She started taking them two years ago after her second panic attack when her marriage was failing and she couldn't sleep. The pills worked for a while but now she feels just as anxious and depressed while taking them as she did before she started. Recently she tried stopping the medication, but after three days she began to experience worsening anxiety, insomnia, tremors and strange shooting pains in her abdomen and pelvis. She picked up a refill and restarted them but now she feels trapped.

Peace, glorious peace. That's often why we drink alcohol, Canada's favourite sedative-hypnotic drug. Over the years we have developed more effective central nervous system depressants such as ether, chloral hydrate, and the barbiturates. Then came Librium® (chlordiazepoxide) and finally we had Valium® followed by many newer members of the benzodiazepine family of drugs.

Benzodiazepines: Valium (diazepam), Xanax® (alprazolam), Restoril® (temazepam), Rivotril® (clonazepam), Serax® (oxazepam), Ativan® (lorazepam), Halcion® (triazolam), are a few of the members of this class of drugs (the brand names are in capitals, the generic names in parentheses). The main distinguishing feature amongst them is in their speed of onset and duration of action. Whether they are used to treat anxiety, muscle spasm, insomnia or even depression is a matter of marketing. They work by attaching to receptors in the brain and inhibiting or depressing function in those specific nerve cells. If those particular neurons are firing off causing anxiety, panic, arousal that interferes with sleep or seizures, then these pills work their magic and relieve the troubling symptom.

The problem is, continued use of these pills sometimes causes worse problems than the symptom for which they were prescribed.

For some acute problems, benzodiazepines are extremely valuable. Unfortunately, they are overprescribed and overconsumed. They should only be used if there is a clear diagnosis and the benefits outweigh potential risks. With few exceptions benzodiazepines should be taken for from several days to several weeks and then stopped. Studies have shown that after several weeks, due to adaptive changes in the brain, levels of anxiety, depression, sleeplessness and muscle tone return to pre-treatment levels while on this type of medication. Clinical research has shown that prolonged use of benzodiazepines actually makes anxiety and depression worse. Other adverse effects include interference with memory, incoordination and falls, increased risk for car accidents, cognitive problems and potential for addiction especially in those at increased risk because of previous addictive disorder or family history. Elderly people do not handle benzodiazepines well, experiencing many side effects such as confusion, incoordination causing falls, and symptoms mimicking dementia.

For anxiety and panic disorder, sleep disorders and depression where longer duration drug therapy is needed there are pharmacologic alternatives that are safe and non-addicting. Psychotherapy, such as cognitive therapy, has been shown to be superior to benzodiazepines for the treatment of many emotional problems.

Discontinuing benzodiazepines in people who have been taking them for longer than several months should be done gradually and under medical supervision. Sudden cessation can trigger a serious withdrawal syndrome that onsets in one to several days and can range in severity from restlessness, anxiety and insomnia all the way through hypertension, palpitations and vomiting to seizures. It is often difficult to separate withdrawal symptoms from rebound or relapse of original psychiatric symptoms. In some people who have received benzodiazepines for a long period there is a prolonged withdrawal syndrome, with disturbing cognitive, neurologic and multiple organ system symptoms that in some may last many months.

If you are concerned about your use of this type of drug, talk to your doctor. If the medication is still effective and there are no significant side effects you might want to stay on them. If you would like to get off them it might be a good idea to have your doctor arrange a consultation with a physician skilled in addiction medicine to work out a safe, gradual detoxification protocol. If addiction has occurred it will be important to receive further addiction counseling and relapse-prevention therapy so that you can learn effective non-chemical coping skills in order to remain drug free and feeling good.

Dr. Ray Baker is Assistant Clinical Professor in the Faculty of Medicine at the University of British Columbia. He has been awarded fellowships in both Family Medicine and Addiction Medicine. He has been a practicing physician for over 23 years. From 1993 to 1997 he represented Canada on the Board of Directors of the American Society of Addiction Medicine, North America's credentialing body in this specialized area of medicine. His area of special clinical expertise is in assessment and treatment planning of the worker disabled by one of the "invisible disabilities", stress, depression, chronic pain syndrome or substance use disorder.

Dr. Ray Baker, BSc (Hon), MD FCFP, FASAM