Next week, a local television news station here in the Providence, Rhode Island market will begin running a series of special reports on the "opioid epidemic and overdose crisis". This information is always welcome and extremely important as drugs of abuse and patterns of misuse change and the public must be constantly educated, but honestly, that is old news.
Today, especially among seniors, we are heading into and may already be knee-deep in a new drug epidemic --- the abuse of benzodiazepines, so we decided to update a previous blog on the benzo epidemic. And one thing to note, almost one-third of overdose deaths listed as opioid-related have a tie to benzodiazepines, more on this later.
This class of medication is referred to as "Benzos" both on the street and in the normal lexicon of those who legally use them. Benzodiazepines are quite effective at managing anxiety disorders however, they are also highly addictive and powerful drugs that continue to be prescribed all too freely, especially to older adults and senior citizens.
"... over 30% of fatal opioid overdoses also have benzodiazepines in their system... [the actual] overdose is due to the combination of both opioids and benzodiazepines, limiting the effectiveness of Narcan." --- National Institute on Drug Abuse
Although the overdose crisis with benzos has not reached the level of opioids, people are still dying from them and, unlike opioids, there is no Narcan-like medication to stop the overdose process in its tracks. And here is an interesting tidbit on the overdose crisis that we alluded to earlier, the National Institute on Drug Abuse reports that over 30% of fatal opioid overdose victims also have benzodiazepines in their system. Although these are labeled opioid-related, the overdose is due to the combination of both opioids and benzodiazepines, limiting the effectiveness of Narcan. With that, let's take a deep dive into the problem of benzodiazepine abuse.
Substance Abuse and Seniors
"Substance use disorders among our seniors have nearly doubled since 2006, affecting almost 6 million older adults," said certified elder law Attorney RJ Connelly III. "The reality is that seniors who abuse or misuse medications or illicit drugs face many more risks than younger people due to cognitive impairments, medication interactions, nutritional concerns, poor social supports, and the risk of falls. Substance abuse and misuse is also linked to increased mortality rates and higher costs of healthcare. The problem with benzodiazepines is that even when using the prescribed dosage, seniors can suffer significant side-effects and symptoms resulting in misdiagnoses. So, it's not just opioids we need to be aware of, but an entire range of drugs, both legal and illegal."
"...these are stereotypes, and as we all know, stereotypes die hard because, in most cases, they are the refuge of those who are neck-deep in denial."
Americans continue to have a stereotypical view of substance abuse, misuse, and addiction. We like to say 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 as we all know, 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 in this blog, at any age.
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 legally prescribed medications, benzodiazepines, were the 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 dances and drive-in movies.”
“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.”
"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
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 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 dared 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 increased 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 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 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 in trying to keep up with the community’s expectations of our family.”
"...we lived in a good area where people like us didn't have drug problems, or so they thought... [Mom] was fighting a losing battle in trying to keep up with the community's expectations of our family." --- Marta
“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, she 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 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 he 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 was failing but at least the anxiety was under control. Then came the news of Rick’s death.”
“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," Marta stated.
“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 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 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 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 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 emergency services 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.”
"Mom was always good with her meds, being a retired nurse and all, but I genuinely believed the benzos had confused her to the point that she took too many of them..." --- Marta
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 us that when she was cleaning up the house, she found an empty bottle of Valium which she had filled for her just two weeks before.
“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 genuinely 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."
"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 Connelly. "We continue to be captivated by today's headlines regarding the “Opioid Epidemic” with little attention being paid to the use of benzodiazepines which can be just as or even more problematic than opiates. And for seniors, they continue to be the silent epidemic that no one wants to confront."
"We continue to be captivated by today's headlines regarding the 'opioid epidemic' with little attention being paid to the use of benzodiazepines...and for seniors, they continue to be the silent epidemic that no one wants to confront." --- Attorney RJ Connelly III
The Problems with Benzos
When it comes to all demographic groups, benzodiazepines are implicated in over 30% of drug overdose cases 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 or alcohol, their effects are magnified (called synergism) and can lead to rapid death, usually respiratory depression -- hence their implication in overdose deaths.
Seniors are 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 given what we know, the question is why this over-prescribing continues?
A Different Generation with Different Drugs
"Even in 2022, 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 dynamics of this discussion."
"It’s no secret that the baby boom generation has now become today’s seniors, growing up in an era where the mantra “if it feels good, do it” was echoed among the youth and the counterculture," 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 failing 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, Miltown became the most prescribed drug 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 common to see signs posted in neighborhood pharmacies proclaiming that they were out of Miltown but with a promise that “more will be here tomorrow”.
"[Miltown] was 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..."
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 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.
Next week in part 2 of our blog on benzodiazepines, we will take a deeper look into issues with dependence, contraindications, and how the effects of benzos can mimic the symptoms of Alzheimer's disease and other dementias.