This month is National Recovery Month, a national observance held every September by the Substance Abuse and Mental Health Services Administration (SAMHSA) to promote and support new evidence-based treatment and recovery practices, the emergence of a strong and proud recovery community, and the dedication of service providers and community members across the nation who make recovery in all its forms possible. Recovery month is in its 32nd year and celebrates the gains made by those in recovery from addictions. And to observe this month, our September blogs will feature information on substances of abuse that affect our seniors.
"Substance use disorders among our seniors have nearly doubled since 2006, affecting almost 6 million older adults," said Attorney RJ Connelly III. "The reality is that seniors with a substance use problem face many more risks than younger people due to cognitive impairments, medication interactions, nutritional concerns, poor social supports, and the risk of falls. Abusing substances is also linked to increased mortality rates and higher costs of healthcare."
Americans continue to have a stereotypical view of substance abuse and addiction. It happens to the “other family” -- not ours. Many believe it is a problem of the “lower class”, those lacking education, the young, the homeless, and even minorities. These are stereotypes and stereotypes die hard because, in most cases, they are the refuge of those who are neck-deep in denial. In truth, addiction and abuse can be found in every family, every culture, every economic class, and, as we will discuss today, at any age.
In this week's blog, we are going to discuss benzodiazepines, the hidden epidemic of abuse among seniors. Although they are first prescribed as a well-intentioned intervention to help older adults with anxiety or ease some of the symptoms of depression, research now shows that as many as one in four seniors who use them go on to use them long-term.
When we 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 who had 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 during the last game of his senior high school season he blew out his knee 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 really wanted to do was play football and since that wasn’t a possibility, 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 took a job as a third-grade teacher in a town close to her childhood home. But her family was not without problems – especially her Dad.
“He was haunted by Vietnam,” 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 up 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 at night in a cold sweat, pacing around, sometimes crying but always taking a drink before settling back down into bed. He also hated the sounds of fireworks although he tolerated them to make sure my brother and I had fun during our trips to Disneyland or to 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 did get benzos from our family doctor to deal with the overwhelming anxiety he had, 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 very 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 months more of 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 I think because of that, 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. According to her, it was a well-known secret that her dad was an alcoholic, but no one dare speak about it. This caused tremendous stress for her mother, who seemed to age at a rapid pace. Then her brother’s behavior took a significant turn for the worse.
“Rick’s pain was being medicated by more and more narcotics and he was taking Dilantin and Klonopin for his seizures. Dad’s drinking became worse and worse leading to angry outbursts at everyone in the family. I moved into my own apartment and my brother couldn’t take the abuse and spent more time away from home hanging out with a pretty negative crew," Marta said.
“He began staying out all night. Then that turned to him disappearing for days on end, then weeks and months. He got arrested a lot 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 turned into 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. Being a nurse, she knew the dangers of mixing benzos and alcohol, but she dare 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 in trying 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 and 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 expectations of the community. I’m glad that they said it was an accident, but I think I know what really happened – and so did Mom,” said Marta with 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 when it came to the money they both had earned and put together a retirement plan and knowing Rick’s problems, 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” and 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 seemed to be failing but at least 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 that he had a high amount of benzos and alcohol in his system and he died from choking on his own vomit. This was the last straw for Mom."
“The doctor increased her Valium dosage even higher on top of the other medications she was taking. Her memory was failing fast, she was still having problems sleeping and was experiencing what seemed to be 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 maybe the beginning of dementia. I decided to do some reading 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 considerably 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 on her own. I mean, she was so independent most of her life but I had concerns 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 of that discussion. In my heart, though, I knew something just wasn’t right with her.”
One afternoon at work, she received a call from her mother who said that 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 which she had filled for her just two weeks before nearly empty.
“There were over thirty pills missing from what should have been there. Mom was always good with her meds, being a retired nurse and all, but I truly believe the benzos had confused her to a 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? Maybe I should have been tougher with the doctor. If I did, maybe she would still be here,” with that, Marta broke down.
"I cannot stress enough my concerns about the overuse of benzodiazepines among older adults and seniors and the problems they develop as a result and the side effects that are often attributed to the aging process," said Attorney RJ Connelly III. "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. And for seniors, benzodiazepines continue to be the silent epidemic that no one wants to confront."
The Problems With Benzos
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. Now when I say implicated, it is important to note that by themselves, benzodiazepines can be relatively safe even though they are highly addictive. But when used with any number of 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 the use of 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 substantially 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 and the question is why.
