Benzodiazepines - the Silent Epidemic of Overprescribing in Seniors
By Don Drake, Connelly Law Offices, Ltd.
"We continue to have a stereotypical view of substance abuse and addiction," said professional fiduciary and certified elder law Attorney RJ Connelly III. "It happens to the 'other family' -- not ours. It happens to the 'other people' - not us. Many believe it is a problem of the 'lower class', those lacking education, the young, and even minorities. These stereotypes die hard because, in most cases, they are the refuge of those neck-deep in denial. In truth, addiction and abuse can be found in every family, every culture, and every economic class. But our discussion today is not focusing solely on addiction but on the overprescribing of medications, specifically to seniors, which can lead to dependence, abuse, and withdrawal."
"As a country, we have focused on overprescribing opioids, and rightfully so," said Attorney RJ Connelly. "But the overprescribing of another class of drugs, benzodiazepines, has become a pervasive problem, especially among seniors in primary and long-term care settings. Although benzodiazepines are less deadly than opiates, they are still implicated in deaths, especially among those using prescription opiates and multiple medications, such as the elderly."
"The dangers of these drugs, for older individuals, include lethargy, confusion, increased risks of falls and fractures, and a significant impairment when they are behind the wheel. Long-term use can result in dependence, withdrawal-induced delirium, seizures, and death. Given these concerns, let's look deeper at benzodiazepine use and America's love affair with these medications."
A Family Destroyed by Benzodiazepines
I first met Marta when she came to counseling after the death of her elderly mother. She grew up in a rural farm town in Northern New Jersey and from a family whom others viewed as leaders in the community -- and she lived through family tragedies where benzodiazepines were central players.
Her father was a Vietnam veteran with his own construction company, and her mother was a nurse in the emergency room at the county hospital. Her brother Rick was a phenomenal athlete in high school and was bound for a Big Ten college with a full athletic scholarship. Sadly, his dreams were dashed when he blew out his knee during the last game of his senior high school season, attempting to dive for a touchdown.
“But it wasn’t a problem," said Marta, “my family could afford to send him to college, but he decided to join Dad in the construction business. All he wanted to do was play football, and since that wasn’t possible, college wasn’t important to him.”
For Marta, she found her calling in working with children. Attending the State’s top teaching college, she graduated near the top of her class and worked as a third-grade teacher in a town close to her childhood home. But her family was not without problems – especially her dad.
“Vietnam haunted him,” Marta remembered. “They took an eighteen-year-old kid from a farm family and put him in charge of picking up pieces of soldiers that were blown apart. He packed the pieces the best he could and shipped them back to a grieving family, hoping they would get as close to a whole body as possible to bury. Pretty tough stuff when other kids his age were back home still going to proms.”
“When he and my mom got married, she told me how he woke up in a cold sweat at night, pacing around, sometimes crying but always taking a drink before settling back into bed. He also hated the sounds of fireworks, although he tolerated them to ensure my brother and I had fun during our trips to Disneyland or Fourth of July celebrations at the local football field.”
“In those days," Marta said, “if you were a man who talked about his feelings, you were considered weak. Even worse, those guys coming back from Vietnam were viewed by many as war criminals and not patriots. Although he never complained, he got benzos from our family doctor to deal with his overwhelming anxiety, and on top of this, he drank -- a lot.”
Marta said that things did get better as the kids in the family grew older. When her brother joined Dad in the construction business, they grew remarkably close and seemed to have a special bond until the accident.
“Rick fell off a roof during a job at a church as my father watched. He broke both legs, his pelvis and had a serious head injury. He was in the hospital for months and then more rehab after that. When he came home, he was never the same. His head injury caused memory problems, constant headaches, and seizures. The connection he had with my dad was gone. His personality was different. He walked with a limp, and his legs were always in pain. Dad blamed himself, and his drinking became heavier and more frequent even with the benzos.”
As this was occurring, Marta’s mother did her best to keep up the family image in the community. She said it was a well-known secret that her dad was an alcoholic, but no one dared speak. This caused tremendous stress for her mother, who seemed to age rapidly. Then her brother’s behavior took a significant turn for the worse.
