Addiction to Anti-anxiety Medication: Benzodiazepines
Guest: Dr. Robert Mallin – Family Medicine
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Robert Mallin, Associate Professor of Family Medicine, here at MUSC, and an expert in the area of substance abuse. Dr. Mallin, one of the hot topics, rather controversial topics, is in the use of anti-anxiety medications that are called benzodiazepines, which are used for anxiety, used for sleep, but also have some abuse potential. Just to clarify, what are some of the common medications in this category?
Dr. Robert Mallin: We’re talking about drugs like Xanax, or Alprazolam, which is the generic name of it, Valium, which the generic is Diazepam, Atavan, which Lorazepam is the generic name, and Klonopin, which Clonazepam is the generic name. Those are probably the most commonly used medications today like that.
Dr. Linda Austin: How about some of the sleep medications?
Dr. Robert Mallin: Well, the ones that are most popular right now, like Ambien and Lunesta, and Sonata, these are not actually benzodiazepines, but they work in the brain in the very same areas, so they end up having the same risks associated with them.
Dr. Linda Austin: And they can, potentially, be abused?
Dr. Robert Mallin: They certainly can.
Dr. Linda Austin: Let’s talk about some definitions. When you think about addiction to these agents, what are the criteria for addiction, as opposed to just long-term appropriate use of them?
Dr. Robert Mallin: Well, I think, like any addiction, whether it’s to alcohol or benzodiazepines, or narcotics, what you’re, most importantly, looking for is a loss of control over use. The patient begins to use more and more of the substance and is unable to control that use, typically causing some pretty significant consequences, and they continue to use despite these consequences. I think that’s the primary issue with addiction, as opposed to physical dependence, which, if you use these medicines long enough, you will experience physical dependence, which simply means that if you stop them suddenly, you will have some withdrawal symptoms.
Dr. Linda Austin: So, a bad sign, then, if somebody needs to take more and more of these medications to get the same effect?
Dr. Robert Mallin: Well, that would be tolerance, rapidly increasing tolerance. And, particularly for benzodiazepines, when it increases over what we generally consider the abnormal dosing of these drugs, that’s a red flag, yes.
Dr. Linda Austin: How addictive are these medications, let’s say, compared to alcohol?
Dr. Robert Mallin: What a great question? I tend to think of them as being the same. And I do that because, in the brain, they both work at what we call the gabba receptors, and they’re both gabba agonists, meaning, they increase the effect of gabba -aminobutyric acid, which is the name of the receptor. The truth is, though, that when you talk about how addictive a medicine is, usually what you’re talking about is its reinforcing aspect. And the reinforcing aspect of a medicine means, how much does this medicine make you want to have another dose? That’s usually most associated with the rapidity of which the blood level goes up.
I’ll give you an example. In terms of benzodiazepines, the drug Alprazolam is a very short-acting benzodiazepine and, consequently, the blood level goes up very quickly and, hence, it’s a pretty reinforcing medication, generally more abused than the longer-acting drugs, like Diazepam, or more medium-acting drugs like Atavan.
The way to look at this in terms of alcohol would be, you may have heard about the rage, particularly over in Britain, and somewhat over here, of people aerosolizing alcohol and breathing it in, in a mask. This became a big rage for a very short period of time, until they realized that people were getting drunk really fast from this process, because, again, it increased the blood level of alcohol very quickly. And this is the reinforcing business that I’m talking about. And that’s what it means when people say, is this medicine more addictive than another medicine? The truth is that it doesn’t have anything to do with that, because it’s the brain that’s addicted. So, for a patient who doesn’t have the disease of addiction, it really doesn’t matter how reinforcing the medication is, they don’t ever lose control over their use.
Dr. Linda Austin: As a psychiatrist, I prescribe these medications a lot, and I would agree with you that it’s about like alcohol. You know, just as most people can drink alcohol and not become alcoholic, there are some people who cannot tolerate it all without becoming addicted in a pretty significant way. And that seems to be true, also, with these medications.
Now, you mentioned that rapidity, especially for Xanax or Alprazolam, there is now a long-acting form of Alprazolam, Alprazolam XRs, Xanax XR, do you think that is equally likely to cause that problem?
Dr. Robert Mallin: I think it’s probably less likely to cause difficulty. But, again, the real issue, in my mind, is the patient that’s taking it, rather than the medication. So, the longer-acting drug has a tendency to cause less rebound anxiety and rebound symptoms associated with it, which I think is a good thing. I think it’s less likely to be abused than the shorter-acting form, and it’s true for, pretty much, any medication.
Dr. Linda Austin: I had cause, recently, to look at a lot of literature on this topic. I was actually debating the issue of the addictive potential of these medications with some doctors who took a strong position, saying that it was very addictive. And all the studies that I could put my hands on showed that, for bona fide anxiety disordered patients, over a period of several months, actually, the use of these medications goes down, that as they use them regularly and become calmer, knowing that they have a safety net there if they should need it, they seem to use it less and less, not more and more, which I think is very reassuring.
I also had the sense that we are, with anxiety disorders, where we used to be with depression, that it was often underrecognized and undertreated. That’s not so much true for depression. I think, often, physicians, and other people, don’t appreciate how debilitating anxiety can be.
Dr. Robert Mallin: I think you’re absolutely right. I think that these are very safe medications in patients who don’t have addiction. In patients that do have addiction, just like every other substance that can be addictive, it can be a dangerous medication to take.
Dr. Linda Austin: And then that becomes a difficult issue because there’s a population of people who become addicted to alcohol because they have a social anxiety disorder. That really presents a conundrum to the doctor.
Dr. Robert Mallin: Or, as you pointed out, many people who have alcoholism have anxiety disorders. And the question of how best to manage them becomes a real issue since we know that benzodiazepines increase the same area of the brain, they have the same effect on the brain as alcohol and, consequently, the risk of relapse is real. It can be a real struggle sometimes as to what is the best way to manage that.
Dr. Linda Austin: Dr. Mallin, thanks so much for talking with us today.
Dr. Robert Mallin: Thank you.
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