In part one of our two-part blog on the dangers of benzodiazepines, we discussed the dangers of this drug and looked at a family who had significant issues because of over-prescribing. We also looked at the medications that preceded the discovery of benzodiazepines and why they looked like a reasonable alternative at the time. In part 2 of our blog on this subject, we will explore the safety and effects of benzodiazepines on seniors, and why some medical experts are saying that these drugs should never be prescribed to older adults.
"The use of benzodiazepines among seniors is rampant and trying to convince them that they can be harmful is truly an uphill battle," stated certified elder law Attorney RJ Connelly III. "There are people who have used this medication on a consistent dosage for years so to suggest that they have become dependent on them can cause pretty strong reactions in people since even the hint of a 'drug problem' can be extremely stigmatizing. But nearly all gerontologists I have spoken with say that even those who have taken benzos for an extended period without noticing any problems do face potential harm to their bodies."
Benzodiazepines versus Barbiturates
When benzodiazepines hit the market in the early 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 and prescriptions for the general population started to drop – but they 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 being prescribed at high rates to seniors. Now to be fair, this class of drugs is still safer than barbiturates as their main danger occurs, as discussed in part 1 of our series 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 so dangerous for seniors that a group of physician geriatric experts has indicated that there exists no safe level of use in elderly patients.
"...benzodiazepines are 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.
So popular were benzodiazepines with the public, especially women, that they were referred to as "mother's little helper" and the Rolling Stones had this minor hit in 1966 with this song about Valium.
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 medical literature warns against the long-term use of this drug in seniors, prescriptions continue to be written. An Athena Health report indicated that those over the age of sixty-five are prescribed benzodiazepines more than any other age group. And ten percent of women over the age of sixty-five are prescribed one of these drugs compared to just six percent of men, nearly twice the rate - but why the disparity?
"An Athena Health report continued to show that those over the age of sixty-five are prescribed benzodiazepines more than any other age group."
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, but that's a blog for another day.
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 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. Another 2017 study of emergency room visits for adverse events involving benzodiazepines or “Z-drugs” 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 block the benzos from binding, leading to acute withdrawal symptoms in those who have been taking them long term. Benzo withdrawal includes seizures, high fevers, and psychosis and can be life-threatening.
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 by 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 results 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? Simply, check the prescription bottles. Below is a list of some of the most prescribed benzodiazepines:
Be especially concerned if this person is exhibiting some of the symptoms we mentioned earlier. And more than anything 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, that 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.
"...benzodiazepines should never be stopped immediately as withdrawal can be deadly. It may take weeks or even months to taper off these medications safely...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 because 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
In some cases, the senior may not have just developed a physical dependence upon the drug, but also a psychological one that may need additional substance use disorder counseling and support. Remember, the belief that seniors cannot develop a substance use disorder is untrue, and if one is present, they deserve as much attention and care as any other age group.
"If you think that a loved one may be misusing or abusing prescription medications, have a talk with them and if that is unsuccessful, discuss this with the prescribing physician," said Attorney Connelly. "Don't chalk up behaviors and actions you are observing as just another condition of aging. There is help available and programs that specialize in providing treatment for older adults, and the good news is, most insurance plans cover treatment for in-patient addiction treatment."