“Increased narcotics were medicating Rick’s pain, and he was taking Dilantin and Klonopin for his seizures. Dad’s drinking worsened, leading to angry outbursts at everyone. I moved into my own apartment, and my brother couldn’t take the abuse and spent more time hanging out with a pretty negative crew away from home," Marta said.
“He began staying out all night. Then that turned to staying away for days, weeks, and months. He was often arrested for buying and selling drugs, disorderly conduct, and shoplifting. He ended up doing time in the county jail more than once.”
“By this point, Dad’s drinking became an all-day thing, and Mom became a basket case. The stress of trying to keep the family together, even though we were old enough to take care of ourselves, was like a ton of weight on her shoulders. As a nurse, she knew the dangers of mixing benzos and alcohol, but she dared not confront Dad. Remember, we lived in a good area where people like us didn’t have drug problems, or so they thought…she was fighting a losing battle to keep up with the community’s expectations of our family.”
When it seemed like things could not get any worse, tragedy struck. “One day, during one of his drunken sprees, Dad got angry, tore out of the house, and jumped in his pick-up truck despite my mom’s pleas not to. About ten minutes later, my mom saw the state police speed by and instinctively knew something had happened to Dad," Marta remembered. And it did. His truck was found on a county road wedged between two trees, still running. He was killed instantly. The coroner’s report said it was an accident, but Marta believed he had reached a point where he had enough and killed himself.
“He was fighting the demons of Vietnam, the guilt of my brother’s injury, and the community's expectations. I’m glad they said it was an accident, but I think I know what happened – and so did Mom,” said Marta, her voice trailing to a whisper. “She was devastated.”
“Thankfully, Dad did have his finances in order. Despite his alcoholism, he had a good head on his shoulders regarding the money. They both had earned and put together a retirement plan and knew Rick’s problems, and he had a special needs trust set up for him so he wouldn’t use any inheritance to fuel his drug habit. Knowing she was set financially took some stress away, but her anxiety over his death and Rick’s problems took a toll on her. She was deteriorating fast and ended up quitting her job at the hospital.”
Marta reported that Mom’s anxiety was “over the top,” at times, she seemed confused, stressed, and unable to sleep. She took her to the family doctor, who referred her to a psychiatrist.
“He gave her Valium and some other medications. It seemed to help. She was at least getting some rest. But I did express some concern when it seemed every couple of months. The doctor was increasing the amount of Valium she was taking. I mean, she was older now and not as strong as she used to be, and her memory also was failing more, but the anxiety appeared to be under control. Then came the news of Rick’s death.” Marta said that her brother, who had been in and out of jail and drug treatment programs, was found dead at a friend’s house.
“They found him lifeless on a bed at a friend’s apartment. The autopsy reported many benzos and alcohol in his system, and he died from choking on his vomit. This was the last straw for Mom."
“The doctor increased her Valium dosage even higher than the other medications she was taking. Her memory was failing fast. She was still having problems sleeping and was experiencing hallucinations. She was unsteady on her feet and spent most of her day sitting in a recliner in front of the picture window because she always felt dizzy. I reported my concerns to the doctor, but he felt this was just a part of aging or the beginning of dementia. I decided to read on benzos and was horrified by what I learned. I went back to her doctor, but he assured me he was watching things and that without the Valium, things would be worse for her. I listened to him and stopped listening to my gut feelings about this drug.”
Marta then offered to move in with her mother to help her and even discussed with her the possibility of moving her into an assisted living program.
“She became furious at me, insisting she could live independently. She was independent most of her life, but I was concerned about her ability to cook, clean, and take her medication appropriately. I didn’t want to cause any more stress in her life, so I backed off that discussion. In my heart, though, I knew something wasn’t right with her.” One afternoon at work, she received a call from her mother, who said she had fallen earlier and was not feeling well. Marta left the school and rushed over to her house.
“I knew it was bad. I could hear her struggling to breathe and was more confused than usual. I called 911 and told them what had happened. By the time I got to the hospital, it was too late. Mom was dead. The fall had caused a brain injury which, according to the doctor, was the cause of death.”
