By Katie Balestra
Special to The Washington Post
Tuesday, June 30, 2009
Stan Starr, a 54-year-old financial consultant, sat in the back of the room filled with blue chairs, quietly tapping his Converse sneakers on the carpet. The 12 steps to recovery, enshrined by Alcoholics Anonymous, were printed in large black letters on a wall. But Starr was there because of a different drug -- a class of prescription medication called benzodiazepines.
Five years ago, he couldn't sleep at night, his heart raced, he had wrenching stomach pains and felt as if his skin were crawling off his bones. He was in the midst of a 2 1/2 -year battle to withdraw from the drug Klonopin, which his psychiatrist had prescribed to him for anxiety. "I went through sheer living hell," he said. "I didn't know if I was going to make it."
Benzodiazepines, often prescribed to manage anxiety, panic and sleep disorders, include Xanax, Ativan, Valium and Klonopin. Originally pushed as an alternative to barbiturates, their use has grown rapidly in the past 30 years. But critics say their long-term effects have gone largely unaddressed. Health professionals and consumers are increasingly recognizing that taking the drugs for more than a few weeks can lead to physical dependence, often ending with a grueling withdrawal.
The benefits of the drugs have been heralded by both physicians and patients. On Askapatient.com, a Web site where consumers can rate medicines, one person wrote in April that Xanax was the "best thing that ever happened to me." Another wrote in March, "This drug saved my life."
In 2008, 85 million prescriptions were filled for the top 20 benzodiazepines, an increase of 10 million over 2004, according to IMS Health, a health-care information company based in Norwalk, Conn. Those getting prescriptions in 2004 included 66,000 veterans suffering from post-traumatic stress disorder, according to a study released by Department of Veterans Affairs physicians last summer.
Worldwide revenue for Xanax rose to $350 million last year, up nearly 50 percent from 2003, according to pharmaceutical company Pfizer's financial reports.
Critics say benzodiazepines are broadly over-prescribed and can have serious side effects. Some patients find themselves on high dosages after a few years because their bodies need more of the drug to get the same effect, according to health experts.
Medical guidebooks say the drugs bind to receptors in the brain and spinal cord, intensifying the effects of the neurotransmitter gamma-aminobutyric acid, or GABA. "So pretty much it kind of tells your brain to slow down," creating a calming effect, said Stephanie Licata, a Harvard Medical School behavioral pharmacologist who studies the medications. In some people, that can lead to memory loss and impaired motor skills.
John Steinberg, a physician and former medical director of the chemical dependency program at the Greater Baltimore Medical Center, estimates that 10 to 20 percent of those taking the drugs for extended periods will have problems with dose escalation and physical dependence. "For a serious side effect, that's a fairly large, significant number," he said. "It is, after all, a devastating and debilitating adverse effect for those who experience it."
Benzodiazepine dependence has received greater attention in Great Britain than in the United States. In 2004, the British government took a stand in limiting prolonged use, issuing advice to all doctors that the drugs should be prescribed only for short periods.
Heather Ashton, a professor of clinical psychopharmacology at Newcastle University in England, who has studied the drugs since the early 1980s, said long-term use also affects one's mental state. "For one thing, which is what people regret most, there is a breakup of family life, because you're in a sort of daze; you don't realize that you're neglecting your children, or not listening to them or forget what they're saying," she said.
Some doctors have been turning to selective serotonin reuptake inhibitors, such as Paxil, to replace benzodiazepines in the treatment of anxiety, although those antidepressants may also produce withdrawal symptoms. Steven Daviss, chairman of psychiatry at the Baltimore Washington Medical Center, said SSRIs are a safer alternative for panic and anxiety disorders, with less risk for dependence and a less dangerous withdrawal.
The ordeal of withdrawing from benzodiazepines can rival that of kicking a heroin habit, according to some who have had success. Abrupt withdrawal can result in hallucinations, seizures and even death, experts say.
Last year, after jail officials in Cleveland denied R&B singer Sean Levert's repeated requests for his Xanax, he hallucinated for hours and ultimately died from the effects of withdrawal, according to the coroner's report cited in court records. His widow sued the corrections center and medical staff. The suit is pending.
Some seeking to withdraw from the drugs have turned to online support groups. Debra Standiford, a nurse who leads a benzodiazepine support site on the Yahoo Web site, said membership has grown to 3,800 people from 200 in 2000, gaining two to three members each day.
For Starr, the financial consultant who attends addiction meetings, his withdrawal from Klonopin was life-altering. He said he started taking the drug in 1996, after experiencing anxiety about a pending divorce. A psychiatrist he saw had recommended the medication. "I was overwhelmed by life at the time," Starr said. "I didn't really feel that mood-altering substances were necessarily the answer to life, but at the time that was my alternative."
Soon after starting to take the drug, Starr's anxiety began to disappear. But over time, it came back, and the medication was not as effective. Six years later, he said, he went to see a new psychiatrist, and she told him he needed to get off Klonopin, that he had become addicted. "It was like a shock to me," he said. Shortly after, Starr made the decision to withdraw and began to taper off the drug. He felt withdrawal symptoms immediately and took an extended leave from work. "It was ripping me apart inside," he said.
After taking his last pill in February 2002, Starr said, "the fireworks started." Over a year and a half, he could sleep for no more than a few hours at a time, his heart raced and he had night sweats. Sometimes he couldn't tell if he was speaking clearly, and he completely withdrew from family and friends.
No one could tell him how long the symptoms would last. "All I saw was horror, and I didn't see any way out," he said. After 2 1/2 years, he started to return to eight hours of sleep.
As benzodiazepines grew in popularity, studies began to document their abuse potential. In 1979, the Senate Subcommittee on Health and Scientific Research held a hearing on the drugs, where Sen. Edward Kennedy (D-Mass.) said, "If you require a daily dose of Valium to get through each day, you are hooked and you should seek help."
The next year, the National Institute on Drug Abuse declared that withdrawal from the drugs was in fact mild, "seldom leading to any serious consequences," and physical dependence was mostly avoidable. Pharmaceutical companies began releasing new types of benzodiazepines, marketing some for panic attacks and sleep problems.
Robert DuPont, former director of the National Institute on Drug Abuse, who has written several books on addiction and anxiety and maintains a psychiatric practice in Rockville, said the drugs are widely successful in treating panic and anxiety. He said that 90 percent of his patients have no difficulty taking the medicine, and those with problems are most likely to be people who've had issues with addiction in the past.
"The typical patient that I see with anxiety is taking [benzodiazepines] well within the green-light zone," he said. Addiction is an entirely different issue, having to do with a person "essentially falling in love with a chemical high," he said. "For those people, they're booze in the form of a pill."
Some physicians recommend that people experiencing anxiety and panic attacks exhaust other options before turning to the drugs. According to Jerilyn Ross, the director of the Ross Center for Anxiety and Related Disorders in Washington, cognitive behavioral therapy is one of the most effective ways to treat anxiety and panic disorders; she said it is effective on its own 90 percent of the time.
Katie Balestra is a freelance writer based in Washington. Comments: firstname.lastname@example.org.