Benzodiazepines are a class of drugs that work in the central nervous system and act on specific brain receptors. Benzodiazepines attach to receptors in the brain and make the nerves in the brain less sensitive to stimulation, causing a calming effect. Benzodiazepines are commonly abused drugs but are also used to treat alcohol withdrawal, anxiety, used as muscle relaxants, panic disorders, and seizures. Benzodiazepine use is problematic and does lead to overdose and death. Within Canada, benzodiazepines are a controlled substance under Schedule IV of the Controlled Drugs and Substances Act.
Benzodiazepines generally share the same pharmacological properties as sedatives, hypnotics, skeletal muscle relaxants, and anticonvulsants. When benzodiazepines are prescribed for medical purposes, there are significant risks and problems caused by cognitive impairment and paradoxical effects like aggression or behavioural disinhibition. Long-term use of benzodiazepines causes decreasing effectiveness, physical dependence, benzodiazepines withdrawal syndrome, and an increased risk of dementia and cancer.
How do Benzodiazepines Affect the Body?
According to Health Canada, the most common short-term effects of benzos include dizziness, confusion, drowsiness, constipation, memory loss, slurred speech, muscle weakness, and loss of coordination and balance. It is also not uncommon for the user to experience delusions, hallucinations, skin reactions, euphoria, agitation, and aggressiveness. Benzodiazepines affect the body in different ways, especially when the drug is abused.
Like other drugs, Benzos create a pleasure reward loop within the brain, causing a pleasurable sensation for users by increasing dopamine levels in the brain. According to an article published by the National Institute on Drug Abuse, the pleasurable sensations that make addictive drugs addictive occur when dopamine levels in the brain reward area surge. The author suggests that "when benzodiazepines limit the interneurons restraining influence, the dopamine-producing neurons release more dopamine." Overall, addictive drugs cause long-lasting changes in the reward system.
Additionally, long-term use causes tolerance, dependence, and withdrawal symptoms, even if the drug was not misused. The pleasure reward cycle caused by the drugs creates a dependence. Stopping the use of these drugs suddenly results in withdrawal symptoms that become difficult to manage without proper help. Also, these drugs cause cognitive problems. According to research, in studies of short and long-acting benzodiazepines, the drugs consistently induced non-amnestic deficits in attention and information processing.
Other research has shown that long-term benzodiazepine users were significantly impaired. Moderate to large weighted effect sizes were found for all cognitive domains, per evaluations done to determine the long-term effects on cognitive functioning. There are significant risks when misusing or using benzodiazepines. Long-term Medical detox programs and substance abuse treatment are effective solutions to help someone stop using the drug safely and become rehabilitated.
What Do Benzodiazepines Look Like?
There are numerous different kinds of Benzodiazepines; here are a few examples:
Common Street Names and Illegal Use of Benzodiazepines in Canada
Benzodiazepines are a sedative and prescribed to treat varying issues, yet they are addictive and commonly abused. Some of the common brand names included: Xanax, Valium, Klonopin, Ativan, Restoril, and Librium. The common street names are benzos, blues, candy, chill pills, french fries, downers, sleeping pills, totem poles, tranks, and Z bars. Under the Controlled Drugs and Substances Act of Canada, benzodiazepines are listed as a Schedule IV substance. Offenders found trafficking Schedule IV controlled substances are liable for either an indictable offense with a maximum penalty of three years incarceration or a summary offence with a maximum penalty of 12 months incarceration.
According to the Drug Enforcement Administration, benzodiazepines are a drug that produces central nervous system depression. Someone abusing the drug obtains them by getting prescriptions filled from multiple doctors, forging prescriptions, or buying diverted pharmaceutical products on the illicit market. Typically, benzodiazepines that have a rapid onset are abused to produce a euphoric effect. The abuse of these drugs is often associated with polysubstance use. For example, diazepam and alprazolam are used in combination with methadone to potentiate methadone's euphoric effects.
Additionally, it is not uncommon for cocaine addicts to use benzodiazepines to relieve the side effects of binge cocaine use. The drug is also used to augment the side effects of alcohol withdrawal and has been used to facilitate sexual assault. According to Statista. 12,248 daily doses of benzodiazepines were prescribed per day per 1000 population in Canada during 2017. The province of New Brunswick had the highest number of daily doses, followed by Newfoundland and Labrador and Prince Edward Island.
The History of Benzodiazepines in Canada
In 1955 a chemist named Leo Sternbach first identified the first benzodiazepine, chlordiazepoxide. By 1960 the drug was marketed as Librium, followed by Valium in 1963. By the mid to late 1970s, benzodiazepines topped all most frequently prescribed lists. Unfortunately, it was not until the 1980s; clinicians noticed the spectre of abuse and dependence despite early warning signs 15 to 20 years prior.