Marta said she could have accepted that her fall was caused by age, but she didn’t believe this to be the case. She told me that when she was cleaning up the house, she found the bottle of Valium she had filled for her just two weeks before nearly empty.
“Over thirty pills were missing from what should have been there. Mom was always good with her meds, being a retired nurse and all, but I honestly believe the benzos had confused her to the point that she took too many of them, and that caused her to fall. Why didn’t I spend more time with her? Why didn’t I monitor her medication closer? I should have been tougher with the doctor. If I did, maybe she would still be here,” with that, Marta broke down.
Not Just an Opioid Epidemic
"We are continually captivated by today's headlines regarding the 'Opiate Epidemic,' with little attention being paid to the use of benzodiazepines which can be just as or even more deadly than opiates," said Attorney RJ Connelly. "For seniors, benzodiazepines remain the silent epidemic that no one wants to confront. So, let’s start this conversation by looking at the benzodiazepine problem."
When it comes to all demographic groups, benzodiazepines are implicated in over 30% of drug overdose rates in the United States, according to the Centers for Disease Control. The word implicated is important because benzodiazepines can be safe even though they are highly addictive. But when used with other medications and alcohol, their effects are magnified (called synergy) and can lead to rapid death -- hence their implication in overdose deaths.
Seniors, however, appear to be more adversely affected by this class of drugs than any other group. Not only due to the synergistic factor but because of their aging bodies and falls.
One long-term study by the National Institutes of Health raised serious concerns about using these medications in senior citizens. The study found that among all adults 18 to 80 years old, about 1 in 20 received a benzodiazepine prescription in 2008, the period covered by this study.
This number rose with age, from 2.6 percent among those 18 to 35, to 8.7 percent in those 65 to 80, the oldest group studied. Long-term use — a supply of the medication for more than 120 days — also increased markedly with age. Of people ages 65 to 80 who used benzodiazepines, 31.4 percent received prescriptions for long-term use vs.14.7 percent of users 18 to 35. And more recent studies show the same trend and practices continuing.
Why? Because of the mistaken belief – or stereotype – that older users will not abuse medications. But we are dealing with baby boomers here, which we will discuss later.
Women in all age groups were about twice as likely as men to receive benzodiazepines. Among women 65 to 80 years old, 1 in 10 were prescribed one of these medications, with almost a third of those receiving long-term prescriptions. More current numbers suggest that the number of prescriptions being written for benzodiazepines has not slowed down.
The stereotype that women are more “prone” to anxiety disorders and that men don't usually speak about their levels of anxiety -- which they usually treat with alcohol -- may be responsible for this.
So, what are benzodiazepines, and why have they stayed under the radar screen? To find answers to these questions, let’s examine the history of America’s love affair with drugs and how we got here.
America and Drugs - A Love Affair
It’s no secret that the baby boom population is today’s seniors. They grew up in an era where the mantra “if it feels good, do it” was echoed among the youth and the counterculture. “Sex, Drugs and Rock and Roll” emblazoned T-shirts and was immortalized in everything youth-oriented. It became a way to deal with societal issues of the time – Vietnam, Civil Rights, and the economy. This led to a new attitude among this age group and has carried over into adulthood and their senior years.
Think about the classic movies and television shows of the time. Any trauma or horrible situation on the screen was handled by a doctor handing out “tranquilizers” (usually to the female characters). That’s how people were taught to cope by Hollywood, and this became the learning curve for our society.
As our nation transitioned from a war economy and had to adjust to millions of people returning from military jobs, they were facing a slowdown in manufacturing, a rise in inflation, and an increase in unemployment, creating massive anxiety in the country (and the world, for that matter) and the public clamored for help. And the help they sought came in a medication bottle -- drugs called tranquilizers (barbiturates).
The tranquilizers of the day were highly addictive and way too powerful for an adult to use daily and continue to function responsibly. Something else was needed to address the day-to-day stress without zoning out millions of Americans. Then came a breakthrough.
In the mid-fifties, a drug called Miltown hit the market (named after the town in New Jersey where it was manufactured) and was considered a “mild tranquilizer” and joined similar drugs like Equanil and Reserpine. Soon, they became the most prescribed drugs in history up to that point.