A Different Generation With Different Drugs
"Even in 2021, there continues to be the mistaken belief – or stereotype – that grandma or grandpa will not abuse medications," said Attorney Connelly. "But we are dealing with baby boomers here, and that changes the conversation drastically."
"It’s no secret that the baby boom population are today’s seniors, who grew up in an era where the mantra “if it feels good, do it” was echoed among the youth and the counter culture," continued Attorney Connelly. “'Sex, Drugs and Rock and Roll' emblazoned T-shirts and was immortalized in everything youth-oriented. It became a way to deal with the societal issues of the time – Vietnam, Civil Rights, and the economy. This led to a new attitude among that age group that has carried over into adulthood and now into their senior years."
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 was found in a medication bottle through drugs called tranquilizers (barbiturates).
The tranquilizers of the day were extremely 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-50s, a drug called Miltown hit the market (named after the town in New Jersey where it was manufactured) and was considered to be 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” (it was considered a “weakness” for men to take them, as they treated their anxiety with alcohol as we discussed in a previous blog). Their use was so widespread that it was not uncommon to see signs posted in neighborhood pharmacies proclaiming that they were out of Miltown but with a promise that “more will be here tomorrow”.
Doctors, pressured by the pharmaceutical companies as well as 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 in its users and increased 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.
A Safe Alternative?
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.
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 negative effects of long-term benzodiazepine use were issued with seniors being one of the main groups targeted. Despite this concern, benzodiazepines continued to be a hugely popular class of drugs.
And now, in the 21st Century, benzodiazepines are still prescribed at relatively high rates. Now to be fair, this class of drugs is still safer than barbiturates as their main danger occurs, as discussed earlier when used with other medications or substances that cause respiratory depression, whereas barbiturates can cause respiratory depression on their own and directly cause death and overdose.
However, in seniors, benzodiazepines – by themselves – have serious and sometimes deadly consequences. In fact, benzodiazepines are considered to be so dangerous for seniors that a group of physician geriatric experts has indicated that there exists 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 them and their use with other CNS depressants. This is the strictest warning put on the labeling of prescription drugs or drug products by the FDA when there exists reasonable evidence of serious hazards with a drug. Even so, benzodiazepines continue to be prescribed for the elderly to treat anxiety and sleep problems in conjunction with other medications at alarmingly high rates.
Benzos and the Aging Body
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 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 that we experience as we grow older. The process of aging tends to slow nearly all body functions, including the liver, which means 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 and can approach toxic levels even when taken as directed.
As the body stores benzodiazepines, the accumulation of this drug continues as the body is unable to effectively eliminate it. 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 but in a much different way than barbiturates.
The Benzo Addiction
The National Institute on Drug Abuse (NIDA) considers benzodiazepines to be one the most addictive substances known to man, behind heroin, cocaine, and nicotine. This is because 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.
Unfortunately, even as the medical literature warns against the long-term use of this drug in seniors, prescriptions continue to be written. A recent Athena Health report continued to show that those over the age of 65 are prescribed benzodiazepines more than any other age group. Ten percent of women over the age of 65 are prescribed one of these drugs compared to just six percent of men, nearly twice the rate - but why the disparity?
According to Dr. Robert Roca, the chair of the American Psychiatric Association's Council of Geriatric Psychiatry, “women are more likely to express distress” while men tend to hold their feelings. The problem with this, as we discussed before, men tend to use alcohol to deal with anxiety.
Mixing Prescription Medications
So now let’s look at the dangers of combining these drugs with other medications. When it comes to overdose risk, the combination of benzodiazepines and opioids is indeed the most dangerous, a concern that prompted the Black Box warning by the Food and Drug Administration regarding the use of these two classes of medications together.
A 2017 study shows that the combination of opioids with benzodiazepines is especially risky in the first 90 days of concurrent use. These include the following benzodiazepines - alprazolam (Xanax), diazepam (Valium), and clonazepam (Klonopin), which are most frequently prescribed to seniors in order to alleviate anxiety.
The analysis showed that overdose risk was five times higher for patients taking both drugs during the first 90 days compared to those only taking just an opioid. The risk was doubled for those taking both drugs during the next 90 days. After 180 days, the risk of overdose was roughly the same as taking only opioids. There are a number of reasons for this, including the patient's understanding of the side-effects and when to report them as well as how the patient takes them. In any case, it is important to know that based on this study, if an overdose is to occur, it will be in the first three to six months, something caretakers should be aware of.