According to a ten-year follow-up population-based study from Canada, it was found that despite increased awareness and warnings regarding the risks associated with long-term use of benzodiazepines, the rates of inappropriate prescribing had changed very little. Between 1996 and 2006, approximately 8.4% of the population used the drugs, and 3.5% were doing so long-term. A comparison study of benzodiazepine use in Canada and Australia found that usage in Canada was over twice that of Australia.
According to the journal of the College of Family Physicians of Canada, soon after, benzodiazepines were introduced in the 1960s as a safer alternative to other hypnotics, and numerous adverse side effects were reported. The side effects included: hangovers, memory impairment, emotional blunting, tolerance, dependency, and increased risk of falling and being involved in motor vehicle accidents. Overall, benzodiazepine use has not decreased; some studies have found that elderly people had a higher tendency toward long-term use than younger people. Other studies found that continued use was often attributed to difficulties associated with stopping.
According to the Canadian Centre on Substance Use and Addiction, the use of prescription sedatives among the Canadian population has remained stable since 2013. The prevalence of sedative use is highest among older adults and among women. Between 2016 and 2017, the non-medical use of sedatives among high school students doubled when compared to 2014-2015. Within Canada, most prescription sedatives are classified as Schedule IV drugs under the Controlled Drugs and Substances Act. The use of these drugs is only legal when licensed medical practitioners prescribe them.
What are the Short-Term and Long-Term Effects of Benzodiazepines?
There are significant risks associated with using benzodiazepines. Initially, long-term use leads to developing a tolerance to the drug. Combining benzos with other drugs increases the risk of overdose. However, even short-term use for a medical reason can still cause adverse effects.
According to the same Health Canada page as previously mentioned, the most common short-term effects are as follows:
- Loss of coordination and balance
- Memory loss
- Slurred speech
- Muscle weakness
The most common long-term effects, per Health Canada, are as follows:
- Physical dependence and addiction
- Problems learning and or concentrating
Most sedatives increase the neurotransmitter gamma-aminobutyric acid activity that results in decreased brain activity—central nervous system depressants slow brain activity through different means. Benzodiazepines are prescribed at low to moderate doses for medical reasons. However, it is not uncommon for larger doses to be prescribed to treat insomnia, emotional distress, yet it causes severe drowsiness and impaired coordination. Some of the initial short-term effects are slurred speech, impaired coordination, decreased heart rate and blood pressure, and impaired judgment.
Long-term use causes chronic fatigue, vision problems, mood swings, aggressive behaviour, slowed reflexes, breathing problems, liver damage, sleep problems, and even sexual dysfunction. Also, long-term use creates tolerance and dependence, leading to dangerous withdrawal symptoms and addiction. According to the British Journal of Medical Practitioners, tolerance is a phenomenon that develops with many chronically used drugs. The body responds to the drug's presence by making adjustments to overcome the effects of the drugs.
However, changes in the brain occur, making certain receptors less responsive, decreasing the drug's effectiveness. As a result, the originally prescribed dose has less effect, and a higher dose is needed to avoid withdrawal. The article points out that dependence has two components: psychological dependence and physiological dependence.
Benzodiazepine Overdose in Canada
When benzodiazepines are taken as directed for medical reasons, the risk of overdose is low. However, the abuse of these drugs increases the risk of overdose, especially when abused with other drugs. Also, long-term use does increase the risk of overdose because of the increased tolerance and dependence.
Benzodiazepines are central nervous system depressants, which affect the brain that controls the heart and respiratory function. When an overdose occurs, these functions slow to dangerous levels, and the biggest danger is slowed breathing. When not enough oxygen reaches the brain, rapid cell death results in coma and brain damage.
In 2019, the CBC reported a spike in overdoses related to opioid-sedative mixes citing information gathered from the Vancouver Coastal Health Authority. The Vancouver Coastal Health issued a warning about the deadly combination with fentanyl and benzodiazepines. Per a 2013 article in the Huffington Post citing data gathered from Health Canada's public database, benzodiazepines continue to be widely used across Canada—approximately four million prescriptions are filled annually in Ontario, for example. However, the Canadian Center on Substance Use and Addiction notes that there are no national estimates on the prevalence of overdose deaths due to sedatives or benzodiazepines.
In 2014, it was estimated that under 800 people died from central nervous system depressants, which was a 13% increase from 2007. Data from British Columbia indicated that between 1996 and 2013, people who inject drugs in Vancouver reported that those using benzodiazepines and opioids were more than twice as likely as those using opioids to fatally overdose. Within Ontario, benzodiazepines were involved in roughly half of all fatal overdoses in 2015.
