
support him.
Okay, case number three A65-year-old male was referred to
(27:03):
our clinic because he was onchronic alprazolam and his
doctor retired and his newdoctor didn't want to prescribe
them for him because she felt itwas inappropriate.
And so the patient had ahistory of anxiety and his
primary care doctor had put himon Alprazolam at four milligrams
a day.
Now you all know that's afairly high dose and what's
(27:24):
amazing is this primary caredoctor had been giving this
patient Alprazolam for years andhad never referred him for any
mental health services.
So he comes to me, I believe,health services.
So he comes to me.
I believe, given what I'mlecturing you about, that he has
BIND and he has panic disorderand an anxiety disorder.
(27:45):
I actually think he probablyhas some PTSD because he had a
bad accident that led to hisanxiety and panic disorder
starting in the first place.
And he was pretty clear.
I'm going to use the brand namehere Xanax is the only thing
that helps my anxiety.
I don't want anything else.
I've tried to refer him fortherapy services.
He declines, and I think this iswhere we see that chronic
(28:08):
benzodiazepine use is not asbenign as we were led to believe
years ago.
And you know his doctor 20years ago was probably doing
what we thought was goodmedicine then.
In fact, I just want to remindyou, in medical school I was
taught to treat benzos withanxiety and we didn't understand
how chronic benzo use couldlead to profound changes in the
(28:29):
brain.
My case continues His anxietythanks to his chronic benzo use
and bind has only worsenedbecause of the years he's been
on Alprazolam and the Alprazolamdidn't help his anxiety.
And I always try to tell himthis, you know, I'll tell him
like, if it really helped youranxiety, why are you on them 20
(28:51):
years later?
And he really will not workwith me on this.
And I keep trying to try to gethim some services and let's try
a non-addictive med.
He did, to his credit, accept anon-addictive sleep aid, but at
a certain point I'm going tohave to tell him like, look, I
think this is wrong, I'm goingto have to have you see someone
(29:13):
else or have you see apsychiatrist.
I just feel like I'm makingyour anxiety worse and it's
going to be a difficultconversation with him that I'm
going to have to have and again,I feel so bad for him.
Anxiety is really, reallyuncomfortable.
He actually does not have abenzodiazepine use disorder.
He is not addicted, he does notcrave it, he does not misuse it
, but because he's been onbenzos for so long, he has
(29:36):
tolerance, he is dependent andhe has benzodiazepine-induced
neurological dysfunction and hisanxiety has never been treated.
It's very frustrating.
Okay, as I mentioned, we talkedabout rebound symptoms.
Rebound symptoms are the ideathat when people try to come off
(29:56):
of benzodiazepines, thesymptoms that they were
originally treated for emergeworse than before.
And he gets this a lot.
His anxiety gets worse overtime.
I've been seeing him for abouta year.
I can tell, even in the yearthat I've been seeing him, that
his anxiety only continues toworsen.
And a little bit of levity here,this was a meme.
(30:17):
I don't always make baddecisions, but when I do, I make
sure to repeat them over andover again, and this is a lot of
what we see in patients thathave been managed with
benzodiazepines for years andyears and years is, to some
extent, no one really knows whatto do with them, except just to
try to continue to taper off ofthem, get them on better, safer
medications.
But some of these patients havebeen on benzodiazepines for
(30:39):
like 60 years and the changes intheir brains are just profound.
Okay, so what do I do?
In my practice, a single dose ofa benzodiazepine before a
medical procedure is not mypreferred medication.
But if someone hasclaustrophobia and they need to
(31:04):
get an MRI, a single dose ofdiazepam isn't really going to
hurt anything.
Given how much frustrationbenzodiazepines cause my
patients and I I just I reallystruggle to even sign the
prescription if I have to writethem.
I've had a number of patientsthat were put on benzodiazepines
before they came to me and asI'm working on tapering with
them, I'll continue them ifthey're not dependent on just a
(31:26):
few doses a week.
So I had one patient come to me.
Her primary care doctor put heron lorazepam for anxiety and she
came to me basically saying Iwant to get off of them but I
don't know what to do with myanxiety.
And she is amazing.
She has worked so hard on heranxiety, believe it or not.
She went on YouTube and watchedvideo after video on how to
(31:49):
treat anxiety and she on her own, along with her therapist, has
come up with all these greatcoping strategies.
She'll use really cold water onher neck to distract her when
she's got a really bad anxietyattack and she's now completely
benzodiazepine free.
But there was a point where Iwas only giving her basically
four doses of lorazepam a week.
As she was building her skills,I needed her to start triaging
(32:13):
her anxiety.
Oh, I'm anxious, but it's onlya little bit.
I'm going to do some breathingexercises or I'm going to
meditate.
But when she was just losing itshe had a little bit of
lorazepam that she could take aswe were building her mental
health skill set.
And then, unfortunately for thechronic benzodiazepine patients,
it's just tapering over severalmonths and it's a really
(32:33):
frustrating problem.
Again, if one of my patientscomes to me and says, dr Grover,
I want you to get me onSuboxone for my opioid use
disorder and they've got apsychiatrist who's managing them
on benzos, that's between themand the other doctor.
If they want me to take it over, I tell them the only way I can
offer you benzodiazepines is totaper you off of them.
(32:54):
And I've had patients fire me.
They don't want to come off ofthem.
And what's really frustratingfor me as a doctor is, let's say
, somebody is sober and theirdrug of choice is opiates.
When they have a slip-up we canstabilize them on suboxone or
methadone or, if it's alcohol,we'll do a quick course of
medications to manage theirwithdrawal.
(33:14):
Getting people off of benzostakes so long and it's so
uncomfortable for the patient.
If people relapse and they tellme they relapse on benzos, I
just know it's going to bemonths of work for the patient
and I.
And then again, just becauseweaning involves dropping the
dose.
People feel benzodiazepinewithdrawal pretty regularly
throughout the weaning process.
It's a really frustratingproblem.
(33:38):
Okay, I don't know if anyonegets my joke from Saturday Night
Live, but let's stop here andwe will do some questions Before
we wrap up.
A huge thank you to the MontageHealth Foundation for backing
my mission to create fun,engaging education on addiction,
and a shout out to thenonprofit Central Coast Overdose
(33:59):
Prevention for teaming up withme on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(34:19):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
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