But opioids are not the only drug when taken together with benzodiazepines that can cause serious side effects. Let's look at three classes of medication that also need to be monitored;
Insomnia Drugs - Known as “Z-drugs” and prescribed to help battle insomnia, many medical providers are unaware that they have a similar mechanism of action as benzodiazepines. These drugs include Ambien, Lunesta, and Sonata. When these medications are used in combination with benzodiazepines, they can cause blackout spells. In another 2017 study of emergency room visits for adverse events involving benzodiazepines or “Z-drugs”, it found a 4-fold increase in risk for serious events when the two medications were combined.
Stomach medications - Known as proton pump inhibitors (PPIs) used to treat acid reflux, medications such as Prilosec, Nexium, Prevacid, and Protonix have been shown to increase the blood levels of benzodiazepines by interfering with the way the liver clears them from the body. As a result, the side effects of benzodiazepines are magnified causing increased confusion, sedation, dizziness, falls, and driving mishaps. The most common PPIs associated with these side effects are Prilosec and Nexium.
Fluoroquinolone Antibiotics - Fluoroquinolones are antibiotics that are commonly used to treat a variety of illnesses such as respiratory and urinary tract infections. These medications include Cipro, Levaquin, and Avelox. Since they compete for the same binding site as benzos, the antibiotics actually block the benzos from binding, leading to acute withdrawal symptoms in those who have been taking them long term. Benzo withdrawal can be life-threatening resulting in seizures, high fevers, and psychosis.
Other Health Risks
In articles published in late 2017 and 2019, benzodiazepines and related drug use were associated with a 40 percent increase in mortality among persons with Alzheimer's disease, according to a study released from the University of Eastern Finland. The findings were published in the International Journal of Geriatric Psychiatry.
The study also found that the risk of death was increased right from the initiation of benzodiazepines and related drug use. The increased risk of death may have resulted from adverse events caused by these drugs, including fall-related injuries, such as hip fractures, as well as pneumonia, and stroke.
One theory put forward by the researchers, based at several institutions across Finland, is that the sedative effects of benzodiazepines may increase the risk of pneumonia by boosting the likelihood of aspiration of saliva or food into the lungs.
This theory correlates with the study’s finding that pneumonia risk is highest at the start of benzodiazepine use, as the sedative effect is more pronounced initially before tolerance is built up, according to researchers.
When it comes to stroke risk, the researchers found that the use of benzodiazepines was associated with a 20 percent increased risk of stroke among persons with Alzheimer's disease. The findings encourage careful consideration of the use of benzodiazepines and benzodiazepine-like drugs among persons with Alzheimer's disease, as stroke is one of the leading causes of death in this group.
Finally, benzodiazepine use while using alcohol can be a deadly combination. A recent study shows that seniors who go to hospital emergency rooms because of drug interactions are usually the result of combining these two powerful sedatives which result in a synergistic effect. Again, this results in increased falls, car accidents, and respiratory depression issues.
Know the Medications
So how do you know if someone you love is taking these drugs? Check the bottles. Below is a list of some of the most commonly prescribed benzodiazepines:
Be especially concerned if this person is exhibiting some of the symptoms we mentioned earlier. And above all else, if visiting a medical professional about odd behaviors or symptoms that may indicate the presence of dementia, provide them with the list of medications they are taking.
"Despite the documented dangers, there continues to be a dearth of education for those prescribed these medications, which includes the knowledge of mixing them with other CNS depressants like alcohol, " said Attorney Connelly.
If an older adult is struggling, remember, treatment is available for them.
First and foremost, benzodiazepines should never be stopped immediately as withdrawal can be deadly. It could be that the benefits of benzodiazepines may very well outweigh the possible side effects. Those using benzodiazepines long-term need professional healthcare management when the decision is made to stop them. It may take weeks or even months to taper off these medications safely. As stated earlier, immediately stopping these medications can result in irrepressible and fatal seizures.
The National Institute on Drug Abuse (NIDA) describes withdrawal as a group of physical and psychological symptoms that manifest as a result of stopping the regular dosage of a particular drug. Withdrawal symptoms are far-ranging and in almost all cases, they tend to exaggerate the very physical manifestations they were supposed to suppress, including irrepressible and fatal seizures.
Individuals should never attempt to quit using benzodiazepine suddenly or on their own without medical advice and supervision. It may take weeks or even months to taper off withdrawal symptoms safely without adversely affecting your life. The following are symptoms associated with benzodiazepine withdrawal:
Increased heart rate
Inflated blood pressure