The signs of a benzodiazepine overdose include the following:
- Slurred speech
- Blurred vision
- Loss of coordination
- Difficulty breathing
According to the Indian Journal of Medical Specialties examining the epidemiology of sedatives-hypnotic overdose in various developed and developing nations—overdoses place a huge economic burden on any country. Moreover, the Canadian Centre on Substance Use Reports that lost productivity is significant attributable harm to sedative use. Also, premature mortality, long-term disability, absenteeism, and impaired performance are ways to lose productivity. The effects of fatal and non-fatal overdoses are felt within many areas of the Canadian economy, specifically within the healthcare system.
Reversing and treating a benzodiazepine overdose begins with contacting emergency services and being as specific as possible when speaking with 911. For example, it is important to provide the person's height, weight, age, and whether they are taking any other drugs, prescribed or not. Medications like Narcan are used to reverse an overdose's effects, but immediate medical attention is needed. According to John Hopkins Medicine, the dosage of benzodiazepine varies depending on the patient and their history of sedative use.
Every brand or benzodiazepine agent has a different relative potency in milligrams. However, exceeding the recommended dose or mixing with other drugs will likely lead to overdose. Generally, peak concentration within the body occurs within one to two hours when absorbed orally. A lethal amount of the drug is different for every person, and there are different contributing factors. Most overdoses occur when benzodiazepines are used with alcohol, opioids, or other prescription drugs.
When someone experiences a non-fatal overdose due to benzodiazepines, it is essential to access treatment. Detox is the first step, and this is typically a medically supervised detox. Stabilization is essential to ensure the proper transition to substance abuse treatment. Rehabilitation then treats the addiction, making it possible for the person to maintain sobriety and live drug-free.
Benzodiazepine Addiction in Canada
Becoming addicted to benzodiazepines is relatively easy. According to the Canadian Centre on Substance Use and Addiction, the prevalence of use with prescription sedatives among the general population was 12% in 2017, which was a one percent increase from 2015. Youth in Canada have the lowest prevalence of prescription sedative use among all Canadians. Among youth aged 15 to 19, the rate of past-year prescription sedative use was 5.1%, yet was higher among adults aged 20 to 24.
The prevalence of past-year use of prescription sedatives among adults in 2017 was 12.6%, which was two times higher than youth. In Canada, older adults have the highest prescription sedative use rate among all Canadians, at 16.5% in 2017. Overall, women in Canada had a higher rate of prescription sedative use compared to men. Among First Nations in Canada, approximately 6.1% reported past-year use of prescription sedatives and 1.3% of First Nations Youth.
Countless benzodiazepine addictions begin with prescriptions that are taken too long or misused. As mentioned above, research has shown when benzodiazepines are used; it causes a surge in dopamine levels, which floods the brain. The sudden strong wave of pleasure becomes rewarding and irresistible. The addictive power of benzodiazepines is similar to opioids and the progression from use, abuse, and addiction occur relatively quickly. Benzodiazepine dependence occurs when the drug user develops a tolerance, experiences withdrawal symptoms, engages in drug-seeking behaviour, and continued use despite harmful effects.
The continued use of benzodiazepines is usually associated with the avoidance of unpleasant withdrawal reactions. Most people that continue using benzos do so to avoid withdrawal symptoms, but long-term use leads to more serious withdrawal symptoms. Benzodiazepine dependence develops with long-term use yet can even occur with low therapeutic doses. Overall, addiction occurs when the individual misuses the drug to avoid cravings and relieve withdrawal symptoms.
Additionally, quitting benzodiazepines is extremely difficult and usually requires medical detox. Some of the signs and symptoms of substance abuse include feelings of having to use drugs regularly, having intense urges, needing more of the drug, taking larger amounts, spending money on the drug, and not meeting obligations and work responsibilities. Also, despite the consequences, continuing to use the drug and doing things to use the drug that an individual would not normally do. Recognizing the signs of drug use is important, like problems at school or work, physical health issues, neglected appearance, changes in behaviour, and money issues.
According to Health Canada, problematic substance use happens when someone uses drugs or alcohol in a harmful way that has negative effects on their health and life. The regular use of benzodiazepines leads to addiction, and overcoming addiction requires well-rounded treatment that involves detox, inpatient rehab, or outpatient treatment.
Benzodiazepine Addiction Treatment in Canada
Treatment for benzodiazepine addiction is necessary when someone is physically dependent and cannot stop taking the drug, or when the individual is addicted to the drug and ignores the consequences of their addiction. Physical dependence for benzodiazepine could be treated through a medically supervised detox under proper medical supervision and withdrawal management. Typically, withdrawal management involves using medication to alleviate and ease withdrawal symptoms. It is important to speak to a medical professional or receive an addiction assessment to determine what treatment methods are needed.