Marketed as “miracle drugs”, they were used to treat the anxiety and stress of the “everyday housewife” as it was considered a “weakness” for men to take them. Their use was so widespread it was not uncommon to see signs posted in neighborhood pharmacies proclaiming that they were out of Miltown with a promise that “more will be here tomorrow”. Doctors, pressured by the pharmaceutical companies and their patients, wrote out prescriptions in record numbers.
But the wonders of this class of drugs were short-lived. It turned out that Miltown and the other “mild” barbiturates were just as addictive as their more powerful predecessors, creating a rapid dependence on its users and increasing the dangers of overdosing. Pharma had to find a new medication to address America’s hunger for a ‘feel-good’ drug. Enter benzodiazepines, discovered accidentally while researching an alternative for the barbiturates.
The Arrival of Benzos
When benzodiazepines hit the market in the mid-1960s, they were touted as safer than barbiturates and embraced by the medical profession as the next “wonder drug” to treat the “nervousness and anxiety” of the American people. Movies and books like "Valley of the Dolls" and television series like "Peyton Place" told stories of a drug-loving culture. The day's music reflected the ongoing love affair with barbiturates and benzodiazepines.
By the mid-1970s, benzodiazepines had become one of the most prescribed drugs in the United States and in most developed countries around the world. As these medications reached their height of popularity, the initial euphoria exhibited by medical professionals began to wane for the general population – but continued to be used liberally for their senior patients.
As the 1980s rolled around, warnings on the adverse effects of long-term benzodiazepine use were issued, with seniors being one of the groups targeted. Despite this concern, benzodiazepines became a hugely popular class of drugs.
And now, in the 21st Century, benzodiazepines are still prescribed at high rates. This class of drugs is safer than barbiturates as their main danger occurs, as discussed earlier when used with other medications or substances that cause respiratory depression. In contrast, barbiturates can cause respiratory depression on their own and cause death and overdose without other drugs or substances being present.
However, in seniors, benzodiazepines – by themselves – can have severe and sometimes deadly consequences. Benzodiazepines are considered so dangerous for seniors that a group of geriatric physician experts has indicated that there is no safe level of use in elderly patients.
Based on these concerns, the Food and Drug Administration (FDA) has issued a black box warning for their use with other CNS depressants. This is the strictest warning on labeling prescription drugs or drug products by the FDA when reasonable evidence of serious hazards exists with a drug. Even so, benzodiazepines are prescribed for the elderly to treat anxiety and sleep problems at alarmingly high rates.
Some of the direct effects of benzodiazepines on seniors include drowsiness, confusion, mental clouding, lethargy, and the inability to concentrate. Other side effects include blurred vision, night wandering, incontinence, nightmares, and appetite changes. Secondary dangers of these drugs include cognitive difficulties, falls and fractures due to impaired balance, and automobile accidents – and as mentioned earlier, statistics indicate that benzodiazepines are the number one drug implicated in falls caused by medications.
These drugs are also problematic due to the physiological changes seniors experience as they age. The aging process tends to slow nearly all body functions, including the liver, so it takes longer for a senior’s body to process this medication. In addition, an aging body also tends to store this drug in fat cells. Given this, the level of benzodiazepines in the body of a senior tends to be higher than that of a younger person using the same amount. It can approach toxic levels even when taken as directed.
As the body stores benzodiazepines, the accumulation of this drug continues as the body cannot eliminate it effectively. Because of this dangerous cycle, the side effects become atypical and can lead to a misdiagnosis of other conditions of aging, including dementia and Alzheimer’s disease.
And one other thing about benzodiazepines -- they are highly addictive and in a much different way than barbiturates. Benzodiazepines affect dopamine production within the brain. Dopamine is a neurotransmitter associated with pleasure, reward, and motivation. When any activity – sex, eating, substance abuse – causes excessive dopamine levels (rewarding, pleasurable activities), the brain is “trained” to repeat that behavior. Because of this, the National Institute on Drug Abuse (NIDA) considers benzodiazepines one of the most addictive substances known to man, behind heroin, cocaine, and nicotine.
Unfortunately, even more issues are associated with the long-term use of benzodiazepines in seniors. We will continue the discussion in our next blog.