Originally published in The Ottawa Citizen April 23, 2002
Original Title: Around the Benz

Mr. T. is a strapping 85 year-old man who suffers with an anxiety disorder. He also cares for his wife who is severely affected by Alzheimer’s. Twenty years ago he was prescribed clonazepam (Rivotril), a benzodiazepine (BDZ). He became dependent upon them to control his anxiety. BDZs and the elderly do not mix well.

Benzodiazepines such as Alprazolam (Xanax), oxazepam (Serax), diazepam (Valium), Rivotril and lorazepam (Ativan) are widely prescribed medications. They are used for the immediate treatment of seizures and convulsions, detoxification from alcohol, muscle spasms, pre-surgical sedation, insomnia and most commonly for anxiety related disorders and conditions. Some people use them for jet lag use or if they have an air travel phobia.

Perusing the product monographs found in the Compendium of Pharmaceutical and Specialties (CPS), the big blue tome in your doctor’s office, benzodiazepines are not indicated for long-term use. Approximately 15 percent of the adult population has taken a BDZ one or more times over the past year. One to two percent has taken them daily Mr. T. is a strapping 85 year-old man who suffers with an anxiety disorder. He also cares for his wife who is severely affected by Alzheimer’s. Twenty years ago he was prescribed clonazepam (Rivotril), a benzodiazepine (BDZ). He became dependent upon them to control his anxiety. BDZs and the elderly do not mix well.

Benzodiazepines such as Alprazolam (Xanax), oxazepam (Serax), diazepam (Valium), Rivotril and lorazepam (Ativan) are widely prescribed medications. They are used for the immediate treatment of seizures and convulsions, detoxification from alcohol, muscle spasms, pre-surgical sedation, insomnia and most commonly for anxiety related disorders and conditions. Some people use them for jet lag use or if they have an air travel phobia.

Perusing the product monographs found in the Compendium of Pharmaceutical and Specialties (CPS), the big blue tome in your doctor’s office, benzodiazepines are not indicated for long-term use. Approximately 15 percent of the adult population has taken a BDZ one or more times over the past year. One to two percent has taken them daily for 12 months or longer. Some patients have been using them for decades. The elderly are major consumers of this medication.

Patients prefer them because of their rapid onset of action and that they can be used on an “as needed” basis. They are problematic medications because of their abuse potential and effect on concentration, driving and balance. Long-term daily use over months and years can lead to habituation, dependency and tolerance (needing increasing doses to produce the same effect).

They are responsible for confusion and poor balance especially upon awakening in the middle of the night as many elderly people are wont to do. They have an increased risk of falling that can unfortunately lead to broken hips, internal bleeding and head injuries. Driving the following day is statistically hazardous (doubling the risk of a crash) even after the sedating effects of the medication have waned. Reaction times and reflexes are diminished. This is true for young and old drivers alike.

BDZs are particularly damaging to the sleep cycle. The normal sleep cycle has four stages (1 – 4) plus a dream stage (REM sleep). The first two stages are associated with light sleep followed by the deeper more restful third and fourth stages. We all know these stages quite well. When roused from deep sleep we have that “hung- over” feeling whereas awakening from light sleep is a mere nuisance. Benzodiazepines increase the time spent in stage one sleep and interfere with the deep stages. Although you will sleep, it is not refreshing. Sleep cycles can be damaged by their long-term use. This is another reason why people have such a difficult time stopping BDZs. They become dependent upon them to induce sleep since their brain is now unable to do so independently.

Newer non-addictive medications are available to help people with insomnia such as Zaleplon (Starnoc) and Zopiclone (Imovane). Starnoc helps you fall asleep. Imovane reduces the duration of light sleep but increases the time spent in deep sleep thus preserving sleep architecture (the normal sleep cycle).

Although effective for acute (sudden) anxiety, BDZs do nothing to treat the underlying cause of anxiety disorders. These disorders are interrelated with Major Depressive, Obsessive-Compulsive, Generalized Anxiety and Panic Disorders. All these conditions are treated with non-addictive medications that treat the disease and not the symptoms. Anxiety usually wanes once the underlying cause is treated.

There specific indications for BDZ use. Most physicians do not like to prescribe them especially when other alternatives are available. The problem: Starnoc and Imovane are not covered under the Ontario Drug Benefit program. This leaves many patients and physicians unable to choose this option. Many elderly patients do not have supplementary health insurance. The group most at risk is yet again penalized. Score another point for the short-sighted bureaucrats at the Ministry of Health.

BDZs are relatively contraindicated in patients with current alcohol and drug abuse problems and for those in recovery programs. They should never be used during pregnancy because of the risk of birth defects. It can lead to dependence and withdrawal symptoms in the newborn. Patients addicted to BDZs are advised not to abruptly stop their medication because it can lead to seizures. Withdrawal has to be done slowly and under the direct management and close supervision of a physician.

Mr. T. switched to an anti-depressant medication. Over the course of five weeks he gradually reduced his clonazepam dose until he was able to completely stop. His anxiety has disappeared and my anxiety about a potential disaster abated. He is better able to care for his wife.

If you have concerns about this issue talk to your doctor. If warranted, seek alternative solutions to your problem. And get a good night’s sleep.