Detox stabilizes the person physically, and it is not uncommon to enter treatment after detox. During detox, an assessment or evaluation may help the client begin treatment if required. The withdrawal symptoms associated with benzodiazepine addiction have the potential to be intense. Typically, detox could last one to two weeks, but this depends on the type of drug and pre-existing medical conditions. The severity of withdrawal depends on the current dose, how long it has been taken, whether more than the recommended dose is used, if other drugs are used, and whether the person is being treated for polydrug use.
Possible withdrawal symptoms include anxiety, insomnia, irritability, restlessness, headaches, sweating, nausea, vomiting, aches and pains, panic attacks, depression, seizures, and delirium. The best way to stop using benzodiazepines is to have the withdrawal symptoms effectively treated and focus on further stabilization. Helpful strategies following detox and withdrawal management are cognitive behavioral therapy, meditation, mindfulness training, exercise, nutritional therapy, and peer support groups. Long-term treatment after withdrawal management or detox depends on the reasons the person became addicted to the drug.
According to Withdrawal Management Services in Canada: The National Treatment Indicators Report—between 2015 and 2016, over 146,000 unique individuals accessed publicly funded specialized substance use treatment services across the different provinces. Most people that accessed treatment services did so for their own problematic substance use. Withdrawal management in the country includes residential and non-residential services. Overall, men accounted for 68% of withdrawal management treatment admissions while women accounted for 31%.
According to the National Treatment Indicators Report for 2016-2018, over 105,000 people accessed publicly funded, community-based substance use treatment services within the different provinces. Most individuals accessing treatment reported any illicit drug as a problem substance. Overall, alcohol was the most frequently reported problem substance by 64% of treatment admissions. Following alcohol, other commonly reported drugs were cocaine and cannabis. Between 2016 and 2018, there was an overall increase of 7% in the number of people reporting cocaine use and a 13% increase in methamphetamine use.
Benzodiazepine Statistics in Canada
Benzodiazepines are central nervous system depressants—this means that these drugs depress or slow down brain activity. These drugs are commonly prescribed for medical reasons but are also abused and misused for the euphoric effects. According to the Canadian Centre on Substance Use and Addiction, prescription sedatives among the Canadian adult population have remained stable since 2013. Overall, the prevalence of prescription sedative use is highest among older adults and is higher among women than men.
Pharmaceutical drug addiction is a common problem for many Canadians, and some addictions begin with prescription drugs that are misused or not taken as directed. According to the 2019 Canadian Pharmaceutical Market Highlights, retail pharmacies dispensed 742.7 million various prescriptions, and combined retail, and hospital purchases increased 6.3% to $30.7 billion. According to the Canadian Institute for Health Information, the overall quantity of benzodiazepines and benzodiazepine related drugs dispensed in Canada declined by 5.9% between 2016 and 2017.
British Columbia and Alberta have the largest decreases in the rate of prescribed benzodiazepines and benzodiazepine related drugs. However, despite lowered prescription rates, benzodiazepine addiction and recreational drug use is a common problem. The older demographic in Canada is particularly affected by benzodiazepine misuse and abuse. According to the Canadian Coalition for Seniors' Mental Health, benzodiazepines are among Canada's most prescribed medications.
There are significant health risks for seniors that are prescribed benzodiazepines. For example, they are more likely to experience drowsiness, clumsiness, falls, fractures, confusion, trouble breathing, and problems driving. Overall, benzodiazepines should be avoided by older adults. In Ontario, during 1998, benzodiazepines were prescribed to 23.2% of Ontario residents aged 65 and older and then declined to 14.9% in 2013.
Terminology Surrounding Benzodiazepines
|Anti-Anxiety Medication||Anxiolytics are medications that are used to treat a health condition called anxiety. Also, these drugs are prescribed to treat insomnia and other health conditions. However, the risk of dependence and or addiction with anti-anxiety medications is high with short-term and long-term use.|
|Benzodiazepines||Sometimes referred to as benzos, these are a class of psychoactive drugs that work in the central nervous system. Benzodiazepines work by blocking the excessive activity of nerves in the brain and other areas within the central nervous system.|
|Central Nervous System Depressants||This is a broad term used to describe drugs that include sedatives, tranquilizers, and hypnotics. CNS depressants slow down brain activity, which is why they are prescribed to treat anxiety, panic, acute stress reactions, and sleep disorders.|
|Over-Sedation||Drowsiness or over-sedation is the most common adverse effect of neuroleptic drugs. However, most people develop tolerance to this effect, yet over-sedation and respiratory depression can have devastating outcomes if not properly treated.|
|Endocrine Effects||Benzodiazepines affect the central control of endocrine function by an action of the hypothalamus or anterior pituitary. Long-term use causes significant adverse effects on this system within the body.|